Medicare Compliance

This section outlines regulatory compliance program requirements for Medicare.

Delegate/Vendor Oversight: Medicare Advantage or Part D Programs

  • Standards of Conduct - Distribution & Awareness
    • Delegates must distribute their own written policies, procedures or standards of conduct or the UnitedHealth Group Code of Conduct to employees who support the administration or delivery of program benefits or services.

    • Standards of Conduct must be distributed within 90 days of hire and annually thereafter.

    • Delegates must retain proof of distribution for each employee.
       

    Delegates working on our organization’s Medicare Advantage Part C or Part D programs must provide to their employees either their own written policies, procedures or standards of conduct that include all the required CMS elements, or the UnitedHealth Group Code of Conduct.

    CMS Requirements

    • Commitment to comply with all applicable federal and state standards.
    • Describe compliance expectations.
    • Implement a compliance program.
    • Provide guidance to employees and others on dealing with suspected, detected or reported compliance issues.
    • Explain how to communicate compliance issues.
    • Describe how compliance issues are investigated and resolved.
    • Include policy of nonintimidation/nonretaliation for good faith reporting.

    Find the UnitedHealth Group Code of Conduct in the Standards of Conduct section. 

  • Fraud, Waste & Abuse and Compliance Training
    • Delegates working on our organization’s Medicare Advantage (MA) or Part D programs must provide Waste & Abuse (FWA) and General Compliance training  to employees who are involved in the administration or delivery of our MA or Part D benefits or services.

    • It is recommended that training be completed within 90 days of hire and annually thereafter. 

    • It is recommended that delegates document and retain dates, methods, materials used and employees trained.

    Confidential reports can be made to UnitedHealth Group’s Vendor Fraud Hotline: 877-401-9430

    Key Regulatory and Guidance Information and Resources

    Find more information on Reporting Suspected FWA.

  • Exclusion Checks
    • Delegates must review the federal exclusion lists maintained by the Office of Inspector General and the U.S. General Services Administration.

    • Reviews of federal exclusion lists must be completed prior to hiring or contracting with employees and must continue on a monthly basis.

    • Proof of the method used, date performed, employee list and results found must be documented and retained. 

    Notification is required for excluded individuals or entities. UnitedHealth Group Compliance & Ethics Help Center: 800-455-4521

    Definitions

    • Hiring or contracting employees: Employees are defined as hired staff, management and temporary workers for your company, or subcontractors that have involvement in or responsibility for a delegated core function in the administration or delivery of Medicare Advantage Part C or Part D health plan benefits and have access to PHI/PII.
       

    Find more information on Exclusion Checks.

  • Document Retention

    Delegates must retain records for 10 years to show compliance with regulatory requirements.

    Find more information on Document Retention.

  • Offshoring Reporting & Downstream Delegates
    • Notification is required prior to moving services offshore that involve sharing of protected health information (PHI) or personal identifiable information (PII). Please contact your UnitedHealth Group representative to initiate the review and approval process.

    • Delegates must report any offshore subcontracting that involves receiving, processing, transferring, handling, storing, viewing or accessing PHI or PII.

    • Delegates must hold their downstream entities or subcontractors that support the delivery or administration of program benefits or services accountable for the same Compliance Program requirements.

    Find more information on Downstream Delegates.