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Compliance and Quality Take Center Stage in Medicare

We write often about how compliance and quality are taking center stage throughout our healthcare system now that the Centers for Medicare and Medicaid Services (CMS) is the national policy-maker. Recently we gave an hour-long webinar on major trends in Medicare compliance and quality. You can watch the recording here, or read on for a few written highlights:

Overview:

  • The Value-Based Purchasing environment taking hold stresses three important factors: (1) Compliance and best practices; (2) Star Rating and additional revenue tied to quality; and (3) Risk adjustment to reward additional revenue to those who have members with the greatest acuity.
  • The new Medicare audit regime came out in 2012 but has been put on steroids since January 2014, with record numbers of suspensions of enrollment and marketing, as well as civil monetary penalties (CMP).
  • The Star program has been an amazing success. The number of 4 and greater Star plans have moved from 14% in 2010 to 49% in 2016. Seniors and others in Medicare are flocking to the high performers. The number of members in 4 and greater Star plans has increased from about a quarter to over 75%

Compliance and Audit:

  • In 2015, CMS deliberately made audit universe reporting more complex so that it can move from a random sample of cases to the ability to identify problematic cases. Thus, CMPs and enforcement actions will likely continue to increase with time. 2015 was a launch year for the new system. CMS is likely to give much less flexibility to plans this year about the layout and what the fields mean.
  • Disclosed and self-identified issues can help plans avoid major penalties and sanctions. So be pro-active throughout the year in identifying issues and remediating, even once you receive an audit notice.
  • Plans get in trouble when they have inadequate delegated oversight. Remember that your administrative subcontractors will need to abide by the same rules as the plan does and CMS will look to you – not your PBM or other subcontractor – for compliance.
  • In the webinar, we discuss the major audit findings over the past few years for CDAG, ODAG, and MOC. What is interesting is that most of these findings are not isolated to a few plans – the vast majority of them are consistent deficiencies found with a majority of plans.
  • A case is no longer compliant if you decision it on time. CMS expects that decisioning, member and provider communication, and effectuation (if applicable) are all done in the required timeframe. CMS is closely watching when your member and provider communication enter the postal stream.
  • Much more focus is being put on the consistent use of evidence-based criteria for each case. A decision alone is no longer the main focus.
  • Case misclassifications are a major finding. Cases that should constitute appeals end up being second prior authorization cases. Plans are opening only grievances when they should be logging both grievances and prior authorizations or appeals.
  • Clear, concise, appropriate, and timely communication is an imperative. Plans misstep here often, especially on notification of appeal rights and quality of care grievance rights externally.
  • CMS is looking for plans to focus on outreach to get required documentation before decision-making. Denials for lack of documentation is increasingly taboo.
  • Plans continue to receive major findings related to how Pharmacy Benefits Managers (PBMs) administer formularies, conduct UM edits, and fill transition supplies.
  • Plans fail on not documenting any expressed dissatisfaction as a grievance.
  • At the same time, CMS is asking that plans thoroughly document and investigate all grievances, establish a root cause, and document remediation.
  • Model of Care (MOC) is an increasing focus, given the enormous potential CMS sees in these plans. Key findings include: (1) timeliness of Health Risk Assessments; (2) reassessment as the health of the member demands, but especially for care transitions; (3) ensuring that an interdisciplinary care team (ICT) tracks and intervenes in favor of the member; and (4) ensuring that there is an actionable care plan that tracks goals and goals met.
  • Compliance program findings are much less, but where they are present, CMS is citing plans for systemic issues related to auditing and monitoring within the plan and down to delegated entities.

Star and Quality:

  • Plans need to focus both on Part C and D measures as now one-third of all measures tie to the drug program.
  • While clinical measures are usually weighted higher, about two-thirds of all measures are now survey and administrative measures that look more to member and provider satisfaction as well as health plan operations.
  • Part C scores are now about 4.5, but Part D scores for MA-PD plans stand in the mid 3s. This has dragged down overall scores and stops many plans from achieving high scores.
  • Standalone Part D scores are especially problematic, standing at an average overall of just 3.4, down from last year’s 3.75.
  • Plans need to push their PBMs to pay more attention to both compliance and quality issues to drive Part D scores. This will dictate success in the future.
  • The MTMP Comprehensive Medication reconciliation measure is especially low, sitting at 2.3 this year.
    Part C and D measures will get more complex in the future, with a series of new and overhauled measures slated. One promises to measure the ability for plans to keep people out of the hospital for preventable conditions, as opposed to readmissions.
  • Numerous best practices are emerging to drive Star scores, especially on the Part D side. Treating members holistically and tying medical and pharmacy together carries great promise to boost both sides of the equation.

To view the complete webinar, click here to register and view. You can also access the presentation slides.

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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