CMS Focus: Compliant Independent Review Entity Data

The focus on compliant Independent Review Entity (IRE) data should come as no surprise to Part D sponsors. In December 2016, the Centers for Medicare & Medicaid Services (CMS) released the Health Plan Management System (HPMS) memo, Compliance and Enforcement Actions Related to Part D Auto-Forwards, indicating sponsors with inordinately high auto-forward rates were subject to compliance actions that could be escalated to enforcement actions. The memo established a threshold rate, and in spring of 2017, CMS began imposing civil monetary penalties (CMPs) on Part D sponsors with demonstrated non-compliance with coverage determination and redetermination auto-forwards to the IRE. And with that, the die was cast.

The Timeliness Monitoring Project (TMP) is an opportunity to demonstrate compliant processes and data integrity in support of CMS’ Star Ratings. With this data collection effort, the playing field is leveled in the evaluation of sponsors’ IRE data. The TMP effort by CMS – while offering a fair and balanced methodology as it seeks to assess all plans instead of those identified in a targeted review – also provides CMS a separate and distinct window beyond program audits in identifying sponsors with problematic organization and coverage determination processes.

Plans that are unable to provide complete and accurate universes will be at risk with both their Part C and Part D Star Ratings as described in the December 12, 2017, HPMS memo, Timeliness Monitoring Project (TMP). “CMS considers data integrity issues, if identified, as an indicator that a contract’s measure data are invalid for the Star Ratings. CMS may also independently evaluate the data to gain insight into sponsors’ performance in these two program areas.”

The unfortunate reality is that an inability to accurately capture data within organization systems is likely symptomatic of any number of inefficiencies, for example:

  1. Lack of systems/analytics to compile data needed to assess compliance with CMS expectations
  2. Insufficient monitoring efforts
  3. Potential for processing inefficiencies such as inadequate resources, training, or expertise

CMS proposes a scaled reduction in a sponsor’s Star Ratings data that is found to be incomplete or “lack integrity.” The consequences of a lowered Star Rating can be a devastating blow to sponsors. Yet often, performance issues remain inadequately addressed. Plans sometimes need help knowing where to begin.

Sponsors can readily utilize the Audit Process and Data Request guidance for Organization Determinations, Appeals, and Grievances (ODAG) and Coverage Determinations, Appeals, and Grievances (CDAG) as the playbook on IRE auto-forward compliance.

Start with a great outreach process

  • Is plan staff aware of what clinical information is required to make a well-informed decision?
  • Is there a consistent, timely, and well-documented process in place for provider outreach?
  • Can this be evidenced in your systems, and more importantly, is this being tracked and monitored by plan staff?

Follow up with timely and sound decision-making

  • Do the decision-makers have all the information they need to make the decision?
  • Are decisions primarily made based on sponsor formulary/Evidence of Coverage (EOC), clinical criteria, federal regulations, CMS guidance, compendia, or peer-reviewed literature (where allowed)?
  • Are there any trends in plan denials for lack of clinical information? What efforts are being made to address those trends?

Ensure adequate notification processes exist

  • Plans should have well-established processes for enrollee and provider notification that includes consistent methods of outreach, clear and unambiguous documentation in systems, with well-written and understandable denial rationale.
  • Notifications must be timely, with documentation of both oral and written outreach detailed in plan systems. Plans must be able to evidence when the notification(s) entered the mail stream.

Sponsors have the ability to ready themselves by:

  • Regular monitoring through sample mock auditing
  • Developing dashboard reporting to assess the veracity of the data
  • Evaluating universe creation and testing it: can all steps be evidenced in plan systems?
  • Ensure internal processes for organization determinations and reconsiderations/coverage determinations and redeterminations are working effectively

Gorman Health Group’s Clinical Solutions practice area has a talented team of registered nurse professionals with experience in operations and implementations in various healthcare lines of businesses. Add to that Gorman Health Group’s Compliance consulting expertise and data analysts, and you have the winning combination in driving better member outcomes and ensuring member satisfaction. One call can lead to the answers your plan is seeking!




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