Adjusting Star Ratings for Audits and Enforcement Actions

Within the Draft Calendar Year 2018 Call Letter, the Centers for Medicare & Medicaid Services (CMS) acknowledged the valuable comments received from the industry related to the use of audit findings and enforcement actions in the Star Ratings Program. As a result of those comments, CMS proposes a revision of the Beneficiary Access and Performance Problems (BAPP) measure.

First, what is the BAPP measure? You can find information on this Part C measure in the 2017 Star Ratings Technical Notes. As described, the agency checks each plan to see if there are problems with the plan, for example, whether members are having problems getting services and if plans are following all of Medicare’s rules. The current BAPP measure is based on CMS’ sanctions, civil monetary penalties (CMPs), and Compliance Activity Module (CAM) data. CAM data includes notices of non-compliance, warning letters, and ad hoc corrective action plans.

In the Draft Call Letter, CMS is proposing a number of revisions to the BAPP measure for the 2018 Star Ratings.

• CMS is proposing to change the data time frame to the period from July of the measurement year to June of the following year. For example, the time frame for the 2018 Star Ratings would be July 2016 through June 2017. (Current data time frame for 2017 Star Ratings is January 1, 2015, to December 31, 2015.) This change would address feedback to use more recent data for the CMP portion of the measure.
• In addition, CMS proposes to employ the first option outlined in the November 10, 2016, Request for Comments, that is, the agency would apply the same scaled CMP deduction to all contracts cited in the CMP notice based on a ratio of the unadjusted CMP amount to enrollment at the time of the enforcement action. So, let’s say a parent organization has five contracts cited in a CMP notice. CMS will calculate the BAPP deduction by dividing the CMP by the total enrollment of those five contracts. The resulting BAPP measure deduction would apply to all five contracts.
• CMS also proposes the total deduction for a contract for CMPs be capped at 40 points instead of 40 points per CMP, which is what is in place today. Furthermore, CMS proposes retaining both the current BAPP measure score reduction for contracts under sanction and the current CAM deductions.

After all this work, CMS is also considering whether to implement proposed BAPP measure changes for 2018 or 2019. For more information on proposed changes to Star Ratings, refer to our expert commentary on this key aspect of the program.

It is recommended Compliance, Operations and Star Ratings professionals consider scenarios and how this would affect their Star Ratings. Ideally, a plan will keep CMPs and CAM data to a minimum, but the reality is with program audits, timeliness monitoring, an annual release of CMPs for Annual Notice of Changes/Evidence of Coverage issues, provider network accuracy reviews, and CMS’ revitalized focus on nondiscrimination and accessibility, it is expected there will be plenty of data for CMS to inform this measure.

Resources

Gorman Health Group’s Summary and Analysis of the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter is now available. Download now >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

Our Star Ratings subject matter expert discusses several key changes for Star Ratings in the 2018 MA Draft Call Letter. Read now >>