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May 2018 Compliance Insights

May 2018 Compliance Insights

COMPLIANCE NEWS

Part C & Part D

Calendar Year (CY) 2019 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter

April 2, 2018 – CMS released Calendar Year (CY) 2019 Medicare Advantage Capitation Rates, Medicare Advantage and Part D Payment Policies, and Final Call Letter. To view this announcement, click here. The release revealed a few significant changes from the draft of the February Call Letter previously released. Click here to read our blog on the draft and final call letter.

Medicare Advantage Program and Prescription Drug Benefit Program (Part D) for Calendar Year 2019 (CMS-4182-F) Final Rule

During the Spring of 2017, CMS released a Request for Information soliciting ideas to help improve MA and PDP benefits. CMS received numerous ideas in response to the Request for Information from beneficiaries, Medicare Advantage and Part D sponsors, advocacy groups, and other stakeholders. The policies in the MA and PDP final rule are responsive to this feedback.

The final rule can be reviewed here.

MEDICARE REGULATORY AND AUDIT UNIVERSE REPORT UPDATE

Annual Regulatory Reporting Changes

CY 2018 Parts C & D

The CY2018 Part C Reporting Requirements are posted on the CMS website.

The CY2018 Part D Reporting Requirements are posted on the CMS website.

  • No material changes from 2017 to 2018, changes were mainly clarifications

CY 2019 Part C

On March 26, 2018, CMS posted the proposed CY 2019 Part C reporting requirements, including a crosswalk of changes, on the CMS website. The 60-day comment period will end May 25, 2018.

SUMMARY OF CHANGES:

  • Organization Determinations and Re-considerations (ODR): Eighteen (18) additional data elements; two (2) deleted data elements; one (1) revision
    • Added elements – Allows CMS to obtain more information about who is submitting requests for ODR and whether the service or claim is being provided by a contracted or non-contracted provider.
    • Deleted elements – CMS deleted timeliness elements for ODR to be consistent with Part D reporting.
    • Revision – Data elements changed from numbers (i.e. 6.1) to Letters (A), to be consistent with Part D reporting.
  • Grievance: Nine (9) data elements deleted
    • Deleted elements – CMS no longer needs this information for monitoring purposes.
  • Mid-Year Network Changes: Suspended
  • Private-Fee-For-Service Provider Payment Dispute Resolution Process: Suspended
  • MMPs: Revision
    • MMPs will no longer be required to report data specific to ODR and Grievances under Part C reporting.

IMPACT TO MEDHOK REPORTS:

  • Grievance: Clients may amend BI Tool Report if desired. We recommend keeping the grievance categories in the report for internal monitoring purposes.
  • ODR: The Part C Regulatory report will be updated to account for the added elements. The timeliness data will not be removed as the report serves as a timeliness monitoring tool.

CY 2019 Part D

On February 28, 2018, CMS posted the proposed CY 2019 Part D reporting requirements, including a crosswalk of changes, on the CMS website.

  • The 60-day comment period ended April 16, 2018.
  • Through May 16, 2018, Center for Medicare (CM) staff will review all received comments and questions and revise the document appropriately. Also, CM staff will prepare a response document summarizing all received comments and questions, and their responses. A revised Part D reporting requirement document will be provided.
  • CM has requested the Part D reporting requirements be posted in the Federal Registry on June 1, 2018, and the 30-day comment period will end July 2, 2018.
  • From July 5, 2018 to August 6, 2018, CM staff will review all received comments and questions, and revise the document appropriately. Also, CM staff will prepare a response document summarizing all received comments and questions, and their responses. A final Part D reporting requirement document will be delivered for OMB review by December 14, 2018.

SUMMARY OF CHANGES:

  • Enrollment: Nine (9) revisions, three (3) additional data elements
  • Retail, Home Infusion, and Long-Term Care Pharmacy Access Section: Deleted
  • MTM: Twelve (12) revisions, two (2) additional data elements
  • Grievance: Nine (9) data elements deleted
  • Improving Drug Utilization Review Controls: One (1) revision, one (1) additional data element
  • CD/RD Section – Rejected Pharmacy Transactions Section: Deleted
  • CD/RD Section – Coverage Determinations: One (1) revision, five (5) data elements deleted
  • CD/RD Section – Re-determinations: One (1) revision, two (2) data elements deleted

IMPACT TO MEDHOK REPORTS:

  • MTM: The MTM regulatory report is being updated to reflect the revisions and additional data elements.
  • Grievance: Clients may amend BI Tool Report if desired. We recommend keeping the grievance categories in the report for internal monitoring purposes.
  • CD/RD: No change. The Part D Regulatory report will not be updated based on the revisions and the deletions of timeliness data, as the report serves as a timeliness monitoring tool.

Audit Universe Reporting Changes

On December 6, 2017, CMS announced changes and updates to program audits in 2018 and posted the updated version of this document on the program audit website.

MTM

The Medication Therapy Management (MTM) pilot protocol is being suspended and will not be conducted in 2018.

MMP

The two Medicare-Medicaid Plan (MMP) Pilot 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. On December 21, 2017 CMS issued the SARAG and CCQIPE CY 2018 MMP Audit Protocol Updates.

      SARAG Protocol Updates

  • Updated service authorization request definition to reflect that service authorization requests can be initiated by service coordinators or care coordinators. Thus, such authorization requests should be included in the service authorization request universes (MSSAR and MESAR).
  • Clarified that provider payment requests will be included in the pre-entrance conference webinar that will verify the accuracy of the dates and times provided in the record layouts. However, Table 3: M_Claims, will continue to be excluded from the SARAG timeliness calculation.
  • Corrected various record layout character lengths.
  • Removed the New York and California specific columns in Table 1: MSSAR (formerly Columns N and O) and Table 2: MESAR (formerly Columns O and P).
  • Added the required field First Tier, Downstream, and Related Entity to the Table 12: MMP Call Logs record layout to match the ODAG Call Log record layout.
  • Reduced the Table 12: MMP Call Logs universe review period to 10 days of calls.
  • Clarified State Fair Hearings, IRE, ALJ, or MAC overturns compliance standards in the Appropriateness of Clinical Decision-Making & Compliance with SARA Processing Requirements element.
  • Clarified that CMS reserves the authority to make any sample substitutions it deems necessary even though the intended sample set for the Appropriateness of Clinical Decision-Making & Compliance with SARA Processing Requirements element remains unchanged.
  • Clarified the record layouts and compliance standards to more clearly reflect that aid pending appeal could apply to denied and approved plan level appeals and external appeals.
  • Updated field descriptions for Date written notification provided to member and Date written notification provided to provider in Table 3: M_Claims.
  • Added clarification to the field description for Type of Service in Tables 1-6.

CCQIPE Protocol Updates

  • Clarified that Model of Care documents are no longer required audit documentation.
  • Removed record layout fields Cumulative dollar amount of claims paid, Cumulative dollar amount of claims denied, Cumulative # of claims paid, and Cumulative # of claims denied (formerly columns P-S) in Table 1: Medicare-Medicaid Plan Member (MMPM).
  • Added the field Member’s Current Risk Stratification Level to Table 1: Medicare Medicaid Plan Members (MMPM).
  • Updated ICT compliance standard 3.3.2 to clarify that the focus of the compliance standard is whether the ICT members possess the training required per the 3-way contract.

Call Log Universes

CMS is reducing the number of calls required for submission by shortening the review time periods as follows:

  • Plans with <50,000 enrollees: Plans should submit 10 days of calls based on the date the call was received by your organization, PBM, or other entity. The 10-day period must begin on the first Sunday of the CDAG/ODAG universe period and will go through two Tuesdays.
  • Plans with ≥50,000 but <250,000 enrollees: Plans should submit seven (7) days of calls based on the date the call was received by your organization, PBM, or other entity. The 7-day period must begin on the first Sunday of the CDAG/ODAG universe period and will go through Saturday.
  • Plans with ≥250,000 enrollees: Plans should submit three (3) days of calls based on the date the call was received by your organization, PBM, or other entity. The 3-day period must begin on the first Sunday of the CDAG/ODAG universe period and will go through Tuesday.
  • Upon issuance of the audit engagement letter, the period of days in the review period will be clearly identified in the Audit Submission Checklist. This will make it easy for sponsoring organizations to understand exactly which days of call logs are subject to audit.

* With the exception of this change and updates to MMP protocols, all other protocols will remain unchanged in 2018.

2019:

In preparation for audit year 2019 and the start of a new program audit cycle, CMS is currently redesigning the audit record layouts, impact analyses, and other data collection templates to maximize efficiency and reduce burden on the industry. On April 2, 2018, CMS posted the proposed Medicare Parts C and D Program Audit Protocols and Data Requests. On April 6, 2018 CMS announced an opportunity for sponsoring organizations and other stakeholders to comment. Comments must be received by June 1, 2018, electronically or by mail per the instructions in the notice.

CDAG

ODAG

A summary of the proposed Part C Organization Determinations, Appeals and Grievances (ODAG) audit universe report changes are below. MedHOK is in the process of mapping and creating the new reports in anticipation of the proposed changes becoming final.

SPECIAL NEEDS PLAN (SNP) MODEL OF CARE (MOC)

A summary of the proposed Special Needs Plans (SNP) Model of Care (MOC) audit universe report changes are below. MedHOK is in the process of mapping and creating the new reports in anticipation of the proposed changes becoming final.

Table 1 SNPE Record Layout

  • Report inclusion criteria is all current SNP enrollees as of the date of the audit engagement letter
    • Major change from 2018 inclusion criteria of all SNP beneficiaries who have been enrolled in any of the sponsoring organization’s SNPs, with no breaks in enrollment (i.e. continuously enrolled) for a period of at least 13 months as of the engagement letter date
  • List each enrollee only once
  • Include enrollees with disenrollment effective dates at the end of month in which you receive your audit engagement letter
  • Exclude enrollments received before the date of the audit engagement letter that are not effective until the first day of the month following the audit engagement letter

Impact Analysis Requests

  • Care Coordination Impact Analysis (CC-IA)
    • Due within 10 days of Request
    • List of enrollees impacted by the Care Coordination issue(s) identified during the 26-week period preceding the date of the audit engagement letter through the date the issue was identified on audit
    • All enrollees missing either a completed HRA, ICP or ICT as specified in the request for an impact analysis
    • HRA Utilization fields added to ensure all issues identified within the HRA are on the member care plan
    • For Individualized Care Plans (ICPs), was the member was involved in the ICP development, dates of ICPs, and the basis for current and previous ICP updates
    • For Interdisciplinary Care Teams (ICTs), was ICT involved in creating and updating care plan, PCP invitation for participation, ICT meetings at least annually and MOC training for all ICT participants
    • For Transitions of Care, CMS asks if the member experienced a hospitalization or healthcare change, was ICP updated and was transitional care offered post discharge
  • HRA Timeliness Impact Analysis (HRAT-IA)
    • Due within 10 days of Request
    • List of enrollees who did not receive a timely initial and/or annual HRA during the 26- week period preceding the date of the audit engagement letter through the date the issue was identified on audit
    • HRA completion date is the date the HRA is returned to the sponsoring organization
    • HRA event fields must meet the definition of the associated HRA event in accordance with the MOC in place at the time the event occurred
    • Additional fields to record the initial/annual outreach attempts required by MOC, outreach attempts made, date of first and last attempt, refusals, completion dates, and the unable to contact letter date

The Social Security Number Removal Initiative and Impacts on Record Layouts

The transition period where CMS will accept either the HICN or MBI when submitting data to the agency will run from April 1, 2018 through December 31, 2019. Therefore, in audit record layouts currently requiring submission of a HICN, a MBI or HICN will be accepted beginning on April 1, 2018. As the format of the MBI is distinctly different than the HICN, it is not necessary to add an MBI qualifier. Currently, the only program area impacted by this change is Part D Formulary and Benefit Administration.

Part D

2019 Formulary Submission Information

On March 27, 2018, CMS provided guidance to help Part D Sponsors with the submission of CY 2019 formularies. For additional information about 2019 formulary requirements please see 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 the 2019 Draft Call Letter.

To see this and other information regarding 2019 Formulary Submissions, click here to see the memorandum entitled “CY 2019 Formulary Submission Information.”

HPMS Formulary Submission Process Video

CMS created a video training tool demonstrating the HPMS formulary submission process for plan users. The training video is available on the CMS YouTube channel and can be viewed by clicking here.

Part D COB Files

CMS released an HPMS memo on March 27, 2018, outlining two important updates regarding the processing of Part D COB files:

 1. Updates to the Daily COB File

CMS changed the format of the Daily COB file beginning April 1, 2018. In support of the Medicare Card Project, the Health Insurance Claim Number (HICN) will be replaced by the Medicare Beneficiary Identifier (MBI) on the file. The file length will remain the same. Click here for more information about the Medicare Card Project

2018 Full Replacement Coordination of Benefits (COB) File

On April 23 – 27, 2018, each Part D plan received a full replacement COB file for all enrollees with other coverage. Due to file size constraints, sponsors with a large number of Part D enrollees with other coverage may have received multiple COB files over the three-day interval. These files contained no special identifiers to distinguish them from the normal daily COB notification files, but they were identifiable based on the date of receipt and the large size of the files. The daily COB process ceased while full replacement files were being generated. Therefore, the full replacement files did not include record updates that would normally be included in the daily COB notification files. Any record updates that occurred April 23rd through April 27th were sent in the daily notification files following completion of the full replacement file process.

Click here to review the HPMS memo regarding the Part C COB file updates.

MMP

MMP Application of Deductibles and Cost-Sharing When Reimbursing Non-Contract Providers

March 28, 2017- CMS released a HPMS memo tilted “Clarification to Guidance on Medicare-Medicaid Plan (MMP) Application of Deductibles and Cost-Sharing when Reimbursing Non-Contract Providers.”

In the memorandum, CMS provided clarifying guidance to MMPs on the reimbursement of non-network providers for Medicare-covered services.

Click here to review the HPMS memo:

MMPs and the Provisions in the CY 2019 Final Call Letter

April 3, 2018 – CMS provided clarifying guidance to MMPs on the applicability of the provisions in the CY 2019 Final Call Letter issued on April 2, 2018.

The HPMS memo can be viewed by clicking here:

MMP Provider and Pharmacy Directory Call

CMS will host a Provider and Pharmacy Directory call for MMPs on Wednesday, June 13, 2018 from 1:00 p.m. to 3:00 p.m. EDT. CMS will use call to:

  • Illustrate year-over-year improvements in directory monitoring findings from CY 2016 through CY 2018
  • Feature MMP process improvements, lessons learned, and best practices
  • Highlight areas where opportunities for further improvement remain

PACE

2018 PACE Audit Updates

April 23 2018 – CMS released an HPMS memo providing an overview of the PACE audit process improvements and reminders for 2018. They also announced they will be issuing their first PACE Annual Report later this year that provides an overview of the 2017 CMS PACE audits including: common conditions identified, audit scores, and lessons learned. A preview of the 2017 PACE audit trends will be presented at the 2018 Medicare Advantage and Prescription Drug Plan Audit & Enforcement Conference & Webcast on May 10, 2018.

2018 PACE Audit Process Improvements:

  • PACE Organizations will still have 30 calendar days to submit all required universes; however, for 2018, auditors will start the element review approximately two weeks after universes are received rather than the four weeks used in 2017.
  • Audit fieldwork for both routine and trial period audits will be conducted over two consecutive weeks. Week 1 of fieldwork will be performed off-site through desk review or webinar and will include the review of the Service Delivery Requests, Appeals and Grievances (SDAG) element. During week 2 of fieldwork, the audit team will conduct an in-person review of the onsite element, and any elements not reviewed or completed in week one.
  • The review and issuance of engagement letters, Immediate Corrective Action Required (ICAR) notifications, draft reports, and final reports will now be done by the MOEG’s Division of Analysis, Policy and Strategy (DAPS).
  • Core audit leads have been identified. These audit leads will be responsible for managing the CMS audit team, ensuring the audit protocol is followed, and reporting conditions to the PACE Audit Consistency Team (PACT) following the audit fieldwork. They will also be responsible for communicating with PACE Organizations both before and during the audit. Additionally, Account Managers (AMs) will no longer participate as an audit lead or audit team member for any organization they oversee; however, AMs will be responsible for monitoring the implementation and release of all corrective action plans (CAPs) following the audit.
  • All CMS audit elements, samples, and supporting documentation will be reviewed and collected by the CMS audit team. While CMS is ultimately responsible for collecting and documenting all findings related to the CMS protocol, SAAs may be onsite with the CMS team and may choose to review the information collected by CMS.
  • The Health Plan Management System (HPMS) requirements have been updated to allow for easier navigation and response to CMS requests within the audit module. These updates include: allowing organizations to upload and download multiple files at the same time (excluding universe files); entering draft audit report comments and responses directly into HPMS; and allowing for ICAR notification directly from the HPMS.

To review CMS’s full summary and Reminders, click here to review the HPMS memo.

SECURITY NEWS

Phishing attacks are getting more and more sophisticated with creative phishing “lures.” Many attacks are circumventing technical controls and making it to your inbox. Phishing is used in a high percentage of cyberattacks on healthcare organizations. Research conducted by Cofense (formerly PhishMe) suggests as many as 91% of cyberattacks start with a phishing email.

Keep your employees from getting hooked with a good phishing training program along with periodic self-inflicted campaigns to bolster the learning. The program should include some real attack examples the company has experienced. Be sure to include the fact that phishing attacks can come from within, using employees’ contact lists. Follow up with regular reminders about phishing attacks and how to spot them to keep everyone vigilant. Rewarding employees that identify and report phishing attacks is a great way to keep enthusiasm up for the program.

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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