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January 2019 Compliance Insights

Important Reminders

On January 22, 2019, CMS issued a Revised Notice of Denial of Medicare Part D Prescription Drug Coverage (CMS-10146) effective January 1, 2019. Plans must begin using this new notice as soon as possible, but no later than 30 days from issuance of this HPMS memo – February 21, 2019.

The revised notice must be provided to Part D enrollees when a plan issues a fully or partially adverse coverage determination. The Part D standardized letter has been revised to include the following:

Updated language reflecting changes made in the 2019 Final Rule (CMS-4182-F) Lengthening Adjudication Timeframes for Part D Payment Redeterminations and IRE Reconsiderations (§§ 423.590 and 423.636). The adjudication timeframe for Part D standard redetermination requests for payment at § 423.590(b) and the related effectuation provision § 423.636(a)(2) includes language changing the timeframe for issuing decisions on payment redeterminations from 7 calendar days from the date the plan sponsor receives the request to 14 calendar days from the date the plan sponsor receives the request.

 

Compliance News

2019 Timeliness Monitoring Project (TMP)

Once again CMS will conduct an industry wide monitoring project in 2019. The Timeliness Monitoring Project evaluates the timeliness processing of Medicare Advantage (Part C) organization determinations and reconsiderations, as well as Medicare Prescription Drug (Part D) coverage determinations and redeterminations. The audit includes a retrospective collection and review of 2018 data from sponsors with active contracts in CY2018 and CY2019.

CMS is eliminating the collection of Table 9 (Standard IRE Auto-forwarded Coverage Determinations and Redeterminations) and Table 10 (Expedited IRE Auto-forwarded Coverage Determinations and Redeterminations) for CDAG. Also, the changes eliminate four (4) ODAG universes: Table 1 (Standard Pre-service Organization Determinations), Table 2 (Expedited Pre-service Organization Determinations), Table 3 (Requests for Payment Organization Determinations (Claims), and Table 4 (Direct Member Reimbursement Requests).

These monitoring efforts affect the plans ability to demonstrate that their Independent Review Entity (IRE) data is accurate as CMS uses this information in its Medicare Part and Part D Star Ratings. A reduction in Star Ratings measure can occur if a sponsor fails to submit requested data or fails to submit complete data.

CMS will collect data in three (3) waves, the first beginning in January 2019. The universe review will be for February, March and/or April 2018 depending on the size of the sponsor. Sponsors with a total enrollment (across all contracts subject to this monitoring project) over 250,000 enrollees will submit one month of data (February), sponsors with an enrollment of 50,000 to 250,000 enrollees will submit two months of data (February and March), and sponsors with an enrollment of less than 50,000 enrollees will submit three months of data (February, March, and April).

Beginning in January 2019, organizations will receive a data request email from the following mailbox: TimelinessMonitoring@cms.hhs.gov. This email will include additional instructions on the timeframe being tested, how to submit the data through the Secure File Transfer Protocol (SFTP), actual deadlines for submission, and information on when validation webinars will be scheduled.

Please refer to the December 21, 2018, HPMS memo 2019 Timeliness Monitoring Project (TMP) for full details.

 

Clarifications from CMS

CMS Medicare Preclusion List – MedHOK Update

In our November 2018 Newsletter, we talked about how the Centers for Medicare and Medicaid Services (CMS) rescinded the requirement that providers serving Medicare Advantage (MA) and Part D (PDP) plans be enrolled in the Medicare program in April of last year. Instead, CMS is dictating that these plans ensure that none of the providers in MA and PDP plans appear on the Preclusion List that CMS maintains and updates regularly.

In general, the Preclusion List includes individuals that have committed or are suspected of committing fraud, waste and abuse (FWA) or have run afoul of other Medicare requirements. CMS will assemble these suspect providers from various lists within CMS. Providers will be notified of their potential inclusion on the list and their appeal rights. CMS will add the provider only after an appeal is denied. CMS will make the initial Preclusion List available beginning January 1, 2019, with updates monthly.

MedHOK submitted four (4) questions to CMS to obtain further clarification. Please see MedHOK’s question, along with the response from CMS.

  1. If a provider is precluded, is it the case that the Part C or Part D request must be denied or does the plan have any discretion (e.g., for exigent or emergent reasons) – health of member)?

No. The beneficiary should be notified “as soon as possible but not later than 30 days from the posting of the list” and the beneficiary should have “at least 60 days’ advance notice” before a plan denies payment/rejects claims associated with a precluded provider.

  1. If they must be denied or does not meet exigent circumstances, will this be reported on the universe as a denial or as a new category of Precluded Provider?

The case should be included in the appropriate universe, based on how it was processed (e.g. denial). If denied due to a “precluded” provider, indicate the reason in the issue description field.

  1. Is this subject to an Appeal by member within health plan?

We have revised the letter to clearly state that the appropriate action for the enrollee to take is to find another provider in the area to furnish these services and to contact the plan if assistance is needed. In addition, an enrollee always has the right to seek a coverage decision from the plan if there’s a question regarding coverage for an item, service or drug.

  1. Would a drug denial be treated as a Prior Auth, Exception etc.

Please clarify, for reporting purposes?

It sounds like while drugs and services should be denied, once the timeframes for notification and waiting has passed, any request that comes in as a coverage request should be denied with a reason of precluded provider. In addition, if a member were to appeal, the appeal should be processed as an appeal with the same reason for denial. While they are being directed to a new provider (a plan says that in its notification and perhaps in its CD or OD denial language). On the universe we would report the appropriate reason in the description field.

Please exclude any cases that were rejected/denied because of the provider being named on the Preclusion List (as this is not a coverage request) from the CDAG universe submissions. While an enrollee always has the right to request coverage determination as defined at § 423.566(b), the coverage determination process will not result in the relief sought by the enrollee if the issue is that the prescriber is on the Preclusion List; the appropriate resolution is for the enrollee to find another provider. Therefore, issues related to provider preclusion should be excluded from the CDAG universe.

On the one issue you asked for clarification, I was getting to the fact that if any request should go through the CD or OD or appeal process, would we treat the case as a simple authorization request. I think that is what you are indicating. This is more an issue for CD.

 

Security News

Did you make any New Year’s Resolutions?  How about adding change the default password on those IoT devices you got for Christmas to that list. Default passwords on connected devices can put your data privacy at risk of being exposed. It may seem obvious for some devices that resemble a computer or tablet, but what about that cute little drone with the HD video camera or the cool fitness tracker you wear night and day to track your steps and your sleep. Connected devices bring amazing convenience and fun to our lives. They also bring security concerns. Changing weak, guessable, or hardcoded passwords is the first thing you can do for added security and comfort. According to the OWASP Top 10 Internet of Things 2018, we should all take some time to research these devices and see if we need to take added steps to secure them.

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