Highlights from 2017 CMS Audit and Enforcement Conference
The Centers for Medicare & Medicaid Services (CMS) hosted their annual Audit and Enforcement Conference on Thursday, May 11, and addressed the following topics:
- 2017 Program Audits
- Audit Protocol Updates: Compliance Program and Medicare Medicaid Plan
- Medication Therapy Management (MTM) Panel
- 2016 Program Audit and Enforcement Report
- Timeliness Monitoring
- Civil Money Penalty (CMP) Methodology
The presentations and recordings of the morning and afternoon sessions are posted here. All sessions merit a review by Compliance and operational teams at sponsors and delegated entities alike. Apart from the communicated clarifications and content provided on the slides, CMS allowed for numerous question and answer periods, both after each session as well as at the end of the day. Here I capture highlights of those Q&As.
Can an Independent Auditor (IA) follow the same CMS process of providing samples 1 hour before webinar sessions? In regards to the IA process, most sponsors do follow CMS protocol when doing validation, but it does not really matter to us how soon samples are delivered. It’s ok if you get them a little sooner. Most IAs do use the same protocol and timing, but it is not prescriptive, which is why there is not a lot of guidance around how IAs should audit.
If we had a CAR for CDAG clinical appropriateness, would the validation audit focus on that CAR, or would the validation audit need to be a full-scale CDAG audit? When it comes to that, the sponsor simply needs to validate the condition. A full CDAG audit is not required; just that particular condition.
To what extent are Invalid Data Submission (IDS) conditions a problem in 2016? They were not terribly problematic. Last year there may have been eight across seven sponsors, but CMS would like to see those at zero.
Now that you have covered 94% of enrollment with Cycle 2 audits, when do you plan to start a third cycle? CMS is not sure and is still looking at that.
Can or will CMS share overall observations in Timeliness Monitoring regarding performance? CMS believes they will be able to this summer.
How does CMS come up with the common conditions in calculating CMPs? CMS takes this from the annual audit report.
When are CMP notices posted on the CMP website? CMS posts CMPs as a result of program audits before end of February. For CMPs not related to audits, the agency posts those immediately after they are imposed.
In regards to call log universe, do we include calls placed to other vendors as a part of normal business (such as calls to transportation vendor) which do not pertain to main customer service? No, CMS wants only calls going to the main customer service line.
Is it appropriate to report date request received as AOR receipt date, or should sponsor report initial receipt date as request received? For ODAG tables with these two fields, sponsor should populate as each column specifies. CMS does consider both fields when doing timeliness calculations.
Will CMS release a revised Compliance Chapter 9/21 to reflect change in Elements from 7 to 3, or is this just a change in methodology? CMS is actively revising manual guidance. Compliance program requirements are still the same, but audit approach has changed. Do not confuse the three audit elements (Prevention Controls and Activities, Detection Controls and Activities, and Correction Controls and Activities) with the seven core elements outlined in chapter guidance.
Is there a timeline when CMS is expecting MTM audit activities to migrate from pilot to standard? At this point, it is not determined.
From a long-term perspective, considering validation is 150 days and MTM is a calendar year, how would this area be handled from a validation perspective? At this time, MTM not subject to validation. It is still to be determined if it will be subject to validation in the future.
How will appeals timeliness monitoring affect future audits? To the extent that the timeliness monitoring effort becomes annual, it would make absolutely no sense to review timeliness audit, but that change remains to be seen. However, there is a difference in that timeliness monitoring is a review of a snapshot of the year before. CMS may want to phase timeliness review out of program audits. CMS also answered the question from the perspective of the agency using results to target for audits. CMS noted they always like to compare data to audit scores and results to see if there is anything meaningful but confirmed there are no plans for that in the future.
"While CMS indicated they would not use results from the timeliness monitoring for referrals for audit, CMS did indicate they would study the results to see if there is a correlation to audit results," says a colleague on the Operational Performance team. "Knowing what is in your data and using it for process improvement should be on every plan’s radar." Since CMS staff indicated that the timeliness monitoring could one day potentially replace the timeliness review on program audits, sponsors should get ahead of that curve by using their timeliness monitoring data for their own internal review.
As always, we love to hear your thoughts and perspectives on agency activities as well as your experiences in the government programs space. Keep an eye on this blog for more updates from my colleagues on this week's conferences.
Resources:
The Gorman Health Group 2017 Forum concluded recently in New Orleans with over 200 of our closest clients and partners. John Gorman provides key takeaways from the event here. Make sure to join us next year!
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The Achilles Heels of Part D in Program Audits: FA and CDAG Administration
This may seem like the movie “Groundhog Day,” but Formulary Administration (FA) and Coverage Determinations, Appeals, and Grievances (CDAG) continue to hobble plan sponsors’ Centers for Medicare & Medicaid Services (CMS) program audit results. Failure to properly administer their CMS-approved formulary continues to plague plan sponsors. As a result, enrollees experience inappropriate denials of coverage at the point of sale and were delayed access to their medications, never received their medications, or incurred increased out-of-pocket costs in order to receive their medications. Plan sponsors continue to be tripped up in the following areas of FA:
Administration of CMS-Approved Formulary
- Rejecting prescriptions for formulary medications that were written by out-of-network providers
- Improper coding of the approved drug list
- Failure to allow claims for extended day supplies on initial prescriptions
- Failure to appropriately test and/or implement coding of quantity limits (QLs) in the adjudication system, resulting in inappropriate rejections
Administration of CMS Transition Policy
- Improper look-back period of member history
- Did not register beneficiaries’ historical claims in a timely manner, which led to sponsors not properly identifying beneficiaries’ historical drug regimen and eligible transition fills
- Denied beneficiary access to transition fills as a result of errors in enrollment data; for example, beneficiaries who were new enrollees were coded as continuing enrollees
- Failed to allow claims for formulary drugs dispensed in the smallest commercially available package size when the day supply, based on the prescribed dose, exceeded the plan’s day supply benefit
- Processed transition fills for only some of the drugs that were subject to a cross-contract year formulary change
- Processed concurrent drug utilization review edits as safety edits during transition, thereby inappropriately restricting drug access during the transition period
Effectuation of Prior Authorizations
- Not dating the effectuation for approvals to the earliest request of drug purchase date resulting in enrollees’ delayed or denied access to prescription drugs, having to receive formulary alternatives, or having to pay out-of-pocket in order to receive their drugs
Application of Quantity Limits
- Utilized maximum daily dose limits that were more restrictive than the CMS-approved QLs and/or Food and Drug Administration maximum recommended daily doses
- Applying incorrect adjudication logic for the type of QL submitted on the approved formulary (Type 1 QL Qty/Time submitted but applying Type 2 daily dose logic prevents partial refills)
- Applied QLs to non-formulary medications
Application of Step Therapy
- Using improper look-back period to establish prior drug history
- Applied prior authorization edits on claims for beneficiaries with a utilization history of protected class drugs
CDAG findings remain a costly area for plans. To date in 2017, 10 plans have been hit with a civil monetary penalty (CMP) – 80% of them were cited for a violation related to Medicare Part D CDAG requirements.1 Plans should be reviewing the common conditions and evaluating their own practices to identify risk areas. A compliance and operational assessment should be completed prior to CMS audit activities to ensure adequate staffing and oversight is in place to avoid potentially costly audit findings. The most common cited conditions seen year over year remain the following:
- Denial letter rationales
- Untimely Independent Review Entity (IRE) auto-forwards
- Insufficient prescriber outreach
- Untimely decisions and/or notifications
- Not effectuating exceptions through the end of the plan yea
- Misclassification of coverage determination or redetermination requests as grievances and/or customer service inquiries
Other areas which were cited in the CMPs and represent additional case selection potential in the 2017 draft audit protocols are the following:
Misclassification of reconsiderations as organization determinations or re-openings
- Re-openings are considered a remedial action that should be used sparingly. Inappropriate use of this procedure would delay case forwarding to the IRE, thereby delaying or denying enrollees’ right to the appeal process.
Improperly dismissed coverage request
- Dismissing a coverage determination instead of making a decision (approval or denial) should be done in very limited circumstances, usually limited to cases where a review is not required (e.g., party requesting coverage is not a proper party). If dismissed inappropriately, enrollees are denied access to the appeals process, which may result in delayed or denied access to medication.
1(https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/PartCandPartDEnforcementActions-.html_
Resources:
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
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Perhaps a Visit to the Physical Therapist Is in Order – Make Sure Your CDAG Process Is Not a Weak Spot
Coverage Determinations, Appeals, and Grievances (CDAG) remain a compliance Achilles heel for many Part D sponsors. The Centers for Medicare & Medicaid Services (CMS) has noticed! Challenges with interpreting CMS regulations and guidance and operational restrictions have the potential to create a very costly gap. CMS is increasing scrutiny of this area in 2017.
CMS identified this weak spot and has provided additional communications via the Common Conditions, Improvement Strategies, and Best Practice memos, Job Aids, and proposed clarifications in the 2018 Draft Call Letter. The 2017 Draft Audit Protocol proposes expanded case selection in the Clinical Decision-Making (CDM) 2017 Program Audits and increasing enforcement actions related to Part D Auto-Forwards.
GHG’s experience in assisting plans with Part D operational assessments and participation in CMS Program Audits has identified the following areas for greatest risk of non-compliance:
Timeliness – Despite overall improvements in recognizing the importance of adhering to the processing and notification regulatory time frames, many plans still struggle. On December 16, 2016, CMS released a memo describing their intent to increase the compliance to enforcement escalation process and intent to issue Civil Monetary Penalties (CMP) on a quarterly basis to sponsors that fail to meet an established threshold. The expected CMP outlier threshold is 15 or more auto-forwards per 10,000 beneficiaries per quarter. For smaller plans whose enrollment is less than 800, fewer than 10 IRE cases/appeals per quarter, and fewer than 10 auto-forward cases per quarter will be excluded from the analysis.
Classification and Processing of Re-Openings – GHG has observed sponsors that liberally utilize the reopening of coverage determinations and decisions. Sponsors may reopen a case, as a remedial action, under certain conditions; however, CMS expects plan sponsors to limit their use of the reopening procedure, so don’t get carried away! The reopening procedure must be used to process clerical errors but not the failure to execute the determination process itself to ensure enrollees have been afforded appropriate appeal rights. This scenario is on CMS’ radar for the 2017 Program Audits. Based on the draft protocol, an additional five cases may be selected for review to assess appropriate classification and processing of dismissals, withdrawals, and/or reopenings.
Tiering Exceptions – If your benefit is set up with a mix of brand and generic drugs on a formulary tier, you may need to loosen the purse strings. If a formulary tier contains both brand and generic drugs as determined by New Drug Application (NDA) and Abbreviated New Drug Application (ANDA) status, some sponsors have been incorrectly denying tiering exception requests. Many Immediate Corrective Actions Required (ICARs) were issued for this reason during the 2016 Program Audits. In the 2018 Advance Notice and Draft Call Letter, CMS provides clarification about their expectations for tiering exceptions. If a plan sponsor has a mixed tier, the lowest tier would be the tier containing alternatives to the requested drug. Make sure to review your formulary and understand the CMS definitions of “brand” and “generic” to appropriately assess your tiering exceptions procedures!
For a hands-on workshop on CDAG, plan to attend the GHG Forum April 26-27, 2017, in New Orleans. Our Conference Brochure and Preliminary Agenda Is Now Available! Download it to see the additional topics we have in store for you at this year’s event.
Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
Resources
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It’s Product, Benefit, and Premium Time for 2018
Whether you are just updating your current product benefits, are offering a new plan benefit package (PBP), new product, or service area, or are new to Medicare Advantage altogether, now is the time to start planning for the 2018 bid submission.
It is best practice in the bid process to utilize a working team approach, with one clear leader. The team should include representatives from the following areas to ensure the best product is brought to market, and, when it is offered, that the implementation of the product is seamlessly implemented. Some of the members who should be included are:
- Sales/Marketing
- Finance/Actuary
- Network
- Pharmacy
- Medical and Health Management
- Operations
- Compliance
GHG believes, at the beginning of the bid process, it is important to level-set the team on the marketplace. Some of the analyses we typically like to present include:
- Service area demographics
- Medicare penetration
- Current membership analysis
- Enrollment trend analysis
- Results of the Annual Election Period (AEP): Who are the winners and losers this AEP, and why?
- Product analysis
- Benefit analysis
- Competitive analysis
Strong planning is key in the bid process. You want to understand the goals upfront and make sure your product and benefits can deliver. We have found weekly meetings, a detailed project plan with strong leadership, and project management skills are critical if you want to limit the number of iterations and last-minute back and forth that brings along the increased risk of errors.
Having a strong operations component incorporated in the process helps identify the planning needed to seamlessly implement benefit changes and pinpoint impacts on customer service. The Sales and Marketing team are key in characterizing product differentials and how the benefits will be sold, and not only how the sales team will sell, but if the Sales team can sell the benefits.
We could go on, but you get the importance of every department working together and pulling their weight. GHG has seen the success of plans who get the need for a deliberate process, as well as those plans in nail biting situations – hoping it all comes together at the end. Let me tell you, the first way is always preferable! So get your analysis started, put your project plan together, and start putting together your team if you haven’t already!
Resources
Don’t miss our webinar on Tuesday, January 31, at 1:00 PM EST, where we will provide an informative session on how to conduct a feasibility study to develop a successful growth strategy for your organization. Register now >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year's event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
2017: Taking Stock to Inform Next Steps
As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if you believe in the effects of Mercury in retrograde.
- The audit protocols continued to be a work in progress not only for sponsors, vendors, and industry partners like Gorman Health Group, but also for the authors at the Centers for Medicare & Medicaid Services (CMS). A myriad of industry comments were submitted for consideration as they relate to the draft 2017 version. By now, most sponsors should have already incorporated similar methodology into audit and monitoring processes as a complement to existing methods.
- Sponsors without established monitoring and oversight focus on the accuracy of their network information have been subject to CMS review, have sought outside assistance to verify network accuracy, or have worked or are working internally to varying degrees to remediate known gaps in their processes. Per CMS, the Medicare Parts C & D Oversight and Enforcement Group (MOEG), in coordination with the Medicare Drug & Health Plan Contract Administration Group (MCAG), are taking a comprehensive approach to monitor, audit, and validate compliance with network accuracy requirements. MOEG’s pilot will use MCAG’s monitoring results to audit and validate correction of deficiencies. Some of the highest Star-rated plans can tell you about their network validation efforts and best practices, and it’s not a one-way street ‒ providers need to collaborate with sponsors and be proactive when information changes. We may expect to see enforcement actions stepped up as a result of CMS’ maturing efforts in validation of network accuracy.
- Earlier in 2016, our Operations team highlighted areas to keep an eye on based on the 2017 Draft Call Letter. They included the one-third financial audits, timely processing of coverage determinations and redeterminations, as well as data integrity. CMS has since noted they will increase penalties for outliers of Coverage Determinations, Appeals, and Grievances (CDAG) auto-forward rates, and they confirmed they will continue to raise the consequences for ongoing noncompliance in this area in 2017. The appeals timeliness monitoring effort announced on November 29 will provide CMS even more data for review and action.
- Later in the year, our Pharmacy team recommended key strategies to prepare for the coming year, including conducting Pharmacy Benefit Manager delegation oversight audits and conducting targeted audits. Most, if not all, of the mentioned strategies require a group effort, which begs the question: Did you have the time and the resources to accomplish all you wanted to do by end of year?
This is a good time to rethink methodologies and reorganize in preparation for changes to come. The key here, especially this month, will be to take stock of what we do not have control over, set those things aside, and plan to take action where we can.
Resources
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We can help your MA-PD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Visit our website to learn more >>
Reflections on the Basics of Delegation Oversight
Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to understand complex language and reading concepts without the foundation or basics. It would be quite an overwhelming few months for anyone.
With any course of study, it is important to start from the beginning. Furthermore, if you want to master that course, teamwork and collaboration allows for practice and improvement towards fluency.
As we start wrapping up 2016 (and wrapping up holiday presents), it’s a good time to reflect on the basics. What does this have to do with delegation oversight? The basic premise of delegation is that you are entrusting someone to perform an activity on your behalf. If you are looking to delegate for success, we recommend the following key steps to take place at the very beginning:
- Get to know your delegate partner via pre-delegation discussions, site visit, and audit.
- Understand how your delegate will demonstrate effective, compliant activities on your behalf.
- Agree upon monitoring and auditing activities ahead of time, leaving room for augmentation.
We have seen many examples of delegation oversight programs and activities over the course of the year, and some Compliance Officers and Operations leaders find themselves in the delegation oversight equivalent of enrolling in Advanced French. That is, they were not involved in pre-delegation activities and, therefore, did not have a chance to advocate for the sponsor's obligations towards an effective compliance program. Without the basic foundation, they find themselves in an uphill battle when they try to get data or ask for changes to monitoring frequency.
“Oversight of delegated entities can be an overwhelming task,” says Beth Matel, Senior Director of Compliance Solutions. “To help ensure a sponsor has the cooperation of the entity to which they have delegated responsibilities, they must start by including the pertinent contractual provisions outlined in Medicare Managed Care Manual, Chapter 11, Section 100.4 - Provider and Supplier Contract Requirements and 100.5 - Administrative Contracting Requirements.” Sponsors delegating Part D administrative or health care service functions will need to ensure the appropriate subcontractor contractual language is in place as well.
Our Compliance Solutions team is grateful for all the opportunities we have had this year to support our client partners and share best practices, from the basics to the advanced. As you reflect on your delegation oversight programs, give yourself a present if you:
- Have strategies in place to ensure shared data is sent and received correctly each time (especially membership data!).
- Conduct immediate root causes analysis in response to inquiries or grievances regarding something potentially amiss.
- Complete robust testing prior to new benefit implementation.
- Partner as a team (Compliance and Operations) to ensure success together.
- Maintain a dedicated unit focused on delegation oversight.
- Stay up to date on the Centers for Medicare & Medicaid Services requirements and changes as they affect your delegates and communicate them timely.
Bonne chance!
Resources
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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.
Resources
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.
Resources
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.
Resources
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 >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
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.
Resources
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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