Change is here: CMS Finalizes Chapter 13

It seems like only yesterday that I was submitting comments in response to CMS’ draft chapter 13.  It was, in fact, way back in April of 2007, when I was a budding young compliance analyst determined to keep a plan on the right track.

The review of draft chapter guidance was one of the best examples of CMS partnership that the organization afforded to plans.  But yesterday marked a new beginning: CMS released the final, updated Chapter 13: Medicare Managed Care Beneficiary Grievances, Organization Determinations, and Appeals, made effective retroactively to March 23, 2012.  No opportunity to provide comment on a five-year old chapter in desperate need of a face lift.  We can only speculate on why this is.  It’s possible that a deadline needed to be met and there was simply no time to share the draft with the industry. Many (but not all) of the changes had already been communicated to the public via memos and past call letters.  I don’t see it as a huge red flag; Chapter 4 was released as draft yesterday as well, and CMS recently solicited feedback on certain Marketing Guidelines changes.  So you still have a voice.

For this final chapter, however, organizations should quickly begin reviewing which policies and procedures need updating.  But don’t stop there.  Once revisions are made, be sure to communicate via specialized training. And document it!  Not only will you be working toward your effective Compliance Program requirement to provide specialized training, but you will also be ensuring that this high-risk area stays sharp.  And if you face endless hurdles for updated P&Ps to go through your internal approval process, take this final chapter on the road ASAP to the Medical Directors office, Customer Service, Utilization Management, Appeals and Grievances and your provider community. They are all directly affected by these recent changes. 

Chapter 13: Read it, learn it, live it, love it.