First Tier, Downstream and Related Entities (FDR)
Scott and White Health Plan (SWHP) must follow all applicable laws, regulations, and standards. SWHP must also follow the guidelines for compliance issued by the Office of Inspector General of the U.S. Department of Health and Human Services. These guidelines indicate that vendors, suppliers, and contractors who partner with SWHP should follow the same compliance guidelines as SWHP while working on SWHP business.
CMS Compliance Program Actionable Requirements
Scott and White Health Plan contracts with the Centers for Medicare and Medicaid Services (CMS) to administer Medicare Part C and Part D benefits to Medicare members. SWHP may delegate some of these responsibilities – providing core health plan functions or health care services – to contracted external vendors. Vendors contracted to provide a core health plan function are designated as First Tier, Downstream, Related Entities, or “FDRs."
SWHP should maintain the ultimate responsibility for ensuring its FDRs meet the requirements of the Medicare program and fulfill the delegated functions. This includes CMS compliance requirements. While the requirements are fully outlined in the contracts, ‘actionable’ requirements are listed below.
Fraud, Waste, and Abuse (FWA) Training
CMS requires that FWA training be completed annually by employees involved in the administration or delivery of Medicare Parts C and D benefits.
FDRs must ensure their employees receive training within 90 days of the contract effective date, and annually thereafter.
- Vendors who subcontract with entities to administer Part C and/or Part D benefits on behalf of the vendor are referred to as “downstream entities." These “downstream entities” (subcontractors) must also complete FWA training within 90 days of contracting with the vendor, and annually thereafter. Vendors must ensure their subcontractors meet CMS training requirements.
- Vendors and subcontractors enrolled in Medicare Parts A or B or accredited as a supplier of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are deemed to have met the FWA training requirement.
CMS has created a standardized FWA training module, which is available through their website at the CMS Medicare Learning Network (MLN). FDRs supporting SWHP Medicare business can access this training to satisfy the training requirement. To access the CMS training material, please follow the instructions below:
- Navigate to http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ProviderCompliance.html
- Scroll to the “Fraud and Abuse Related Resources” section
- Click on “Medicare Parts C and D Fraud, Waste, and Abuse Training and Medicare Parts C and D General Compliance Training”
- Follow the instructions within the CMS document
Screening for Excluded Individuals
SWHP may not use federal funds to pay for services, equipment, or drugs prescribed or provided by anyone excluded by the Department of Health and Human Services, Office of Inspector General, and the U.S. General Services Administration. FDRs must screen their employees and subcontractors prior to employment or contracting, and monthly thereafter. FDRs can find more information and links to the exclusion databases through the following websites:
Annual FDR Compliance Attestation
FDRs will be required to attest annually in writing to the following:
- The Baylor Scott & White Code of Conduct has been made available to its employees.
- FWA training was completed by the appropriate employees or the vendor is deemed to have met the FWA training requirement (records of training attendance, course materials, or documentation to establish FDR is deemed may be requested).
- No excluded persons or entities provided services under the contract with SWHP
- Employees have been screened for conflicts of interest in performing their job functions as required under the Baylor Scott and White Conflict of Interest Policy.
Signed attestations (scanned copy of wet signature) following the completion of a contract year should be emailed to SWHPComplianceDepartment@bswhealth.org.
To report potential fraud, waste or abuse, or any other compliance issues, please contact our Ethics line at 1-866-245-0815, or through our website: Scott and White Health Plan Compliance Helpline