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Healthcare Compliance Blog

CMS Audit Universes as a Tool for Ongoing Compliance Monitoring

One of the most arduous and time-consuming activity for MAPD and PDP plans is the creation of the required universes for submission to the CMS. Health plans often struggle with the critical step of universe creation followed by ensuring that the universes are clean or error-free.
If you have been through a CMS program audit in 2015 or 2016, you would be familiar with the rigors of timeliness review of your Part C Organization Determinations, Appeal, and Grievances (ODAG) and Part D Coverage Determinations, Appeals, and Grievances (CDAG) universes to validate the accuracy of universes and to measure timeliness in each of the audit areas.
CMS Update
Now, all MADP and PDP plans will face reviews, regardless of whether they are selected for a CMS audit this year. CMS in November 2016 announced that it will implement an industry-wide timeliness monitoring activity related to Part C organization determinations and appeals and Part D coverage determinations and appeals. This has two reasons, one, to evaluate the integrity and completeness of the Independent Review Entity (IRE) data, and second, to improve the overall monitoring of compliance.
Beginning January 2017, CMS started collecting 7 ODAG universes and 10 CDAG universes from each contract to assess timeliness in processing both Part C and D requests, as well as compliance with forwarding cases to the IRE. The CMS describes an acceptable universe in terms of field type, length, and description, as well as how to determine the dates for date fields.
Plans have a maximum of three attempts to submit accurate and timely universes during a CMS audit, failing which they could be referred for Invalid Data Submission (IDS) condition for every audit element that cannot be tested or grouped by the type of case. This could adversely impact STAR ratings and audit score. Failure to successfully submit universes may result in compliance actions by CMS.
Universes as a powerful compliance tool
To mitigate risks arising from generating inaccurate or untimely audit universes, we empower plans to create clean, accurate and timely audit universes that are CMS-ready and can also be used as a tool for ongoing compliance monitoring. The universes can be a powerful tool for plans to evaluate their operational performance. Ongoing review of universes can also help plans identify issues proactively and address them in advance.

Questions to ponder?
Are you generating clean universes for CMS submission?
What is the error rate? What is the cost in terms of man-hours needed to rectify errors?
Are you using your universes as an ongoing monitoring tool?
Are you facing penalties and delays?

To know about our solution for generating clean audit universes, please visit Universe Scrubber.

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