By: Diane Ramey and Susan Russo
The main theme of the 2018 Centers for Medicare & Medicaid Services (CMS) Spring Conference was enhancing Medicare Advantage and Part D plans’ role in providing value-based care. From improving the quality of encounter data for enhanced payment systems to ensuring adequacy in provider networks, each session tied into this theme in various ways, and the keynote emphasized how CMS continues to strive toward this common goal.
To improve encounter data integrity, CMS is making changes to its core activities of analysis, communication with Medicare Advantage Organizations (MAOs), monitoring, and compliance. CMS continues to issue new guidance as part of its communication with MAOs, including, most recently, guidance on population of specific data fields, submission of National Provider Identifiers, the Medicare Card project, and use of chart review records. A consolidated encounter data submission guide and a more user-friendly Customer Service and Support Center operations website will be coming soon.
The main driver of risk adjustment work for 2019 was the 21st Century Cures Act, under which CMS must evaluate the impact of including additional diagnosis codes related to mental health and substance abuse disorders and the severity of chronic kidney disease in its risk adjustment model. Following its review, CMS has proposed adding new Hierarchical Condition Categories (HCCs) to the model:
Substance Use Disorder, Mild, Except Alcohol and Cannabis (HCC 56)
Reactive and Unspecified Psychosis (HCC 58)
Personality Disorders (HCC 60)
Chronic Kidney Disease, Moderate (Stage 3) (HCC 138)
Added select drug and alcohol poisoning codes to existing Drug/Alcohol Dependence to create “Substance Use Disorder, Moderate/Severe, or Substance Use with Complications” (HCC 55)
Other updates include evaluation of adding a count of conditions to the model, updating the data years, and updating the method used for diagnosis selection to align with the encounter data filtering method.
CMS will begin to phase in these changes in 2019 by implementing the recalibrated End Stage Renal Disease dialysis and functioning graft model and the updated CMS-HCC model without count variables. The Payment Condition Count model will be phased in beginning in 2020. In 2019, CMS will also update its risk scores for non-Programs of All-Inclusive Care for the Elderly plans by adding 25% of the risk score calculated using encounter data and fee-for-service (FFS) diagnoses with 75% of the risk score calculated using Risk Adjustment Payment Systems and FFS diagnoses.
CMS continues to research and assess the ICD-10 diagnoses and mappings to HCCs and RxHCCs, reclassifying mappings where pertinent and analyzing model calibrations for stability and accuracy.
Call Letters relating to Star Ratings have focused on:
2019 Star Ratings Measure Set Updates
Emphasizing statin use in patients with diabetes and those with cardiovascular disease, as well as on reducing the risk of falling
2019 Scaled Reductions
Independent Review Entity (IRE) data completeness issues
Used 2017 Timeliness Monitoring Project data to reduce a contract’s appeals measure-level Star Rating from one to four stars
Categorical Adjustment Index
Values will be determined by adjusting measures that remain after applying specific exclusion criteria
For contracts operating solely in Puerto Rico or otherwise meeting specific criteria
Adjustments to Consumer Assessment of Healthcare Providers and Systems (CAHPS) and Healthcare Effectiveness Data and Information Set (HEDIS) measures
Plans should also watch for these upcoming releases relating to socio-economic status:
The Office of the Assistant Secretary for Planning and Evaluation’s second report to Congress
2019 HEDIS Volume 2: Breast Cancer Screening, Colorectal Cancer Screening, Comprehensive Diabetes Care — Eye Exam Performed, and Plan All-Cause Readmissions
2018 Pharmacy Quality Alliance: Medication Adherence for Diabetes Medications, Medication Adherence for Hypertension, and Medication Adherence for Cholesterol
CMS updated its Consolidation Policy. CMS assigns Star Ratings for the first and second years following a consolidation based on the enrollment-weighted mean of the measure scores of the two former contracts. The first year uses July enrollment of the measurement period, except survey-based and Call Center measures. The second year uses July enrollment of the measurement year, except measures from HEDIS, Health Outcomes Surveys, and CAHPS.
Finally, starting in 2021, Star Ratings will increase the weight of patient experience and access measures to two.
For Contract Year 2019, CMS has finalized the framework under which Part D plan sponsors may voluntarily adopt drug management programs for beneficiaries who are at risk of misusing or abusing frequently abused drugs, as required by the Comprehensive Addiction and Recovery Act (CARA).
Under the minimum criteria, plan sponsors must review Potential At-Risk Beneficiaries (PARBs), or those beneficiaries who meet certain drug, prescriber, or pharmacy use criteria, and who do not meet the criteria for exemption.
Coverage limitations may apply to all Frequently Abused Drugs (FADs), which are opioids and benzodiazepines, except for buprenorphine for medication-assisted treatment and injectables.
Plan sponsors must perform case management for each PARB by engaging in clinical contact with prescribers and verifying whether the PARB is an At-Risk Beneficiary (ARB). Case management, a prescriber agreement (with exceptions), and beneficiary notice are required before a plan sponsor may limit an ARB’s access to coverage of FADs through point of service edits, pharmacy lock-ins, or prescriber lock-ins. The first notice to the beneficiary informs them of their status as a PARB, the proposed coverage limitation, and 30 days to submit relevant information, in addition to other elements. The second notice to the beneficiary informs them of their status as an ARB, an explanation of the limitations, and appeal rights. Alternatively, the second notice informs the beneficiary that they are not an ARB and will not be subject to the proposed coverage limitation.
Individuals who are identified as a PARB or an ARB are also subject to restrictions on the duals/Low-Income Subsidy Special Enrollment Period, though other election periods are still available as relevant. The limitation ends if:
The beneficiary is determined not to be an ARB
The plan sponsor does not take any additional action within 60 days
The beneficiary is enrolled in the plan
Until the ARB status is successfully appealed
When the status expires or is terminated by the plan sponsor
In addition to the changes under CARA, CMS is also conducting a small pilot to develop best practices for opioid naïve 7-day supply limits and care coordination safety edits. CMS is looking for about three plan sponsors to help pilot test and share feedback with CMS through summer 2018.
New in 2018, CMS will review contract-level networks every three years. Each January, the Health Service Delivery (HSD) reference file will be released via (HPMS). From February to June, there will be an informal network consultation with Regional Office Account Managers and Central Office staff. During this time, organizations submit their HSD tables in the Network Management Module in HPMS, receive their Automated Criteria Check report, and may submit exceptions.
Valid reasons for exception requests include:
Provider(s) moved/retired or facility(ies) closed
Provider(s)/facility(ies) may cause enrollee harm
Provider(s)/facility(ies) are inappropriately credentialed under MA regulations
Provider(s)/facility(ies) do not contract with any organization
Provider(s)/facility(ies) contract exclusively with another organization
Micro, Rural, and Counties with Extreme Access Considerations counties
In June, the plan sponsor must have removed counties, verified the service area, and submitted bids with a formal network review from June to September. Compliance is assessed from September to January.
Initial applications that fail to meet CMS’s network requirements as of January 1 may be suppressed from the Medicare Plan Finder, but still may enroll new members. Once the applicant demonstrates compliance, it will be added back to the Medicare Plan Finder.
Beginning in 2019, CMS Program Audits will have a new approach. Data requests will be separate from the Audit Process Documents.
Revisions to the Audit Process Documents were made to enhance transparency into CMS’s audit approach on sampling selection, review, and scoring, thereby making it easier for plans to conduct mock audits. All protocols will have a new table format.
Currently the data collection tools CMS created for 2019 are posted on the CMS Paperwork Reduction Act (PRA) website (CMS-10191). The comment period closes June 1, 2018. Revisions to tools will adjust the scope and simplify collection for the following:
Pre-Audit Issue Summary sheet
Data Request Documents specific to program area
Independent Validation Audit Work Plan Template
Root Cause Template
Program Audit Questionnaire
Modifications to data requests will include:
Special Needs Plans (SNP)
Change of program name to Special Needs Plans-Care Coordination and Quality Improvement Program Effectiveness(SNP-CCQIPE)
Reduction in scope of data collected and addition of a questionnaire
Introduction of a tracer methodology sample review and revision to timeliness assessments
Coverage Determinations, Appeals & Grievances (CDAG) and Organizational Determinations, Appeals & Grievances (ODAG)
Reduction in number of universe submissions
New universe CDAG: Table 7: Unprocessed Cases
Removed supplemental questionnaire and revised scope of universe requests
Streamlined impact analysis
Modification of audit elements:
Appropriateness of Clinical Decision-Making & Compliance with Processing Requirements has been changed to Processing of Coverage Requests
Grievances and Misclassification of Requests to Classification of Requests has been changed to Classification of Requests
Compliance Program Effectiveness (CPE)
Removed self-assessment questionnaire and reformatted remaining questionnaires as fillable forms
Combined internal auditing and monitoring universes
Revision to data points in some universes and renamed record layouts
Formulary Administration (FA)
Revised record layout to capture Medicare Beneficiary Identifier
Added a supplemental questionnaire
Removed website review
Based upon feedback from stakeholders’ experience on the validation process, the 2017 CMS Program Audit Validation/Close-Out Process Listening Session, and comments provided on the CY 2019 Draft Call Letter proposed enhancements, CMS has finalized Independent Validation Audit (IVA) changes. These changes can be reviewed in the 2019 Final Call Letter dated April 2, 2018.
CMS provided further clarification regarding Conflict of Interest (COI) for Independent Audit (IA) firms, effective for 2018 program audits. Plans may utilize the same firm for annual external CPE and IA, provided the firm has not provided consulting or assistance with the correction of audit findings; utilize a firm that conducted “mock audits” or prior independent audits, again without assistance on correction of audit findings; and firms that have conducted data validation audits. Additionally, for the 2018 program audits, CMS has extended the time frame to complete IVAs from 150 to 180 days. Extensions beyond 180 days will be considered on a case-by-case basis.
CMS provided modifications to the thresholds used to determine when a plan must hire an independent auditing (IA) firm, effective for 2019 program audits and beyond:
More than five non-CPE conditions cited in final audit report must hire an IA
CPE conditions are not excluded from validation
Where plans fall in relation to threshold determines if CMS or IA will conduct the validation
As previously mentioned, CMS has included the IVA work plan template in PRA Package, and the effective date is for the 2019 program audits. Key elements of the work plan template include a summary of the prior Medicare work with plan being audited and provisions of the audit team staffing (two auditors per program area) and credentials. CMS clarified what would be deemed sufficient clinical expertise/credentials for evaluation program area.
FA/CDAG: formulary administration, transition, processing coverage request requirements (e.g., pharmacist)
CDAG/ODAG/MMP-SARAG: processing coverage request requirements (e.g., physician)
MMP-SARAG: evaluating level of care and social supports necessary for provision of long-term services and supports for dual-eligible population (e.g., social worker)
SNP-CCQIPE/MMP-CCQIPE: care coordination and quality improvement program effectiveness requirements, model of care processes, health risk assessments, interdisciplinary care teams, and care coordination and care planning (e.g., nurse)
By implementing the work plan template, CMS anticipates a shorter approval period.
Beginning in 2019, plans will be required to submit the IVA report, unaltered to CMS, and copy the IA firm. This submission process is optional for 2018 program audits.
CMS provided a summary of the report released on May 8, 2018.
As of the close of the 2017 Compliance Program Audits, 42% of Part C and D sponsors were audited as part of “Wave 2” CMS program audits. Overall the audit scores were lower in 2017: 1.10 versus 2016: 1.22.
The most common Immediate Corrective Actions (ICARs) were provided:
Sponsor misclassified coverage determination or redetermination requests as grievances and/or customer service inquiries.
Sponsor did not auto-forward coverage determinations and/or redeterminations (standard and/or expedited) that exceeded the CMS-required time frame to the IRE for review and disposition.
Sponsor did not demonstrate sufficient outreach to providers or enrollees to obtain additional information necessary to make appropriate clinical decisions.
Sponsor did not notify enrollees, and providers if the providers requested the services, of its decisions within 72 hours of receipt of expedited organization determination requests.
Sponsor failed to properly administer its CMS-approved formulary by applying unapproved utilization management practices.
Referrals to the Division of Compliance Enforcement resulted in imposing 24 Civil Monetary Penalties (CMPs) and three intermediate sanctions during CY 2017 and early 2018. With 18 CMP actions as a result of 2017 Program Audit referrals, total was $2,599,800.