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CMS Timeliness Monitoring To Challenge Plans

CMS Timeliness Monitoring To Challenge Plans

If plans that just went through a Medicare program audit thought they could breathe a quick sigh of relief, they will need to think again. And plans that are expecting a program audit soon might just be in store for double the work.

This week the Centers for Medicare and Medicaid Services (CMS) announced that it will be implementing a new timeliness review for medical and pharmacy prior authorizations and appeals. The monitoring appears to be one of the most far-reaching exercises that plans will be put through, aside from program audits themselves.

The announcement took plans by surprise and was originally slated for December. Due to an outcry from plans, CMS has postponed the collection of data until January 7, 2017.

CMS states clear rationale for the monitoring that is consistent with goals and objectives over the past few years.

  • Beneficiary harm must be avoided at all costs.
  • Beneficiary protections are key to ensure access of medical and pharmacy benefits and services.
  • Timeliness has been a major finding for both medical and pharmacy cases in program audits. Monitoring beyond the program audits is important.
  • Questions about the integrity and completeness of the Independent Review Entity (IRE) data are possible. As well, Star Ratings now include measures of plans’ timely and appropriate appeal decisions. If data issues are found, it could mean the data cannot be used in calculating the relevant Star scores.
  • Targeted annual program audits are not sufficient to ensure scrutiny across all plans each year. CMS has said the monitoring will become an annual submission process after this first round.

In the initial monitoring, CMS will collect various ODAG and CDAG audit universes from each contract to assess all plans’ timeliness in processing medical and pharmacy requests as well as plans’ compliance with forwarding cases to the IRE. Reviews will be conducted by two private audit firms. Upon notice, beginning January 7, 2017, plans will need to submit their universe submissions within 15 business days.

The universes in the table below are in scope. Note that while the memo says this is an appeals monitoring exercise, authorization requests are clearly in scope as well. Between one (1) month and three (3) months of data must be submitted (depending on plan size; the smaller the contract the longer the timeframe) and will cover cases between February and April 2016. Like a program audit, it covers plan-conducted and delegated cases. The submission will be at the parent organization level and would cover multiple contracts if applicable. Plans that were audited in 2016 do not need to submit data for this request if they successfully submitted the CDAG and ODAG universes specified without any Invalid Data Submission (IDS) conditions and had at least one month of 2016 data for each of the universes.

CMS will review the data and schedule a Webinar to ensure that the universe data matches the data in the plan system. If data are not valid, plans will be required to resubmit data and undergo further validation. Timeliness tests will also be performed on the universes. Issues with universe submission as well as timeliness rates could result in compliance actions. Results will be taken into account to determine validity of the Star measures.

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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