Program Audits

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Customized Organizational Structure and Governance PowerPoint Presentation

Organizational Structure and Governance Presentation
Prepared by: [Sponsoring organization’s Name]
[Date]

Page 1 of 10

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Customized Organizational Structure and Governance PowerPoint Presentation

Instructions for Completing the Organizational Structure and Governance PowerPointTemplate
•

The Organizational Structure and Governance presentation provides valuable information regarding your
organization's Medicare business, organizational structure, key personnel and compliance program operations for
the CMS program audit.

•

This presentation is a central resource for CMS and will be referenced often during the program audit.

•

Sponsoring organizations 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 supplemental documentation submission.

•

The length of this presentation is at the discretion of the sponsoring organization as long as its content is responsive to and
inclusive of all the information requested.

Page 2 of 10

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Customized Organizational Structure and Governance PowerPoint Presentation

Table of Contents

•

Basic Organization Information

•

Corporate Governance & Accountability

•

Medicare Business Operations & Organizational Charts

•

Compliance Program Infrastructure and Processes

Page 3 of 10

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Customized Organizational Structure and Governance PowerPoint Presentation

Basic Organization Information
•

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, and Commercial

•

Does your organization serve as a FDR or serve in
any other capacity to other sponsoring
organization(s)?

List all subsidiaries and affiliated corporations of
parent company (include contract numbers, if
applicable) lines of business

•

How many first tier entities are currently
delegated to perform Medicare functions on
your organization’s behalf?

•

Total Membership

•

•

Number of MA/PDP covered lives versus Total
covered lives for all business

Identify your PBM(s) 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(s) perform on
your behalf.

•

History (including key milestones)

•

Organization’s lines of business and active
Medicare contract numbers

•

Location of Headquarters, operational and satellite
offices

•

Service Area/ GeographicFootprint

•

For-Profit or Not-for-Profit

•

Publicly-Traded or Privately-Held

•

•

Total number of employees

•

Number of staff at each location

•

Number and percentage of staff dedicated to
Medicare C/D business operations

Page 4 of 10

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Organizational Structure and Governance Presentation Template

Medicare Enrollment and Membership Growth
Year

Membership as of
December 31st

Membership
Growth

Percent Growth

Current Year -3

Current Year -2

Current Year -1

Current Year

Page 5 of 10

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Organizational Structure and Governance Presentation Template

Corporate Governance and Accountability
INSTRUCTIONS:
•
•

•
•

•

Provide organizational charts depicting corporate structure and where the Medicare line of business fits into the sponsoring
organization’s overall business.
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.
Identify senior management responsible for the Medicare line of business.
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, Medicare-Medicaid plans oversight, etc.).
Demonstrate your corporate governance structure, including governing body and accountable senior management
responsible for Medicare Parts C/D business operations and compliance. – See example on the following page.

Page 6 of 10

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Organizational Structure and Governance Presentation Template

Page 7 of 10

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Organizational Structure and Governance Presentation Template

Percentage of time senior executives dedicate to Medicare vs. other lines of business
Name

Senior Leader 1

Senior Leader 2

Page 8 of 10

Position

Percent time spent
on Medicare

Percent time spent on all
other business

CEO

35

65

Compliance Officer

60

40

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Organizational Structure and Governance Presentation Template

Medicare Business Operations & Organizational Chart
INSTRUCTIONS:
•

Demonstrate your Compliance Program/Department and core Medicare Part C and/or Part D business organizational
structure, including senior management to whom the Compliance Officer reports (include names of individuals and
titles). – See example below.
VP, Gov’t
Operations

ia
Co plian
Offi

Co plian

Co plian

Sp ialis

Sp ialis

Co plian
Taining

Co plian
sistan

Sp ialis

Page 9 of 10

v.05-2020

Program Audit Data Request
Compliance Program Effectiveness (CPE)
Organizational Structure and Governance Presentation Template

Compliance Program Infrastructure and Processes Overview
INSTRUCTIONS: Provide an overview of the sponsoring organization’s standardized processes, tools and controls used to conduct
the day-to-day oversight of compliance and FWA issues that may impact Medicare Parts C and D business operations.

•
•
•
•

Describe any major changes to the compliance program infrastructure and business operations since the
last CMS program audit (if applicable).
Describe your relationship and communication with CMS (e.g. quarterly meetings with CMS Account
Management, remediation with issues brought to the sponsoring organization’s attention by CMS, etc.)
What is the sponsoring organization’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.

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 10938-NEW (Expires: TBD). The CMS control number is CMS-10717. The time required to
complete this information collection is estimated to average 701 hours per response, including the time to review instructions, search existing data resources, gather the data
needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please
write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims,
payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the
information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact 1-800-MEDICARE.

Page 10 of 10

v.05-2020