skip to Main Content

CMS Pushing Plans on Compliance While Lending a Helping Hand

CMS Pushing Plans On Compliance While Lending A Helping Hand

Strategic Insights has written often about the ever-increasing regulatory focus practiced by the Centers for Medicare and Medicaid Services (CMS) in the Medicare Advantage and Part D worlds. Over the past few years, Civil Monetary Penalties and suspension of marketing and enrollment have reached record levels, with CMS diving deep into both plan processes and clinical operations. Two recent events however show that CMS is committed to pushing even further to ensure plan accountability.

Over the past several weeks, a number of plans have received notice of a monitoring study surrounding how plans handle both medical and pharmacy denials. These amount to supplementary audits that are not part of the regular audit process and do not appear to put plans in jeopardy of noncompliance as they are in pilot mode right now. Over the past several years, CMS has sanctioned many plans for inconsistent and/or poor denial practices, such as not sending out the correct denial notices and required appeal rights notifications.

From what we have been able to gather, some of the biggest and highest-performing plans and PBMs have been “volunteered” by CMS for the monitoring study. (It is hard to say no when your rich uncle writes and says he is coming to town and wants to stay for a while!) The monitoring study appears to cover denials from end to end, including timeliness, outreach, determination of whether the correct denial notice was issued with correct appeals rights, as well as whether the verbiage in the letter was clear and concise and informed members of the next steps in the process. There is even a universe file requirement for both the medical and pharmacy portions of this supplementary audit. To show the level of detail, CMS included specific focus on denial of drugs to treat Hepatitis C.

The fact that high-performing plans were chosen is not surprising as it points again to CMS’ desire to gather even more best practices from plans and then set a clear and sufficiently robust compliance approach moving forward. CMS has prided itself in providing clear and concise direction well in advance of ramping up the audit regime. To the degree that even greater focus will be placed on these areas to protect consumers, CMS wants the greatest inventory of best practices and clear case studies to share with the broader Medicare Advantage insurer community. We expect the monitoring study to repeat in future years and expand to include a larger number of players.

Additionally, CMS recently released six Job Aids to help plans meet compliance mandates. The Job Aids cull together all of the audit findings from 2011 and 2014 and recommend the strategies plans can use on a day-to-day basis. Below is a link to the policy memo and Job Aids published on April 20, 2016, by CMS via HPMS. https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/ProgramAudits.html

The Job Aids cover the CDAG and ODAG audit findings, but CMS plans on introducing ones regarding Formulary Administration, Special Needs Plan Model of Care, and Compliance Program Effectiveness in the future to complete the package.

Job Aids Summary:

CADG and ODAG Correct Case Classification: These Job Aids review how to determine differences between:

  • Organization Determination (OD)/Reconsideration (RD) versus Grievance versus Inquiry
  • Coverage Determination (CD)/Redetermination (RD) versus Grievance versus Inquiry

The Job Aids briefly state that workers may need to open more than one case type depending on the circumstance, especially if someone is complaining about a service not being covered. They also caution that if there is a question regarding what the member is asking, the customer service person should ask if the member wants the service in question covered and, if so, open an authorization request. CMS also notes requirements for quality of care grievances and oral grievances.

CDAG and ODAG Reasonable Outreach: While CMS does not look kindly on denials for lack of clinical documentation, CMS is spelling out a few basic rules regarding minimum requirements in these Job Aids:

  • Make three attempts
  • Use various modes of contacts
  • Contacts should be spaced out at various points in time
  • Be specific about what is needed
  • Document all outreach attempts thoroughly

CDAG and ODAG Denial: As noted above, this area is one of the hottest topics for CMS right now. CMS’ Job Aids here make the following main points:

  • Ensure the use of the correct template for either authorizations or appeals
  • List the denial criteria
  • List the lack of information that caused the denial if applicable
  • The rationale in the letter should match case notes
  • The language of the denial should be appropriate to the needs of the member (e.g., language) and the specific case
  • Clear and concise language should be used
  • For drugs, make sure you know the drug, dose, and administration.
  • For drugs, review approved formulary criteria for the drug.
  • For Part B versus D drugs, ensure you use the CMS language in the denial letter notices

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.

Back To Top