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Risk assessment and monitoring plansJanuary 2016

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A deep dive

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YOUR DIVERS:Steve Bunde –VP Integrity and Compliance & Internal Audit, HealthPartners

Laurena Lockner –Sr Manager Monitoring & Compliance, HealthPartners

Stephanie Moscetti –Program Manager, Integrity and Compliance, HealthPartners

AGENDA:

Developing and communicating the risk assessment

Aligning the monitoring plan to the risk assessment

Understanding risk areas

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Risk assessments

Risk

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Template considerations• DETERMINE risk criteria• REVIEW risk equation• DETERMINE risk ratings• ENGAGE leaders• ANALYZE trends • REVIEW process

SHARE

DEVELOP

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Risk development

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BOTH

‐Audit guides‐Regulatory guidance

‐Review topics 

COMMERCIAL

‐Certification requirements‐CMS FFM compliance priorities

GOVERNMENTPROGRAMS

‐State contracts

Risk process

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MEET with business areas

CREATE and distribute summary document

REVIEWwith Leadership

REVIEWwith Compliance Committee

MONITOR periodically

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Align monitoring plans to risk assessment

Resources

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Limited resources

Determine monitoring strategy

Distinguish between auditing & monitoring

Identify all areas

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Work plans

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Consider inherent vs. residual risks

Understand business 

monitoring and results

Coordinate with internal 

teams

Don’t forget FDRs and rotation planning

Align work plan with risks

Reporting

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DETERMINE reporting format         

(up front)

CONSIDER action plans in reports

PRESENT monitoring results to 

business leaders, compliance and board committees

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Understand commercial and Government Programs risks

Defining high risk

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BOTH

‐Financial risk‐Regulator 

focus‐Audit protocol‐New  rules

COMMERCIAL

‐False Claims Act

‐Litigation

GOVERNMENTPROGRAMS

‐Beneficiary impact

‐Audit findings‐Delegates

‐New contracts

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GP significant risks

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PART D

DELEGATED ACTIVITIES

COVERAGE/ORG DETERMINATIONS

COMPLIANCE PROGRAM

Commercial significant risks

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GENERALEdge Server, 3Rs, APTC/CSR, MLR/Risk Corridor, Taxes

FFM P&Ps, Provider Directories, Agent/Broker requirements

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QUESTIONS

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Contact Information

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Steve BundeSteven.D.Bunde@HealthPartners.com952.883.6541

Stephanie MoscettiStephanie.M.Moscetti@HealthPartners.com952.883.7602

Laurena LocknerLaurena.S.Lockner@HealthPartners.com952.967.7650