How Will the CMS Updates Affect Your Medicare Advantage and Prescription Drug Plans?

6 Major Points from the 2017 CMS Spring Conference


The Centers for Medicare & Medicaid Services (CMS) recently held their spring conferences and provided sponsors with many updates to the current activities occurring as well as changes in the future. There was focus on 2017 program audit protocols and the outcomes of the most recent audits conducted by CMS.

Guidehouse provides six major highlights from the spring conference on changes to the Medicare Advantage (MA) and prescription drug plans.

1. Auto-Forwarding Coverage Determinations Cases to the Independent Review Entity
CMS has determined that an excessively high auto-forward rate demonstrates a failure of a sponsor’s compliance with the requirements for processing coverage determination and redetermination within the required timeframes. Beginning in 1Q 2017, CMS will be imposing Civil Monetary Penalties quarterly on Sponsors with excessively high auto-forward rates. CMS has set the outlier threshold at a rate of 15 or more auto-forward per 10,000 beneficiaries per quarter. Some exclusions apply.

2. Provider Directory Review
CMS completed the first review cycle of provider directories. The review included 5,832 providers and approximately 11,646 locations. An average provider error rate was 41%. The second review cycle commenced in November 2016. CMS will provide sponsors the results on a rolling basis. Some of the most common deficiencies were: the lack of identifying providers who are accepting new patient or are NOT accepting new patients, listing providers contract effective or termination date in the directory, and identifying when a provider has significant limitations on patients they see. CMS highly encourages sponsors to conduct their own monitoring and oversight of provider directories.

3. Social Security Number Removal Initiative Update
The Medicare Access and CHIP Reauthorization Act of 2015 mandates the removal of the Social Security Number-based Health Insurance Claim Number from Medicare cards to address current risk of beneficiary medical identity theft. The legislation requires that CMS mail new Medicare cards with a new Medicare Beneficiary Identifier by April 2019, a transition period will run from April 2018 through December 31, 2019. CMS will address complex systems changes for over 75 systems, conduct extensive outreach and education activities, and analyze the many changes that will be needed to systems and business processes.

4. 2017 Program Audits
CMS reviewed the four phases of the 2017 audit program and the enhancements which have been made to better serve sponsors. This year audits will include various audit tools and aides which will reside in HPMS and provide increased timeframes for submitting documentation requested due to audit fieldwork findings. CMS provided clarifying guidance on instructions and field name/description for universe tables for each of the program audits.

CMS will be conducting 40 audits in 2017. Initial letters were sent beginning February 21, 2017, with final letters going out around September 25, 2017.

5. Audit Protocol Update

CMS reviewed the changes in 2017 audit protocols. Compliance Program Effectiveness has the most significant changes to the universe submission, supporting documentation and tracer review. The focus in 2017 is on a grouping of the previous seven elements into three. The three audit elements focus on the prevention, detection and correction controls and activities. Of note, attributed to the change there is no longer a tracer template to use for creation of the tracer.

Only Sponsor-disclosed issues are reported on the Pre-Audit Issue Summary. CMS is no longer requiring the disclosure of “self-identified” issues that have not been previously reported to CMS.

The final Medicare-Medicaid Program (MMP) Audit Protocols were release on April 28, 2017. Protocols specific to MMP: 1) MMP Service Authorization Requests, Appeals and Grievance and 2) MMP Care Coordination and Quality Improvement Program Effectiveness. Protocols remain a pilot for 2017. The audit period will be extended an additional week to specifically address MMP audits.

6. Timeliness Monitoring Project (TMP)
The Timeliness Monitoring Project was conducted in early 2017 in three waves collecting ODAG and CDAG universes from all plans. Potential application of the data may be to:

1) identify additional areas where clarification is needed in respect to data collection
2) study contract level difference in timeliness of appeals, identify any new areas of concern
3) provide a statistical basis for scaled reductions to Star Ratings vs. the standard change to a 1 star

CMS plans on conducting TMP again next year; however, they may consider changing the methodology.

Guidehouse has studied these changes in depth and can help your organization prepare for a CMS audit utilizing the 2017 audit protocols.


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