Preparing For The 2017 Call Center Monitoring
On November 16, 2016, the Medicare Drug Benefit and C & D Data Group of the Centers for Medicare & Medicaid Services (CMS) issued the “2017 Part C and Part D Call Center Monitoring and Guidance for Timeliness and Accuracy and Accessibility Studies”.
In an effort to ensure continued call center compliance in 2017, CMS has contracted with IMPAQ International, LLC, to monitor plan sponsors’ call centers. Although the call center requirements are nothing new for health plans, CMS describes the elements which will be monitored and provides tips on how to prepare for the monitoring studies. IMPAQ will conduct two studies – the Timeliness Study and the Accuracy and Accessibility Study.
As we are quickly approaching January 1, now is the time for plan sponsors to identify call center compliance issues and work to not only clean up any messes but to also beef up your call center staff. Compliance actions may be on the line, but so is the face of your organization – besides providers, your call center staff engages your members and prospective members most often. A confident and well-trained call center staff is crucial to your prospective and current member experience! Carrie Barker-Settles, Director of Sales & Marketing Services, says, “One of the most important beliefs in developing a strong member experience is effective communication to the member. A health plan may want to consider what messages, tone, look, and feel they want the member to see, read, and hear with every touchpoint.
Contact us for ideas on how we can partner with you to efficiently monitor your call centers in preparation for the 2017 CMS Call Center Monitoring and to empower and revitalize your call center staff and strengthen your member experience.
Below are further details on the 2017 CMS Call Center Monitoring:
Timeliness Study
- Measures plan sponsor’s current member call center phone lines and pharmacy technical help desk lines to determine average hold times and disconnect rates.
- Conducted year-round with quarterly compliance actions.
- Plan sponsor’s will receive a compliance action for the Timeliness Study if: 1) it fails to maintain and average hold time of two minutes or less; and 2) it fails to limit the disconnect rate of all incoming calls to 5% or less.
- Results will be available quarterly through the Health Plan Management System (HPMS).
Accuracy and Accessibility Study
- Measures plan sponsor’s prospective call center phone lines to determine: 1) the availability of interpreters; 2) TTY functionality; and 3) the accuracy of plan information provided by customer service representatives.
- Conducted from February through May with compliance actions taken when an organization’s interpreter availability is less than 75%, its TTY score is lower than 65%, or its rate of accurately answering questions is below 75%.
- Results will be provided via HPMS and announced via an HPMS email.
Do this now:
- Verify the accuracy of your 2017 Part C and Part D call center phone numbers in HPMS by January 2, 2017.
- Conduct internal monitoring to identify any compliance concerns for timeliness.
- Ensure interpreter availability and monitor call center calls to ensure foreign-language calls are handled according to your policies and procedures.
- Ensure your call center staff is prepared to promptly respond to beneficiary questions – CMS has their timer set at seven minutes!
- Test all your call center lines to ensure your ability to accept calls.
- Regularly test your TTY device to ensure proper functionality.
- Ensure your call center staff is trained and ready to respond to questions regarding items listed in the Medicare Marketing Guidelines, Section 80.1.
- Ensure your call center staff is trained on the 2017 benefit information.
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At Gorman Health Group, we want to change the perception that member experience is the responsibility of Sales and Customer Service, instead showing organizations that member experience is a comprehensive approach with full transparency and cross-functional leadership. Visit our website to learn more about our Member Experience Services >>
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Preparing for the 2018 Medicare Advantage and Part D Application Season
On October 31, 2016, the Centers for Medicare & Medicaid Services (CMS) posted the 30-day releases of the 2018 Medicare Advantage and Part D new application and service area expansion instructions for public comment.
While this is not an annual process for each Sponsor, it is a yearly undertaking for Gorman Health Group. It is also a busy time for CMS staff who field the Notices of Intent to Apply and subsequent application submissions. Substantive proposed changes include the following:
- Chart of Required Attestations by Type of Applicant – The chart was revised to provide the applicants with clarification in identifying fiscal soundness requirements.
- Administrative Management – CMS clarified the information for the two-year ban period and inserted the date for the two-year period for the current application cycle.
- State Licensure – CMS clarified the information regarding licensure requirements, which should reduce the number of deficiencies related to licenses that automatically renew after the applications are due.
- CMS Provider Participation Contracts and Agreements – CMS removed the attestations due to duplicative and redundant language.
- Health Services Management and Delivery (HSD) –
- CMS clarified the information for applicants regarding Medicare certification requirements based upon public comments received in response to the 60-day comment period. Medicare certification is only required for applicable providers and facilities.
- CMS clarified the information for Regional Preferred Provider Organization (RPPO) applicants regarding the network requirements and contract agreements. The volume of RPPO applicants has been extremely minimal in previous application cycles.
- CMS clarified the instructions for applicants regarding the submission and process for HSD tables and Exception Requests based upon public comments received in response to the 60-day comment period.
- Revised attestation in Eligibility, Enrollment, and Disenrollment to include an additional option for beneficiaries to make a disenrollment request by calling 1-800-MEDICARE.
- CMS revised the signature authority for a Special Needs Plan upload document to include both Chief Executive Officer (CEO) and Chief Operating Officer (COO) based upon feedback from the previous application cycle.
- CMS clarified the information for applicants related to the regulatory requirements in the development of the Model of Care (MOC).
The Part D application documents note they made no substantive changes, instead providing a redlined version to outline updates made to reflect the 2018 cycle and instruction clarifications. Keep your eyes open for the final applications to be released sometime in January, along with the no-cost training calls CMS will hold prior to the submission date of February 15, 2017.
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The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization. Don’t let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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PBM-Supported Part D Measures Impact Quality Bonus Payment Revenues
Regulatory time frames around coverage determinations and appeals have existed since the inception of the Part D benefit. Timely access to medications has been a hallmark of the “member protective” stance the Centers for Medicare & Medicaid Services (CMS) has taken since Day 1. So how is it, even 10+ years into the delivery of the program, compliance with these time frames continues to be the bane of health plan Compliance and Star Ratings teams?
When CMS posted the 2017 ratings in October, the Medicare Advantage Prescription Drug (MA-PD) plan averages actually fell from 4.5 and 3.3, respectively, in 2016 to 3.9 and 2.9 in 2017. How can this trend be accounted for in the wake of ongoing CMS pronouncements regarding its dismay at the large number of auto-forwards sent for external review and that it would closely watch outliers and take vigorous enforcement actions against plans?
Even with all of the prodromal warnings by CMS, we have started to see the impact of low scores in these two measures in the newly released 2017 Star Ratings. Thirty-four plans that earned ≥4 stars in 2016 dropped below 4 stars in 2016 and will lose their Quality Bonus Payment (QBP) revenues. Of these, 53% earned only 1 star on both the Part D Appeals Upheld and Appeals Auto-forward measures, which, even if “artificially” reduced via unsatisfactory performance in CMS audits, were found to have substandard performance in this area.
Are Pharmacy Benefit Managers (PBMs) the culprit? Minimally, it must be restated the origin of these Star Ratings stemmed from compliance and member protection concerns, and if they were performing adequately, would have gone the way of, say…. call center hold times (by the same PBMs), which improved enough to be dispatched to the display measure list. Even with performance guarantees, intensive oversight by plans, onsite inspections, and internal audits, these misadventures continue to occur, and dire consequences follow. In general, PBM performance guarantees cannot begin to compensate for the potential lost bonus revenue, and plans are re-evaluating performance criteria, degree of health plan oversight required, and, in some cases, pondering the insourcing of all coverage determination-related activities. It may be time for “zero tolerance” in the health plan stance toward vendor-provided coverage determination services, as even one missed time frame may be a harbinger of more to come.
For questions or inquiries about how Gorman Health Group can support your organization’s Part D Star Ratings efforts, please contact me directly at lerwin@ghgadvisors.com.
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GHG anticipates that CMS will continue adjusting thresholds, curving the Star Ratings year after year in an effort to separate the remarkable from the ordinary. Now is a critical time – MA Plans must examine not just this year’s score and what contributed to it, but their Plan’s score history in the Stars program and what it says about the enterprise’s overall approach to key issues. Visit our website to learn more about how we can help your organization >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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CMS Provides Reminders on Key Dates in the MA-PD Application Process
Open Enrollment for the Affordable Care Act Marketplaces and the Annual Election Period for Medicare is underway. But this month also marks the start of required Centers for Medicare & Medicaid Services (CMS)-facing activities necessary for the application process.
Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group, points out “for many MA-PD applicants, activities are already underway. Oftentimes, Sponsors do not realize that the application requires all hands on deck until it is too late. It is a multi-disciplinary effort that requires attention to detail and collaboration at all levels of the organization.”
CMS recently released the following memos, providing reminders on key dates in the application process.
Release of Notice of Intent to Apply for Contract Year 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) and Related CY 2018 Application Deadlines
CMS released information and key dates about the Contract Year (CY) 2018 Notice of Intent to Apply (NOIA) web tool and key dates for the CY 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) application cycle.
2018 Application Activity Key Dates
NOI deadline to ensure access to CMS’ HPMS..............................................................November 14, 2016
CMS sends NOIA confirmation e-mails…………………………........................................November 30, 2016
CMS User ID connectivity form submissions must be received.....................................December 2, 2016
CY 2018 applications posted on CMS websites..................................................................January 10, 2017
Final day to submit NOIA for 2018……………………….....................................................January 27, 2017
CY 2018 applications submission deadline.......................................................................February 15, 2017
Medicare-Medicaid Plan (MMP) Notice of Intent to Apply for CY 2018
CMS released information and key dates about the CY 2018 NOIA web tool and key dates for the CY 2018 MMP application cycle.
CY 2018 Application Key Dates
NOIA deadline to ensure access to CMS’ HPMS..............................................................November 14, 2016
CMS sends NOIA confirmation e-mails……………………...............................................November 30, 2016
CMS User ID connectivity form submissions must be received by...................................December 2, 2016
CY 2018 applications posted on CMS websites................................................................January 10, 2017
Final day to submit NOIA for 2018……………………….....................................................January 27, 2017
CY 2018 applications submission deadline........................................................................February 15, 2017
Value-Based Insurance Design (VBID): Year 2 (CY 2018) Request for Applications
The Center for Medicare and Medicaid Innovation also announced the release of the Medicare Advantage (MA) VBID model test’s Request for Applications (RFA) for CY 2018. MA-VBID is an opportunity for plans to offer supplemental benefits or reduced cost sharing to enrollees with certain chronic conditions. Organizations that wish to participate in the model test in 2018, including those participating in 2017, must respond to the CY 2018 RFA by January 20, 2017, at 4:00 p.m. Eastern Time.
The application process is an arduous one. Completing the application requires cooperation from your entire organization. The actual submission leaves no room for error, and the review process requires quick thinking and prompt responses to CMS follow-up questions. As always, Gorman Health Group is here to assist your organization with the application process.
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Don’t let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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CMS Releases New Guidance on Coverage Determinations & Redeterminations
On October 18, 2016, the Centers for Medicare & Medicaid Services (CMS) issued enhanced guidance on outreach attempts to support coverage decisions in its memo titled “Guidance on Outreach for Information to Support Coverage Decisions.” In recent years, CMS Program Audits have consistently identified the failure of plans to have documented sufficient outreach attempts when more information is needed to make a coverage decision. Guidance hasn’t been clear on what CMS expected, but it was obvious based on audit results most plans were not meeting the level of outreach CMS considered to be sufficient. The memo has many critical points every plan should be reviewing and implementing.
Here are four items your plan should look at today to determine system and process capabilities to support the new clarifications:
- Ability to Begin Outreach Quickly – How quickly does your plan open a coverage request or redetermination? Most plans process expedited cases quickly, but standard requests are often in a queue that may take days to open and review for completeness. The new guidance requires the initial request for additional information for a standard Part C organization determination to be sent within two calendar days of receipt and a redetermination request to be sent within four calendar days. This means plans must not only be able to triage weekend requests for expedited versus standard requests but determine if standard requests need more information.
- Multiple Outreach Methods – CMS outlined several methods for requesting information. Those include telephone, fax, email, and standard or overnight certified mail. Many plans use one or maybe two methods. CMS indicated, upon review of cases, consideration will be given to the plan’s use of multiple means of communication.
- Documentation of Outreach Attempts – It is critical systems be able to both store and report on the methods and date/time of the communication. CMS noted for emails and faxes, the timestamp is the evidence. For mail, it is the date/time of the postmark, which is a change from the mail date often used in internal systems. For telephonic outreach, it is the date and time of the call. In addition to the date and time documentation, plans should document two other critical pieces of information for the outreach attempt: 1) the specific description of the required information being requested and 2) the name, phone number, fax number, email, or mailing address of the point of contact. In the case of a phone call, the plan should document with whom they spoke, what was discussed or requested, and what information was obtained.
- Ability to Enforce Response with Contracted Providers – CMS has often indicated there is a concern plans are unable to get timely responses from their contracted providers. In the new guidance clarification, CMS reinforces this requirement. CMS expects plans to set up contractual requirements to support contracted provider responses to requests for information. Additionally, CMS is looking to health plan physicians to outreach to contracted providers when more information is needed to make a determination and the provider did not respond to requests.
While the new requirements may be aggressive, they do provide additional clarity on what CMS is expecting health plans to complete in order to be compliant. The question is, what types of systems and process changes will be needed to store and report on these changes?
Gorman Health Group (GHG) subject matter experts have been a part of numerous CMS audits and have observed similar feedback from the auditors. We have worked on remediation projects to implement this type of enhancement as well as recommend this to our clients on operational assessment projects. We know the struggles these changes present and can assist you in working through them. Implementing these changes may be challenging, but the end results of higher compliance and consistent, fully reviewed decisions for members will be worth it.
If you have questions about implementing the changes outlined in this memo or whether your current processes are compliant, we can help. You can reach us through our website or by emailing me directly at jbillman@ghgadvisors.com
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CMS conducts their audit and provides a list of risks and a short timeframe (ninety days) to correct the deficiencies. We can help. Visit our website to learn more about how we can help ensure the right actions have been taken to remediate the issues found >>
New Webinar: The 2017 Star Ratings are out! Join John Gorman, GHG's Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on October 27 at 1 pm ET for a cross-functional review of the 2017 Star Ratings ― from key program updates and 2017 Part D insights to emerging Pharmacy and Pharmacy Benefit Manager issues, new medication measures, and strengthening the connection between risk adjustment and Star Ratings. Register now >>
New Webinar: On November 1 at 2:30 pm ET, join GHG's John Gorman and Melissa Smith as well as Eric Letsinger, President of Quantified Ventures, a firm committed to supporting the progress of the social enterprise community, and his colleague Brendan O’Connor, an Impact Manager, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
2017 Readiness Checklist – Valuable Tool or an Exercise in Redundancy?
Some people are list makers and wholeheartedly embrace the value of checklists. They utilize lists to manage tasks, stay focused, and ensure high-quality results. A publication by the Institute of Health’s Committee on Quality of Health Care in America, titled “To Err is Human: Building a Safer Health System,” lays out the value of checklists in improving patient safety. We should view the Centers for Medicare & Medicaid Services (CMS) Readiness Checklist in that same view: it is a tool to allow health plans to improve the quality and compliance of their health plan and safety of their members.
As with all checklists, the process can be a “check the box” experience or a valuable tool to make sure everything is in place and nothing was forgotten. We all know to expect a CMS Readiness Checklist on an annual basis, but do we use this amazing tool to its fullest? Be sure you make this a serious exercise to evaluate your program and readiness for 2017. Some sections may be redundant year after year, but health plans find broken processes year after year, sometimes through negative member experience―don’t let that be your plan.
Every item on the Readiness Checklist should be reviewed and validated. Some items are new and may take more time and effort to validate. Here are four new items on the 2017 Readiness Checklist where you may want to invest additional time:
- Medicare-Medicaid Dual Eligibles Non-Discrimination and Cost Share Protection – The 2017 Readiness Checklist has a new emphasis on protecting the rights of lower income members, particularly Medicare and Medicaid dual eligibles and others eligible for the Low Income Subsidy (LIS). CMS also highlighted this topic in their conference in September. Plans are required to ensure dual eligible beneficiaries are not balance billed for deductibles, coinsurance, or copayments for which they are not responsible. CMS is requiring plans to verify they have procedures in place to ensure their providers do not discriminate against beneficiaries due to their dual eligible status or balance bill those members who receive assistance with Medicare cost-sharing from a state Medicaid program. It is a health plan’s responsibility to manage their provider network to prevent this type of abuse of Medicare and Medicaid full dual eligible individuals.
- Best Available Evidence (BAE) – CMS included additional guidance for plans to review their BAE process. CMS expects plans to have processes in place to allow BAE to be accepted at the point of sale. If health plans do not have scripts in place to assist their member services and pharmacy help desk staff, then they must be developed and put in place to support members requesting assistance with BAE-type issues.
- Online Enrollment Center (OEC) Application Receipt Date – One policy change this year is the way the receipt date is calculated for OEC applications. Plans need to calculate the receipt date to 11 hours earlier than the time and date stamp provided on the CMS file.
- Non-Discrimination and Alternate Language Tagline Language – CMS also raises the new requirement for Non-Discrimination and Alternate Language Tagline translation language plans are now required to distribute to their members. CMS is requiring plans to verify they have processes in place to satisfy these new requirements.
This year’s release is earlier than previous years, allowing plans more time to validate and implement all actions. Similar to last year, CMS has changed the attestation process for the 2017 Readiness Checklist to a strategic conversation between plans and their CMS Account Managers. Without that formal attestation process, don’t devalue the Readiness Checklist and required actions – utilize the tool as the valuable resource it is which will ultimately make your health plan better and your members safer. To err is human, and for that reason, redundant validation is a critical step to make sure your program is ready for 2017.
Our consultants have implemented items from the 2017 Readiness Checklist for health plans just like yours. If you need assistance verifying you are ready for 2017 or have questions on your processes, we can help. You can reach us through our website or by emailing me directly at jbillman@ghgadvisors.com.
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New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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CMS Releases Long-Awaited Civil Money Penalty Calculation Methodology
On September 13, 2016, the Centers for Medicare & Medicaid Services (CMS) quietly released its long-awaited proposed methodology on the calculation of Civil Money Penalties (CMPs). The memo describes the calculation method of CMPs for Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), Cost Plans, and Programs of All-Inclusive Care for the Elderly (PACE) plans in 2017. While CMS is not mandated to release this methodology, it did so in response to industry concern over transparency of CMP calculation and to provide more clarity to compliance operations. Comments on the proposed methodology are due to CMS by 5:00 p.m. ET on October 13, 2016.
Given that 60% of the referrals for potential enforcement actions stemmed from MA and Part D program audits, this memo focused on CMP calculations for deficiencies detected during such audits. For each deficiency identified, CMS determines whether the sponsor:
- Failed to substantially carry out the contract;
- Is carrying out the contract in a manner inconsistent with the efficient and effective administration of this part; or
- Is no longer substantially meeting the applicable conditions of 42 C.F.R Parts 422 or 423.
CMS then calculates CMPs on a per enrollee or per determination basis, as developed during its pilot, to standardize CMP calculations in 2014. The main difference CMS made between the pilot and its proposed calculation is the slight increase in penalty amounts over time to "encourage" compliance with CMS' rules. CMS also introduced an enrollment-based limit on the maximum CMP amount a sponsor can receive for each deficiency.
CMS calculates the standard penalty amount by taking the CMP amount and multiplying it by the number of enrollees or determinations. CMS then applies the aggravating and/or mitigating factors, multiplied by the number of enrollees, to the CMP which either increases or lowers the amount. Finally, CMS applies the enrollment-based or per determination limit, which caps the overall penalty CMS can issue.
The specific amounts CMS applies for the above can be found in the memo.
"In my daily conversations with Compliance professionals, the challenge to compile clean universes on the first pass is still that — a challenge — regardless of plan size," says Regan Pennypacker, Senior Vice President of Compliance Solutions. "This memo clarifies the agency will also consider Invalid Data Submission (IDS) as a condition that could result in beneficiary harm. This is cited when a Sponsor fails to produce an accurate universe within three attempts. CMS has noted this would be cited for each element which cannot be tested, and counts as one point in the scoring. CMS will calculate a CMP for this deficiency on a per determination basis."
This proposed methodology comes during the same time frame federal agencies are increasing CMP maximums across the board to comply with the Federal Civil Penalties Inflation Adjustment Act of 2015. The Department of Health and Human Services (HHS) released its interim final rule on September 6 across all its agencies. Some MA maximum penalties will see a maximum increase more than double its current amount. However, as the CMP methodology memo points out, CMS rarely utilizes the maximum amounts currently, instead using amounts that are likely to "better encourage the remaining non-compliant sponsors to improve performance." Currently these amounts are significantly lower than the maximum possible CMPs, however, this memo clearly puts plans on notice continued non-compliance will lead to increased penalty amounts that will cause a greater sting. Given this notice penalties among health plans for common infractions will increase, health plans should make sure to focus on highest risk areas like delegation oversight and appeals and grievances.
Now is the time to confirm those responsible for pulling and compiling CMS universes are equipped with the tools and skills to complete the task. Failure to produce accurate universes after a third attempt during an audit will significantly impact a CMP. Contact us for ways we can help.
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The Centers for Medicare & Medicaid Services (CMS) audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. Visit our website to learn how we can help you >>
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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Part D Benefit Administration Continues to be Important Monitoring for CMS
Your Pharmacy Benefit Manager (PBM) may have already provided to you their benefit testing pan for 2017. Based on many years of experience, that is not going to be enough. In the September 12, 2016, memo entitled "Contract Year 2016 Part D Formulary Administration Analysis (FAA)", the Centers for Medicare & Medicaid Services (CMS) reiterates their concern with the accuracy of formulary coding. In previous years' analysis, 9 out of 88 (10. %) Plan Sponsors were found to have failed FAA, meaning greater than 20% of the sampled rejects were determined to be inappropriate. The parameters for the 2016 FAA are:
- Sponsors are required to submit all point of sale (POS) rejected claims relating to the following four categories:
- Non-formulary status;
- Prior Authorization (PA);
- Step Therapy (ST); and
- Quantity Limits (QL).
As a Plan Sponsor, whether you delegate all or part of your Part D drug benefit set-up to your PBM, CMS expects Plan Sponsors to demonstrate effective management of the CMS-approved formulary to ensure timely beneficiary access to clinically appropriate medications.
CMS expects Plan Sponsors to understand regulatory requirements and to oversee their PBM to ensure the benefit administration by the PBM is compliant and accurate. Beneficiaries must be able to receive the Part D drugs to which they are entitled consistent with the plan's CMS-approved benefit from January 1 through December 31 of the plan year.
To accomplish this, it is essential to perform comprehensive benefit administration testing of formulary files and system edits prior to going "live" in the adjudication system. In addition, it is required to perform a regular review of rejected POS pharmacy claims as well as to perform regular oversight of other delegated PBM functions.
You can reduce your compliance risk of transition non-compliance by testing transition fill look-back logic, which must accurately identify transition eligible beneficiaries and drugs eligible for transition fills; maintaining formulary consistency for beneficiaries across years and during the year; ensuring formulary edits are effectively tested for accuracy prior to implementation; and by ensuring the PBM does not administer the Part D benefit based on either Medicaid or commercial program requirements.
In the likely event of a Compliance Program Audit, CMS seeks to determine how the Plan Sponsor properly administers the CMS transition policy and its approved formulary by avoiding unapproved utilization management (UM) practices, PAs, QLs, rejecting formulary medications as non-formulary, and maintaining beneficiary access to protected class drugs during transition and throughout the year. Failure to properly use approved formularies creates high audit risk, a possible civil monetary penalty (CMP), or even plan sanction.
Performing a comprehensive Benefit Administration Test review of the formulary and UM system edits prior to going "live" on January 1 of every new plan year requires a robust, systematic process for comparing the CMS-approved formulary benefit to a comprehensive claims universe in order to ensure all covered drugs, tiering, and UM edits are consistently and accurately adjudicated.
Our Pharmacy experts can create a plan and conduct in-depth benefit administration testing for your organization to validate everything is working precisely as it should before the new plan year begins. We can ensure your PBM is processing claims consistent with your CMS-approved prescription drug benefit.
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New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
We can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Contact us today to get started >>
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Sales Oversight — Essential Guidelines
All agents are expected to comply with the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines, federal and state laws, and health plan rules, policies, and procedures. But what does that mean, and how can health plans enable their employed sales staff and contracted agents to stay compliant while achieving target goals and growth?
Some organizations may have sales management monitoring tools and processes to review the agent's compliance, quality, and performance thresholds. In most cases, sales management personnel are required to provide ongoing monitoring of agent sales activities and performance.
Below are a few key components to Medicare sales force and distribution channel management:
- Ensure all agents selling Medicare products complete and pass all required training
- Communicate all product and regulatory information
- Ensure agents participate in any required remedial training
- Communicate the results of all ride-along evaluations
- Document any complaints or corrective action plans in the agent's file, which should be held for a minimum of two years
- Ensure any corrective action plan is completed and reported back to the health plan
- Report terminations of any agents/brokers to the state and the reason(s) for the termination
Gorman Health Group (GHG) suggests implementing a variety of compliance monitoring programs to ensure all agents are conducting sales, marketing, and enrollment activities in accordance with federal, state, and health plan regulations, rules, and guidelines. With the Annual Election Period (AEP) just several weeks away, health plans should be finalizing their sales oversight and agent performance standards. Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, says: "We know it's not easy. These activities take a village. A solid partnership between the creative minds in Sales and the rules-minded Compliance staff is critical to success. A sponsor with a well-planned roadmap for AEP will be one step ahead of competitors that have not executed as well."
To promote compliant behavior, health plans, sales management, agency owners, and agents should take an active approach to compliant behavior — attend additional training, understand and follow the rules and regulations outlined in the Medicare Marketing Guidelines, and always lead by example.
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
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Strive For Progress, Not Perfection, Because It Doesn't Exist
This week was a productive one for CMS and Compliance professionals. The 2015 Part C and Part D Program Audit and Enforcement Report was published on September 6, and the 2016 Fall Conference took place on September 8.
Highlights of the report include the publication of the most common conditions. CMS provided the frequency of the conditions from 2011 to present as well as the percentage of sponsors affected in 2015. Conditions which have been present six out of six years include the following:
- FA: Sponsor failed to properly administer its CMS-approved formulary by applying unapproved quantity limits
- FA: Sponsor failed to properly administer the CMS transition policy
- FA: Sponsor improperly effectuated prior authorizations or exception requests
- CDAG: Denial letters did not include adequate rationales, contained incorrect/incomplete information specific to denials, or were written in a manner not easily understandable to enrollees
- CDAG: Sponsor did not demonstrate sufficient outreach to prescribers or beneficiaries to obtain additional information necessary to make appropriate clinical decisions
"The repetition of these usual six only goes to show the complexity and ambiguity involved with ensuring beneficiary harm does not occur. The key is to identify and correct the issues before CMS makes a visit as well as having a long-range plan in place for continual improvement," says Charro Knight-Lilly, Senior Vice President of Client Relations. The report answers many commonly asked questions regarding methodology for sponsor selection, process improvement strategies, and enforcement actions. By having audited sponsors with such a large number of enrollees during the first year of the audit cycle, CMS hopes to cover 96% to 98% of beneficiaries enrolled.
The Fall Conference included a range of topics such as application updates, network adequacy, and anti-discrimination rules (the implementation of which continues to confound the industry). In my experience, some of the most valuable feedback comes directly from plan sponsor staff, and that was no exception on Thursday. Jenny O'Brien described UnitedHealthcare's shift from reactive and responsive to proactive, strategic, and innovative. Her words resonated about the need for Compliance staff to be this way. In all honesty, readers shopping around for a motto for a Compliance Awareness campaign should use those three words and call and thank her.
Based on Gorman Health Group's observations of 2016 activities, CMS is continuing with their audit schedule full steam ahead, but the science has still not been perfected — and it will never be. As much as CMS is working to refine audit processes to improve consistency and accuracy, that's what responsible sponsors do every day. Continue to share your feedback with CMS regarding their processes, and, as always, you can reach out to us for insight and assistance.
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The Centers for Medicare & Medicaid Services (CMS) audit practices have undergone a few changes in recent years, but the core focus remains the same: beneficiary protections. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more about our audit services >>
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