3 Key Aspects from State of Compliance

They say people fear public speaking more than death. I can tell you from public speaking experience, it is far preferable than death (though if you could bring me back like the red witch did Jon Snow, that could be one heck of a ride). Having an audience of friendly faces is also a huge help when presenting. Today, I share highlights from a recent speaking engagement on the state of compliance. For the sake of time, I boiled it down to three key sections: audits, readiness initiatives, and compliance reviews.

1. We are bearing witness to CMS’ continual changes to Program Audit layouts and processes. We know more clarifications are to come, and it is our role to keep our clients armed with the most up-to-date knowledge based on our individual experiences and interactions. We shared some common conditions as seen by Gorman Health Group as well as some ideas for addressing low-hanging fruit. For example, audit prep goes a long way with putting your best foot forward when presenting data. This is where penny-wise, pound foolish comes in. If you do not invest the time now to prepare, you could pay for it in the long run. Another recommendation is to evaluate member letters for comprehension. If you have a member advisory panel, show them some denial rationales and get real feedback. If they don’t know their next step to getting their drug or service reviewed again, it’s a problem. I raise this because, in my experience, this has been an issue for over a decade.
2. There are a number of non-audit activities CMS so kindly makes available to the industry, and they come in the form of readiness assessments, reviews, and checklists. CMS may evaluate applicants new to the market for their preparedness to determine how far along they are in supporting all those Part C and Part D attestations submitted with an application. Under the financial alignment initiative, a readiness review is performed on each and every Medicare-Medicaid Plan that comes to market. Finally, all Sponsors are on the receiving end of CMS’ annual readiness checklist. CMS gives you the tools; we are always enlightened when we see what folks do with them.
3. Finally, we focused on compliance review results of issuers in the Federally-Facilitated Marketplace. CMS shared these findings via report, and the results were not kind. Policies, agent training, notice errors, and contract issues plagued the results. And with the good faith policy ending at the close of 2015, this means civil money penalties can be leveraged this year, and past performance will be taken into account.

It’s a struggle to boil down valuable industry insight for a presentation, since I risk leaving no time for audience questions, and it’s even harder to pare down a blog post. Luckily, I can take questions at any time. I won’t close with Game of Thrones’ most popular Stark family tagline but instead with a sentiment from Ser Davos: “Loyal service means telling hard truths.” We share our perspective of those hard truths in the service of our clients, who in turn are in the service of beneficiaries, the people who matter most. Email me at rpennypacker@ghgadvisors.com.

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