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Healthcare Compliance Blog

2015 CMS Audit Protocol: Your Takeaway

In early February, the CMS released its new audit protocols and process updates for 2015 for Medicare Advantage organizations and Part D sponsors. The new audit memorandum has given way to a lot of speculation and confusion among the medicare advantage community.

As per the new mandate, 2015 begins a new audit cycle, wherein sponsors audited in the previous audit cycle (2010-2014) will be re-audited in the new cycle. In the 2014 audit, CMS has audited parent organizations that provide services to 96% of Medicare Advantage and Prescription Drug enrollees. A number of smaller sponsors were not audited in the 2014 audits.

CMS has established that it “will continue to utilize a risk-based approach to select sponsors for audit (both high and low risk), while also taking into account other key factors like, the sponsor has never previously been audited; the sponsor is new to the program; or the sponsor represents a large percentage of MA or Part D enrollment” for the 2015 Program Audit Cycle.

In this blog we attempt to bring more clarity on the areas that have been discontinued, modified and added and what the policy changes mean in terms of impact and compliance.

Discontinued elements

  1. Formulary and Benefit Administration Element (FA)
    What’s new: The review of the Pharmacy and Therapeutics (P&T) Committee has been removed. CMS indicated that it will continue to evaluate alternate methods to review the use of the P&T Committee and the implementation of the committee’s recommendations.

Modified elements

  1. Organization Determinations, Appeals, and Grievances (ODAG) & Coverage Determinations, Appeals, and Grievances (CDAG).

    What’s new: Modifications have been made to the ‘universe timeliness test and universe submissions’. In the past CMS required only consolidated data. However, CMS found it difficult to test timeliness using consolidated data. Hence, for 2015 CMS has requested additional universes to test data. This makes it crucial for entities to verify that all universe requirements are documented and reviewed regularly.

    http://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/ProgramAudits.html

    This change has resulted in significant increase in the number of universes submitted and the number of samples requested.

  2. Compliance Program Effectiveness (CPE)

    What’s new: Under the new protocol for this element the seven elements of a compliance program will be tested through ‘five tracer samples’ that will be traced as they move through the organization’s compliance department.

Newly added elements

CMS will initiate two pilot elements starting mid 2015 for which test scores will be given in the 2016 cycle.

  • Medication Therapy Management (MTM): A Pilot Program
    Sponsors are required to have an established MTM program to ensure optimum therapeutic outcomes for targeted beneficiaries through improved medication use. The objective of this program includes:

    1. Assess the sponsor’s performance against the CMS-approved MTM program.
    2. Educate sponsors and correct area(s) of deficiency
    3. Identify possible performance measures.
  • Provider Network Adequacy: A Pilot Program
    Sponsors are required to maintain an adequate provider network including specialty and subspecialty providers. The objective of this program includes:

    1. Evaluate adequacy of sponsor provider network.
    2. Examine the plan network and validate open access.

Audit process changes

  • Timeframes

    A selected sponsor will receive a letter of engagement six weeks prior to the start date. Upon receipt, the plan sponsor will have three weeks to submit universes to CMS. CMS increased this time to allow plan sponsors additional time to review and correct errors if any prior to submission.

  • Penalty

    For the 2015 cycle, CMS has added a high cost to incorrect universe submission. If there are errors in the third submission the plan will be give an ICAR for all elements tested on that universe. With this move CMS expects plan sponsors to submit correct universes in a timely manner.

  • Beneficiary impact analysis

    Within five days of receiving the audit engagement letter, the plan sponsor is liable to submit a beneficiary impact analysis to identify and highlight any previously disclosed and self-identified non-compliance issue/s. The sponsor must have rectified the issue before receipt of the engagement letter. CMS will consider an issue corrected if there is evidence of appropriate and adequate remediation, both in the sponsor’s systems and for the sponsor’s enrollees. CMS allows a maximum of three attempts to provide the Pre-Audit Issue Summary and the associated beneficiary impact analysis. If multiple attempts are made, CMS will consider the last document submitted.

To view the full CMS memorandum, click here.

How Inovaare’s A&G software can help

Inovaare’s out-of-the-box yet simple compliance Appeals and Grievances solutions automate member appeal process, enforce compliance and generate various management, operational, compliance and quality related dashboard and reports. The Grievances software enables organization to manage various types of member grievances and provides end-to-end process from case intake to case closure. With built-in regulatory rules and appropriate case categorization, the grievances system helps organization to achieve regulatory compliance and quality mandates.

The TracX software from Inovaare offers a centralized repository for all the evidence required for review and submission during the audit. Using TracX entities can, not only meet the CMS threshold of 95% compliance, but also identify the missing elements comprising 5%, and be prepared before the CMS audit submission. TracX, has been known to bring to light and rectify critical process errors that could result in significant penalties and possibly sanctions. TracX is a perfect compliance solution in view of the narrow lead time between the Program Audit notice and the audit submission, making the compliance process less cumbersome, on-time and error-free.

With multiple audit updates and mandate changes, Inovaare’s CQMS software can help you automate quality and compliance operations, reduce risk, lower operational cost and increase compliance visibility.

Be ready, be compliant with Inovaare compliance software!

To know more about our compliance products, click here.

What are the potential risks?

  • CMS Imposed 43 CMP totaling $8 Million on some 30+ plans.
  • Possible suspension of enrollment and marketing.

Be ready before it is too late

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