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IRE Auto-Forward Sanctions Robust Over Past Several Years

IRE Auto-Forward Sanctions Robust Over Past Several Years

As a follow-up to our recent blog on 2017 Civil Monetary Penalties (CMPs), we thought it would be important to review Independent Review Entity auto-forward findings by the Centers for Medicare and Medicaid Services (CMS) the past several years. After all, this is one of the hottest topics at CMS right now.

Because every audit is not published, we mined the CMS CMP website and analyzed every CMP related to a Program Audit conducted from 2014 through 2017, as well as independent CMPs levied for inordinate auto-forwards. What we found were multiple findings each year that led to CMPs on plans.
We have summarized findings in the chart below, but here are the highlights:

  • 27 total findings touching IRE auto-forward issues
  • While findings have tailed off a bit over the past two years, five (5) plans received CMPs in part due to issues with their auto-forwards in 2017.
  • Three (3) CMPs were issued in 2017 alone for inordinate auto-forwards. This stems from the late 2016 memo that established the IRE auto-forward monitoring program. One plan received two (2) CMPs for violations in the first and fourth quarters of 2017. We see CMS getting harsher here over time by scrutinizing additional plans.
  • In the review period, 22 findings touched failure to auto-forward, failure to timely auto-forward, and failure to appropriately auto-forward. Thus, not only is CMS looking at whether plans forwarded all of the required cases, but also whether timeframes were met and if the plans followed the appropriate regulations (including requirements for what is submitted and preparation of case submissions). These findings were largely tied to the Part D side of the plan.
  • While smaller in number, CMS also sanctioned plans on issues related to timely notification of the member of the IRE case status and effectuation of overturns

It is also important to remember that IRE auto-forward measures significantly impact Star performance. Sanctions accrue to plans with poor track records, but now plans with poor track records will also incur Star penalties. The 2019 Call Letter calls for a reduction to plans’ Star scores on the four measures in the chart below if there are data integrity issues related to IRE auto-forward issues.

CMS will drop Star achievement (potentially multiple Star levels) based on how egregious the plan’s record is on auto-forwards. CMS’ data integrity initiative recognizes that the data from poor performers are either incomplete or inaccurate and plans should be penalized in Star. Currently, performance on this measure is mixed and sometimes volatile. Clearly, consistently high performance on this measure is needed to ensure achievement and retention of 4 Star or greater overall status.

Note that the MA-PD D002 measure is subject to great volatility. For the 2017 Star measure (CY 2015 performance), 5 Star status was achieved by plans that had less than or equal to 2.7% cases untimely auto-forwarded. For the 2018 Star measure (CY 2016 performance), 5 Star status was achieved by plans that had less than or equal to 11.6% cases untimely auto-forwarded. Each cut point was similarly impacted. It shows a major erosion in overall performance on this measure for MA-PD, while PDP performance actually got better.

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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