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Blue Cross Blue Shield of Michigan Best Compliance Practice for Management of Patient Protection and Affordable Care Act

Reina Navarra Manager, Business Compliance Oversight Office Blue Cross Blue Shield of Michigan is a nonprofit corporation and independent licensee of the Blue Cross and Blue Shield Association.

Topics ●  Implications of Patient Protection and Affordable Care Act ●  BCBSM Compliance Approach ●  Best Practice Model ●  Compliance Plan ●  Business Compliance Oversight Office Key Roles ●  Compliance Liaison Council ●  Compliance Management Tools and Education


Implications of PPACA (Patient Protection and Affordable Care Act)

Rapid and Unrelenting Changes Characterize Today’s Environment 1.  Multiple regulators: CCIIO - The Center for Consumer Information & Insurance Oversight CMS - Centers for Medicare and Medicaid Services HHS - Department of Health and Human Services DIFS - Department of Insurance and Financial Services

2.  Guidance on regulations continues to emerge while development is underway 3. Aggressive timeframes 4. Sweeping volumes of change


BCBSM Compliance Model

BCBSM  PPACA   Compliance     Oversight  Model  


Best Practice - Our Foundation Enables Success

2013 Be=er  Prac>ce  Model,    Internal  Audit  Associa>on  



Internal Audit  


PPACA Compliance Plan

• The compliance plan, required to be a Qualified Health Plan, is designed to outline the key roles and responsibilities associated with PPACA compliance management and oversight. • The plan is consistent with current work and compliance liaison charter which breaks compliance oversight into tiers (Compliance Liaisons and the Business Compliance Oversight Office). • Key roles and responsibilities are divided among BCBSM business area staff, Compliance Liaisons, Public Policy/Office of the General Counsel, Office of National Health Reform program management and Business Compliance Oversight Office. • CMS Seven elements of an effective compliance program are incorporated

Written Policies, Procedures, Standards

Compliance Officer, Compliance Committee, High Level Oversight

Effective Training and Education

Effective Lines of Communication

WellPublicized Disciplinary Standards

Effective System for Routine Monitoring, Auditing, Identification of Compliance Risks

Procedures and System for Prompt Response to Compliance Issues


Business Compliance Oversight Office Key Roles

•  Advise and consult with business areas on implementing controls to comply with PPACA regulations •  Oversee policies and procedures management •  Educate business areas and provide tools for regulatory audit readiness •  Maintain deficiency database and track deficiency resolution •  Monitor and report on compliance metrics •  Own and maintain compliance management system •  Apply risk intelligent approach in annual planning and business consulting 7

Health Care Reform Compliance and Empowerment

A Risk  Intelligent  Approach  -­‐    Success  through  Empowerment  

Understand the   Boundaries  

Be Transparent   with  Decisions   and  Assign   Accountability  



• Best prac>ce  vs.   Evaluate  Op%ons   sufficiency   • Cost  and  benefits   • Impacts  and  probability   Iden%fy  the  Risk   • What  uncertain   • Compliance  risks  may  consider:   event  or  effects   • Member  harm   • Financial  loss   could  happen   • Know  the  facts   • Audit  risk   • Reputa:on/Market  Share   8

Compliance Liaison Council

Others eBig, Appeals

OGC Human Performance

Small Group

PPACA Compliance Medicaid


Liaison Council



Customer Service

Actuarial And Underwriting


Health Care Value

Sales & Marketing IBU


Compliance Management Tools and Training

• Compliance Management Playbook • PPACA Mandate Inventory Log • BCOO Share Point tool • Compliance Liaison and business area formal training Overall Training Results

Future 2014 plans include a computer based training and certification process.




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