• 2016 MA & PDP Fall Conference Covers Laundry List of Issues
  • Let BluePeak School You on the 3 Rs
  • Proposed 2017 Civil Money Penalty Methodology Released for Comment
  • BluePeak Debuts Universe Monitoring Service
  • Come See Us at One of Our Events!
2016 MA & PDP Fall Conference  Covers Laundry List of Issues
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CMS covered a laundry list of issues in last month’s 2016 MA & PDP Fall Conference, but the answer to an industry-wide question, when will the 2017 draft audit protocols become finalized, came near the conclusion of the conference, during the question-and-answer session. CMS hopes to respond to comments this month and open another 30-day comment period. So, it appears the 2017 protocols will be finalized in December, at the earliest.

Following are highlights from the 2016 MA & PDP Fall Conference:

  Sanctioned Plans and Star Ratings
  • Star Ratings of plans under sanction are no longer being reduced.
  • CMS is considering reinstating the reduction to sanctioned contracts’ overall Star Ratings, by deducting a value, instead of automatically downgrading to 2.5 stars; developing an audit measure for Star Ratings, using audits conducted in the past few years; or revising the current Beneficiary Access and Performance Problems (BAPP) Star Ratings measure to reflect the varying sizes of CMPs.
  • CMS will include the above proposals and ask for plans’ feedback in the Draft 2018 Call Letter.
  Sanctioned Plans and Medicare Plan Finder
  • Beneficiaries who are not enrolled in a sanctioned plan will not be able to select a sanctioned plan for comparison purposes, view pricing-related information for a sanctioned plan or view the sanctioned plan’s overall Star Rating.
  • CMS will continue to display pricing-related information for current members of a sanctioned plan.
  • All beneficiaries will now be able to see contracts under sanction.
  • Sanctioned plans will be identified by a Sanctioned Plan button that links to more information, including the sanction notice and statement that the plan cannot enroll new members.
  Medicare Advantage (MA) Applications
  • CMS required full network reviews for Contract Year (CY) 2017 Service Area Expansions (SAEs), and this change carries over to CY 2018.
  • SAE criteria is in HPMS and Network Management Module (NMM). CMS will update criteria in mid-January, giving plans time to test their networks before applications are due in mid-February.
  • CMS required plans to resubmit previously approved SAEs and Partial County submissions for CY2017.
  • CMS expects exception requests, such as Partial County, to be rare and warranted. Exceptions template was revised to exclude “not a viable option.”
  • New application template is streamlined with more Y/N questions and options to select specific data sources.
  • Applicants can submit a waiver of the 2-year contracting ban that occurs when a plan non-renews or terminates a contract for 2 years from the start of the Contract Year.
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  Online Provider Directory Review
  • The top 5 deficiencies from CMS’ provider directory reviews are: provider not at that location, phone number, address, provider not accepting new patients and address-suite number.
  • The plan’s parent organization has 2 weeks to respond to deficiencies and 30 calendar days to make updates to their directories.
  • The majority of plans are 30-40 percent deficient, ranging from 1.77-87 percent.
  • CMS’ biggest concerns are provider not at location and provider not aware of contracting status. Plans must educate providers.
  • CMS will release a memo on provider directory best practices and the methodology of their review.
  Reducing Inappropriate Billing of Qualified Medicare Beneficiaries (QMBs)
  • CMS has been working with Medicare-Medicaid Plan (MMP) demonstration programs in 10 states with over 350 participants to improve the experience of dual-eligible beneficiaries.
  • The QMB program pays for some or all of Medicare premiums and cost-sharing for dual-eligible beneficiaries.
  • A CMS-commissioned study on QMB billing practices found: erroneous billing, QMBs paying cost-sharing or referred to collection agencies, difficult appeals process and confusing billing process.
  • CMS plans to strengthen education and supports for beneficiaries, revise instructions to plan and providers, conduct targeted outreach, explore administrative reforms to promote compliance and minimize negative effects on access to care.
  • Plans should promote compliance and antidiscrimination. Providers cannot refuse to serve members based on QMB status.
  • States can limit QMB payments by adopting “lessor-of” policies – applying the Medicare or Medicaid rate, whichever is less. Providers receive less for treating QMB patients than other Medicare beneficiaries.
  • CMS recommends looking at grievances and complaints as part of monitoring providers.
  • Strategies that plans have found effective include: identifying QMB status early on for providers, allowing access to online eligibility status, and looking at Explanation of Payments (EOPs) and Remittance Advices (RAs) to ensure language is clear to patients that charges don’t apply.
  Overview of the Comprehensive Addiction and Recovery Act
  • Law that allows Part D Sponsors to limit at-risk beneficiaries’ access to certain drugs becomes effective January 1, 2019.
  • Plan would send initial notice to member, advising of at-risk status, resources and appeals rights, and a second notice, with similar language, within 30 days of the initial notice.
  • The Part D sponsor selects the prescriber and pharmacy, for the at-risk member to use, and must provide them with a 30-day notice.
  • A Point-of-Sale notice will be provided when the member attempts to purchase a drug at a non-selected pharmacy.
  • Part D sponsors must ensure reasonable access.
  • CMS will hold a stakeholder meeting no later than January 1, 2017.
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    Communications for People with Disabilities (Section 504)
  • Plans must comply with Section 504 of the Rehabilitation Act of 1973 and Section 1557 of the Affordable Care Act (ACA) of 2010 to communicate with persons with disabilities.
  • A best practice is for a plan to have the same formats as CMS – Braille, large print (18-point font), audio CD, data CD and Qualified Reader, with large print being the most commonly requested format.
  • Plans are not required to have all documents in alternative formats, only upon request. CMS prints on demand.
  • Communication accessibility is not limited to providing documents; plans may also entertain requests for auxiliary aids, teletypewriters (TTYs), video remote, sign language, etc. Plans must ensure persons with disabilities can access online appointment systems, electronic billing, information kiosks, internet applications, websites, etc.
  • A format is not required if the plan can demonstrate that it would be a fundamental alteration or financial burden. CMS indicated this is a “very high standard.”
  • If a requested format is not provided, the plan should still find a way to work with the member.
  • There is no specific timeframe to respond to requests, but plans need to set up timeframes that don’t impact members’ ability to work within Medicare program timeframes. CMS will allow plans to extend timeframes to provide formats, such as Braille.
  • CMS expects the member to make a request for a format one time and not each time the member needs a communication from the plan.
  • There is no burden of proof on, and plans are not allowed to ask, the individual to prove disability.
  • Plans should work with their CMS Account Manager if they have questions about Section 504.
  Communication for People with Limited English Proficiency
  • Section 1557 of the ACA prohibits discrimination on the basis of race, color, national origin, sex, age or disability.
  • Plans are required to include a nondiscrimination notice or tagline on significant communications and publications.
  • Plans can exhaust existing stock before using the notice/tagline and are not required to resubmit previously submitted materials.
  • The multi-language insert in the Medicare Marketing Guidelines replaces the required notice/tagline.
  • The Office of Civil Rights (OCR) will release a Frequently Asked Questions (FAQ) on Section 1557. Questions regarding Section 1557 should be directed to OCR.
  • Plans must have a civil rights grievance procedure.
  • When asked if CMS would monitor plans’ compliance with Section 1557, CMS said it does not have a monitoring program in place at this time.

The School Year is Well Underway, but There’s no Break When It Comes to Compliance. Let BluePeak School You on the 3 Rs.
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Readiness – BluePeak has performed dozens of mock CMS program and validation audits, assisted clients undergoing actual CMS program audits, and conducted compliance and operational assessments for clients. Let BluePeak’s seasoned team of consultants get you and your team audit ready!

Remediation – BluePeak has helped CMS-sanctioned clients reduce their time under sanction by assisting with the development and implementation of corrective action plans (CAPs). BluePeak consultants can help you and your team with CAPs, whether as a result of a CMS program audit, CMS sanctions, or as part of your internal monitoring and auditing plan.

Repetition –  BluePeak has helped clients develop and implement monitoring and oversight plans, based on clients’ needs and CMS-recognized best practices. Know you need dashboards with CMS metrics, but don’t know where to start? Contact BluePeak for a free consultation!

    Medicare Parts C and D Oversight and Enforcement Group (MOEG) 

    In an effort toward increased transparency and sponsor compliance, CMS released a proposed Civil Money Penalty (CMP) methodology for Plan Year (PY) 2017 in September. The proposed methodology outlines how CMPs are calculated for Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), Cost plans, and PACE plans.

     CMS began using the proposed methodology as a pilot in 2014 to impose 16 CMPs totaling $3.7 million. In 2015, the number of CMPs decreased to 14; however, the 14 CMPs totaled $8.5 million – an increase of 44 percent from 2014. 

    Calculation:
    1.    CMS applies a standard penalty amount (per determination or per enrollee) 
    2.    CMS adds an additional amount, per enrollee or contract, for aggravating factors that contributed to the harm
    3.    CMS subtracts from the amount, per enrollee or contract, for mitigating factors that alleviated harm

    Total penalty for violation = (Standard Penalty x number affected) + (Aggravating factors x number affected) – (Mitigating factors x number affected)

    Amount of the CMP – CMS reminds sponsors that it has the authority to issue up to $25,000 for each affected enrollee or determination if the deficiency has, or very likely can, harm one or more enrollees. It outlines the following amounts, noting that they can change in the future to encourage remaining non-compliant sponsors to improve performance.

    Maximum CMPs – Fortunately, there is a limit to the extent of a CMP. For per enrollee deficiencies, amounts are limited by the enrollment of the parent organization as depicted below.
      BluePeak Debuts Universe Monitoring Service

      An incomplete and incorrect universe can add 1 point toward your CMS Program Audit score and take a whole lot more from your bottom line - $25,000 more, per violation/contract.

      An Invalid Data Submission (IDS) condition is cited when a plan fails to produce a complete and accurate universe within 3 attempts. At $25,000 per contract, an IDS can significantly increase the overall CMP amount assessed by CMS for conditions found during a CMS Program Audit.

      BluePeak developed UMS as an audit-readiness resource for plans. Every plan should be monitoring their universe data on a regular basis, but the reality is that universe monitoring competes with the organization’s other priorities and resources and gets pushed to the back burner. Until a CMS Program Audit, and that’s not the time to start a fire drill. BluePeak is composed of industry experts who’ve been there, done that. We built UMS just for you.

      BluePeak consultants can review your universe data for technical issues, such as blank cells, incorrect formats and inaccurately populated fields. Our seasoned subject matter experts can also analyze your universe data and identify potential operational issues, such as untimeliness, that would be red flags to CMS auditors. In addition to calculating timeliness, we use a proprietary analytics system, unique to the universes for each program audit area, to identify potential underlying issues. Issues that, left undetected, have a way of surfacing during CMS Program Audits.
      Come See Us at One of Our Events!
      Internal Mock Audit Best Practices
      Babette Edgar, Principal and Kim Mullins, Sr Consultant
      November 10-11, 2016 :: Coral Gables, FL
      Booth #301
      Diane Ramey,  VP, Business Development  and Michelle Rigby, Sr Consultant
      November 15-18, 2016 :: Atlanta, GA
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