2015-2016 CMS Program Audit Protocols Update

It’s Christmas in October (and Hanukkah, too) if you’ve been waiting for the revised 2015-2016 Program Audit process and protocols. Let’s get right down to it!

You’ll want to review all 20 documents (made up of the memo, data requests, supplemental questions, templates, and impact analysis layouts) for their significant enhancements and make necessary changes in your own oversight programs. What are some significant changes, and what do they mean for you?

Overall Process

• If the Sponsor fails to provide “accurate and timely” universe submissions twice, it will be cited as an observation in an audit report. After the third failed attempt, the Centers for Medicare & Medicaid Services (CMS) will classify this as an Invalid Data Submission, or IDS.  There is NO reason a universe should be submitted late. Some of our Sponsor partners have required additional time for certain submissions, and they requested that time from CMS and got it. Nothing should irk senior leadership more than a universe being submitted a few minutes late, especially considering data issues in program audits directly impact Star Ratings.
• CMS Account Managers will be playing a greater role in the validation of pre-audit issue summaries, which are made up of disclosed and self-identified issues. CMS also clarifies if CMS identified an issue during the course of routine monitoring and brought it to the Sponsor’s attention, it would be classified as a self-identified issue. There are specific timing issues CMS will consider in determining whether an issue is corrected or uncorrected.  It is best practice for Compliance departments to incorporate a log similar to what CMS has provided in the management of disclosed and self-identified issues.

CPE

• Reduction of employee interviews, with addition of interview(s) of those responsible for managing accountability for FDR oversight.  Not a surprise seeing as this has been a consistent finding for CMS throughout 2015 and previous years.  Sponsors should coordinate and start mock interviews now with those who are responsible.  CMS is seeing gaps in FDR oversight compliance whether or not you have three FDRs or three dozen.
• By the numbers:
  1. Tracer templates narrowed down from 2 to 1;
  2. Tracer samples increasing from 5 to 6, all to be conducted in week 2, so Compliance staff can participate in week 1 activities;
  3. There are 3 options for providing supporting documentation for tracers: embed into your Tracer, upload via SFTP, or have it immediately available onsite.
• CMS has incorporated a documentation request list to help them review the effectiveness of a compliance program.  These documents will need to be submitted along with the 5 universes for this audit area.  CMS has also provided a template for the Sponsor to demonstrate organizational structure and governance.   This template includes a number of questions and data requests, and should help auditors compare apples to apples.

CDAG and ODAG

• Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) universe time periods will be determined by the Sponsor’s enrollment size. In addition to numerous data layout clarifications and updates, CMS also details which universes may be combined with others to determine effectuation and notification scores.
• As previously announced in 2016, Part C and Part D grievances should be submitted based on date of resolution notification. They include a reminder not to include Complaints Tracking Module (CTM) cases in grievance universes.  (Who is still including CTM cases in grievance universes?  Please call us, whoever you are, and let us help!)

Formulary Administration (FA) and Special Needs Plan Model of Care (SNP-MOC)

• Thankfully, there were no significant changes noted in the core processes for these audit areas.  Plans will note CMS has added the Cardholder ID to the SNP Enrollees (SNPE) record layout, and, more importantly, they request separate record layouts be submitted for each unique MOC rather than per contract.

Pilot Protocols

CMS commits to releasing the pilot protocols for Medication Therapy Management (MTM) and Provider Network Adequacy later this year.

• They describe one of their objectives for the MTM review to “initiate enforcement actions and/or identify possible performance measures for sponsors to implement.” Technically, CMS can refer a Sponsor for enforcement action for any aspect of the audit. Why highlight it in MTM? Get busy making sure your program is in order.
• No surprises in network adequacy — CMS has emphasized they will be evaluating networks for adequacy by also evaluating whether or not participating providers’ practices are open to treat enrollees. Some of our partner clients have already started their own internal evaluations to ensure this important beneficiary protection is met.

This year’s audit season was a whirlwind of many things. For Sponsors and auditors alike, it’s fair to say the industry struggled with the earlier-published protocol.  Now that this document set has been released for 2015 and 2016, this should allow some breathing room for all to start implementing changes in tools, reports, and monitoring efforts.  Unfortunately, that breathing room overlaps the upcoming holiday season, so perseverance is key!  There is truly no rest for the weary.

Resources

In addition to monitoring your operations and auditing the organization’s performance, CMS also audits the compliance function.  In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Let us help you create a culture of compliance. Contact us today to get started >>

If your organization is interested in a mock audit utilizing the latest protocols. We can help! The Online Monitoring Tool™ is our compliance software designed to help organizations operating in Medicare, Medicaid and the Health Insurance Marketplace track the compliance of their operations. Learn more >>

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>

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