Strive For Progress, Not Perfection, Because It Doesn’t Exist

This week was a productive one for CMS and Compliance professionals. The 2015 Part C and Part D Program Audit and Enforcement Report was published on September 6, and the 2016 Fall Conference took place on September 8.

Highlights of the report include the publication of the most common conditions. CMS provided the frequency of the conditions from 2011 to present as well as the percentage of sponsors affected in 2015. Conditions which have been present six out of six years include the following:

• FA: Sponsor failed to properly administer its CMS-approved formulary by applying unapproved quantity limits
• FA: Sponsor failed to properly administer the CMS transition policy
• FA: Sponsor improperly effectuated prior authorizations or exception requests
• CDAG: Denial letters did not include adequate rationales, contained incorrect/incomplete information specific to denials, or were written in a manner not easily understandable to enrollees
• CDAG: Sponsor did not demonstrate sufficient outreach to prescribers or beneficiaries to obtain additional information necessary to make appropriate clinical decisions

“The repetition of these usual six only goes to show the complexity and ambiguity involved with ensuring beneficiary harm does not occur. The key is to identify and correct the issues before CMS makes a visit as well as having a long-range plan in place for continual improvement,” says Charro Knight-Lilly, Senior Vice President of Client Relations. The report answers many commonly asked questions regarding methodology for sponsor selection, process improvement strategies, and enforcement actions. By having audited sponsors with such a large number of enrollees during the first year of the audit cycle, CMS hopes to cover 96% to 98% of beneficiaries enrolled.

The Fall Conference included a range of topics such as application updates, network adequacy, and anti-discrimination rules (the implementation of which continues to confound the industry). In my experience, some of the most valuable feedback comes directly from plan sponsor staff, and that was no exception on Thursday. Jenny O’Brien described UnitedHealthcare’s shift from reactive and responsive to proactive, strategic, and innovative. Her words resonated about the need for Compliance staff to be this way. In all honesty, readers shopping around for a motto for a Compliance Awareness campaign should use those three words and call and thank her.

Based on Gorman Health Group’s observations of 2016 activities, CMS is continuing with their audit schedule full steam ahead, but the science has still not been perfected — and it will never be. As much as CMS is working to refine audit processes to improve consistency and accuracy, that’s what responsible sponsors do every day. Continue to share your feedback with CMS regarding their processes, and, as always, you can reach out to us for insight and assistance.

Resources

The Centers for Medicare & Medicaid Services (CMS) audit practices have undergone a few changes in recent years, but the core focus remains the same: beneficiary protections. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more about our audit services >>

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