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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