Feeling the Madness! The 2020 CMS Program Audit Cycle Begins

This March, sports will not be the only excitement—health
plans are gearing up to receive audit notices as we enter the second year of
the four-year Program Audit Cycle. The ball is in your court… Your team’s
readiness depends on review of the current audit protocols and practice,
practice, practice.
Are you performing “mock” auditing to identify risks?

The Centers for Medicare and Medicaid
Services (CMS) started the current audit cycle in 2019 with a number of audit changes
and process improvements to assist plans, including:

  • Removal
    of Audit Element Review
    : Suspension of the review of Call Logs and the
    Website audit element from the Formulary and Benefit Administration protocol, as
    well as removal of the Enrollment Verification audit element from the Special
    Needs Plans Model of Care (SNP MOC) protocol.
  • Streamlining
    : Release of the Program Process Overview document with the
    Program Audit Validation and Close Out guidance, along with a Program Audit
    Frequently Asked Questions (FAQs) on the CMS program audit website.
  • Compliance
    Program Effectiveness (CPE) Protocol Changes:
    suspension of the CPE self-assessment questionnaire and several changes to the
    CPE universes.

CMS is continually seeking “…to improve
audits by soliciting sponsor feedback,” and recently opened for comment on the
proposed changes for 2020. Some notable changes include reductions in audit
elements and protocols, such as:

  • Removal of Part D Coverage Determinations, Appeals, and Grievances (CDAG) Table 9 (Standard Independent Review Entity [IRE] Auto-Forwarded Coverage Determinations and Redeterminations [SIRE]) and Table 10 (Expedited IRE Auto-Forwarded Coverage Determinations and Redeterminations [EIRE]), as well as removing Table 16 Call Logs.
  • Reducing timeliness CDAG sample size from 75 to 65 and increasing Grievances from 10 samples to 20, likely to compensate for the removal of Table 16 Call Logs.
  • Edits to the CDAG universe requirements, including updating the notification requirements to coincide with Parts C and D Enrollee Grievances, Organization/Coverage Determinations and Appeals Guidance Section 10.5.3 and adding exclusion language throughout the remaining tables.
  • Removal of ODAG Table 14 Call Logs and reducing timeliness samples from 65 to 60 cases and Clinical Decision-Making from 40 to 35, while also increasing Grievance samples from 10 to 20.

The industry anxiously awaits the
distribution of the updates, as the current audit protocols are set to expire
April 30, 2020.

GHG assists plans with implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.

Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

On December 30, 2019, the Centers for Medicare & Medicaid Services (CMS) announced updates to the Parts C & D Enrollee Grievance, Organization/Coverage Determination and Appeals Guidance, which became effective as of January 1, 2020.  Noteworthy changes are summarized below:

  • In Section 10.5.3, the guidance was expanded to include more detail about verbal notifications. This section details when and under what circumstances the verbal notification is considered delivered, what defines a successful verbal notification (e.g., speaking with the person that submitted the request or leaving a voicemail message), and the appropriate steps to take if written notice is required along with verbal notification. CMS also deleted subsection 10.5.4: Good Faith Effort to Provide Verbal Notification, which was a new section introduced in the February 2019 version of the Guidance. There is a notable revision to guidance for a favorable decision that a plan “may” deliver written confirmation of its decision after initially providing verbal notification of the decision. This is a change from the 2019 guidance indicating the plan “must” deliver written notification. (See updated Section 40.8.)
  • Throughout the Parts C & D Guidance, CMS revised existing requirements to now include Part B Drugs.
  • Section 40 (Coverage Determinations, Organization Determinations [Initial Determinations] and At-Risk Determinations) has several significant updates:
    • There is a more detailed description of the process for requesting a Part C pre-service organization determination or Prior Authorization (PA). CMS provides clarification that Medicare Advantage (MA) plans should be prepared to address medical necessity as required in these scenarios. (See Section 40.1.)
    • There is a new Part D provision that applies to circumstances where a plan is asked to waive a PA or other Utilization Management requirement. Updated language provides for tolling of the timeframe by up to 14 calendar days after the receipt of a request to receive the supporting statement. (See Sections 40.4 and 40.5.3.)
    • Also noted are new Part D notification timeframes surrounding Exception Requests. In previous guidance, plans were instructed not to keep requests for supporting statements open indefinitely. This language is deleted in the updated guidance, and in its place, CMS outlines specific new timeframes for enrollee and prescribing physician (as appropriate) notification of plan decisions for both expedited and standard requests, and includes notification timeframes for circumstances when the supporting statement is not received with the 14 calendar day timeframe.
    • CMS has included Part B Drugs in the decision timeframes (favorable, partially favorable, or adverse) as well as processing timeframes (72 hours for standard requests for Part B Drugs and 24 hours for expedited). CMS also clarified that requests for Part B Drugs and payment timeframes cannot be extended.
  • Section 50 Reconsiderations and Redeterminations (Level 1 Appeals) contains a number of updated clarifications to existing requirements. Most noteworthy changes are the provisions for adjudication timeframes for Part B Drugs. 
  • CMS clarifies Health Care Pre-Payment Plans (HCPPs) are not regulated by Section 100 (Provider Notices in Hospital, SNF, HHA and CORF Settings [Part C Only]) and clarifies that HCPP enrollees must follow Original Medicare immediate review processes.
  • The Medicare Managed Care Appeals Process Overview for Part C (Appendix 1) is amended to include timeframes for Part B Drugs in both the standard and expedited processes. Also, for both Parts C and D Process Overviews, the “Amount in Controversy” (AIC) is increased to $170 at the Administrative Law Judge (ALJ) Hearing stage. The AIC is also increased at the Federal District Court stage to $1,670.

Plans should carefully review the
updates and incorporate the numerous changes to existing plan policy.

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GHG assists plans in implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.

2020 Readiness Checklist

On October 3, 2019 the Centers
for Medicare & Medicaid Services (CMS) released the 2020 Readiness
Checklist highlighting critical operational and contractual requirements for
Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs),
Medicare-Medicaid Plans (MMPs), and Cost Plans. 
The readiness checklist is released annually and, when used as a
“self-assessment,” can be an effective tool for validating organizational
compliance with Annual Election Period (AEP) and 2020 plan coverage requirements.  With this self-assessment, the organization
will have both a working knowledge of their state of readiness as well as a roadmap
for process improvements.  It’s important
to note that organizations are required to identify risks and notify their CMS account
manager(s) and should anticipate follow-up discussions on those areas of focus.

Plan Sponsors should carefully
review the checklist for regulatory changes and updates that may have occurred
since the 2019 checklist’s release.  Remember,
this checklist is intended as a summary of the critical requirements.  Plans should refer to all new guidance,
memos, Final Rules, and the Call Letter for the detailed interpretation of CMS

A few examples of focus areas that may be new or expanded
for 2020 include:

  • Precluded
    Providers and Prescribers
    - For 2020 CMS has expanded on the expectations
    for managing precluded providers and prescribers.  In addition to requiring beneficiary notices:
    MAOs/Part D Sponsors must deny payments for a health care item or service,
    reject the pharmacy claim, or deny the beneficiary request for reimbursement
    when the prescribing individual is on the Preclusion List. 
  • Timeframes
    for adjudicating Part B Drug Requests
    – The Medicare Advantage (MA) and
    Part D Drug Pricing Final Rule (CMS-4180-F) issued in May 2019 introduced new,
    shortened adjudication timeframes for Part B drugs. MAOs must ensure requests
    are adjudicated and favorable decisions are effectuated in accordance with the
    new guidelines.
  • Medicare
    Plan Finder Data (MPF)
    – For 2020 Part D Sponsors should ensure access to
    the Health Plan Management System (HPMS) Part D Pricing File Submission Module
    for both Part D pricing file submission and quality assurance (QA) validation
    results.  The updates and announcements
    previously available on the MPF Communications Website are now posted in the
    module’s Documentation section.
  • Medicare
    Marketing -
    Updates to the Medicare Communications and Marketing Guidelines
    (MCMG) will impact marketing and communication materials and activities. Plan
    Sponsors must ensure the respective materials comply with the most current
  • Prescription
    Drug Event (PDE) Requirements
    – Part D Sponsors must ensure submission of
    data and information necessary for CMS to carry out payment provisions are
    submitted through the Prescription Drug Front-End System (PDFS) and processed
    by the Drug Data Processing System (DDPS). 
    Details about what is required to become certified to submit data, along
    with guidance on data submission and other resources, is available on the
    Customer Service Support Center (CSSC) website.
  • Coverage
    Gap Discount Program (CGDP)
    – CMS expects Part D Sponsors to be familiar
    with their responsibilities to participate in the CGDP, and provides
    information about the CGDP portal, onboarding training and CGDP Portal Sponsor
    User Guides available from the TPAdministrator.com website in the Reference

GHG conducts readiness assessments for its clients to help identify any areas of risk related to upcoming plan year preparedness. This is especially important for Plans new to the market in 2020. Contact us today for additional information.

CMS Focus: Compliant Independent Review Entity Data

The focus on compliant Independent Review Entity (IRE) data should come as no surprise to Part D sponsors. In December 2016, the Centers for Medicare & Medicaid Services (CMS) released the Health Plan Management System (HPMS) memo, Compliance and Enforcement Actions Related to Part D Auto-Forwards, indicating sponsors with inordinately high auto-forward rates were subject to compliance actions that could be escalated to enforcement actions. The memo established a threshold rate, and in spring of 2017, CMS began imposing civil monetary penalties (CMPs) on Part D sponsors with demonstrated non-compliance with coverage determination and redetermination auto-forwards to the IRE. And with that, the die was cast.

The Timeliness Monitoring Project (TMP) is an opportunity to demonstrate compliant processes and data integrity in support of CMS’ Star Ratings. With this data collection effort, the playing field is leveled in the evaluation of sponsors’ IRE data. The TMP effort by CMS – while offering a fair and balanced methodology as it seeks to assess all plans instead of those identified in a targeted review – also provides CMS a separate and distinct window beyond program audits in identifying sponsors with problematic organization and coverage determination processes.

Plans that are unable to provide complete and accurate universes will be at risk with both their Part C and Part D Star Ratings as described in the December 12, 2017, HPMS memo, Timeliness Monitoring Project (TMP). “CMS considers data integrity issues, if identified, as an indicator that a contract’s measure data are invalid for the Star Ratings. CMS may also independently evaluate the data to gain insight into sponsors’ performance in these two program areas.”

The unfortunate reality is that an inability to accurately capture data within organization systems is likely symptomatic of any number of inefficiencies, for example:

  1. Lack of systems/analytics to compile data needed to assess compliance with CMS expectations
  2. Insufficient monitoring efforts
  3. Potential for processing inefficiencies such as inadequate resources, training, or expertise

CMS proposes a scaled reduction in a sponsor’s Star Ratings data that is found to be incomplete or “lack integrity.” The consequences of a lowered Star Rating can be a devastating blow to sponsors. Yet often, performance issues remain inadequately addressed. Plans sometimes need help knowing where to begin.

Sponsors can readily utilize the Audit Process and Data Request guidance for Organization Determinations, Appeals, and Grievances (ODAG) and Coverage Determinations, Appeals, and Grievances (CDAG) as the playbook on IRE auto-forward compliance.

Start with a great outreach process

  • Is plan staff aware of what clinical information is required to make a well-informed decision?
  • Is there a consistent, timely, and well-documented process in place for provider outreach?
  • Can this be evidenced in your systems, and more importantly, is this being tracked and monitored by plan staff?

Follow up with timely and sound decision-making

  • Do the decision-makers have all the information they need to make the decision?
  • Are decisions primarily made based on sponsor formulary/Evidence of Coverage (EOC), clinical criteria, federal regulations, CMS guidance, compendia, or peer-reviewed literature (where allowed)?
  • Are there any trends in plan denials for lack of clinical information? What efforts are being made to address those trends?

Ensure adequate notification processes exist

  • Plans should have well-established processes for enrollee and provider notification that includes consistent methods of outreach, clear and unambiguous documentation in systems, with well-written and understandable denial rationale.
  • Notifications must be timely, with documentation of both oral and written outreach detailed in plan systems. Plans must be able to evidence when the notification(s) entered the mail stream.

Sponsors have the ability to ready themselves by:

  • Regular monitoring through sample mock auditing
  • Developing dashboard reporting to assess the veracity of the data
  • Evaluating universe creation and testing it: can all steps be evidenced in plan systems?
  • Ensure internal processes for organization determinations and reconsiderations/coverage determinations and redeterminations are working effectively

Gorman Health Group’s Clinical Solutions practice area has a talented team of registered nurse professionals with experience in operations and implementations in various healthcare lines of businesses. Add to that Gorman Health Group’s Compliance consulting expertise and data analysts, and you have the winning combination in driving better member outcomes and ensuring member satisfaction. One call can lead to the answers your plan is seeking!




Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe

HEDIS Deadlines Approaching

It’s HEDIS® time again! Health plans should have data collection and audit activities in full swing for Healthcare Effectiveness Data Information Set (HEDIS®) 2018. High-performing plans will have started the hybrid chart collection and medical record review.

January 31 is the National Committee for Quality Assurance (NCQA) deadline for the HEDIS® 2018 Roadmap. This document is used by HEDIS® auditors as the backbone for evaluating a plan’s systems and processes to ensure the plan’s HEDIS® results comply with NCQA standards for reporting.

February 16 is the due date for submitting the Healthcare Organization Questionnaire (HOQ) to NCQA. Populating the HOQ can be confusing for some plans, but it is important to get it right to prevent surprises when it is time to upload final data submissions in June.

HEDIS® results are a significant portion of CMS Star Ratings and NCQA accreditation scores, so it is critical for plans to understand all the moving parts and multiple deadlines of the HEDIS® process. Gorman Health Group has the expertise to help your plan implement a robust strategy and targeted actions for delivering measurable HEDIS® improvements.


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Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>