Medical Mutual contracts with external entities that provide administrative and healthcare services for our Medicare Advantage Prescription Drug (MA/PD) Plan. These entities, known as FDRs, help Medical Mutual to be more cost effective and efficient. Some services provided by external entities are required under our contracts with the Centers for Medicare and Medicaid Services (CMS) and, therefore, need additional oversight to ensure compliance.
What is an FDR?
FDR stands for first tier, downstream or related entity. We use the CMS definitions of these vendor types:
- First Tier Entity – any party that enters into a written arrangement, acceptable to CMS, with a Medicare Advantage Organization or Part D plan sponsor or applicant to provide administrative services or healthcare services to a Medicare eligible individual under the Medicare Advantage program or Part D program. (See 42 C.F.R. §§ 422.500 & 423.501).
- Downstream Entity – any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage benefit or Part D benefit, below the level of the arrangement between a Medicare Advantage Organization or applicant or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services. (See 42 C.F.R. §§ 422.500 & 423.501).
- Related Entity – any entity related to a Medicare Advantage Organization or Part D sponsor by common ownership or control that: 1. Performs some of the Medicare Advantage Organization’s or Part D plan sponsor’s management functions under contract or delegation; or (2) Furnishes services to Medicare enrollees under an oral or written agreement; or (3) Leases real property or sells materials to the Medicare Advantage Organization or Part D plan sponsor at a cost of more than $2,500 during a contract period. (See 42 C.F.R. §§ 422.500 & 423.501).
If you are an FDR, prior to your contract and annually thereafter, an authorized representative from your organization must attest to your compliance with the Medicare Compliance Program requirements. You can complete your annual attestation online here.
In the event of a CMS audit or upon request, you may also be asked to provide evidence of your compliance with the requirements.
Are You an FDR?
Medical Mutual established a procedure to identify all FDRs. We used the criteria outlined in Chapter 21 of the Medicare Managed Care Manual. We gave you this web address because we’ve identified you as an FDR.
Requirements for FDRs
It’s important that our FDRs are in compliance with applicable laws, rules and regulations. The Medicare Compliance Program requirements apply to entities that Medical Mutual contracts with to perform administrative and healthcare services relating to MA/PD contracts with CMS. Although we contract with FDRs, Medical Mutual is ultimately responsible for fulfilling the terms and conditions of our contracts with CMS and meeting applicable Medicare program requirements.
As an FDR with Medical Mutual, you are required to comply with the regulations outlined below.
Compliance Program Requirements
The Medicare Compliance Program FDR requirements include, but are not limited to:
- Fraud, Waste and Abuse (FWA) training and general compliance training
- Compliance policies and Code of Conduct distribution
- Exclusion list screenings
- Reporting FWA and compliance concerns to Medical Mutual
- Offshore operations and CMS reporting
- Record retention
- Specific federal and state compliance obligations
- Monitoring and auditing of FDRs
FDRs are expected to understand and maintain compliance with all applicable Medicare regulations and federal and state laws governing the delegated function. Medical Mutual will require internal monitoring of the delegated function. We will request routine reporting to verify you’re compliant with applicable rules and regulations.
FDRs will also submit to monitoring and/or auditing efforts initiated by Medical Mutual and/or other third party auditors, such as CMS. All suspected incidents of non-compliance must be reported to Medical Mutual immediately.
If you have questions, please contact your Medical Mutual Provider Contracting Representative. If you are unsure who your Provider Contracting representative is, please visit Provider.MedMutual.com.
If you suspect Fraud, Waste, Abuse or Non-compliance, you are obligated to report the incident to Medical Mutual immediately. You can report the incident anonymously by phone at (800) 762-8130 or online.