Our blog has been ripe with information lately regarding Centers for Medicare and Medicaid Services (CMS) Civil Monetary Penalties (CMPs), Program Audit Findings, as well as, the focus on Independent Review Entity (IRE) Auto-Forwards. The compliance regime and changes are not slowing as is evidenced by the proposal from CMS to significantly overhaul universe submission formats, changes in audit protocols and major changes to annual reports. All this comes on top of major changes and adjustments in the recent past to universes. CMS has posted proposed protocol and report changes since December 2017. Some comment periods concluded already, but others go through May 25, 2018 and June 1, 2018.
CY 2019 Part C Reporting
On March 26, 2018, CMS posted the proposed CY 2019 Part C reporting requirements, including a crosswalk of changes, on the CMS website. The 60-day comment period will end May 25, 2018.
Summary of Changes:
- Organization Determinations and Reconsiderations (ODR): 18 additional data elements; two (2) deleted data elements; one (1) revision
- Added elements – Allows CMS to obtain more information about who is submitting requests for ODR and whether the service or claim is being provided by a contracted or non-contracted provider.
- Deleted elements – CMS deleted timeliness elements for ODR to be consistent with Part D reporting.
- Revision – Data elements changed from numbers (i.e. 6.1) to Letters (A), to be consistent with Part D reporting.
- Grievance: Nine (9) data elements deleted
- Deleted elements – CMS deleted elements that were no longer needed for monitoring purposes.
- Mid-Year Network Changes: Suspended
- Private-Fee-For-Service Provider Payment Dispute Resolution Process: Suspended
- MMP: MMPs will no longer be required to report data specific to ODR and Grievances under Part C reporting.
CY 2019 Part D Reporting
On February 28, 2018, CMS posted the proposed CY 2019 Part D reporting requirements, including a crosswalk of changes, on the CMS website. The 60-day comment period ended April 16, 2018.
Summary of Changes:
- Enrollment: Nine (9) revisions, three (3) additional data elements
- Retail, Home Infusion, and Long-Term Care Pharmacy Access Section: Deleted
- MTM: 12 revisions, two (2) additional data elements
- Grievance: Nine (9) data elements deleted
- Improving Drug Utilization Review Controls: One (1) revision, one (1) additional data element
- CD/RD Section - Rejected Pharmacy Transactions Section: Deleted
- CD/RD Section - Coverage Determinations: one (1) revision, five (5) data elements delete
- CD/RD Section - Re-determinations: one (1) revision, two (2) data elements deleted
Program Audit Protocol and Universe Changes
On December 6, 2017 CMS announced changes and updates to program audits in 2018 and posted the updated version of this document on the program audit website. With the exception of the items listed below, all other protocols will remain unchanged in 2018.
MTM: The Medication Therapy Management (MTM) pilot protocol is being suspended and will not be conducted in 2018.
MMP: The two Medicare-Medicaid Plan (MMP) Pilot audit protocols, Service Authorization Requests, Appeals and Grievances (SARAG) and Care Coordination and Quality Improvement Program Effectiveness (CCQIPE), will be fully operational program areas in 2018.
Summary of SARAG Protocol Changes:
- Updated service authorization request definition to reflect that service authorization requests can be initiated by service coordinators or care coordinators. Thus, such authorization requests should be included in the service authorization request universes (MSSAR and MESAR).
- Clarified that provider payment requests will be included in the pre-entrance conference webinar that will verify the accuracy of the dates and times provided in the record layouts. However, Table 3: M_Claims, will continue to be excluded from the SARAG timeliness calculation.
- Corrected various record layout character lengths.
- Removed the New York and California specific columns in Table 1: MSSAR (formerly Columns N and O) and Table 2: MESAR (formerly Columns O and P).
- Added the required fields First Tier, Downstream, and Related Entity to the Table 12: MMP Call Logs record layout to match the ODAG Call Log record layout.
- Reduced the Table 12: MMP Call Logs universe review period to 10 days of calls.
- Clarified State Fair Hearings, IRE, ALJ, or MAC overturns compliance standards in the Appropriateness of Clinical Decision-Making & Compliance with SARA Processing Requirements element.
- Clarified that CMS reserves the authority to make any sample substitutions it deems necessary even though the intended sample set for the Appropriateness of Clinical Decision-Making & Compliance with SARA Processing Requirements element remains unchanged.
- Clarified the record layouts and compliance standards to more clearly reflect that aid pending appeal could apply to denied and approved plan level appeals and external appeals.
- Updated field descriptions for Date written notification provided to member and Date written notification provided to provider in Table 3: M_Claims.
- Added clarification to the field description for Type of Service in Tables 1-6.
Summary of CCQIPE Protocol Changes:
- Clarified that Model of Care documents are no longer required audit documentation.
- Removed record layout fields Cumulative dollar amount of claims paid, Cumulative dollar amount of claims denied, Cumulative # of claims paid, and Cumulative # of claims denied (formerly columns P-S) in Table 1: Medicare-Medicaid Plan Member (MMPM).
- Added the fields Member’s Current Risk Stratification Level to Table 1: Medicare-Medicaid Plan Members (MMPM).
- Updated ICT compliance standard 3.3.2 to clarify that the focus of the compliance standard is whether the ICT members possess the training required per the 3-way contract.
Call Log Universes: CMS is reducing the number of calls required for submission by shortening the review time periods as follows:
- Plans with <50,000 enrollees: Plans should submit 10 days of calls based on the date the call was received by your organization, PBM, or other entity. The 10-day period must begin on the first Sunday of the CDAG/ODAG universe period and will go through two Tuesdays.
- Plans with ≥50,000 but <250,000 enrollees: Plans should submit seven (7) days of calls based on the date the call was received by your organization, PBM, or other entity. The 7-day period must begin on the first Sunday of the CDAG/ODAG universe period and will go through Saturday.
- Plans with ≥250,000 enrollees: Plans should submit three (3) days of calls based on the date the call was received by your organization, PBM, or other entity. The 3-day period must begin on the first Sunday of the CDAG/ODAG universe period and will go through Tuesday.
- Upon issuance of the audit engagement letter, the period of days in the review period will be clearly identified in the Audit Submission Checklist. This will make it easy for sponsoring organizations to understand exactly which days of call logs are subject to audit.
In preparation for audit year 2019 and the start of a new program audit cycle, currently CMS is redesigning the audit record layouts, impact analyses, and other data collection templates to maximize efficiency and reduce burden on the industry.
On April 2, 2018, CMS posted the proposed Medicare Parts C and D Program Audit Protocols and Data Requests. On April 6, 2018, CMS announced an opportunity for sponsoring organizations and other stakeholders to comment. Per the instructions in the notice, comments must be received by June 1, 2018, electronically or by mail.
In 2015, CMS massively expanded the number of universes and both CMS and plans struggled with the changes throughout 2015 and 2016. In 2019, CMS will return closer to the number of universes present in 2014, but with some new features as well.
CDAG: A summary of the proposed Part D Coverage Determinations, Appeals and Grievances (CDAG) audit universe report changes are below:
ODAG: A summary of the proposed Part C Organization Determinations, Appeals and Grievances (ODAG) audit universe report changes are below:
Special Needs Plan (SNP) Model of Care (MOC): The following segment outlines a summary of the proposed SNP MOC universe report changes. As we have seen in recent audits, CMS is really honing in on SNP MOC operations to ensure that plans are following the Model of Care, completing the assessments, creating care plans, ensuring that care plans are updated when changes in health status occurs for each member, and that plans are focusing in on member and care team engagement during the creation and updating of the care plans. Based on the changes we see in the universe, SNP MOC audits will get tougher.
- Included universe population changes significantly, moving to a point in time review of members vs. those continuously enrolled:
- Current -- All SNP beneficiaries who have been enrolled in any of the sponsoring organization’s SNPs, with no breaks in enrollment (i.e. continuously enrolled) for a period of at least 13 months as of the engagement letter date.
- List all current SNP enrollees as of the date of the audit engagement letter
- List each enrollee only once
- Include enrollees with disenrollment effective dates at the end of month in which you receive your audit engagement letter
- Exclude enrollments received before the date of the audit engagement letter that are not effective until the first day of the month following the audit engagement letter
- Other significant universe changes were:
- Removed record layout fields Cumulative dollar amount of claims paid, Cumulative dollar amount of claims denied, Cumulative # of claims paid, and Cumulative # of claims denied, removed enrollment mechanism, date sponsor received enrollment request
- Added the field Enrollee’s Risk Stratification Level /Score at time of audit engagement and was an ICT created/identified
- Modified the HRA reporting fields
- Care Coordination Impact Analysis (CCIA)
- Due within 10 days of Request
- List of enrollees impacted by the Care Coordination issue(s) identified during the 26-week period preceding the date of the audit engagement letter through the date the issue was identified on audit
- All enrollees missing either a completed HRA, ICP or ICT as specified in the request for an impact analysis
- HRA Utilization fields added to ensure all issues identified within the HRA are on the member care plan
- For Individualized Care Plans (ICPs), was the member involved in the ICP development, dates of ICPs, and the basis for current and previous ICP updates
- For Interdisciplinary Care Teams (ICTs), was the ICT involved in creating and updating care plan, PCP invitation for participation, ICT meetings at least annually and MOC training for all ICT participants
- For Transitions of Care, CMS asks if the member experienced a hospitalization or healthcare change, was ICP updated and was transitional care offered post discharge
- HRA Timeliness Impact Analysis (HRAT-IA)
- Due within 10 days of Request
- List of enrollees who did not receive a timely initial and/or annual HRA during the 26-week period preceding the date of the audit engagement letter through the date the issue was identified on audit
- HRA completion date is the date the HRA is returned to the sponsoring organization
- HRA event fields must meet the definition of the associated HRA event in accordance with the MOC in place at the time the event occurred
- Additional fields to record the initial/annual outreach attempts required by MOC, outreach attempts made, date of first and last attempt, refusals, completion dates, and the unable to contact letter date.