CMS-10191 SIU/FWA Prevention and Detection Questionnaire

ATTACHMENT I-E
MEDICARE ADVANTAGE AND PRESCRIPTION DRUG COMPLIANCE PROGRAM
EFFECTIVENESS (CPE)
SIU/FWA PREVENTION AND DETECTION QUESTIONNAIRE (FWA-Q)
(Rev. 2. 10-2016)
Name of Sponsoring Organization:
MA-PD/PDP Contract Numbers:
Name and Title of Person Completing Questionnaire:
Date of Completion:

Directions for Completing the SIU/FWA Prevention and Detection Questionnaire:
This questionnaire will assist CMS with understanding the sponsoring organization’s program to prevent,
detect and correct suspected fraud, waste and abuse for their Medicare line of business.
The responses to these questions may be discussed during the onsite portion of the CPE audit.
We recognize that your time is valuable and appreciate your availability to provide responses to our
questions regarding the compliance program.
If multiple individuals are responsible for the operations and oversight of first-tier, downstream
and related entities (e.g. Corporate Compliance Officer, SIU Director, Ethics and Integrity
Officer, Investigators, etc.) and have different responses to the questions, please consolidate
responses and incorporate into one document.
Please specifically note the following when completing the questionnaire:
•

“You” refers to your organization, not necessarily a specific person.

•

“Employees” refer to employees, including senior management, who support your Medicare
business.

•

“Compliance Officer” refers to the compliance officer who oversees the Medicare business.

•

“CEO” refers to the Chief Executive Officer of the organization or the most senior officer,
usually the President or Senior Vice President of the Medicare line of business.

•

“Compliance Program” refers to your Medicare compliance program.

•

If the Medicare contract holder is a wholly owned subsidiary of a parent company, references
to the governing body, CEO and highest level of the organization’s management are to the
board, CEO and management of the company (parent or subsidiary/contract holder) that the
organization has chosen to oversee its Medicare compliance program.

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ATTACHMENT I-E
MEDICARE ADVANTAGE AND PRESCRIPTION DRUG COMPLIANCE PROGRAM
EFFECTIVENESS (CPE)
SIU/FWA PREVENTION AND DETECTION QUESTIONNAIRE (FWA-Q)
•

“FDRs” refer to the organization’s first-tier, downstream and related entities contracted to
perform an administrative or healthcare service to enrollees on behalf of the Sponsor.

•

“First Tier Entity” refers to any party that enters into a written agreement, acceptable to CMS,
with an MAO or Part D plan sponsor or applicant to provide administrative services or health care
services to a Medicare eligible individual under the MA program or Part D program.

•

“Downstream Entity” refers to any party that enters into a written agreement, acceptable to CMS,
with persons or entities involved with the MA benefit or Part D benefit, below the level of the
arrangement between an MAO or applicant or a Part D plan sponsor or applicant and a first tier
entity. These written agreements continue down to the level of the ultimate provider of both
health and administrative services.

•

“Related Entity” refers to any entity that is related to an MAO or Part D sponsor by common
ownership or control and
o performs some of the MAO or Part D plan sponsor’s management functions under
contract or delegation
o furnishes services to Medicare enrollees under an oral or written agreement; or
o leases real property or sells materials to the MAO or Part D plan sponsor at a cost of more
than $2,500 during a contract period.

•

If the Medicare contract holder is a wholly owned subsidiary of a parent company, references
to the governing body, CEO and highest level of the organization’s management are to the
governing body, CEO and management of the company (parent or subsidiary/contract holder)
that the organization has chosen to oversee its Medicare compliance program.

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ATTACHMENT I-E
MEDICARE ADVANTAGE AND PRESCRIPTION DRUG COMPLIANCE PROGRAM
EFFECTIVENESS (CPE)
SIU/FWA PREVENTION AND DETECTION QUESTIONNAIRE (FWA-Q)
1. How long have you been employed with the sponsor and been in involved with FWA prevention
and detection activities?

2. Have you held any positions in the company, prior to being the person or a part of the team
responsible for managing delegated entities?

3. Is FWA managed by one individual or a team/department such as the compliance department or
special investigations unit (SIU)?

4. Provide a general overview of the unit/department responsible for conducting surveillance and
methods of investigation relating to potential FWA (e.g. number of personnel, types of detection
and prevention activities, etc.)

5. Describe the working relationship between the compliance department and SIU as it relates to the
compliance program.

6. Describe a few of the mechanisms that exist for employees, providers, members and FDRs to
report compliance, ethics and FWA concerns and how are they advertised internally and
externally. Please indicate if multiple hotline numbers are used to report various categories of
compliance and FWA inquiries.

7. How many reports did the hotline(s) receive during the audit review period? If multiple hotline
numbers to report various categories of compliance and FWA inquiries, please separate responses
for each hotline number.

8. From your perspective, does the number of calls received demonstrate the effectiveness of your
reporting mechanisms?

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ATTACHMENT I-E
MEDICARE ADVANTAGE AND PRESCRIPTION DRUG COMPLIANCE PROGRAM
EFFECTIVENESS (CPE)
SIU/FWA PREVENTION AND DETECTION QUESTIONNAIRE (FWA-Q)
9. Describe proactive measures to investigate suspicions of FWA and inappropriate payments made
by the sponsoring organization.

10. How does the organization engage participation from the NBI MEDIC, law enforcement and other
business partners on suspected FWA cases or investigations?

11. How many suspected FWA cases were referred to the NBI MEDIC or law enforcement agency
within the audit review period?

12. Describe the triage process for cases referred to the SIU for fraud investigation, including
timeframes associated with the intake and validation functions.

13. Describe how data analytics or data analysis software are used to monitor potential FWA activity
and identify unusual patterns in the delivery of Medicare Parts C and/or D benefits (e.g. queries for
pharmacy patterns, provider billing, drug utilization, etc.).

14. What types of reports from the PBM assist with identifying potential and suspected unusual trends,
utilization patterns, provider billing practices that pose the greatest risk to the Medicare program?

15. Does the organization use the web-based application tool, The Predictive Learning Analytics
Tracking Outcome (PLATO), made available by CMS? Explain whether the use of PLATO has
been effective for your organization?

16. Provide an overview that describes the organization’s monitoring activities in the HEAT Medicare
Strike Force cities. HEAT is the joint HHS-DOJ Health Care Fraud Prevention and Enforcement
Action Team. The list of the nine cities can be found at:
https://www.stopmedicarefraud.gov/aboutfraud/heattaskforce/

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ATTACHMENT I-E
MEDICARE ADVANTAGE AND PRESCRIPTION DRUG COMPLIANCE PROGRAM
EFFECTIVENESS (CPE)
SIU/FWA PREVENTION AND DETECTION QUESTIONNAIRE (FWA-Q)
17. How are the CMS fraud alerts issued through the Health Plan Management System (HPMS)
incorporated into FWA prevention and detection monitoring and audit activities?

18. Would you like to share any best practices that may assist others with succeeding in preventing,
identifying, and controlling FWA practices?

19. Highlight a few accomplishments of the FWA operations/SIU during the audit review period.

20. Do you have any questions or comments for CMS?

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