CMS 2015 Spring Conference
Some important points came out of the Centers for Medicare & Medicaid Services’ (CMS’) Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast; the presentations and videos of the event can be found here in CMS’ Event Archives. If you did not have a chance to attend or watch it live, please watch the videos for important changes pertaining to many aspects of the MA-PD program. Speakers addressed Part C and Part D call letter updates, policy and technical changes, Quality Improvement Project (QIP) and Chronic Care Improvement Program (CCIP) lessons learned and best practices, the new network management module, enrollment updates, and fraud, waste, and abuse (FWA).
From the Compliance perspective, we heard the following loud and clear:
- Enrollment in MA-PD is growing with the aging of baby boomers. CMS is taking a proactive stance to improve the program by stressing the need to work together with plans to provide care more efficiently and provide quality.
- Finalized program changes allow CMS to require MA organizations or Part D plan sponsors to hire an independent auditor to validate correction of CMS audit findings. The good news is − some of you are doing this today. Having another set of eyes on your correction efforts provides you with a level of assurance you may not be able to obtain by having internal staff performing validation. Ever hear that phrase, “There are three sides to every story: yours, mine, and the truth?” Getting an independent perspective is so important. While you might not agree with a reviewer’s findings, the point is that it will hopefully bring you closer to the truth than validating yourself.
- CMS clarifies when it is appropriate for an MA plan to invoke an extension on organization determination and appeal requests. Based on what we see, most plan sponsors are invoking extension requests in rare circumstances and strive to meet the regulatory timeframes established without extension. Therefore, plan sponsors should be prepared to update procedures to ensure extensions are only taken when appropriate.
- Network adequacy — Not only is CMS requiring that provider directories be updated real time, they are adding network adequacy to program audit protocols (coming late summer or early fall, according to CMS). CMS is also implementing a way for plans to check their network adequacy by submitting their Health Service Delivery (HSD) tables in the Health Plan Management System (HPMS). Previously, this step was only available within HPMS when submitting an application for a new plan or a service area expansion (SAE). Plans could contract with a vendor or obtain software to check their own network adequacy. We anticipate that CMS’ network adequacy protocol will require a plan to provide real-time data pertaining to whether or not their contracted providers have open panels. I’m aware of one 5-Star plan that has been doing ongoing network adequacy reviews for a while. Those plans that are used to pulling HSDs only at the time of application or (possibly) bid submission should plan now for the additional steps CMS may require of plans to tell the true story of adequacy. Keep your eyes on this blog for more information from my esteemed colleague, Ellie Martin, on network adequacy.
CMS’ upcoming MA-PD Audit & Enforcement Conference & Webcast is taking place on June 16. Prioritize this event in your schedule, and attend either in person or via webinar.
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