Overview

The Helper Bees contracts with vendors as a cost-effective and efficient way of providing administrative and health care services to our members. We are required to perform these services under our contract(s) with our plan sponsors and CMS guidelines.

All service providers, contractors, subcontractors, and vendors must undergo a pre-delegation assessment prior to performing delegated activities or providing services. This assessment includes evaluation against certain specific criteria, carefully considered by The Helper Bees Management, Legal, and Compliance teams. A first tier, downstream, and related entities (FDR) can be identified as any entity meeting some or all of the following criteria:

The Helper Bees is required to provide this function under its plan sponsors contract(s), federal regulations, or CMS guidance
The function directly impacts members or prospective members
The entity interacts directly with members or prospective members either orally or in writing
The delegated entity has access to beneficiary information or personal health information (PHI or PII)
The delegated entity has decision-making authority (e.g., enrollment vendor deciding time frames) or whether the entity strictly takes direction from the sponsor
The delegated entity is in a position to potentially commit health care fraud, waste, or abuse (FWA)
There is risk that the entity could harm enrollees or otherwise violate CMS program requirements or commit FWA

Contract Requirements

The Helper Bees negotiates various types of agreements with vendors, depending on the delegated services and line(s) of business. These include, but are not limited to, agreements with contractors, providers, and facilities; general agencies; and include corporate master service agreements, administrative agreements, and statements of work. Should any new responsibilities be added or removed from an FDR agreement, our Plan Sponsor Account Managers are responsible for notifying and working with our Legal and Compliance Teams for facilitation of such changes.

Compliance Program Requirments

What are the elements of an effective compliance program?

FDRs are required to develop and implement a comprehensive and effective compliance program. There are seven “elements” to this program that must be implemented. During our pre-delegation assessment, we review each FDRs compliance program to ensure that these elements are in place.

Exclusions Screening

Federal law prohibits Medicare, Medicaid, and other federal health care programs, from paying for items or services provided by a person or entity excluded from participation in these federal programs. Therefore, before hiring or contracting, and monthly thereafter, each FDR must check exclusion lists from the Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) and the U.S. General Services Administration (GSA). This is to confirm that employees, board members, and Downstream Entities performing administrative and/or health care services are not excluded from participating in federally funded health care programs.

FDRs can use the following websites to perform the required exclusion list screenings:

OIG List of Excluded Individuals and Entities (LEIE), http://oig.hhs.gov/exclusions/index.asp
GSA’s System for Award Management (SAM), https://www.sam.gov

Statement of CMS Compliance Attestation

I attest to the following:

1. Code of Conduct and Compliance Policies and Procedures: 

I have reviewed The Helper Bees’ Delegation Oversight and CMS Compliance Guide. My organization has received, understands, and has complied with the requirement to provide the following to our employees upon hire and annually thereafter:

Code of Conduct
Compliance policies and procedures

2. Compliance with CMS Requirements:

Code of Conduct
Compliance policies and procedures

3. OIG, Preclusion, and GSA Exclusion Screening:

My organization currently performs exclusion screening prior to hiring or contracting and monthly thereafter to ensure no individual or entity is excluded from participating in federally funded programs. If an individual or entity appears on the exclusion list, they will be removed from any work related directly or indirectly to federal health care programs.

Pursuant to 42 C.F.R. §§ 422.222, 422.504(g)(1)(iv), and 422.504(i)(2)(v), my organization acknowledges and complies with all applicable CMS enrollment and billing requirements and affirms that its employees are not included on the CMS Preclusion List.

4. General Compliance, Fraud, Waste, & Abuse (FWA) Issues Reporting Mechanisms:

My organization maintains a confidential compliance & FWA reporting mechanism that has been distributed and is widely publicized for all employees and contractors within the organization. My organization encourages reporting potential compliance and FWA issues by:

Maintaining our own system
Using The Helper Bees hotline

5. Downstream Entities:

If my organization enters into a written arrangement with a third party to perform any services to fulfill our contractual obligations to The Helper Bees, my organization monitors these entities to ensure they comply with all requirements listed herein.

I hereby certify that I have authority to attest for the group or organization listed below. My organization understands and agrees to fulfill the obligations stated in the CMS Compliance Attestation, and furthermore understands that failure to do so could result in corrective action or termination from continued work with The Helper Bees.

Provider Compliance

Overview

Contract Requirements

Compliance Program Requirments

Exclusions Screening

Statement of CMS Compliance Attestation