Guidelines for Constructing a Compliance Program for ...

Guidelines for Constructing a Compliance Program for Medicaid Managed Care Organizations and PrePaid Health Plans A Product of the Medicaid Alliance for Program Safeguards May 2002 Guidelines For Constructing A Compliance Program for Medicaid Managed Care Organizations and Prepaid Health Plans In June 1997, CMS s Southern Consortium assumed leadership of the Medicaid Alliance for Program Safeguards (Alliance). This Alliance was established with the primary goal of preventing fraud and abuse by assisting States in their efforts, identifying proactive strategies, and sharing information with other Program integrity players. Through leadership, the Alliance strives to encourage participation and communication among State and Federal entities working to fight fraud and abuse. The Medicaid Alliance for Program Safeguards created these Guidelines to be used by managed care entities including managed care organizations (MCOs) and prepaid health plans (PHPs) which contract to do business with state Medicaid agencies.

Monitoring and Auditing The organization must have taken reasonable steps to achieve compliance with its standards by utilizing reasonably designed monitoring and auditing systems. Enforcement and Disciplinary Mechanisms Standards must be enforced through well-publicized disciplinary guidelines. Corrective Actions and Prevention

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  Guidelines, System, Auditing, Auditing systems

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