CMS 2015 Oversight and Enforcement Conference – Compliance Edition
The pessimist complains about the wind. The optimist expects it to change. The realist adjusts the sail. -William A. Ward
Those who had the opportunity to view or attend the Centers for Medicare & Medicaid Services (CMS) annual Audit & Enforcement Conference & Webcast better start thinking about which group of folks you will be a part of: pessimists, optimists, or realists. In order to maximize your success, you best classify yourself in the realist bucket — quick.
One thing that did not change over last year is CMS’ overall assessment of improvement. Mr. Mulcahy confirmed CMS has still not seen the improvement they had hoped to see after years of issuing best practices and common conditions information to the industry. Go back to last year’s video archives, and you will find he said the same thing last year. According to CMS, sponsors are still surprised by audit activities and findings and unaware of their level of compliance.
Many best practices to combat this type of situation in your organization were discussed during the conference. For example, one organization pulls universes using CMS’ data layouts on a monthly basis. Another organization stressed the need to not only focus on the short term in corrective action plans (CAPs) but also consider the long-term solutions required for long-term success—that includes a deep-dive into processes and continuous training. Once-a-year specialized training will no longer cut it, especially in the areas of Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) where CMS notes sponsors, at times, seem unaware of their compliance.
Some things that are changing are the audit protocol instructions and data layouts currently on the Program Audits site. CMS confirmed there are a number of issues requiring clarification or correction in the protocol — we anticipated this. They hope to release updated protocols by the end of this month, but if a plan is subject to audit in the meantime, they will receive the updates. In terms of audit support, CMS’ Jennifer Smith confirmed there is still a plan for CMS to release a chapter on audit activities. Once released, this should be a great help to plan sponsors. CMS also provided detail pertaining to the Medication Therapy Management (MTM) and Provider Network Adequacy audit pilots, scheduled to be released in late summer or early fall.
We are continuously making adjustments to processes to ensure alignment with CMS activity, and we hope our clients and all plan sponsors are doing the same. The Medicare Parts C and D Oversight and Enforcement Group (MOEG) confirmed that, if any sponsor receives a civil money penalty (CMP) or sanction, they will be expected to engage an independent auditor to validate corrections. CMS confirmed 93% of plans audited in 2013 received some sort of CMP, and at the recent GHG Forum in April, I shared the majority of enforcement actions since 2014 have indeed been related to CDAG and ODAG. Talk about a risk! It really is time to look inward, be a realist, captain your ship, and adjust those sails.
If you have questions pertaining to the audit protocol, CMS advises you to forward any questions to part_c_part_d_audit@cms.hhs.gov. If you have questions regarding the conference, or have questions on how we can assist, please feel free to contact me directly at rpennypacker@ghgadvisors.com.
Resources:
Register now for a new webinar on improving quality ratings and member retention efforts, as well as prominent compliance and service issues plaguing the industry on Friday, June 26 from 1-2 pm ET.
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