Save the date – this year’s Medicare Advantage & Prescription Drug Plan Spring Conference & Webcast will be held Wednesday, May 6, 2015 from 9:30am – 4:30pm. To learn more about this event, please visit the Compliance Training Education and Outreach (CTEO) section of CMS.gov.
CMS requires that Part D sponsors with an approved Medication Therapy Management (MTM) program submit beneficiary-level MTM program data for Contract Year 2014. The reporting deadline for these data is February 28, 2015. See the January 16, 2015 memo for information regarding the submission process.
CY 2015 Part D Reporting Requirements
The Centers for Medicare and Medicaid Services (CMS) has released the CY2015 Part D Reporting Requirements and Technical Specifications. These documents are posted on the HPMS Plan Reporting site and on the external CMS website.
Section IV. Prompt Payment by Part D Sponsors, and Section VIII. Fraud, Waste and Abuse Compliance Programs have been suspended from 2015 reporting requirements.
Common CMS Audit Findings and Future Audits
In our September 2014 edition of Compliance Insights we highlighted the August 27, 2014 HPMS Memo regarding the top five common audit findings based on 2013 Program Audit Reviews.
Although January is a very busy time with new members and benefits, plans should not lose sight of compliance and should revisit this memo and ensure it is reflected in their 2015 audit plan and is shared with senior leadership and other affected stakeholders.
The number of recurrent conditions highlighted in this memo and the frequency with which they have been cited in past memos suggests this information, as well as other internal monitoring recommendations and tools, are not being utilized as expected. Sponsors should be aware that conditions noted in one or more Best Practice/Common Findings memos will be considered an aggravating circumstance during the course of future program audits, which can adversely affect a sponsor’s overall audit score. For example, an observation might be elevated to a corrective action required (CAR) or a CAR might be elevated to an immediate corrective action required (ICAR) if the condition cited had been addressed in a prior Best Practice memo.
Part D Formulary and Benefit Administration (FA)
- Sponsor failed to properly administer its CMS-approved formulary by applying unapproved quantity (61%)
- Sponsor failed to properly administer its CMS-approved formulary by applying unapproved utilization management practices (50%)
- Sponsor failed to properly administer the CMS transition policy (43%)
- Sponsor improperly effectuated a prior authorization or exception request (39%)
- Sponsor failed to provide a continuing beneficiary a transition supply of a non-formulary medication (32%)
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
- Beneficiaries and prescribers did not receive an adequate and/or accurate rationale for the denial (89%)
- Sponsor did not demonstrate sufficient outreach to the prescriber or beneficiary to obtain information necessary to make an appropriate clinical decision (78%)
- Sponsor misclassified a coverage determination or redetermination request as a grievance and/or customer service inquiry (59%)
- Sponsor did not notify the beneficiary or their prescriber, as appropriate, of its decision within 72 hours of receipt of a standard coverage determination request or, for an exceptions request, the physician’s or other prescriber’s supporting statement (56%)
- The Sponsor made inappropriate denials when processing coverage determinations (56%)
Part C Organization Determinations, Appeals, and Grievances (ODAG)
- Sponsor did not make payment decisions within the required 30 or 60 day claims processing timeframes (75%)
- Sponsor did not notify the beneficiary or the provider of its decision within 14 calendar days of receipt of a standard, pre-service organization determination request (58%)
- Beneficiaries and providers did not receive an adequate and/or accurate rationale for the denial (54%)
- When the sponsor denied a request for payment from a non-contracted provider, the remittance advice / denial notice did not state the specific reason for the denial nor did it provide a description of the appeals process (50%)
- Sponsor did not demonstrate sufficient outreach to the provider or beneficiary to obtain the information necessary to make an appropriate clinical decision (50%)
Compliance Program Effectiveness (CPE)
- Sponsor did not review OIG and GSA exclusion lists for any new employee, temporary employee, volunteer, consultant, governing body member and/or FDR prior to hiring or contracting; nor monthly thereafter (64%)
- Sponsor did not provide evidence that it audits the effectiveness of the compliance program at least annually and that the results are shared with the governing body of their organization (36%)
- Sponsor did not provide fraud, waste and abuse (FWA) training or training materials to its FDRs (29%)
- Sponsor did not provide evidence that general compliance information was communicated to its FDRs (25%)
- The Sponsor did not distribute its standards of conduct (SOC) and policies and procedures to employees who supported the Medicare line of business: (1) Within 90 days of hire; (2) when there were updates to the policies and procedures, and, (3) annually thereafter (25%)
Special Needs Plans Model of Care (SNP MOC)
- Sponsor administered the initial health risk assessment (HRA) to a beneficiary more than 90 days after their enrollment (75%)
- Sponsor did not administer the comprehensive annual reassessment within 12 months of the last risk assessment (75%)
- Sponsor did not provide evidence that it had an individualized care plan (ICP) for the beneficiary (58%)
- The ICP did not address issues identified in the HRA (58%)
- Sponsor did not provide evidence of individualized care plan (ICP) implementation through care or case management notes (42%)