Avoid the Sharp Edges and Prepare for Your Next CMS Audit

How can a health plan steer clear of the sharp edges for which the Centers for Medicare & Medicaid Services (CMS) will be looking? I'd like to focus on the clinical side of both Organization Determinations, Appeals, and Grievances (ODAG) and Special Needs Plan Model of Care (SNP MOC) and being prepared for your next CMS audit of these areas.

For ODAG, what should be straightforward still causes plans to have challenges. CMS monitors that plans:

  • Process initial requests in a timely manner
  • Use correct clinical criteria
  • Ensure a matched specialty when indicated and
  • Include external review when indicated

While plans strive to meet these criteria, some still struggle.  In addition, as we all learned in our clinical training, if it is not documented, it is assumed to not have been done. Be sure you have the support of a system designed to manage initial determinations and reconsiderations and document well in the system. Remember, CMS will look for a live file review, and you will want to practice so this segment flows well, showing your team to be well-trained and knowledgeable.

Next, let's look at the components of the SNP MOC reviews. Sections 2, 3, and 4 all require clinical attention. CMS will be looking for documentation that you did what you have committed to in the MOC and your policies. Are initial and annual Health Risk Assessments (HRAs) completed, and how is the information incorporated into the Individualized Care Plan (ICP) and the Interdisciplinary Care Team (ICT)? CMS will also expect to see your quality measures as defined in Element 4 of the MOC.

In my presentation on case management at the 2016 GHG Forum, I stipulated that all SNP MOC members must be in case management. Members who opt out still need to be followed by the Case Management team without direct member input. Successful case management requires a supportive culture, well-trained staff, and system documentation using evidence-based tools. Not only is strong case management a CMS expectation ― it is essential to effectively manage a SNP MOC population.

I hope these thoughts are useful as you manage your Medicare line of business.  Please reach out to me if you have questions, comments, or would like to discuss health plan support from the GHG Clinical Solutions team at mdashiell@ghgadvisors.com.




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