Star Ratings Update: MedPAC Votes to Eliminate Double Bonuses
Star Ratings is already a hot topic in 2016, and we're only one month into the new year. In most recent news, the Medicare Payment Advisory Commission (MedPAC) unanimously voted last month to eliminate the double bonuses associated with Star Ratings, while also virtually unanimously voting to exclude diagnoses collected during in-home assessments from the Medicare Advantage Risk Adjustment model. Although the Centers for Medicare & Medicaid Services (CMS) may opt to take an alternate approach to resolve Risk Adjustment issues within Medicare Advantage, and since CMS can't independently remove double bonuses with amending certain elements of the ACA legislation, this new development is a great reminder of the need to periodically pause and evaluate the value and ROI of programs which remain prominently placed on CMS' radar screen.
When CMS continued their support of in-home assessments in the 2016 Call Letter, we all breathed a collective sigh of relief. And since that announcement, we have seen significant effort by both health plans and vendors to make these assessments even more clinically and socially focused while simultaneously aligning them with Star Ratings measure needs. As a result, any strategic changes made in response to MedPAC's January votes could have a pervasive impact on the care models and operational structure health plans have come to rely on for Star Ratings success. CMS' response to MedPAC's recommendations, along with the plethora of other potential Star Ratings program updates may not only impact health plans and providers, but could also impact a wide array of health services purchased through vendors.
Many health plans (and their vendors) have leveraged risk assessment work streams to hardwire carefully-planned and strategically-prioritized clinical care and care planning activities into in-home assessment workflows in order to seamlessly impact Star Ratings and achieve multi-faceted return on investment (ROI). In addition, the data collected during risk assessments is often stored in centralized data warehouses and used throughout the health plan as a foundation for population health, care management, and consumer experience strategies. And if that wasn't enough, because members often value the relationship with, and advice received from, the clinician they allow into their home, any changes to in-home assessments introduce a host of new risks relative to self-care and disease management, member satisfaction, and consumer experience.
As we await guidance from CMS regarding their response to MedPAC's recommendations and regardless of how CMS ultimately responds to both issues, this is a great time for leadership to study and thoughtfully consider a number of decisions which could result from either the elimination of double bonuses or changes to CMS' treatment of in-home risk assessments:
- What is the downstream Star Ratings impact of any benefits proposed for reduction or elimination?
- How have quality, medical management, pharmacy, Star Ratings measure gap closure, member retention, and other strategic priorities been hardwired into in-home risk assessments?
- What is the secondary ROI from in-home risk assessments on Star Ratings measures, health outcomes, medical loss ratio (MLR), member satisfaction, and member retention?
- Are current work streams adequate to support strong 2016 performance on new Star Ratings measures under consideration for addition to the Star Ratings program?
- How is each department using the data collected during in-home risk assessments?
- How well positioned is the provider network to serve the care planning and care management needs of members currently receiving in-home assessments?
- What types of alternative workflows and tactics will be used in the event diagnoses obtained from in-home assessments are not allowed for risk adjustment purposes?
Because time is of the essence in our industry, strategic planning and change management never ends. As John Gorman has said for years, it will be the most adaptable plans which will both survive and thrive through the tumultuous industry evolution.
In-depth analysis and industry-leading commentary on the key announcements from CMS and MedPAC can be found in this recently created white paper.
Gorman Health Group (GHG) can help you adapt your Star Ratings approach to account for these potential changes and streamline your Star Ratings strategy to influence health outcomes while remaining compliant with CMS regulations. For additional questions and inquiries about how GHG can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.
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Breaking the Incompatibility Barrier — Four Keys to Merging Operational Productivity and Compliance
Can compliance and efficiency co-exist in Operations? Is there a "right" balance between the two, or could it be more of an intertwining of the two? If you have been in Operations long enough, you have been told you have to increase efficiency, reduce staff, and improve handle time or auto-adjudication rates. What you probably have not been told is to be more compliant, except maybe by the Compliance Department. Widgets in, widgets out, is the name of the game.
It's a lot of plates to keep in the air, trying to balance more with less, and now we add in compliance. What if compliance and productivity cannot only co-exist but can cause a department to thrive? Here are the four critical keys to an intertwined compliant, productive Operations team.
- Don't Ignore the Human Factor — Productivity and compliance are both reliant on employees. All the best tools, reporting, and systems can be in place, but if well-trained and engaged employees aren't on the team, we won't have well-run productive and compliant processes and teams. Employee engagement, like member engagement, is critical to success.
- Know the "Why" behind an Action — We need to change compliance from an obstacle to be circumvented to a process to be embraced. We do that by showing the relevance to the process — the "Why." Have you asked your team what the critical Centers for Medicare & Medicaid Services (CMS) requirements are for the activities they perform? Does the Claims staff know the time frames for processing a claim or the requirement for a clear and understandable denial reason? Even more important, do they know why those requirements are in place and how they impact the beneficiary?
- Have the Right Tools — Do you know how many manual work-arounds your team completes on a given day? How many member communications must be manually completed? How much manual research is needed to adjudicate a claim? Does your management know? IT changes are costly and take time, but we must get things on "the list." That's why a current prioritized list of enhancements is needed. Make sure to document the productivity and compliance loss due to the work-arounds. Include team member's input — their voice is important to understanding the true issues. Spearhead the top critical needs on the earliest IT release possible.
- Provide Measurable Results of Success and Failure — How do you and your teams know when you are successful or when you failed? Do your reports show both your production and compliance goals? Typically, Operations has lots of reports, but how are they aligned — with commercial or Medicaid metrics or the unique Medicare metrics? Is this shared with your team?
In the Medicare world, Operations can't be a balancing act — it's all about intertwined compliance and productive Operations teams. At Gorman Health Group, we know how important it is to link compliance and productivity. For actionable advice on this topic and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas.
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To File or Not To File, That Is the Question
We've made it clear through this blog the Centers for Medicare & Medicaid Services (CMS) is throwing down the gauntlet in terms of ensuring Medicare Advantage provider networks are adequate. The biggest change to the 2017 application process supports this initiative. For Service Area Expansions, CMS is requiring current service area network data at the contract level in addition to the pending service area data. Previously, CMS requested only those providers supporting the pending counties. Applicants took to the CMS User Calls to ask clarifying questions about this requirement, including a number of "what if" questions, indicating that applicants either know they have unknowns in their networks, or they know how their network fares and they want to know the consequences. In addition to some provider network documentation changes, here are some other notable changes to the application process:
- Quality Improvement Plan and Crosswalk are no longer required at the time of submission.
- If a contract of the applicant has been terminated or non-renewed over the past two years, a Two-Year Prohibition Waiver Request is required.
- Additional required contacts have been added.
Here are some key dates to keep in mind:
- User Calls took place on January 13 and 20. Current and pending Sponsor applicants are encouraged to review the CMS Part C & D User Call recordings.
- The application deadline is February 17, 2016, at 8:00 PM Eastern time.
- Part C deficiency notices will be sent mid-March.
- Part D deficiency notices will be sent late March.
- Part C and Part D Notices of Intent to Deny or Approve will be sent late April.
- Requests to drop counties are due May 20.
- Part C and Part D Conditional Approvals or Denials will be sent late May.
Additional important dates have been communicated in the Part C and Part D application materials and in the User Call presentations. Something CMS has made clear again this year is that applicants should review all instructions provided, and reach out with questions, as there are no exceptions to the filing deadline. A well-prepared applicant will target for an early submission date so as not to risk getting caught up in a bottleneck of uploads. If you haven't done so already, get ready and start your engines!
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Issues That Will Define Government Health Programs in 2016
The new year brings a slew of issues that will define government-sponsored health programs. Here's what we're watching closely, not necessarily in this order. Opportunities have never been greater in Medicare, Medicaid, and ObamaCare, but execution risk is rising fast. If this was an easy business, we'd be out of business.
Drug Pricing: Prospects for a legal fix in Congress is questionable, and this will be a leading issue in the Presidential campaign. Expect administrative action, demonstration project solicitations from the Centers for Medicare & Medicaid Services (CMS), "comparative effectiveness research" by federal agencies on specialty drugs, and "collaborative pricing" initiatives between pharma manufacturers and payers on high-profile therapeutic classes. Health plan CEOs expect higher specialty drug cost trends to be the biggest driver of medical cost trend in 2016.
Medication Therapy Management (MTM): 2016 is the year MTM gets real. CMS will begin conducting widespread audits of Medicare Advantage (MA) and Part D plan medication reviews, and there is tremendous emphasis on MTM in the Star Ratings system. Making MTM real for your members will require extensive vendor contracting and Pharmacy Benefit Manager (PBM) coordination, so turn your plan's attention to this fast.
Antitrust/Mergers: Sometime in Q3 or Q4 of 2016, the Federal Trade Commission and the Department of Justice Antitrust Division will rule on proposed mergers for Aetna/Humana, Anthem/CIGNA, Walgreens/Rite-Aid, and Pfizer/Allergan. We expect all four deals to be approved but with strings attached; e.g., we expect Aetna/Humana will have to divest 250,000-450,000 lives to get a green light.
Star Ratings: Must be a central focus of all payers and providers in government programs. Star Ratings has transcended MA and Part D. Star Ratings data is already being collected by ObamaCare plans, and over a dozen state Medicaid programs are using CAHPS® and Star Ratings data in contracting with plans for dual-eligible and managed long-term care (LTC) initiatives. And while there aren't major changes to Star Ratings measures in 2016, scoring is the game-changer: 50% more plans will be scored for the first time this year, guaranteeing a shift right in the ratings bell curve and that many of 2015's 4-Star plans will go off the cliff. To maintain progress, plans must run Star Ratings as a program with dedicated leadership and execution spelled out at the workflow level.
Risk Adjustment: 2016 will usher in increased efforts to ensure payment accuracy through more stringent and expansive Risk Adjustment Data Validation (RADV) reviews, and so providers delegated for risk and sharing in a percent of premium will be in the spotlight. CMS is seeking to contract with third-party auditors on RADV, and risk adjustment is a top concern in the Department of Health and Human Services (HHS) Office of Inspector General (OIG) work plan.
Providers and Care Delivery: 2016 will be a transformative year with contracted providers in government programs. Narrow/preferred networks and value-based risk contracting will go mainstream this year, whether providers are ready or not. Huge penalties start this month on network adequacy and accuracy of provider directories, and NAIC's model guidance on provider networks will be a central document governing the issue. Star Ratings measures on access to care and the member experience put new heft and revenue behind network requirements. Provider-sponsored entities will provide a mini-surge of dozens of new plans into MA and Medicaid in 2016 and 2017, especially among Medicare Accountable Care Organizations (ACOs), so keep your friends close and your enemies closer. Home- and community-based services and alternatives to nursing homes will go mainstream in 2016. Retail pharmacies will become the second-most-important provider type for health plans. With crushing burdens of ICD-10 and meaningful use, small and mid-size practices will become overwhelmed and will underperform. Plans will need aggressive oversight, quality improvement, and directory management activities to stay ahead.
Exchange Payment: For the first time in two years, CMS is going to begin paying plans HIX 820s at the member level, which will shine a spotlight on enrollment reconciliation issues that have been lingering. The plans' readiness transition period is from January to March, then it gets real in April.
Medicaid and Dual Eligibles: Unexpected states like LA, SD, and IA are now considering Medicaid expansion. CMS is focusing on new Medicaid quality measures and will be depending heavily on NCQA quality measures to gauge health plans. This will impact payment and future membership for some lower-rated plans. Beneficiary opt-outs in excess of 75% are plaguing early dual-eligible demos, but many states remain in fiscal crisis and need to move ahead to balance budgets.
Compliance: 2015 was a near-record year in CMS enforcement actions, and scores always get settled with insurers in the second term of a Democratic administration. There will be a slew of rules coming from CMS this year as well as expanded audits from OIG. Both agencies' approaches indicate how critical documentation remains: CMS added a number of items to documentation requests for Compliance Program Effectiveness; Medicaid, dual-eligible, and LTC demos are still very documentation-heavy, and CMS found that approximately two-thirds of CMS-reviewed FFM issuer plan policies and procedures (P&Ps) were incomplete or had operational findings with their vendor contracts. So even though there is focus on data monitoring and passed/failed samples, P&Ps and documents are still the cornerstone.
There is no question that 2016 will be a banner year in government programs enrollment, and the long walk in the desert on payment rates in MA and Medicaid appears to be over. But execution risk and the enforcement environment have never been tougher. This year will be a "Darwinian moment:" it's not about being the biggest or even the smartest but being the most adaptable.
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Top Five Operational Resolutions for 2016
Did you know only 8% of people who make New Year's Resolutions achieve them? There are many reasons why resolutions are not accomplished. They may have been too aggressive or priorities changed. Sometimes it's because the goal is too vague or there are far too many and a person is unable to focus on them all.
When it comes to achieving resolutions, there are two keys to success: be specific and stay positive.
Here are our top five operational resolutions to consider for 2016:
- Re-evaluate your controls against current guidance. Are the standards still the same? Is your evaluation process adequate to ensure compliance?
- Fix your highest volume workaround. Every department has them. Some prevent rework, some are due to obsolete systems, some were set up for ease of users, but workarounds are hard to monitor, hard to explain in an audit, and are a risk with staff turnover. Fix it so you have one less thing to sidetrack processes.
- Set up redundancy in processes. We have all been in a place where a single individual knows a process. Your single source of success can easily turn into a single source of failure if that staff person wins the lottery and decides to travel the world.
- Evaluate and improve the highest priority item requiring rework. One client had a high volume of Medicare Secondary Payer (MSP) records which would be closed and then show up again every few months. The rework and premium loss and recovery were a continuous cycle. After evaluating the records, a root cause was identified, which was within the plan's control, and resulted in less MSP churn.
- Celebrate more successes. Does your staff know their compliance rates? Do they know if they are improving month over month? Do they know the compliance issue they reported resulted in better ongoing compliance and prevented harm to members? Celebrating successes not only ensures staff sees the part they play in the big picture but reinforces the requirements.
Gorman Health Group has experienced consultants who can assess and review the operational areas of your organization. We can review current processes and look for efficiencies to improve outcomes and better compliance. Make a resolution to improve your organization's operational areas — we can help make it happen in 2016.
For more information, please contact me directly at jbillman@ghgadvisors.com.
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Three Reasons Why Compliance Program Effectiveness Needs Evaluation Now
Happy New Year! It's a time when your organization may be evaluating whether or not to submit a new application or a service area expansion. This may be when annual training kicks off once again. You may be reviewing attestations to determine which vendors need to provide you with new documentation. And don't forget to ensure the Claims Department has updated systems to reflect the current prompt payment interest rate.
For those of you in Compliance, all of the above might be on your radar, in addition to the day-to-day. If you have not tested or evaluated the effectiveness of your Compliance Program lately, now is the time to do it. Here are three reasons why:
- Major pharmacies cited for repeat violations of privacy violations. Pharmacies arguably make up the largest group of downstream entities for Sponsors. Those contracted pharmacies have been subject to hundreds of Sponsor-specific general compliance and fraud, waste, and abuse (FWA) training in the past, as well as the trainings created by the pharmacy benefit managers (PBMs). (Starting this year, Sponsors must require first tier, downstream, and related entities (FDRs) to take the Centers for Medicare & Medicaid Services (CMS) training and accept the certificate of completion.) As you can see from the article, health information privacy complaints are on the rise. Sponsors should not simply check a box confirming a PBM attested that all pharmacies took training — this should be tested and sampled as part of auditing and monitoring. Furthermore, if and when a potential pattern of issues is identified, a deeper investigatory dive and escalation of corrective actions should be pursued.
- The new season of audits is approaching. At the end of October, CMS released their revised 2015/2016 protocols. Recently, CMS released a memo stating they continue to receive inquiries and concerns not only from Sponsors but also from FDRs regarding the difficulties encountered with adopting the new training requirement. While they have not delayed or retracted the requirement, CMS has decided to suspend their review of the FDR training certification aspect in their program audit protocol. Having this suspended in the audit protocol is by no means a free pass — it only highlights CMS' acknowledgement that implementing their guidance has been a challenge. Plan Sponsors still have the responsibility of ensuring those contracted to service their members understand their obligations, because it doesn't only take an audit for CMS to take action over FDR issues — it could be one call to a Regional Office or an escalated number of Complaints Tracking Module (CTM) cases that places your organization on CMS' radar.
- You may already know where your weaknesses are — evaluate the program and get those weaknesses and corrections documented. CMS has placed the onus on Sponsors to hire independent auditors to validate program audit corrections. If you are targeted this year, why not be as prepared as you possibly can be? Some things you cannot change — but it is of utmost importance you make time to conduct a Compliance Program Effectiveness (CPE) audit.
CMS has never said they are looking for a perfect audit. They expect to find things; therefore, you should also expect to find things in your own CPE audit. By virtue of regularly testing and evaluating the effectiveness, you make strides to strengthen your organization as a whole.
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In addition to monitoring your operations and auditing the organization's performance, CMS also audits the compliance function. In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Learn how GHG can help >>
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Agent Commission: Don't find yourself on the wrong end of the tipping point
Agent compensation for Medicare Advantage has changed drastically since the implementation of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. MIPPA included regulations, for the first time, around Agent/Broker Commission - among many other things. The goal of implementing commission requirements was to ensure there was a level playing field between plans by implementing the Fair Market Value (FMV) limits, thereby removing the incentive for agents/brokers to enroll a beneficiary into the top-paying plan or to churn beneficiaries from one plan to another. Rather, the goal was to ensure the beneficiary was enrolled in the plan that best fit his/her needs.
So, how did it work? Well, for the most part, we have seen the requirements implemented and The Centers for Medicare & Medicaid Services (CMS) prescribed processes followed. However, we've also seen an increasing amount of instances in which plans are trying to get around CMS requirements. For example, by paying exorbitant "override fees" to the Third-Party Marketing Organization (TMO) for little to no actual services in exchange or by not pro-rating commissions per CMS instructions, an issue which we saw addressed twice by CMS via Health Plan Management System (HPMS) memo this Annual Election Period (AEP). See HPMS memos titled, "Agent/Broker Compensation," released on October 30, 2015 and November 20, 2015.
The reality is that CMS has been focusing their Program Audits in recent years on those issues which have direct impact on beneficiary access to care and has not routinely audited agent commission requirements for several years. Have plans taken advantage of the fact CMS has been focusing efforts elsewhere? Yes, we believe so. However, it appears CMS is becoming aware of the non-compliance around agent commission that is pervasive and even standard in the industry, evidenced by the multiple HPMS memos released this AEP addressing issues of non-compliance.
We know that in the past several years, CMS has exercised its authority by handing down Enrollment Sanctions and Civil Money Penalties (CMPs) for non-compliance. In fact, we see the current year-to-date total CMP amount at $4,719,220 — up from $1,131,505 in 2013.
So, the question is not if CMS will take action to address non-compliance around agent commission, the question is when. More importantly, when CMS does take action, on which side of the tipping point will your Organization land?
If you're not sure where to start, here are some recommendations:
- Review your agent/broker and TMO contracts to ensure the contract language is in compliance with CMS requirements — pay particular attention to the "admin fees" being paid to the TMO.
- Review actual payments made to agents/brokers to ensure the payment system is calculating the accurate amount based on current compensation schedules on file with CMS.
- Review actual payments made to agents/brokers when the amount should have been pro-rated to ensure the payment system is calculating the amount accurately.
If you have questions or need clarification regarding any of the information listed above, contact us here and a team member will be in touch with you shortly.
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CMS Clarifies Key Audit Terminology
Immediate Corrective Action Required (ICAR), Corrective Action Required (CAR), and Observation. These terms have become part of the vocabulary for Compliance specialists, auditors, analysts, managers, directors, and Compliance Officers who so often field questions from Operations. Let's consider the following scenario: Compliance has just completed an internal audit of Claims Operations and has identified findings. This leads the Ops team to ask, "Are these findings CARs or ICARs?"
Last week, the Centers for Medicare & Medicaid Services (CMS) issued a memo clarifying certain definitions which apply to their Program Audit process. This clarification was released in response to Sponsors who have provided feedback stating they feel the process for determining CARs, ICARs and Observations is not transparent, and they lack the ability to determine how audit conditions will ultimately be classified. CMS has posted clarified definitions for these terms, as well as the term Invalid Data Submission (IDS) here on their CMS Program Audit website. While I will not re-write the memo, CMS hopes these key term definitions provide the industry with the transparency it sought. In short:
- ICAR: These are items CMS identifies during an audit as systemic deficiencies so severe they require immediate correction. CMS cites lack of access to medication and/or services as well as immediate threats to enrollee health and safety. ICARs count as two points in the scoring methodology.
- CAR: These are items CMS identifies during an audit as systemic and requiring correction, but the correction can wait until the audit report is issued. (This does not mean wait until the audit report is issued!) CMS clarifies that CARs may affect beneficiaries but not in a way immediately impacting their health and safety, and count as one point in the scoring.
- Observation: These are non-systemic, typically one-off issues of non-compliance identified during the audit. No points are assigned in the scoring methodology for Observations.
- IDS: This is cited when a Sponsor fails to produce an accurate universe within three attempts. This will be cited in 2016 for each element which cannot be tested, and counts as one point in the scoring.
CMS directs plans to send any questions to their mailbox at part_c_part_d_audit@cms.hhs.gov. Take it from me, the CMS team is responsive to posed questions. An informed and more prepared industry will hopefully make for a smooth 2016 audit season for CMS and for Sponsors.
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Evolution of Validation: Selecting an Independent Auditor
The Centers for Medicare & Medicaid Services (CMS) audit validation process has evolved over the past few years. Here is what you should know about the changes and how to best prepare to contract with an Independent Auditor, or IA.
Let's go back to 2012. CMS was conducting the validation of audited Sponsors' corrective action plans (CAPs) by retesting areas found to be problematic. While the terminology has changed, the charge was led at that time by the Regional Office. In 2013, validation became an activity conducted by the Medicare Parts C & D Oversight and Enforcement Group (MOEG) at Central Office and Regional Office staff. Any items that resulted in a Corrective Action Required (CAR) or an Immediate Corrective Action Required (ICAR) were subject to validation.
As part of the 2013 validation timeline, the Sponsor had seven days from the issuance of the final audit report to submit a CAP for each condition. If we reference the 2014 Part C and Part D Program Audit and Enforcement Report, CMS outlined the average number of days which elapsed after an audit notice was issued.
If we take a look at the average days elapsed from the Exit Conference to the Final Report Issued date, the number of days elapsed has decreased, from 241 days in 2011 to 99 days in 2014. Based on the last year of reported data, plans still had a healthy three months from the verbal acknowledgement of CARs and ICARs (that is, the Exit Conference) to the issuance of the final report in order to implement corrections. In theory, by the time the final report was issued, some issues could have been corrected and, therefore, could have been ready for validation. However, time had to elapse for CMS to approve the CAPs, and after that point, CMS allowed Sponsors another 90 calendar days from that approval to implement and test the results of those CAPs. That's a lot of time when you look at it from the beneficiary perspective.
Fast forward to today — CMS is exercising their authority to require a Sponsor to hire an IA in order to validate if deficiencies found during a CMS program audit have been corrected. In a memo released on November 12, 2015, CMS confirms they will not provide recommendations on IA firms. Instead, they require the Sponsor to attest to both the independence of the IA as well as an absence of conflicts of interest. They point to the 2010 guidance for the selection of a Data Validation auditor for examples of relationships not meeting the standard for organization independence.
We are united with CMS' recommendation that Sponsors solicit proposals to select an IA early in the post-audit phase. Speaking from the auditor standpoint, it is much better for all parties involved to plan early, so exceed CMS' expectations and seek proposals as soon as possible. It's better to have that agreement in place ahead of time, rather than waiting until CMS sends you their instruction to hire an IA. This will give you the time to evaluate your options, so you can best determine their experience and subject matter expertise. When you are accountable to CMS to validate corrections, it is particularly important to partner with someone you can trust to apply a skilled eye to the validation activities. Otherwise, you may be subject to further scrutiny by CMS, which is the last thing any Sponsor needs when coming to the close of their audit process.
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2016 Readiness Review Smaller Size, Bigger Punch.
The Centers for Medicare & Medicaid Services (CMS) released the 2016 Readiness Checklist on Monday, November 9, 2015. The 20-page checklist is full of items CMS is expecting plan sponsors to review and validate it will be compliant for the 2016 calendar year. While CMS won't have an official website for plan sponsors to attest to the readiness this year, they will use other methods to validate compliance. No matter the validation method, CMS' expectations are clear: Part C and Part D plan sponsors should review and validate compliance for each item.
In reviewing the 2016 Readiness Checklist, there are some new and modified requirements as well as other areas of CMS concern. Regardless of whether or not the items are new to the readiness checklist party, they should all be known to you. If they aren't familiar, you may want to check your Health Plan Management System (HPMS) and regulatory guidance distribution process. CMS indicates at the end of almost every requirement where the guidance for that item came from―what Medicare manual or HPMS memo provides the supporting information for that item. CMS makes it convenient to validate what you are asked to validate and attest.
If you have waited until now to implement or validate new guidance from 2015, it will be a stressful few weeks in what is already a very busy time of year. Several items are heavy-hitters and get into the nitty gritty of processes. As in past years, any items which won't be in compliance are to be reported to your CMS Account Manager. No one likes to be on that list.
Many sections of the Readiness Checklist are smaller but have more potential process changes. "By no means should plans see an abbreviated Compliance and Fraud, Waste, and Abuse (FWA) section and start resting on laurels," said Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). Regan went on to say, "In this year's checklist, CMS issues another reminder about the May 24, 2014, regulation change which requires mandates on Medicare Advantage (MA) organizations to require all of their first tier, downstream, and related entities (FDRs) to take the CMS training and accept the certificate of completion of the CMS training as satisfaction of this requirement."
Another change highlighted in the readiness assessment is plan sponsor's appropriate use of extensions for organization and coverage determinations and appeals. In audits, we often see plan sponsors who have failed samples due to extensions granted for contracted providers or when extensions are used early in the process and on a routine basis rather than as an exception. CMS is expecting plan sponsors to review their process for exceptions and ensure they are in compliance.
One change Regan called out is CMS included a recommendation that plan sponsors making pharmacy network changes provide both those pharmacies whose network status is changing and enrollees using those pharmacies with notices of changes specific to their situation. "This is almost certainly a result of CMS' close work with one plan sponsor on effective notification strategies as part of pharmacy network changes. While the plan sponsor had indeed sent letters to supplement the Annual Notice of Changes' (ANOC's) notification of changes, the recommendation is to move to a more personalized notification approach," indicated Regan. "This will allow beneficiaries to make a more informed decision and will also aid pharmacies in understanding their network status."
A senior consultant of Pharmacy & Clinical Solutions at GHG, stated, "The Readiness Checklist is always an excellent method of making sure you have the bases covered for new guidance which takes effect in the new plan year (2016)." Deb went on to indicate there are three items plan sponsors must pay particular attention to in the 2016 Readiness Checklist for Part D. They are as follows:
- The long-delayed requirement "physicians and other eligible professionals who write prescriptions for Part D drugs are required to be enrolled in Medicare in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, unless the prescriber is an ‘Other Authorized Prescriber'." This takes effect on June 1, 2016, and, therefore, plans must confirm their contracted providers, including dentists, are eligible to furnish Part D prescriptions.
- Also, providers must have a valid prescriber National Provider Identifier (NPI) number for Part D claims to be valid. Specifically, "for plan year 2016 and thereafter, claims for covered Part D drugs must include a valid prescriber NPI. Part D sponsors must submit to CMS only prescription drug event (PDE) records containing an active and valid individual prescriber NPI."
- Starting on January 1, 2016, it is CMS' expectation Medicare Advantage Prescription Drug (MA-PD) plan members will not leave a network pharmacy without their prescription for a medication(s) where coverage may available under either Part D, Part A, or Part B. Plan sponsors and/or their PBMs must have processes in place so the network pharmacist can exchange information with the plan sponsor or PBM about the member to make the determination about which arm of Medicare will pay.
Parting words from Regan, "CMS makes it clear these are key requirements, and the checklist is not an exhaustive list. Consider these items to be hot topics CMS will hang their hat on in the coming year." The key to successful MA and Part D programs is to know your business better than anyone, including CMS. The Readiness Checklist is one additional tool to do just that.
Resources
If you need assistance in assessing your organization against the Readiness Checklist or in strengthening your MA or Part D program, GHG's knowledgeable team is here to help you. We've been in your shoes and know the pain points and how to move through them. We can help you prevent that punch from being a knock out. Contact me directly at jbillman@ghgadvisors.com.
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