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The Latest on 2016 Program Audits from CMS’ Fall Conference Yesterday

Yesterday, the Centers for Medicare & Medicaid Services (CMS) held its annual Medicare Advantage and Prescription Drug Plan Fall Conference and Webcast. The agenda included an array of topics, including 2016 Program Audits.

As this is always a hot topic for CMS and those highly impacted by an audit, CMS has received a great deal of feedback from the industry and auditors. An overall consensus thought that errors with appeals and grievances audit protocols were a result of CMS’ large record layout. CMS was requesting data related to the large record layout. Acting on this feedback, CMS announced that it has updated many of the record layouts and protocols, as well as some additional changes:

  • Extraneous fields included in record layouts in error have been deleted.
  • Headers on each of the record layouts have been added, as well as direction on what data should be included or excluded.
  • Data dictionaries have been updated to explain what each field means and what is being requested. Also clarification was provided on how certain data should be reported, such as by request received date, issued date, etc.
  • In Organization Determinations, Appeals and Grievances (ODAG) and Coverage Determinations, Appeals and Grievances (CDAG), grievances will be based on the date of resolution of the grievance and not based on the receipt of the request.

Another topic discussed in yesterday’s webcast surrounds a plan self-disclosing or self-identifying known or potential issues. A self-disclosed issue is one your organization identifies and discloses to your account manager prior to the receipt of an audit start notice. A self-identified issue is an issue you may or may not have been aware of before you received your audit start notice but you have not previously disclosed to CMS. Either way, CMS wants to know.

In 2016, CMS will no longer request a Beneficiary Impact Analysis (BIA) on self-identified and self-disclosed issues prior to the start of or during the audit. CMS found that attempting to confirm correction was a difficult process to operationalize. They will no longer be asking for the BIA; however, they still expect organizations to self-identify and self-disclose.

Furthermore, for organizations that were unable to provide CMS with a valid and accurate universe within three submissions, CMS is no longer offering a “grace period”. For 2016, CMS has created a new condition type called Invalid Data Submission (IDS). When an organization submits an inaccurate universe three times, there will be a certain set of IDS conditions around any element CMS cannot test. For example, if CMS cannot run a universe timeliness test around CDAG for dates and times for 1, 2, or 3 universes, the organization will get an IDS condition relative to CMS’ inability to test decision making notification.

CMS is sending its final audit notices on Monday, September 14, 2015. If an organization does not receive an audit notice after this mailing, it will not be audited in 2015.

Since CMS has made a lot of updates to the 2015 audit protocols and are going to repost them (hopefully in September), those updates will be effective as the 2016 protocols. CMS is not making any additional changes. CMS wants to keep things steady for a couple of years to let the industry catch up.

An HPMS memo will be distributed once the protocols have been reposted. Stay tuned.

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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