2017: Taking Stock to Inform Next Steps

As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if you believe in the effects of Mercury in retrograde.

• The audit protocols continued to be a work in progress not only for sponsors, vendors, and industry partners like Gorman Health Group, but also for the authors at the Centers for Medicare & Medicaid Services (CMS). A myriad of industry comments were submitted for consideration as they relate to the draft 2017 version. By now, most sponsors should have already incorporated similar methodology into audit and monitoring processes as a complement to existing methods.
• Sponsors without established monitoring and oversight focus on the accuracy of their network information have been subject to CMS review, have sought outside assistance to verify network accuracy, or have worked or are working internally to varying degrees to remediate known gaps in their processes. Per CMS, the Medicare Parts C & D Oversight and Enforcement Group (MOEG), in coordination with the Medicare Drug & Health Plan Contract Administration Group (MCAG), are taking a comprehensive approach to monitor, audit, and validate compliance with network accuracy requirements. MOEG’s pilot will use MCAG’s monitoring results to audit and validate correction of deficiencies. Some of the highest Star-rated plans can tell you about their network validation efforts and best practices, and it’s not a one-way street ‒ providers need to collaborate with sponsors and be proactive when information changes. We may expect to see enforcement actions stepped up as a result of CMS’ maturing efforts in validation of network accuracy.
• Earlier in 2016, our Operations team highlighted areas to keep an eye on based on the 2017 Draft Call Letter. They included the one-third financial audits, timely processing of coverage determinations and redeterminations, as well as data integrity. CMS has since noted they will increase penalties for outliers of Coverage Determinations, Appeals, and Grievances (CDAG) auto-forward rates, and they confirmed they will continue to raise the consequences for ongoing noncompliance in this area in 2017. The appeals timeliness monitoring effort announced on November 29 will provide CMS even more data for review and action.
• Later in the year, our Pharmacy team recommended key strategies to prepare for the coming year, including conducting Pharmacy Benefit Manager delegation oversight audits and conducting targeted audits. Most, if not all, of the mentioned strategies require a group effort, which begs the question: Did you have the time and the resources to accomplish all you wanted to do by end of year?

This is a good time to rethink methodologies and reorganize in preparation for changes to come. The key here, especially this month, will be to take stock of what we do not have control over, set those things aside, and plan to take action where we can.

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