Para-Solve may have contracts with the First Tier Organizations (FTOs) which may have contracts with Centers for Medicare and Medicaid Services (CMS) to provide services under Medicare Advantage and Part D programs. Para-Solve relies on our contracted partners to help FTOs to meet the needs of Medicare Members in accordance with CMS’ Medicare Advantage/Part D program requirements. These contracting partners may be considered by CMS to be First Tier, Downstream, and Related Entities (FDRs) because Para-Solve may have delegated some portion of the administrative or healthcare functions relating to its contract with FTOs and/or CMS.
FDR as Defined by CMS
A First Tier Entity is any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization (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. (See, 42 C.F.R. § 423.501).
A Downstream Entity is any party that enters into a written arrangement, 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 arrangements continue down to the level of the ultimate provider of both health and administrative services. (See, 42 C.F.R. §, 423.501).
A Related Entity means any entity that is related to an MAO or Part D sponsor by common ownership or control and
(1) Performs some of the MAO or Part D plan sponsor’s management functions under contract or
(2) Furnishes services to Medicare enrollees under an oral or written agreement; or
(3) 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. (See, 42 C.F.R. §423.501).
Requirements for FDRs
Para-Solve is committed to operating in a manner that meets the requirements of all applicable laws and regulations of the Medicare Advantage and Part D programs. As part of an effective compliance program, CMS requires Medicare Advantage plans to ensure any FDRs to which the provision of administrative or healthcare services are delegated are also in compliance with applicable laws and regulations.
As a partner in serving Medicare Members, we’re grateful for your commitment to ensuring your respective organization’s compliance with Medicare requirements. To support our collective compliance, this page and associated links and documents describe some of the Medicare compliance program requirements applicable to an FDR. Please review and utilize the information and documentation provided to ensure your part in ensuring compliance.
Fraud, Waste and Abuse
Health care fraud, waste, and abuse (FWA) is a national problem that affects all of us either directly or indirectly. National estimates project that billions of dollars are lost to health care FWA on an annual basis. These losses lead to increased health care costs and potential increased costs for coverage. Health care fraud is an intentional misrepresentation, deception, or intentional act of deceit for the purpose of receiving unwarranted payment in part or in whole. Health care abuse is reckless disregard or conduct that goes against and is inconsistent with acceptable business and/or medical practices resulting in unnecessary costs.
1. Fraud is knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses, representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.
2. Waste Overutilization of services, or other practices that, directly or indirectly, result in unnecessary costs to any health care benefit program. Waste is generally not considered to be caused by criminally negligent actions but rather a misuse of resources.
3. Abuse includes actions that may, directly or indirectly, result in unnecessary costs to any health care benefit program, improper payment, payment for services that fail to meet professionally recognized standards of care, or services that are medically unnecessary. Abuse involves payment for items or services when there is no legal entitlement to that payment and the provider has not knowingly and/or intentionally misrepresented facts to obtain payment. Abuse cannot be differentiated categorically from fraud because the distinction between “fraud” and “abuse” depends on specific facts and circumstances, intent and prior knowledge, and available evidence among other factors.
The False Claims Act (FCA) is a federal law that imposes liability on persons and companies who defraud governmental programs. It is the federal Government's primary tool in combating fraud against the Government.
Para-Solve is committed to upholding high standards of honesty and integrity in all areas of practice. Accordingly, Para-Solve believes that it is in the best interest of its contracting partners and the community to prevent FWA, which can have a significant impact on the quality of healthcare and costs. Para-Solve engages in specific activities in addition to routine operational activities which may result in the detection, prevention and reporting of FWA. Para-Solve and our contracting partners are obligated to immediately report any suspicion of FWA. Internal and external reporting mechanisms are available to anyone who suspects FWA within Para-Solve or its contracting partners community.
Para-Solve has developed an annual attestation as part of our efforts to validate each contracted FDR has met CMS requirements. The attestation should be submitted within 90 days of contracting and annually thereafter. The attestation must be completed by an individual in your organization who has signatory authority to make the representations in the attestation.
The attestation addresses the compliance requirements, including:
1. Completion of FWA and General Compliance training and maintaining record of the completion of training.
2. Distribution of Standards of Conduct and maintaining record of distribution.
3. Federal exclusion list screening and maintaining record of timely checks against those lists.
4. Record retention for 10 years.
5. The availability of a system to receive reports (reporting mechanism) of suspected noncompliance and/or FWA that is confidential, allows anonymity, and includes a policy of non-intimidation and non-retaliation.
6. Identification of use of offshore subcontractors.
7. Monitoring and auditing downstream entities.
Para-Solve operates within one of the nation’s most heavily regulated industries. To promote the highest legal and ethical standards within Para-Solve to ensure we meet or exceed the federal and state requirements, Para-Solve has implemented a comprehensive, integrated Compliance Program and Fraud, Waste, and Abuse (FWA) Program. CMS expects Para-Solve to share our standards of conduct and compliance principles with our FDRs. In addition, we must ensure our FDRs adopt and follow either Para-Solve’s or their own standards and principles that reflect a commitment to detecting, preventing and correcting noncompliance with Medicare requirements, including those regarding fraud, waste, and abuse. This material must be shared with the FDR (by Para-Solve) and FDR’s employees (by FDR) within 90 days of hire/contract effective date and annually thereafter.
FDR agrees to comply with Para-Solve’s Standards of Conduct and policies and procedures, or to adopt and comply with its own code of conduct, disciplinary standards and policies and procedures that reflect a commitment to detecting, preventing and correcting non-compliance with Medicare requirements in the delivery of Medicare services, including detecting, preventing and correcting fraud, waste and abuse.
FDR is required to publish disciplinary standards which include its expectation that employees ask Medicare compliance questions and report potential and actual instances of noncompliance with Medicare requirements. Disciplinary standards must also state that any violation of these standards will result in appropriate disciplinary action, up to and including termination of employment. They also must include a non-retaliation policy for good-faith reporting.
CMS Online Resources
CMS provides a wealth of Medicare related educational tools and other resources at www.cms.gov. Below are links to the tools/resources :
Reporting Compliance Issues and Fraud, Waste and Abuse
Reporting is key in the prevention, detection, and correction of program noncompliance and FWA. Para-Solve protects any individual or organization who reports a legitimate concern in good faith from retaliation and intimidation. FDRs are expected to do so as well.
FDRs who fail to report known and/or possible violations or suspected FWA could result in disciplinary action up to and including termination of your contract with Para-Solve. To the extent possible, reports are kept confidential. Anonymous reporting is available through the website: www.Para-Solve.com.
Additionally, reports can be made to Para-Solve at:
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