Business of Medicine


Medicare Advantage Compliance: What You Should Know

The Centers for Medicare and Medicaid Services (CMS) contracts with Medicare Advantage plan sponsors (such as Aetna and Blue Cross Blue Shield), which in turn contract with healthcare organizations to provide healthcare services under the plans. If your organization provides services to Medicare Advantage patients, CMS requires your Medicare Advantage sponsors to ensure that you are meeting certain compliance requirements.

Organizations can become and remain compliant with the Medicare Advantage compliance requirements by completing the following steps:

  1. Create compliance standards, policies, and procedures and designate a compliance officer.
  2. Educate and train all employees on your compliance policies and how to recognize and report noncompliance.
  3. Perform routine self-monitoring and auditing of your compliance policies to recognize any noncompliant practices and/or potential fraud, waste, or abuse (FWA).
  4. Maintain evidence of all these steps to provide to your Medicare Advantage sponsor.

Step One: Establish and distribute Standards of Conduct, policies, and procedures.

A comprehensive compliance plan is a great place to incorporate your organization’s Standards of Conduct and compliance policies and procedures. A Standards of Conduct encompasses the values by which the organization operates. An organization’s compliance policies and procedures lay out the specifics of the compliance program. Your organization should designate someone, such as your practice administrator or an executive officer, as a compliance officer to implement and operate the compliance program.

Step Two: Ensure all employees are aware of and trained on your compliance policies.

It is important that your organization screen all employees (new hires and existing employees) against the OIG’s List of Excluded Individuals and Entities (LEIE) and the General Services Administration’s (GSA) System of Award Management (SAM) for exclusions. The OIG provides an online database so you can search for excluded individuals here. You also can search the GSA SAM database for exclusions. Additionally, background checks should be performed for all employees, specifically looking for any healthcare-related fraud convictions.

Upon hire, your organization should ensure that all employees, including high-level executives, receive fraud, waste, and abuse (FWA) training. CMS provides some standardized modules that meet FWA requirements. Your organization should maintain evidence of your screenings and training to provide to your Medicare Advantage sponsor. Your organization’s employees should be able to identify FWA and know how to report (such as via a call-in hotline or a physical mailing address) actual or suspected noncompliance.

Step Three: Perform routine self-monitoring of your organization’s compliance.

Your Medicare Advantage sponsor will likely require you to be responsible for routine monitoring of the compliance of your organization. It is important to keep evidence of your organizations self-monitoring of your compliance program to provide to your sponsor. Your organization’s compliance officer can help with your self-monitoring in developing a procedure to monitor compliance issues. This can include regularly evaluating your organization’s employee training for effectiveness by monitoring clinical activities for compliance and conducting interviews. Additionally, your organization should review billing and claims practices for any deviations from your organization’s policies. Your compliance officer can determine if a formal internal audit is needed.

Step Four: Maintain records as evidence of your organization’s compliance.

Your organization should ensure that all records of compliance are properly maintained and retained for ten years. This includes records of your compliance policies and procedures and evidence of your organization’s self-monitoring practices as well as records of employee training, internal evaluations conducted, reports of suspected noncompliance, investigations of suspected violations, and any corrective action.

Your Medicare Advantage sponsor can request proof of your compliance to regularly ensure that your organization is following the proper requirements.


Your organization needs to be aware of and in compliance with CMS requirements. A finding of noncompliance, either by report or audit, will come with ramifications from your Medicare Advantage sponsor. If noncompliance is found, your Medicare Advantage sponsor will deliver a corrective action plan. Your organization’s failure to comply could lead to contract termination.


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The information provided in this resource does not constitute legal, medical or any other professional advice, nor does it establish a standard of care. This resource has been created as an aid to you in your practice. The ultimate decision on how to use the information provided rests solely with you, the PolicyOwner.