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Compliance Insights Newsletter – June 2016

Compliance Insights Newsletter – June 2016

IMPORTANT REMINDERS

On Monday, June 13, 2016, the OMB posted the 2017 draft Program Audit Protocols for public comment in the Federal Register. The comment period closes August 12, 2016. The Agency collection number is CMS-10191, the document number is 2016-13917 and document citation is 81 FR 38187.

On May 10, 2016, CMS announced the release of Contract Year (CY) 2017 Model Materials. All Links for the models can be found on CMS’ website here, and links for the standardized documents can be found here. Plans/Part D Sponsors must ensure that their CY 2017 documents are compliant with CMS requirements.

On June 10, 2016, CMS announced the release of the 2017 Medicare Marketing Guidelines (MMG). The 2017 MMG is effective upon release and located on CMS’ website. Please refer to the 2017 Medicare Marketing Guidelines Summary of Changes within the memo.

Medicare Parts C & D Fraud, Waste and Abuse (FWA) Training webinar hosted by the Centers for Medicare & Medicaid Services’ (CMS) Center for Program Integrity (CPI) will be held June 29, 2016, from 12:30 p.m. to 4:00 p.m. Eastern Time (ET). Please log in to the CMS O&E MEDIC website to register for the webinar.

COMPLIANCE NEWS

Medicare Part C Plan Reporting Requirements Technical Specifications Document Contract Year 2016

The Medicare Part C Plan Reporting Requirements Technical Specifications Document Contract Year 2016 Effective Date: January 1, 2016 Version Date April 22, 2016, is now available (click here). At this time, CMS believes this is the final version for contract year 2016.

Major Changes from CY 2015 Technical Specifications:

  • Three reporting sections were updated to include additional data elements:
    • Reporting Section #6 (Organization Determinations/Reconsiderations)
    • Reporting Section #13 (Special Needs Plans Care Management)
    • Reporting Section #14 (Enrollments/Disenrollments)
  • In addition, three new reporting sections were added:
    • Rewards and Incentives Programs,
    • Mid-Year Network Changes
    • Payments to Providers.
  • Reporting Section #12 Plan Oversight of Agents was changed to Sponsor Oversight of Agents and the data due date was changed to the first Monday in February of the following year.
  • The due dates for Grievances and Employer Group Plan Sponsors were also changed to the first Monday in February.
  • The due dates for Enrollment/Disenrollment were changed to last Monday of August and February.

Clarification of Data Elements 13.1 and 13.2 for Reporting Section # 13 Special Needs Plans (SNPs) Care Management

Please strike out the following exclusions that appeared in the Medicare Part C Plan Reporting Requirements Technical Specifications Document Contract Year 2016 Effective Date: January 1, 2016 Version Date April 22, 2016, which is currently available here.

  • Page 26, Data Element 13.1 Exclusion. Strike out: “Enrollees with a documented initial HRA under that plan in the previous measurement year.”
  • Page 27, Data Element 13.2 Exclusion. Strike out: “Enrollees for whom the last HRA was completed less than 365 days prior.”

A revised technical specifications document with these corrections will be available soon.

2016 Part D Reporting Requirements and Technical Specifications

The Centers for Medicare and Medicaid Services (CMS) has released the CY2016 Part D Reporting Requirements and Technical Specifications. Effective May 2016, CMS has extended the reporting due date from the 1st Monday of February to the last Monday in February 2017.

These documents are posted on the HPMS Plan Reporting site and on the external CMS website at this link.

Please note the following corrections made since the May release of these documents. No other changes have been made.

Technical Specifications Document:

  • Section V – Coverage Determinations and Redeterminations Section, Section 3: Reopenings
  • Corrected format of Original_Disposition_Date to MMDDYYYY.
  • Added option 3 “Fraud or Similar Fault” for Reopening Reason to make consistent with the reporting requirements.

Reporting Requirements Document:

  • Section VII – Sponsor Oversight of Agents Section, Section 2: New Enrollments
  • Included option “No data to report” as Data Element Q.

Draft 2017 Part C and Part D Reporting Requirements 60-day Comment Period

The Centers for Medicare & Medicaid Services (CMS) is announcing an opportunity for Medicare Advantage Organizations, Part D sponsors, and other stakeholders to comment on the proposed 2017 Medicare Part C and Part D Reporting Requirements.

* The 60-day notice for the proposed 2017 Medicare Part C Reporting Requirements (CMS-10261; OMB control number: 0938-1054) is published here. This is a revision to a previously approved collection. Comments must be received by July 11, 2016, electronically or by mail per the instructions in the notice. The supporting statement and related forms for the proposed collection summarized in this notice are available here under CMS Form Number CMS-10261.

* The 60-day notice for the proposed 2017 Medicare Part D Reporting Requirements (CMS-10185; OMB control number: 0938-0992) is published here. This is a revision to a previously approved collection. Comments must be received by July 5, 2016, electronically or by mail per the instructions in the notice. The supporting statement and related forms for the proposed collection summarized in this notice are available here under CMS Form Number CMS-10185.

CMS Pushing Plans on Compliance While Lending a Helping Hand

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. Click here for the link to the policy memo and Job Aids published on April 20, 2016, by CMS via HPMS.

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

MMP Star Program Coming to Fruition

The Centers for Medicare and Medicaid Services (CMS) continues its push to bring Star quality performance programs to all lines of business. The program in the Medicare Advantage (MA) and Part D programs is long-standing, and earlier this year CMS finalized its Medicaid Uber Rule, which promises to transform the state entitlement and bring about quality through a similar performance assessment program. Now, CMS has announced further progress in establishing the program for the Medicare-Medicaid Plan (MMP) dual demonstrations program, currently ongoing in about a dozen states.

On November 6, 2015, via an HPMS memo, CMS outlined its long-term objectives and plans for an MMP Star program. We wrote about the overview in our February 4, 2016, Strategic Insights blog. This week (via a June 15, 2016 HPMS memo titled MMP Quality Rating and Performance Data Strategy Update), CMS summarizes and comments on feedback received on its MMP Star proposal from November 2015, announces its 2016 MMP public display of MMP measures, and published proposed 2017 MMP measures. These 2016 and 2017 approaches serve as interim steps, as the long-term plan is developed and adopted.

Please see our blog for more details.

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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