Medicare Parts C and D Universal Audit Guide

(Attachment IV)
Organizational Structure and Governance
PowerPoint Presentation Template
Instructions for Completion:
• Please include specific information using this PowerPoint
template as a guide and responding to the specific requests
listed within the template. The presentation focuses on
various aspects of your organization as they relate to the
operation and effectiveness of your compliance program.
• This presentation is an important part of your
documentation submission. You must provide at least the
information requested in the template; however, you are
not limited to providing only this information, and we fully
expect you to tailor the presentation to your specific
organizational structures and the operation of your
compliance program.

(Attachment IV)
Organizational Structure and Governance
PowerPoint Presentation Template

• [Sponsoring Organization Name]
• [Date]

Table of Contents
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Overview
Corporate Structure
Corporate Governance and Accountability
Medicare Operational Areas
Board Membership, Senior Management
Compliance Reporting Structures

3

Overview
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History (including specific milestones)
Organization’s line of business
Service Area-Geographic Footprint
For-Profit or Non-Profit
Publicly-Traded or Privately-Held
Total Membership
Number of MA/PDP covered lives vs. Total covered
lives for all lines of business

4

Overview
•
•
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Total number of employees
Operational locations
Number of staff at each location
Number and percentage of staff dedicated to Medicare
C/D Operations
• Recent acquisitions and/or mergers (including novations)
(provide dates)
• Percentage of business Medicare, Medicaid, Commercial
• Does your organization serve as a Subcontractor or FDR
to other Sponsoring Organization(s) (PBM, etc.)

5

Overview
Revenue by Lines of Business
Product

YTD 2011

2012(3/31 YTD)

2012
Annualized

Commercial
MA/MAPD
PDP
Other (Please
Specify)
Total

6

Overview
Medicare Enrollment and Enrollment
Growth
Year

December 31
Membership

Membership
Growth

% Growth

2010
2011
2012
2013

7

Corporate Structure
• Provide organizational charts depicting corporate
structure and where the Medicare line of business fits
into your overall business.
• Provide individual organization charts and flow charts of
Part C and Part D operational areas and processes (i.e.,
formulary administration, coverage determinations, and
appeals, grievances, organizational determinations, Part
C access, CTM, enrollment, delegation/vendor
oversight, agent/broker oversight, compliance program ,
etc).
8

Corporate Governance and
Accountability
• Demonstrate your corporate governance structure, including
governing body and accountable senior management responsible for
Medicare Parts C/D operations and compliance.
President and CEO
(% of time
dedicated to
Medicare business)
Audit and
Compliance
Committee Board
of Directors

Vice President
Audit, Compliance,
& Ethics

Assistant Vice
President, Internal
Audit

Director,
Compliance & SIU

Director, Internal
Audit

Manager,
Information
Assurance

9

Corporate Governance and
Accountability
• Percentage of time senior executives dedicate to
Medicare vs. Other Lines of business (list)
Name
John Doe

Position
CEO

% Time Medicare
35%

10

Medicare Operational Areas
• Demonstrate your Compliance Program/Department organizational
structure, including senior management to whom Compliance
Officer reports (include names of individuals and titles).
• How does the Compliance Department interact with the Medicare
C/D Operational Business Units?
VP
Government
Operations

Medicare
Compliance
Officer

Compliance
Specialist

Compliance
Specialist

Compliance
Training
Specialist

Compliance
Assistant

11

Board Membership/Senior Management
• Identify (by name)* members of the Board of Directors, and briefly
summarize their professional experience.
• If the organization does business with any Board members or Board
members’ relatives, please identify and briefly summarize the
nature of the business relationship.
• Are any of the Board members and/or members of senior
management related to each other? If so, please indicate the
nature of the relationship.
• Identify senior management responsible for the Medicare line of
business.
• Identify any Board Members/Senior Management appointed within
the past 6 months.
* If the entity holding the Medicare contract is a subsidiary, identify
both the members of the board of directors of the parent entity as
well as those of the subsidiary contracting entity.

12

Compliance Reporting Structures
• Provide a chart demonstrating Medicare Compliance Reporting
Structures (including Compliance Officer(s), Compliance
Committee, and senior management, and their reporting
relationships among each other and to the governing body).
• If there is a Board-level committee that conducts day-to-day
oversight on behalf of the full Board, please indicate, and identify
members by name.
• If the compliance reporting structures have changed recently, please
identify the changes that have been made and when they were made.
• Please describe or provide a work flow demonstrating how and
when reports regarding the compliance program are provided to the
CEO and Board or board committee.
13

Compliance Issue Resolution
Process
•

Provide a chart demonstrating the compliance issue/potential FWA issue
resolution process (i.e. receipt process, who referred to, who initiates
investigations, referred to operational areas?, corrective action, ongoing
monitoring, tracking, etc.

•

Please identify all sources used to identify compliance and potential FWA
issues (i.e. hotline, audit/monitoring results, emails, management, etc.

14

Delegated Entity Oversight
•

Provide an outline of your system and process for oversight of
delegated entities (i.e., decentralized or centralized operations,

•

Identify the business units are involved or responsible for delegated
oversight?

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Describe how delegated entities are monitored for compliance
program requirements (i.e. how does your organization ensure
delegated entities (FDRs) are satisfying training and education
requirements, exclusions checking, etc.)

• Which delegated entities present the most risk to your organization
and beneficiaries?
• Identify your PBM and functions performed on the Sponsor’s behalf.
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Compliance Program Effectiveness
•

Describe your organization’s process for monitoring and auditing the
effectiveness of your Compliance Program.

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