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Healthcare Compliance Blog

Reasonable Outreach: Are you missing what CMS expects?

The Centers for Medicare & Medicaid Services (CMS) on April 20th of 2016 released several job aids in order to assist plan sponsors with improving their operations and ensuring compliance with CMS requirements.

These job aides are based on common performance issues found in their Coverage Determination Audits of both CDAG and ODAG and continue to be the two areas that are the key source of most audit findings

I want to focus on the one CMS issued for Reasonable Outreach.

The process they outlined is typical, First the staff is expected to Determine if an expedited or standard decision is needed, figure out the level of service requested (expedited or Standard), review the case and if additional information is needed, they are then to follow the Plans protocols to reach out and obtain the information.

Now here is where many plans start to miss what CMS is expecting. First of all, CMS is expecting a minimum of Three attempts to obtain the missing or needed information. Document how outreach was conducted (e.g., phone, fax) and what information is missing or needed. Be specific about what is needed to approve coverage, you will also need to document the date and time of all outreach attempts and whether outreach was successful.

This sounds simple enough, however, you would be surprised how often plans do not properly document what was requested and how many times they reached out for the information.

A few best practices also mentioned in the Job Aide is to:

• Use different methods of outreach from your initial attempt when possible.
• When feasible, make outreach attempts only during business hours. If you can’t then follow the after-hours instructions.
• Leave at least a few hours between attempts for the provider to respond.
• Be specific. Notify provider what information must be received
• Clearly document all outreach attempts; note method, date and time.
• Make sure you thoroughly document all your attempts, including date, time and method

Have a question? Please contact Brenda Wade or Gabe Viola

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