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December 2018 Compliance Insights

December 2018 Compliance Insights

Important Reminders

Any provider in MA and PDP plans must not be on a Preclusion List. Plans may not reimburse or make payment for claims to precluded providers. CMS will make the initial Preclusion List available beginning January 1, 2019, with updates monthly.

In CMS’ December 4, 2018, HPMS memo regarding 2019 Program Audits, it is key to note that CMS will be sending scheduled program audit engagement letters to sponsors starting in March through July 2019. The memo also states they do not anticipate significant changes to the draft consolidation of Chapters 13 and 18 and expect to release the final version in February 2019.

 

Compliance News

2018 Healthcare Lookback

Our jobs in healthcare are never boring and 2018 proved the point. There are just so many moving parts in the healthcare world and it is often hard to sit back and take it all in.

Be sure to read MedHOK’s blog on a quick recap of 2018.

 

2019 Program Audits

On December 4, 2018, CMS announced several changes and updates to program audits in 2019. It is important to understand how program audits will be conducted in 2019. CMS has suspended the collection of several data points and documentation such as CDAG, ODAG and SARAG Supplemental Questions and Call Logs. They are also suspending several data elements from the Compliance Program Effectiveness (CPE) audit.

Beginning in 2019, CMS will evaluate sponsors’ implementation of the Comprehensive Addiction and Recovery Act (CARA) of 2016 through the program audit process. At-risk determinations will be reported as part of the total redetermination count on Table 6 (Standard Redeterminations) and Table 8 (Expedited Redeterminations).

The full details of The Program Audit Process Overview can be found here.

 

2019 Medicare-Medicaid Plan (MMP) Reporting Requirements

CMS has released the Calendar Year 2019 Medicare-Medicaid Capitated Financial Alignment Model Core Reporting Requirements and Value Sets Workbook. In this release, CMS has tried to streamline and clarify reporting expectations for MMPs.

A few notable changes include:

  • Medicare Part D Reporting Requirements – Removed the Retail, Home Infusion, and Long-Term Care Pharmacy Access reporting section.
  • General Changes to MMP-Specific Core Measures – For all core measures, formulas were added to the Analysis sections to further clarify how measure rates are calculated.
  • Core Measure 9.1 – Updated the reporting frequency from quarterly to annually (note that MMPs will continue to report quarterly reporting periods for this measure but will do so on an annual basis).

Core measures 2.1, 2.3, 3.2 and 9.1 were also updated and their corresponding note sections included additional clarifications.

CY2019 2019 MMP Core reports will be in production for all affected clients by March 31, 2019.

The full reporting requirements and value sets workbook can be found here.

 

2019 Parts C & D Reporting Requirements Released

The Centers for Medicare & Medicaid Services (CMS) has announced the Office of Management and Budget (OMB) approval for the 2019 Parts C & D Reporting Requirements.

Specific Part C changes include the addition of new data elements to the Organization Determinations and Reconsiderations (ODR) reporting section to enable CMS to obtain more information about how often enrollees are submitting requests for claims and services and the outcome of plan decisions. The ODR timeliness requirement was deleted to be consistent with Part D reporting. The burden for Part C reporting was reduced by limiting Grievance reporting to totals only and suspending the Private Fee for Service (PFFS) Payment Dispute Resolution Process and Mid-Year Network Changes section. Additional clarification to Payment to Providers reporting was also provided through new Qs & As in Appendix 1 of the 2019 Part C Technical Specifications. Lastly, the Part D Retail, Home Infusion, and Long-Term Care Pharmacy Access section was suspended.

2019 Part C Reporting Requirements and Technical Specifications documents found here.

2019 Part D Reporting Requirements and Technical Specifications documents found here.

 

Change to Health Risk Assessment Tool CMS Submission Requirements

On November 27, 2018, HPMS stated “Effective immediately, special needs plans (SNPs) will no longer be required to submit the Health Risk Assessment Tool (HRAT) to CMS for approval. SNPs are expected to document any changes and make the current HRAT available upon request.

This change will be incorporated into the next update to Chapter 5 of the Medicare Managed Care Manual. SNPs must continue to adhere to CMS policies regarding health risk assessment requirements.

 

New NCQA Programs and Accreditation

NCQA has released two new programs: one designed to improve integration of population health principles into management of defined populations and one to identify health IT solutions that support or meet NCQA standards for population health management.

NCQA Population Health Program Accreditation evaluates how programs that manage the unique needs of a defined population integrate population health management strategies for that population. Organizations are evaluated in data integration, population assessment, population segmentation and targeted interventions. To read more about PHP Accreditation click here.

NCQA also launched the Population Health Management Prevalidation program, which evaluates how health IT vendors meet the needs of organizations providing population health management.

 

Security News

With the introduction of a GDPR-Style Data Privacy Bill and the OCR issuing a request for information on potential updates to the HIPAA rules to improve data sharing, 2019 is going to be an innovative year.  Now is a good time to review your policies governing data inventory and identification. A good data management plan should include documenting data as described by the 5 W’s. Who, what, where, when and why.

  • Who created the data and who is the data owner?
  • What information does the data contain?
  • Where is the data located?
  • When was the data created?
  • Why does the data exist?

Making sure you have documented the answers to these questions will greatly assist project teams when planning upcoming projects. If HIPAA regulations allow more data sharing to improve patient care, you will be able to provide details on the data you already have available. If new requirements for more stringent privacy rules are passed, you will be prepared to quickly apply the necessary security controls.

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