CMS-10191 CPE Audit Organizational Structure and Governance PPT Te

Attachment I-C
MEDICARE ADVANTAGE AND PRESCRIPTION DRUG
COMPLIANCE PROGRAM EFFECTIVENESS (CPE)
AUDIT
Organizational Structure and Governance PPT Template
(Rev. 2, 10-2016)

Prepared by: [Sponsor’s Name]
[Date]

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Instructions for Completing the
Organizational Structure and Governance PPT Template
• The Organizational Background and Structure (OBS) PPT provides
valuable information regarding your organization's Medicare business,
organizational structure, key personnel and compliance program
operations for the CMS audit.
• This presentation is a central resource for CMS and will be referenced
often during the audit.
• Sponsors are expected to create a customized presentation that includes
specific information using this PowerPoint template; however, you are
not limited to providing only this information.
• This presentation is an important part of your documentation submission.

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Table of Contents
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Basic Organization Information
Corporate Governance & Accountability
Medicare Business Operations & Organizational Charts
Compliance Program Infrastructure and Processes

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Basic Organization Information
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History (including key milestones)
Organization’s lines of business and
active Medicare contract numbers
Location of Headquarters, operational
and satellite offices
Service Area/ Geographic Footprint
For-Profit or Not-for-Profit
Publicly-Traded or Privately-Held

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List all subsidiaries and affiliated
corporations of parent company
(include contract numbers, if
applicable) lines of business
Total Membership
Number of MA/PDP covered lives vs.
Total covered lives for all business

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Basic Organization Information
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Total number of employees
Number of staff at each location
Number and percentage of staff
dedicated to Medicare C/D business
operations
Business combinations occurring
within the past 12 months, currently
in progress, or planned to take place
within the next 6 months (e.g.
mergers, acquisitions, novations,
spinoffs)
Percentage of business devoted to
Medicare, Medicaid, Commercial

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Does your organization serve as a
subcontractor or FDR to other
sponsoring organization(s)?
How many first-tier entities are
currently delegated to perform
Medicare functions on your
organization’s behalf?
Identify your PBM and contract
effective date(s)
Do you utilize the same PBM for all
Medicare contracts under the parent
organization?
Describe the functions that the PBM
performs on your behalf.

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Basic Organization Information
Revenue by Lines of Business
Product

2015

2016 (MM/DD/YY)

2016
(Annualized)

MA/MA-PD
PDP
Commercial
Other (please
specify)
Total

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Basic Organization Information
Medicare Enrollment and Membership Growth
Year

December 31
membership

Membership
Growth

% Growth

2015
2016
2017

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Corporate Governance and Accountability
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Provide organizational charts depicting corporate structure and where the Medicare
line of business fits into the sponsor’s overall business.

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Briefly summarize the members and experience of the governing body overseeing
the Medicare compliance program. If the organization does business with any
governing body members’ relatives, please identify the nature of the business
relationship. Indicate if any of the governing body members and/or members of
senior management are related to each other.

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Identify senior management responsible for the Medicare line of business.

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Provide individual organization charts and flow charts of Medicare Advantage (Part
C) and/or Prescription Drug (Part D) business areas and processes (e.g.,
formulary administration, organization & coverage determinations, and appeals,
grievances, claims, quality of care, special needs plans-model of care, enrollment,
agent/broker oversight, compliance program, FDR oversight, etc.).

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Corporate Governance and Accountability
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Demonstrate your corporate governance structure, including governing
body and accountable senior management responsible for Medicare Parts
C/D business operations and compliance. – See example below.

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

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Director,
Compliance & SIU

Director, Internal
Audit

Manager,
Information
Assurance

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Corporate Governance and Accountability
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Percentage of time senior executives dedicate to Medicare vs. other lines of
business (list) – see example below.

Name
John Doe
Jane Doe

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Position
% Time Medicare
CEO
35%
Compliance Officer
60%

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Medicare Business Operations & Organizational Charts
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Demonstrate your Compliance Program/Department and core Medicare Parts C
and/or D business organizational structure, including senior management to whom
Compliance Officer reports (include names of individuals and titles). – See example
below.
VP,
Government
Operations

Medicare
Compliance
Officer

Compliance
Specialist

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Compliance
Specialist

Compliance
Training
Specialist

Compliance
Assistant

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Compliance Program
Infrastructure and Processes Overview
This section of the presentation provides an overview of the
organization’s standardized processes, tools and controls used
to conduct the day-to-day oversight of compliance and FWA
issues that may impact Medicare business operations. This
information is critical for the tracer evaluation portion of the
CPE audit.

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Compliance Program Infrastructure &Processes
• Describe any major changes to the compliance program
infrastructure and business operations since the last CMS audit.
• Describe your relationship and communication with CMS (e.g.
quarterly meetings with CMS Account Management,
remediation with issues brought to sponsor’s attention by CMS,
etc.)
• Describe how and when the Standards of Conduct and policies
and procedures are distributed to employees.
• What is the sponsor’s definition of the term “employee”?
• If there is a compliance committee and/or Board-level
committee that conducts day-to-day oversight of compliance
issues on behalf of the full governing body, please indicate, and
identify members by name.

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Compliance Program Infrastructure & Processes
• Explain how and when the sponsor provides compliance and
FWA training for its employees.
• Discuss the sponsor’s methods of educating employees and
publicizing reporting channels (e.g. hotlines, intranet sites,
posters, etc.)
• Describe how CMS Medicare regulations, requirements and
interpretive guidance (e.g. annual call letter or HPMS guidance
memoranda) are disseminated to the appropriate Medicare
functions for implementation and quality control measures to
confirm appropriate and timely implementation.
• Describe the methods used for tracking compliance issues
through resolution and remediation (e.g. centralized tracking
database, logs, etc.)

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Compliance Program Infrastructure & Processes

• Explain the criteria or provide a workflow for escalating
compliance reports and issues from the Compliance Department to
senior-level management, CEO and Board or board committee.
• Explain how the sponsor performs its risk assessment, consider risk
factors and assigns risk scores.
• Describe the sponsor’s system for assessing organizational
performance against compliance requirements and standards (e.g.
CMS regulations, laws, contract requirements, internal policies and
procedures, etc.
• Describe how and when the sponsor creates and implements its
auditing and monitoring work plans for the Medicare business
operations.
• Describe the process for sharing the results of internal monitoring
and auditing activities with parties within the organization.
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Compliance Program Infrastructure & Processes

• Explain how the sponsor tracks, measures and documents the
effectiveness of their compliance program.
• Describe the sponsor’s process for developing and managing
corrective action plans and remediation efforts designed to correct
noncompliance, ensure the root cause has been addressed and
prevent recurrence.
• Describe how and when the sponsor checks its employees, board
members and first-tier entities against the OIG and GSA exclusions
databases.
• Describe the systems, data analysis and practices for monitoring
and addressing Medicare healthcare and drug FWA.
• Describe the approach and mechanisms used to monitor FDRs
performance against contractual and regulatory requirements.

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