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Providers Play Important Role in Ensuring BCBSNC's Commitment to CMS Compliance

Blue Cross and Blue Shield of North Carolina (BCBSNC) is required by the Centers for Medicare & Medicaid Services (CMS) to maintain and administer a compliance program and a program to fight fraud, waste and abuse.  CMS advises that the seven basic elements of the compliance program include:

  • Maintaining written policies and standards of conduct
  • Instituting high-level oversight, led by a compliance officer
  • Providing effective training and education about Medicare program requirements
  • Providing effective and accessible lines of communication between the compliance officer, employees, and first tier, downstream, and related entities
  • Ensuring that disciplinary standards are well publicized
  • Performing routine monitoring, auditing and identification of compliance risks
  • Establishing procedures for prompt response to compliance issues. 

BCBSNC ensures that these elements are met in the following ways:       

    

  • BCBSNC has a compliance officer and a formal committee structure to provide oversight responsibilities for compliance.

 

  • BCBSNC provides annual training to its employees, its board of trustees, and sales agents on training topics including: the BCBSNC Code of Conduct, Fraud, Waste and Abuse, and Medicare Compliance.  (As stated in Chapters 9 of the CMS-issued Prescription Drug Benefit Manual and Chapter 21 of the Medicare Managed Care Manual) Providers, vendors, and other business partners who have met the Fraud Waste and Abuse (FWA) training through enrollment in Part A or B of the Medicare program, or through accreditation as a supplier of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies)are deemed to have met the FWA training and education requirements for BCBSNC.)

 

  • BCBSNC offers several options for employees, producers and subcontractors to report issues or ask questions, either directly or via anonymous hotlines, or through related online reporting tools.  If there is suspected fraud, waste or abuse, please contact the Special Investigations Unit at 1-800-324-4963. If there are concerns about the actions of a BCBSNC employee, please contact the BCBSNC Ethics Hotline at 1-888-486-1554.

 

  • Consequences for BCBSNC employees who violate the BCBSNC Code of Conduct or the FWA policy are clearly communicated through our internal Code of Ethics and Business Conduct policy, and through annual employee-required training courses.

 

  • BCBSNC monitors hotline reports for trends, analyzes claims data to identify fraud, and reviews key CMS compliance metrics. BCBSNC also performs risk assessments, executes audit plans, and conducts subcontractor oversight.

 

  • BCBSNC has written processes in place to investigate issues, track them to completion, and report matters to government entities when necessary.

 

Due to BCBSNC’s relationship with CMS, Blue MedicareSM- participating providers should be aware of several key federal rules:

 

  • Anti-Kickback Statute - This statute imposes criminal penalties for individuals or entities who knowingly and willfully offer, pay, solicit, or receive remuneration to induce or reward business reimbursement in federal health care programs.

 

  • False Claims Act - This act imposes liability on any person of an organization who submits a claim to the federal government that is known or should be known to be false.

 

  • Excluded Entity Provision of Social Security Act - Medicare Part C and Part D contractors are prohibited from employing or contracting with an individual or entity who is excluded from participation in federal health care programs.

 

If you have additional questions, please contact your BCBSNC Network Management representative who can provide you with more information about these CMS requirements.