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Expect Rigorous CMS Audit Season

Expect Rigorous CMS Audit Season

With the new year now in full swing, Medicare Advantage and Part D plans should begin readying for shutterstock_163640981_audit_image.jpganother rigorous audit season. As we know, The Centers for Medicare and Medicaid Services (CMS) has been turning up the heat on compliance with Medicare regulations each and every year. Major changes started in 2012 and in the first two years of this new regime, CMS issued 27 Civil Monetary Policies totaling over $4.4 million. And from 2014 to today, the Civil Monetary Penalties have more than doubled to over $9.6 million.

CMS announced recently that audit protocols, with a few minor modifications, would remain in place. This indicates that plans should expect CMS giving few passes on issues in 2016 as they did in 2015 due to late arrival of the significantly expanded universe files and some open interpretations. A few important changes of note:

  • The expanded numbers of universes remain in place and CMS will be looking very closely at the validity of each universe. The expanded universes were create specifically to allow CMS to hone in on possible non-complaint areas and cases. In the past, compliance issues may not have been flagged in the sampling. Now, it is almost guaranteed that compliance issues are within the sample. This increases plan exposure to Civil Monetary Penalties and other intermediate sanctions. Please note that on January 19, 2016, CMS issued an addendum to its original release and has supplied some important clarifications to the universe files.
  • CMS has also added a new Invalid Data Submission (IDS) category for plans that cannot fulfill all or part of a universe. On the first two failed attempts, an observation will be noted for a full or partial failure. After three failed attempts, an IDS condition will be logged in the program audit. Missing or unavailable data will also lead to a condition finding. And, if a universe is completely unusable, conditions will be levied against all elements and enforcement action will likely be all but a certainty. So, for plans that were not audited in 2015, begin running your universes reports early and often to get some practice under your belt. Know what fields in your system tie to the universe fields.
  • Remember there is an important distinction between disclosed issues and self-identified issues. In general, it is important to notify CMS of any issues at any point during the year. Disclosed issues are those sent to CMS before the commencement of the audit, while self-identified are reported during the audit process. All disclosed and self-identified issues covering the audit period must again be sent to CMS within 5 days of the notice of the audit to ensure favorable treatment.
  • CMS does view disclosed and self-identified somewhat differently, especially whether these are corrected or not. If an issue is corrected prior to the audit notice (even if it occurred during any portion of the audit period), the assumption is that it has been corrected. In cases of uncorrected disclosed items and self-identified issues, plans could face findings depending on whether issues are corrected or not and when. Thus, the cardinal rule is disclose early and seek a quick path to remediate to avoid the chance of significant negative impact.
  • As yet another signal that CMS is ramping up its oversight, CMS is introducing two pilot audit areas – Medication Therapy Management Program (MTMP) and Provider Network Adequacy. The 2016 Star ratings show MTMP having just a 2.3 average score. Although CMS recently backed off a major overhaul of the program, the audit pilot shows the serious concern it has with poor performance by plans in this area. As a parallel, CMS is increasingly concerned about the true status of plan networks post initial filing of the plan. The pilot is aimed at looking at not only the accuracy of the plan network but whether it is truly accessible (e.g., are providers truly accepting new patients.) Any findings in these two areas will not count against a plan from an audit perspective – at least for now.

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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