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CMS Medicare Plan Outreach Requirements in the Spotlight

CMS Medicare Plan Outreach Requirements In The Spotlight

As anyone involved in a Medicare Advantage Part D (MA-PD) or standalone Part D (PDP) plan knows, the Centers for Medicare and Medicaid Services (CMS) has made compliance with regulatory guidelines a strong focus. One important requirement is that plans must exercise due diligence to obtain sufficient documentation from providers for authorization and appeals requests before denying them for lack of medical necessity criteria met. Audit findings and penalties have been common for plans that do not conduct sufficient outreach because CMS views this as violating its “no beneficiary harm” standard. Its argument is sloppy practices by plans have meant unnecessary denials, extra steps and time for members to file for and wait on both appeals and external reviews, and potential health effects and complications for beneficiaries.

In recent audits, CMS has told plans it is their duty to get required information from providers and avoid denials for lack of documentation. Its audits found that plans:

  • Failed to conduct sufficient attempts at various times of the day (at least three) to gain information.
  • Didn’t document outreach attempts.
  • Prematurely denied cases prior to expiration of timeframes when clinical information was not available. (This is a careful balancing act as CMS expects that plans not deny services too soon but at the same time make accurate coverage decisions as early in the allowable timeframe as possible.)
  • Took extensions on cases when contracted providers were non-responsive on the need for documentation or plans did not conduct required outreach to obtain information. CMS expects that because providers are contracted, there should be no reason to fail to obtain necessary clinical documentation.
  • In a last effort to obtain documentation, plans didn’t use medical directors to engage providers to submit documentation.

CMS expects plans will address all of the above to pass the outreach requirements moving forward. To further bolster its guidance, on October 18, 2016, CMS released a health plan memo that provides additional guidance on outreach attempts. The memo serves as sub-regulatory guidance plans must adhere to and supersedes anything that may conflict in the various Medicare health plan manuals (the manuals will be updated in the future). Because timeframes vary between medical and pharmacy requests, in addition to standard and expedited requests, CMS details exactly what it wants plans to do in each type of case.

Here is what CMS views as the minimum necessary outreach for each case, much of which is taken verbatim from the CMS memo to avoid any potential confusion given the technical nature of the guidance:

General Guidance For All Authorization and Appeals Requests:

  • Plans must make reasonable and diligent efforts to obtain all necessary information, including medical records and other pertinent documentation. The plan is expected to make reasonable efforts to gather all of the information needed to make substantive and accurate decisions as early in the coverage process as possible.
  • Plans are required to conduct outreach within the applicable adjudication timeframe and to document their efforts. The plan must clearly identify the records, information, and documents it needs when requesting information from a provider. The date/time of the postmark or timestamp on e-mails and faxes are considered the date/time of the request to the provider for the information. Requests made by telephone should be documented with the date and time of the call.
  • CMS will determine whether sufficient outreach occurred in cases by looking at whether plans used multiple modes of communication (e.g., phone, fax, e-mail) to obtain required information.
  • The plan’s medical director should be involved in the development and oversight of policies and procedures to ensure the appropriateness of the plan’s clinical decision-making.
  • CMS expects medical directors to design their outreach policies for expedited requests to reflect the immediate need for access to critically needed items, services or drugs, including consideration of how the outreach is conducted and who is making the outreach attempts. This points to medical director intervention in these cases before denial for lack of information.
  • The plan is responsible for ensuring delegated entities adhere to appropriate procedures. Across the board, lack of sufficient delegated oversight has been a huge finding for plans in program audits.
  • When adjudicating requests for Part D coverage for beneficiaries who are enrolled in MA-PD plans, CMS expects the plan to leverage its contractual relationship when the request involves the need for information from a contracted provider. Thus, delegation to a PBM does not free the plan up from contact. It might be that both the PBM medical director and a plan medical director get involved to obtain necessary information.
  • Contract terms between plans and providers are expected to properly incentivize contracted providers to produce requested clinical records and other needed information in a timely manner.
  • Extensions are allowed but generally they should not be done unless (1) the extension has been requested by the enrollee OR (2) the extension is in the enrollee’s interest and (a) it is for purposes of requesting information from a non-contract provider that is necessary to approve the request or (b) because of extraordinary or exigent circumstances. In general, plans cannot extend simply because medical documentation from a contracted provider has not arrived in time.
  • If the plan issues an adverse decision due to the inability to obtain the information needed to approve coverage, the plan should clearly identify that basis and the necessary information in the written denial notice.

Standard Organization Determinations (Medical Prior Authorizations):

  • Plans must conduct a minimum of three attempts.
  • When possible, attempts should be during normal business hours in the provider’s time zone.
  • The first request for information should be made within two calendar days of receipt of the coverage request.
  • CMS expects subsequent requests to be timed in a manner that increases the likelihood of making contact with the provider and receiving the information. Modes and times of contact are important.

Expedited Organization Determinations (Medical Prior Authorizations):

  • Plans must conduct a minimum of three attempts.
  • When possible, attempts should be made during normal business hours in the provider’s time zone.
  • The first attempt to the treating provider should be upon receipt of the request.
  • CMS expects subsequent requests to be timed in a manner that increases the likelihood of making contact with the provider and receiving the information. Modes and times of contact are important.

Standard Reconsiderations (Medical Appeals):

  • Plans must conduct a minimum of three attempts.
  • Attempts should be made during normal business hours in the provider’s time zone.
  • The first attempt to the treating provider should be made within four calendar days of receipt of the request.
  • CMS expects subsequent requests to be timed in a manner that increases the likelihood of making contact with the provider and receiving the information. Modes and times of contact are important.
  • If the plan expects to uphold its initial adverse determination based on lack of medical necessity because the plan needs clinical information from the provider to approve coverage, the physician making the reconsideration should attempt to communicate with the requesting provider about the request before the plan issues its decision.

Expedited Reconsiderations (Medical Appeals):

  • Plans must conduct a minimum of three attempts.
  • When possible, attempts should be made during normal business hours in the provider’s time zone.
  • The first attempt to the treating provider should be made upon receipt of the request.
  • CMS expects subsequent requests to be timed in a manner that increases the likelihood of making contact with the provider and receiving the information. Modes and times of contact are important.
  • While not listed in the memo, our assumption is CMS wants plans to follow the same rules as above if it expects to uphold its initial adverse determination due to lack of documentation.

Standard Coverage Determinations (Pharmacy Prior Authorizations):

  • Plans must conduct a minimum of three attempts.
  • When possible, attempts must be made during normal business hours in the provider’s time zone.
  • The first request for information should be made within twenty-four (24) hours of receipt of the coverage request.
  • CMS expects subsequent requests to be timed in a manner that increases the likelihood of making contact with the provider and receiving the information. Modes and times of contact are important.

Expedited Coverage Determinations (Pharmacy Prior Authorizations):

  • Plans must conduct a minimum of three attempts.
  • When possible, attempts should be made during normal business hours in the prescriber’s time zone.
  • However, given the limited timeframe for obtaining information and issuing a determination for an expedited coverage determination, outreach must not be limited to business hours.
  • The first outreach attempt should be made upon receipt of the coverage request.
  • CMS expects subsequent requests to be timed in a manner that increases the likelihood of making contact with the provider and receiving the information. Modes and times of contact are important.

Standard Reconsiderations (Pharmacy Appeals):

  • Plans must conduct a minimum of three attempts.
  • When possible, attempts should be made during normal business hours in the provider’s time zone.
  • The first request for information should be made within two calendar days of receipt of the appeal request.
  • CMS expects subsequent requests to be timed in a manner that increases the likelihood of making contact with the provider and receiving the information. Modes and times of contact are important.
  • If the plan expects to uphold its initial adverse decision based on lack of medical necessity because the plan needs information from the prescriber to approve coverage, the physician making the redetermination should attempt to communicate with the prescriber about the request before issuing the determination.

Expedited Redeterminations (Pharmacy Appeals):

  • Plans must conduct a minimum of three attempts made.
  • When possible, attempts should be made during normal business hours in the prescriber’s time zone.
  • The first request for information should be made upon receipt of the appeal request.
  • CMS expects subsequent requests to be timed in a manner that increases the likelihood of making contact with the provider and receiving the information. Modes and times of contact are important.
  • When adjudicating expedited redeterminations, if the plan expects to uphold its initial adverse decision based on lack of medical necessity because the plan needs information from the prescriber to approve coverage, the physician making the redetermination should attempt to communicate with the prescriber about the request before issuing the determination.

The sub-regulatory guidance on outreach is an important step CMS is taking as a result of numerous audit findings in this area. As with the Job Aid tools recently published to help plans correctly classify case requests, this outreach guidance helps clarify exact expectations. But at the same, as with the recent changes to the audit universes in 2015 and 2016, these changes will not be easy. CMS will need to clarify exactly what is intended in certain areas. So we see this as an evolutionary process. Just in the past couple of weeks, we have had plans ask us some very important questions that point to some ambiguity and the need for a collaborative process over time between CMS and plans. CMS probably realizes the evolutionary nature of all this already. Some of the initial questions raised include:

  • While first attempt is clarified well, what exactly will the standard be on subsequent attempts? While every case is unique, the standard is still nebulous and standard and expedited cases and timeframes can differ markedly.
  • If multi-modal attempts may be needed, what standard will be used here?
  • The medical director may need to make multiple outreach attempts, especially if a denial decision will be made for lack of documentation. Can these attempts be bundled or must they be discrete (can a general attempt to obtain information be the same as an attempt to alert the doctor that the request will be denied for lack of documentation)?
  • If the first attempt in some cases must be made upon receipt, how much time does a plan really have to make the attempt? Cases often arrive by fax and whether they are standard or expedited is not immediately clear. Fax queues sometimes take a number of hours to work through.
  • What are the incentives that CMS wants to see in provider contracts to ensure they submit documentation?
  • If a plan delegates authorizations and appeals to a PBM, will the PBM medical director engagement be sufficient or does an additional step need to be added that includes the plan medical director?

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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