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Provider Compliance

The Helper Bees created this guide to communicate specific compliance expectations for our service providers, contractors, subcontractors, and vendors who provide, oversee, or support delegated services to our members. Providers are expected to complete this attestation every year. 

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

  • 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 Requirements

  • 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.

  • An effective compliance program should include:
    • Written policies, procedures, and standards of conduct
    • A designated Compliance Officer and Compliance Committee and high-level oversight
    • Effective education which includes training on Compliance; Fraud, Waste, and Abuse; Code of Conduct; HIPAA Privacy; and Exclusion Screening
    • Effective lines of communication
    • Well publicized disciplinary standards
    • Implementation of an effective system for routine monitoring, auditing, and identification of compliance risks
    • Implementation of an effective procedure and system for prompt responses to compliance issues, investigation of potential compliance problems, and prompt correction to ensure ongoing compliance with CMS requirements

Exclusions Screening

  • Office of Inspector General/General Services Administration Exclusion Lists

    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:

Oversight, Reporting, Monitoring and Auditing Requirements

  • General Requirements Related to FDRs Performing Delegated Functions

    The Helper Bees Compliance Team will perform pre-delegation and routine audits of an FDR’s Compliance Program based on risk assessment criteria. Compliance program audits include initial vendor assessment and pre-delegation audits, contract review, and review of specific validation documentation provided to The Helper Bees Compliance Team by the FDR’s Compliance and Audit team(s).

     

    In addition, The Helper Bees Compliance Team will request FDRs to complete a Statement of CMS Compliance Attestation, which is included along with this guide on an annual basis.

     

     

  • Requirements Related to Provider Invoicing of Cancelled, Missed, or Otherwise Unfulfilled Services

    The Helper Bees’ network of credentialed service providers must adhere to CMS requirements with regards to invoicing for encounters which have been cancelled or otherwise missed by the member. As stated in Section 2.9 of the subcontractor agreement, claims data provided may be used for purposes of obtaining payments from Federal or State governments under Federal Health Care Programs, and payments that FDRs receive may be, in whole or in part, from Federal funds. Federal Health Care Programs do not allow for billing of services that have not been rendered. As such, submitting invoices for unfulfilled services in The Helper Bees’ homeAlign platform is strictly prohibited.

     

  • Requirements Related to Unsuccessful Audits of Provider Invoicing  

    Due to the Federal Health Care Programs requirement detailed above, failure to successfully substantiate the completion of services invoiced in The Helper Bees’ homeAlign platform may result in remedial action being taken, to include pay cycle deductions of sums received for the unsubstantiated services.

     

  • Corrective Actions

    Should performance standards not be met, The Helper Bees will work with the FDR to develop a Corrective Action Plan (CAP) to remediate the deficiency. Corrective actions may include training, system changes, or other remediation to correct the issue. The Helper Bees will monitor the effectiveness and satisfactory completion of all CAPs and ensure enforcement of any penalties should the issue(s) not be remediated.

Summary

  • Am I or is my company a First Tier, Downstream, or Related entity (FDR) of The Helper Bees?

    Yes, if you or your company has a written arrangement with The Helper Bees, or you have an arrangement with a company contracted with The Helper Bees to provide:

     

    • Administrative services (vendors, suppliers, etc.) relating to The Helper Bees; or
    • Healthcare services as part of The Helper Bees’ network
  • What are my / my company’s responsibilities as an FDR of The Helper Bees?
    • Sign the Statement of CMS Compliance Attestation every year
    • Report within a reasonable time frame to The Helper Bees all suspected or known instances of non-compliance and/or fraud, waste, or abuse
    • Provide/present required training on general compliance, and fraud, waste, and abuse to all new and established employees (including temporary workers and volunteers), board members, and Downstream Entities after hire or contracting and annually thereafter
    • Provide a Code of Conduct and compliance policies and procedures to employees, contractors, board members, and volunteers
    • Perform exclusion screening of employees, contractors, board members, and volunteers prior to hire/contracting and monthly thereafter
    • Retain records for 10 years (training records and records relating to services)
    • Maintain privacy and security of The Helper Bees’ member information
    • Maintain oversight of your Downstream Entities with any involvement in services relating to The Helper Bees
    • Correct any deficiencies related to misconduct or non-compliance

For Questions and Contact

We hope that the information in this document has been helpful and has effectively communicated ongoing oversight, monitoring, reporting and other compliance expectations to all our CMS Compliance Partners.

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