skip to Main Content

Timeliness Monitoring is Back, Putting a Cramp in Holiday Plans

Timeliness Monitoring Is Back, Putting A Cramp In Holiday Plans

As everyone suspected but perhaps hoped wouldn’t happen, the Centers for Medicare and Medicaid Services (CMS) announced in a recent Health Plan Management Systems (HPMS) memo that timeliness monitoring will be done in 2018 for the second year. For the compliance and business folks, this puts a bit of a cramp in people’s holiday schedules.

Over the past many years, CMS has really ramped up the compliance regime and the institutionalization of timeliness monitoring is a logical part of it. Here’s a recap of the compliance rollout by CMS.

  • 2012 saw CMS rolling out a strict enforcement regime.
  • 2014 saw CMS begin even harsher compliance enforcement, with significant Civil Monetary Penalties (CMPs) and suspensions of marketing and/or enrollment. At last count, since 1/1/2014, 100 CMPs or suspensions have been meted out, totaling $26.7 million. Twelve suspensions have occurred and, in some cases, exceeded 1 year.
  • 2015 saw brand new universes. The number of universes was basically tripled and became very detailed. The aim was to help CMS get to the likely suspect cases that are non-compliant – hence the increase in CMPs.
  • 2016 and 2017 saw further refinement of the universes to ensure correct population and to clear up ambiguity (which continues despite significant changes).
  • In 2016 and 2017, enhanced outreach requirements were added, complicating efforts to ensure timeliness compliance. While CMS has not yet audited on these outreach directives, they are sure to begin in 2018.
  • In 2016 and 2017, CMS ramped up its audit activity.
  • In 2016 and 2017, CMS upped its Independent Review Entity (IRE) oversight monitoring due to concerns regarding Star data integrity.
  • In 2017, timeliness monitoring occurred for the first time in three waves in early 2017 looking back at 2016 case activity.
  • In 2017 we saw our first CMP levied due to inordinate auto-forwards to the (IRE).

The significance of the last four items cannot be overstated. Plans will see their chance of audit, CMPs, and suspensions in a given year increase substantially. And the timeliness monitoring and significant IRE focus increases risk even more. A plan literally cannot hide its poor compliance practices any more. Even relatively good players have much to fear.

Here is the summary of the 2018 timeliness monitoring announcement:

  • Will be performed again in three phases, the first beginning in January
  • Will cover 10 CDAG and 7 ODAG universes
    • Coverage Determinations, Redeterminations, Direct Member Reimbursements and IRE Auto-Forwards
    • Organization Determinations, Reconsiderations, and Direct Member Reimbursements.
  • The submissions will test for timeliness of cases as well as correct auto-forwarding to the IRE.
    Only those organizations with active contracts in both 2017 and 2018 will be covered by the monitoring and receive notices.
  • Program of All-Inclusive Care for the Elderly (PACE), Medicare-Medicaid Plans (MMPs), Medical Savings Account Plans (MSAs), Employer/Union Only Direct (E Contracts), and 1833 Health Care Prepayment Plans (HCPPs) contracts are excluded from the review.
  • Generally, unless there was insufficient data or Invalid Data Submission (IDS) conditions, plans who underwent a program audit in 2017 will not be subject to monitoring review. If issues did arise during a 2017 audit, impacted plans may be subject to partial submissions for monitoring.
  • Detailed setup requirements are outlined in the memo.
  • Plans get 15 business days for submission from the notice date.
  • Case timeframes are March through May 2017, depending on all-contracts size of the sponsor plan.
  • Remember that 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 rate of timeliness for each case type. Additional submissions or a full audit could result from monitoring outcomes.
  • There have been no public findings for 2017 timeliness monitoring, but could be ongoing in some cases and result in finding or penalties being announced in the future.
  • There also is a strong data integrity focus for Star here. As plans are aware, there are four Star measures tied to timeliness, forwarding to the IRE and overturns. If plans do not submit accurately to the IRE, this could skew Star results for these measure markedly. Thus CMS could also adjust these Star measures if CMS levies penalties on a plan for timeliness or IRE auto-forward accuracy.

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