skip to Main Content

March 2018 Compliance Newsletter

March 2018 Compliance Newsletter

Welcome to the March 2018 MedHOK Compliance Newsletter. This issue provides essential compliance, reporting and security announcements affecting your business.

IMPORTANT REMINDERS

CMS released Part C & D reporting requirements effective January 1, 2018

  • Click here to view the Part C reporting requirements
  • Click here to view the Part D reporting requirements

February 28, 2018 Revised State-Specific MMP Reporting Requirements were released

May 9, 2018 Medicare Advantage and Prescription Drug Plan Spring Conference.

In-Person Registration Link: CMS 2018 MA & PDP Spring Conference
Webcast Registration Link: CMS 2018 MA & PDP Spring Conference

May 10, 2018 Medicare Advantage and Prescription Drug Plan Audit and Enforcement Conference
In-Person Registration Link: CMS 2018 MA & PDP Audit Conference
Webcast Registration Link: CMS 2018 MA & PDP Audit Conference

COMPLIANCE NEWS

Transition to New Medicare Numbers and Cards (MBI)

CMS will be removing Social Security Numbers (SSNs) from all Medicare cards.

  • A new Medicare Beneficiary Identifier (MBI) will replace the SSN-based Health Insurance Claim Number (HICN) on new Medicare cards which will be issued to beneficiaries beginning April 2018.
  • There will be a transition period where CMS will accept either the HICN or the MBI when submitting data to the agency. The transition period will begin April 1, 2018, and run through December 31, 2019.

MedHOK is prepared for the change and is working with our clients to implement.

Morphine Equivalent Dose (MED) Edits for Opioid

In the CY 2017 Call Letter, CMS notified Part D sponsors of the expectation to implement either soft and/or hard formulary-level cumulative opioid edits at point-of-sale (POS) based on MME to prevent potentially unsafe opioid dosing. These real-time safety alerts at the time of dispensing are a prospective step to help ensure providers are aware that potentially high-risk levels of opioids will be dispensed to their patients and to promote care coordination.

In this guidance, CMS confirms the enrollee, the enrollee’s representative or the enrollee’s prescriber has the right to request a coverage determination for a drug or drugs subject to the MME edit. Click here to review this guidance and select ‘Medicare-PartD-Overutilization-Control-HPMS-memos’. MedHOK has made enhancements to the platform to accommodate this guidance.

2018 Program Audit Changes/Updates

On December 6, 2017, CMS released a HPMS memo detailing the 2018 program audit process updates:

Audit Process Updates:

  • CMS will be sending scheduled program audit engagement letters from March through September 2018.
  • The field work phase of the audit will be extended from 2 weeks to 3 weeks for all audits.
  • This additional week of field work is meant to provide sponsors with additional time to respond to audit requests and prepare for the onsite Compliance Program Effectiveness (CPE) audit. The CPE audit will always be the last week of field work.
  • A blank version of the Audit Submission Checklist is now posted on the program audit website for sponsoring organizations to use when conducting their own mock audits.
  • The Audit Validation and Close Out phase is now supplemented with additional guidance about how to navigate through a validation audit with an independent auditor. This additional guidance can also be found on the program audit website.

Pilot Audit Report Status Changes:

  • The two Medicare-Medicaid Plan (MMP) focused audit protocols, Service Authorization Requests, Appeals and Grievances (SARAG) and Care Coordination and Quality Improvement Program Effectiveness (CCQIPE), will be fully operational program areas in 2018
  • The Medication Therapy Management (MTM) pilot protocol is being suspended and will not be conducted in 2018

Click here to view the 2018 CMS Program Audit Process Overview on CMS’ website.

Timeliness Monitoring Project (TMP)

The Centers for Medicare & Medicaid Services (CMS), will be conducting timeliness monitoring in three waves during 2018. The first wave of letters was sent out in January. For those plans that have not yet received the audit notice, the table below shows what plans can expect to submit in the coming months (unless you are one of the few lucky plans carved out, including most of those audited in 2017 as well as PACE plans, MMPs, and a few others).

Even as your chance of an audit is increasing dramatically, timeliness monitoring, coupled with CMS’ IRE auto-forward and overturn monitoring, provides CMS annual insight into every plan’s compliance record. The submissions will test for case timeliness, as well as accurate IRE auto-forwarding. Plans get 15 business days for submission from the notice date. Also remember, the monitoring review covers all cases, whether conducted by the plan or delegated entities. Universes will be validated and then reviewed. Fines can be levied for both submission issues as well as findings. CMS will run a timeliness analysis on all validated universes and determine a timeliness rate for each case type. Additional submissions or a full audit could result from monitoring outcomes. Click here to review the full blog post.

Provider Network Review

The Centers for Medicare & Medicaid Services (CMS) completed its second round of Medicare Advantage (MA) online provider directory reviews between September 2016 and August 2017. The review looked at the accuracy of 108 providers and their locations selected in 64 MA plans’ directories (about 1/3 of MA plans, 6,841 providers, and 14,869 locations).

CMS’ Findings:

  • Overall, 52.20% of the provider directory locations listed had at least one inaccuracy.
  • Inaccuracies included:
    • The provider was not at the location listed.
    • The phone number was incorrect.
    • The provider was not accepting new patients when the directory indicated they were.

Key Takeaways:

  • Provider network accuracy is next big compliance headache for plans
  • Review in this area will become as thorough as a standard audit

This is summary of a recently posted MedHOK blog. Click here to see the full blog post.

2019 Call Letter

Due to a recent mandate by Congress, the Centers for Medicare and Medicaid Services (CMS) is releasing the Advance Notice of Methodological Changes for Calendar Year (CY) 2019 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies and 2019 Call Letter in two draft notices. The first came in late December and the second in early February. You can find the official release here for both Call Letters. Additionally, click here to see the full blog post.

SECURITY NEWS

March 4–10 is National Consumer Protection Week (NCPW), an event to encourage people and businesses to learn more about avoiding scams and understanding consumer rights. During NCPW, the Federal Trade Commission (FTC) and its partners highlight free resources to help protect consumers.
NCCIC/US-CERT recommends consumers participate in the FTC/Facebook live chats and review the following NCCIC/US-CERT security tips:

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.

Back To Top