This Is the Year to Get It Right
Five consecutive years of very similar audit protocol, continuous partnering with sponsors to identify improvements, and numerous best practice/common conditions memos. Where are you in audit readiness? Did you evaluate the items in the 2016 Readiness Checklist sent in November? I will get back to that! In the meantime, the Centers for Medicare & Medicaid Services (CMS) has started sending audit letters, so we are aware of sponsors and Pharmacy Benefit Managers (PBMs) alike who are prioritizing CMS’ requests. Early bird catches the worm, am I right? Presumably these plans have larger enrollment, since they will only be required to provide rejected claims for the one month of January.
Some priorities have not changed: Formulary Administration, Compliance Program Effectiveness, Organization Determinations, Coverage Determinations, Grievances and Appeals, and Model of Care activities are all still part of the base protocol. CMS has committed to releasing pilot protocol to review Medication Therapy Management (MTM) as well as Part C Provider Network Adequacy. Why this additional focus?
- CMS’ focus on the reduction of opioid use may be one aspect of piloting the MTM protocol.
- The additional focus on Medicare Advantage (MA) networks is critical. In the past, there was not a requirement to evaluate providers to determine if they were open to new patients or not. If they were contracted and credentialed, then they were used for network adequacy. That does little good for a new member who cannot access that provider.
If you haven’t done so, it is time to circle the wagons. CMS is managing a continuous cycle of new audits, audit report finalization, corrective action plan (CAP) review, and validation requests for a variety of sponsors. You cannot change past data, but you can put in place changes that could make improvements for you going forward. Nothing is more important (arguably) than ensuring your Compliance Program is strong. If you have a robust (and documented!) system for auditing and monitoring, you have a greater chance of finding shortfalls before CMS does. Earlier, I mentioned the 2016 Readiness Checklist, which was released on November 20, 2015. This is the sentence that keeps me up at night:
Should you identify areas where your organization needs assistance or is not/will not be in compliance, your organization must report those problems to your Account Manager directly by email in a timely manner.
While this could be viewed as a requirement to notify CMS upon checklist review (which should have been done prior to 1/1), a conservative interpretation would state that at any time, should you identify areas where the organization won’t be in compliance, the organization must report to the Account Manager. If you look at it that way, then anything on that checklist pertinent to the program audit areas and identified as non-compliant in your audit period best be indicated as disclosed and not self-identified. Otherwise, CMS might ask why they didn’t know about it prior. If you have not received an audit notice yet, do yourself a favor and evaluate your recent disclosures. The list you send to CMS will encompass items from January 1, 2016, through the start of the audit notice.
Resources
CMS audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. 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 >>
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