Change is here: CMS Finalizes Chapter 13
It seems like only yesterday that I was submitting comments in response to CMS' draft chapter 13. It was, in fact, way back in April of 2007, when I was a budding young compliance analyst determined to keep a plan on the right track.
The review of draft chapter guidance was one of the best examples of CMS partnership that the organization afforded to plans. But yesterday marked a new beginning: CMS released the final, updated Chapter 13: Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals, made effective retroactively to March 23, 2012. No opportunity to provide comment on a five-year old chapter in desperate need of a face lift. We can only speculate on why this is. It's possible that a deadline needed to be met and there was simply no time to share the draft with the industry. Many (but not all) of the changes had already been communicated to the public via memos and past call letters. I don't see it as a huge red flag; Chapter 4 was released as draft yesterday as well, and CMS recently solicited feedback on certain Marketing Guidelines changes. So you still have a voice.
For this final chapter, however, organizations should quickly begin reviewing which policies and procedures need updating. But don't stop there. Once revisions are made, be sure to communicate via specialized training. And document it! Not only will you be working toward your effective Compliance Program requirement to provide specialized training, but you will also be ensuring that this high-risk area stays sharp. And if you face endless hurdles for updated P&Ps to go through your internal approval process, take this final chapter on the road ASAP to the Medical Directors office, Customer Service, Utilization Management, Appeals and Grievances and your provider community. They are all directly affected by these recent changes.
Chapter 13: Read it, learn it, live it, love it.
Delegation Nation
Ongoing monitoring and auditing is a widespread challenge, but they are must-dos according to CMS' compliance program requirements. You have some tools, but not enough to capture the full picture. Responsibilities are spread out between departments and delegated entities. Is the risk assessment just a matter of asking for a list of risks, or is it simply a review of the OIG work plan? It's just not enough. Where does your sanity check fall on your annual risk assessment, let alone your daily planner?
When the decision is made to outsource a part of your Medicare Advantage or Part D responsibilities, the onus continues to be on the Plan Sponsor for compliance. That means effective pre-delegation site-visits, collaboration in monitoring and information exchange, and a delegate's demonstrated commitment to meet your organization's needs.
Many Medicare Compliance Officers don't have the resources to fully monitor and oversee the delegates. You get some reports, but then hear from another plan that your biggest delegate is having problems. Now CMS is asking you what you know about it. What systems do you have in place for routine and ad hoc exchanges of information between you and your delegated entity?
Think outside the box when developing your monitoring and oversight strategy, especially when it comes to delegates. Ensure that collaborative efforts are outlined at the service agreement level; otherwise, it's like being in the ocean with no life preserver. If you are not involved at the beginning, you may end up in a regrettable long-term relationship. Insist on being involved at the RFP process. Ask questions: Will the account manager be dedicated to your plan? What are the contents of their canned reports and how are requests for additional information handled? How do current clients feel about this delegate? You check references before you hire an employee -- do your homework before diving into a delegated relationship. CMS expects you to protect your members. Make sure any delegate is ready to meet the obligations for which your plan is responsible.
A Day in the life of the Medicare Compliance Officer
You have so many requirements to follow. You are charged with the interpretation and distribution of the ever-present stream of HPMS memoranda. Operational leadership does not always understand that you can give them the requirements, interpret the requirements, but it's up to them to implement for success. Implementation takes time, often leaving employees performing manual, error-prone tasks until something can be automated. And of course, without automation, the documentation is difficult to find upon CMS request.
So begins another day in the life of the Medicare Compliance Officer: ever-changing, often thankless, and never boring. Sound familiar? In my last post, I mentioned the SCCE/HCCA joint survey on stress, compliance and ethics --take a look. The results should not be too surprising to those in the day-to-day.
Compliance Officers (and their staff) hear so many reasons for not fulfilling compliance obligations:
• We don't agree with your interpretation
• We've never been cited for it before
• Our competitors do it so why can't we
• It's not in our budget
Talk about stress! Many Medicare Compliance Officers that I have worked with find themselves at one of two ends of a spectrum: so embedded in operational decisions that their role is often blurred, or completely carved out of the loop — isolated as demonstrated in the survey results. It is no small task to cultivate and maintain the relationships with operations to fall right in the middle.
For those who find themselves over-involved in operations, a line must be drawn. Often times, the Medicare Compliance Officer is party to decision-making in favor of non-compliant practices. To request concurrence from him or her on something which results in non-compliance is a major stressor to anyone charged with maintaining the relationship between the organization and the CMS account manager. The fact is, a blessing from the Medicare Compliance Officer does not make a wrong a right, so break the cycle if it exists in your organization.
Don't waste your travel budget
We're less than three months from the GHG Forum. This is NOT your usual conference. We've developed a unique educational retreat for management teams working in government programs. I'm thrilled at the presentations our faculty are preparing: we're putting our senior consultants on the stage to deliver case studies, war stories and tales of best practices. But just as importantly, we're building in time for you to react to these sessions with your team--- to develop questions for your track faculty, compare notes, discuss implementing the best practices you've learned about.
We know it's a new concept in an industry that's become accustomed to sales people masquerading as subject matter experts. But we think that's it's badly needed. Many management teams we work with bemoan the lack of time and space to learn, collaborate and plan for success. In this environment, it's easy to simply react. But no one has ever reacted their way to excellence.
No doubt, if you send one to two people they will benefit individually. But isn't the isolation of our departments from each other central to our basic challenge of reforming our plans? We invite you to join other plans (some are sending as many as a dozen attendees) in making the GHG Forum your travel investment for the year. Send a team. We'll show you around.
Stressed? Tell me about it
The Society of Corporate Compliance and Ethics and the Health Care Compliance Association conducted a survey and released their results in a report entitled Stress, Compliance, and Ethics. The survey results address leading causes of stress among compliance and ethics officers. When three of every five respondents agree that they have considered leaving their job, and over half consider their relationship with colleagues to be adversarial or isolated, it is a strong message to take action.
There exists a small pool of Medicare Advantage and Part D Compliance professionals in the country. Of those charged with the responsibilities of the Medicare Compliance Officer, they know full well what CMS has focused on over the past few years: compliance program effectiveness and performance reviews based on data.
CMS expects plans to demonstrate the effectiveness of the Medicare Compliance Officer by way of communication efforts, transparency throughout the organization, and effective training programs, among other things. We know total effectiveness is near impossible when you are not a true partner in the C-suite. Common barriers to compliance program success include:
• Barriers to leadership: Communication becomes a game of "Operator" when the chain is Compliance Officer to Director to Assistant Vice President to Executive Vice President to General Counsel to Audit Committee to CEO… surely the original message got through;
• Insufficient resources: Compliance divisions often do not have the trained staff or the right tools in order to perform the tasks of a well-oiled compliance machine; lots of manual processes, too little automation;
• Operational pushback: Delay, resistance or refusal to maintain compliance standards will have you seeing stars, and not in a good way.
As a true officer of the company, it is CMS' expectation that your role is meaningful and effective. When the title of Medicare Compliance Officer is given to someone without a seat at the table, the effectiveness of the compliance program is at risk. Next week we'll talk some real-life examples that make up a day in the life of these compliance warriors.
PBM Compliance-Oversight: What you Don't Know Can Cost You
Whether plans stick their heads in the sand or not, it doesn't change the fact that delegating services to a contracted entity is emerging as one of the fastest growing areas of audit risk.
CMS defines Compliance-Oversight Activities to include developing effective metrics and controls, monitoring and reporting, and risk assessment with corrective action for any delegated entities or contractors. Compliance refers to all contract compliance requirements and includes FWA compliance elements and requirements of the plan sponsor.
A Compliance-Oversight Plan should be structured in a way that is data driven — quantifiable performance metrics and monitoring with measurable outcomes. The goals of a Compliance Oversight plan should be proactive — to prevent, detect and respond ("find and fix") and focused — targeted on risk areas.
CMS has made it clear that the stakes have never been higher for the cost of non-compliance. In the area of oversight of contracted entities the warnings are beginning to play out in a variety of ways. At best, a plan sponsor can expect a corrective action plan that comes with intense scrutiny. Recently, CMS announced a series of actions against non-compliant activities that included fines and penalties. At worst, a plan risks non-renewal of its contract with CMS.
There are more subtle costs to the lack of compliance oversight that may not bring down the wrath of a CMS audit. Plans that fail to monitor the activities of their PBM effectively may have a deleterious impact on customer satisfaction. Poor satisfaction will result in lower CAHPS scores and reduced Plan Ratings.
Kaiser Health announced this week that the 9 Five-Star Plans earned in excess of $4 billion in bonus payments for 2012 Plan Ratings. Starting in January, plans with three stars or better will get bonuses of 3 to 5 percent of their total Medicare payments. Five-star plans also can market to and enroll members year-round, while all other plans enrollment is limited to Medicare's annual open period. What's more, CMS will aggressively encourage consumers to move their Medicare policies to the higher-ranked plans, giving them a big boost.
Failure to adequately provide compliance oversight to PBMs or other contracted entities is not only risky; it is also a costly failure by a plan sponsor at a time when resources are diminishing. Don't be caught unprepared.
GHG is hosting Medicare Advantage and Part D Compliance Leaders at our Compliance Forum 2011. We'll be addressing CMS' highly energetic regulatory activities and other key issues November 2-4 in Las Vegas. View the preliminary agenda here.
In addition, we're now offering a delayed payment pricing option, just in case your travel budgets have run out before your questions have. If you register now, the registration fee payment will be delayed until January 2012.
Click here to pre-register.
Prescription Drug Abuse: A Growing Compliance Risk for Medicare Advantage Plans
The GAO recently released a report on fraud and prescription drug abuse in Medicare Part D. Prescription drug abuse is a serious and growing public health problem. According to the CDC, drug overdoses, including those from prescription drugs, are the second leading cause of deaths from unintentional injuries in the United States, exceeded only by motor vehicle fatalities. Unlike addiction to heroin and other drugs that have no accepted medical use, addiction to some controlled substances can be unknowingly financed by insurance companies and public programs, such as Medicare Part D.
The report released by the GAO describes beneficiary doctor shopping in the Medicare Part D program for 14 categories of frequently abused prescription drugs. The objectives were:
(1) To determine the extent to which Medicare beneficiaries obtained frequently abused drugs from multiple prescribers;
(2) To identify examples of doctor shopping activity;
(3) To determine the actions taken by (CMS) to limit access to drugs for known abusers.
The analysis found that about 170,000 Medicare beneficiaries received prescriptions from five or more medical practitioners for the 12 classes of frequently abused controlled substances and 2 classes of frequently abused non-controlled substances in calendar year 2008. These individuals incurred approximately $148 million in prescription drug costs for these drugs, much of which is paid by the Medicare program. Most of these 170,000 Medicare beneficiaries who were prescribed prescriptions from five or more practitioners were eligible for Medicare Part D benefits based on a disability. Specifically, approximately 120,000 Medicare beneficiaries (about 71 percent) were eligible for Medicare Part D benefits based on a disability. Of these 170,000 beneficiaries, approximately 122,000 beneficiaries (72 percent) received a Medicare Low-Income Cost-Sharing (LICS) subsidy.
The Government Accountability Office (GAO) is a key driver for identifying issues of accountability in government agencies that translate into Congressional initiatives resulting in CMS auditing activity for Medicare Advantage Plans. CMS currently requires Part D plans to perform retrospective drug utilization review (DUR) analysis to identify prior inappropriate or unnecessary medication use and provide education, such as alert letters, to the prescribers involved. By analyzing historical prescription claims data, the drug plans can identify individuals who are likely obtaining excessive amounts of highly abused drugs or potentially seeking such drugs from multiple medical practitioners. However, according to CMS Part D program officials, federal law does not authorize Part D plans to restrict the access of these individuals, leaving little recourse for preventing known doctor shoppers from obtaining hydrocodone, oxycodone, and other highly abused drugs.
The GAO recommends for CMS to review the findings, evaluate the existing DUR program, and consider additional steps, such as a restricted recipient program for Medicare Part D that would limit identified doctor shoppers to one prescriber, one pharmacy, or both for receiving prescriptions. CMS should consider the experiences from Medicaid and private sector use of such restricted recipient programs, including weighing the potential costs and benefits of instituting the control. In addition to a restricted recipient program, CMS should consider facilitating the sharing of information on identified doctor shoppers among the Part D drug plan sponsors so that those beneficiaries cannot circumvent the program by switching prescription drug plans. Finally, in considering such controls, CMS should seek congressional authority, as appropriate.
Medicare Advantage often employs weak, ineffective DUR programs that fail to identify fraud and abuse in the Part D drug benefit or, once fraudulent or abusive patterns are identified, lack any systematic follow-up of the information. Plans can expect this to become a CMS Audit Hot Button. A relatively small percentage of the Medicare population impacts a significant financial impact. Clearly, there is a favorable ROI for plans to develop strong DUR programs. The Gorman Health Group can help in developing effective, proactive utilization management programs for your Medicare Advantage Plan.
Stars don't matter to real people
Kaiser Permanente published a study on Monday that found only about 6% of Medicare beneficiaries used the CMS star quality ratings to select a Medicare Advantage plan. And only 2% know what their plan's currnet rating is.
What is important to customers regarding their insurance companies? Pay my claims. Fix problems quickly. Don't let problems happen. Don't raise my premiums too much. Otherwise, I don't want to know you are there.
What does CMS measure? Two years ago 90% of a plan's members got their flu shots. What does that mean to me? I get flu shots from my doctor, not from the health plan. And, if I like my doctor, I assume I'm getting good care. One thing I'm sure of: I don't want my health insurance company in the exam room with me.
The star rating system is based on what CMS thinks should be important for Medicare beneficiaries. I haven't found any evidence that CMS surveyed beneficiareis to discover what is actually important to them.
Kaiser Permanente concludes that plans need to do more to inform beneficiareis about the star ratings, so they can make informed choices. I think CMS should scrap the whole thing and start over with the four or five things that really matter to health insurance consumers.
"Lean and Clean" is Key to Survival for Medicare Plans -- Join the exclusive GHG Compliance Forum November 2-4 in Las Vegas
New regs every other week. 500 HPMS notices a year. RADV audits and Star Ratings surveys. Intermediate sanctions and the threat of termination for poor Stars performance. And now a new, uncoordinated CMS Central Office/Regional Office audit approach that could result in multiple government reviews in a calendar year. "Lean and clean" must define a cultural and management revolution among Medicare plans. If you aren't on the compliance train in these next several years, you're going to be under it.
Tell your compliance staff about our latest Gorman Health Group Compliance Forum. This exclusive GHG event is designed for Medicare Advantage health plans and will provide an intensive examination of the state of compliance in MA, with focus on the changing regulatory environment surrounding both Parts C and D. The meeting is limited to GHG client health plan staff ONLY. No vendors, no CMS representatives, to ensure a frank and open discussion about the way forward.
You'll want your team to be in the room to hear the latest from GHG's compliance experts on:
- Practical tips for implementing a fully-integrated compliance program
- Best practice Sales Oversight strategies that have cross-functional impact
- Part D pitfalls and action steps for oversight and monitoring
- Lessons learned from risk areas in compliance, including sales/marketing, enrollment reconciliation and risk adjustment
For registration information and more details, click here.
To check out the preliminary event agenda, click here.
Have a question? You can always reach our team at ghg@ghgadvisors.com.
I'll look forward to seeing you and your team in Las Vegas.
GHG Revenue Management Forum in Vegas Coming October 6-7
We've been saying since passage of the ACA that the next 3 years' survival in Medicare Advantage is all about revenue management. The rules have changed and MA plans need new processes and new solutions to avoid serious financial troubles these next several years. Clinical initiatives often take years to bear fruit. As rates come down due to the ACA cuts, and more pile on from the Congressional Super-Committee, MA plans must pull every revenue lever they have to offset those losses, stay competitive -- and finance the care coordination and complex case management infrastructure essential to securing our long-term future in government programs.
Our clients said, "how?" We're saying: "come to 'Lost Wages' and we'll show you." The venue couldn't be more appropriate for the subject matter. So please join me and GHG's top experts on revenue management October 6-7 at the fabulous Aria Hotel, for an exclusive event for MA health plan senior leadership with responsibilities for finance, revenue management, Star Ratings, and risk adjustment. We will share our state-of-the-art practical strategies for driving revenue in the new age of austerity and accountability.
This forum will offer actionable, tactical insight regarding:
• Performance optimization and efficiency
• Must-have investments in your STARS programs and where to focus to boost your rating
• A cutting-edge risk adjustment program that drives higher, more compliant revenue and better quality and service for members
• Understanding the various components of MA capitation and their implications for your bottom line
This program is designed for senior-level finance decision makers with leadership responsibilities for Medicare Advantage programs. This event will be advanced, but highly practical and action-oriented. As with our previous events, this program is open to health plans only. The cost of this event is $995; space is limited to 60 for this exclusive event. Pre-register now to secure your plan's attendance.
Click here to pre-register
Click here to view the preliminary agenda
If you're in Medicare Advantage these days you're a gambler, so come to Vegas and we'll show you how to win now that the rules have changed.