Compliance Program - What are the Requirements to Implement an Effective Program

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS
Dec 19th, 2014 - Reviewed/Updated Apr 30th

All sponsors are required to adopt and implement an effective compliance program,which must include measures to prevent, detect and correct Part C or D program noncompliance as well as FWA.

 The compliance program must, at a minimum, include the following core requirements:

 1. Written Policies, Procedures, and Standards of Conduct;

 2. Compliance Officer, Compliance Committee, and High Level Oversight;

 3. Effective Training and Education;

 4. Effective Lines of Communication;

 5. Well Publicized Disciplinary Standards;

 6. Effective System for Routine Monitoring and Identification of Compliance Risks; and

 7. Procedures and System for Prompt Response to Compliance Issues.

 In order to be effective, a sponsor’s compliance program must be fully implemented and should be tailored to each sponsor’s unique organization, operations, and circumstances. A compliance program will not be effective unless sponsors devote adequate resources to the program. Adequate resources include those that are sufficient to do the following:

 1. Promote and enforce its Standards of Conduct

 2. Promote and enforce its compliance program;

 3. Effectively train and educate its governing body members, employees and FDRs;

 4. Effectively establish lines of communication within itself and between itself and its  FDRs;

 5. Oversee FDR compliance with Medicare Part C and D requirements;

 6. Establish and implement an effective system for routine auditing and monitoring; and

 7. Identify and promptly respond to risks and findings.

CMS will consider a sponsor’s size, structure, business model, activities, the extent of its delegation of responsibilities to other entities, the breadth of its operation, and the risks it faces in evaluating whether adequate resources have been devoted to the compliance program.