CMS Update Summary

Insights shared at the Health Care Compliance Association Managed Care Conference

On Tuesday, Feb. 13, 2018, during the Health Care Compliance Association Annual Managed Care Conference, Vikki Ahern, director of Medicare Part C and Part D Oversight and Enforcement Group (MOEG) provided a Centers for Medicare & Medicaid Services (CMS) update:

In 2018, audit engagement letters will begin in March. This will be the final year of the second audit cycle for CMS that began in 2015. By the close of 2017, program audits covered 95.3 percent of all Part C and Part D enrolled beneficiaries. The third audit cycle will launch in 2019, for which CMS is looking to redesign audit protocols. The 2018 audit protocols will include the incorporation of the Medicare-Medicaid protocols, as applicable. However, the Medication Therapy Management pilot protocols have been suspended. CMS also released an Audit Submission Checklist, which can be found on the CMS program audit website.

Updates to the 2018 program audits also included enhancements to all four phases of the audit process. In 2018, the Audit Engagement and Submission period will include a reduction in the review period for Part C and Part D Call Log universes. CMS will also be accepting either the Medicare Beneficiary Identifier or Health Insurance Claim Number for Part D Formulary Benefit and Administration universes. The Audit Fieldwork period has been increased from two weeks to three weeks for all sponsors. An additional week was added between the webinars and the Compliance Program Effectiveness audit. Updates to the Audit Reporting phase include utilization of HPMS, for Immediate Corrective Action Required Notification Letters and for sponsors to provide comments to the Draft Final Audit Report.

CMS is proposing improvements to the independent validation and closeout process in response to the industry wide listening session held in mid-2017. Improvements have been proposed in the 2019 Draft Call Letter and include consideration of the following: a) modifications to the threshold to require an independent auditor (Compliance Program Effectiveness (CPE) audit findings may no longer factor into methodology for determining if a validation audit is required); b) clarifications in conflict of interest requirements; c) provisions to provide a validation work plan template for all independent validation auditors; d) an increase of time frame to complete validation audit from 150 days to 180 days; and e) clarify process for independent validation audit report submission.

Two other MOEG topics addressed in the 2019 Draft Call Letter include a Plan Finder Civil Money Penalty (CMP) icon or other type of notice to beneficiaries and the potential to allow CPE audits to meet the annual compliance program audit requirement.

CMS shared improvements to the enforcement process prior to issuing CMPs. CMS is requesting sponsors to scrutinize submitted impact analysis for accuracy prior to submission and are confirming final impact numbers with sponsors prior to enforcement evaluation. In addition to the release of CMP Calculation Methodology, CMS had increased its transparency in enforcement evaluation and calculation by communicating to sponsors referrals and referral communications, as well as providing sponsors with the calculation table for CMPs imposed. CMPs for 2017 are scheduled to be released in February 2018.

Results of the 2017 Timeliness Monitoring Project (TMP) were shared.

Summary of percentage of missing Part C Independent Review Entity (IRE) data

No. of Contracts Mean Median Minimum Maximum
 327 24.41 4.76 0.00 100.00

There were 66 contracts that had no cases that should have been forwarded to the IRE in the TMP time period and were excluded from the analysis above.

Summary of percentage of missing Part D IRE data

Contract Type No. of Contracts Mean Median Minimum Maximum
 MA-PD 277  41.86 45.00 0.00 100.00
PDP 54 35.15 31.92 0.00 100.00

There were 166 contracts that had no untimely cases (152 MA plans and 14 PDPs) and were excluded from the analysis above.

CMS Proposes Policy Changes and Updates for Medicare Advantage and the Prescription Drug Benefit Program for Contract Year 2019 (CMS-4182-P) was issued Nov. 16, 2017, and was published in the Federal Register on Nov. 28, 2017. Comment period closed Jan. 16, 2018. CMS-4182-P promotes innovation and empowers Medicare Advantage (MA) and Part D sponsors with new tools to improve quality of care and provide more plan choices for MA and Part D enrollees. A few of the proposed policy changes include:

  • Additional Transparency for Star Ratings: Use of data from TMP in scaled reductions for the appeals of Star Ratings measures.
  • Modifications to the Part D Tiering Exceptions Process: Revision to the permissible limitations Part D plan sponsors may apply to tiering exception requests.
  • Changes to the Days’ Supply Required by the Part D Transition Process: Change long-term care setting transition time frame, currently 90 days, to a one-month supply.
  • Lengthening Adjudication Time Frames for the Part D Payment Redeterminations and Independent Review Entity Reconsiderations: Increasing the time frame to a maximum of 14 calendar days rather than the current 7 calendar days.
  • Eliminating MA Plan Notice of Forwarded Appeals: Applies to appeal case files forwarded to Medicare’s Part C IRE.
  • Reduce Compliance Program Training Requirements: Removal of the requirement to use CMS-developed training and requirement of first tier, downstream, and related-entities compliance training.

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