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CMS Releases 2017 Draft Program Audit Protocols for MMPs
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Centers for Medicare & Medicaid (CMS) program audits of Sponsors with Medicare-Medicaid Plans (MMPs) will now utilize both the Program Audit Protocols and the Audit Protocols for MMPs for the MMP portion of the audit which were released on Feb. 23.
The Draft Audit Protocols for MMPs were designed to ensure compliance with State and Federal contractual requirements and contain two program areas, detailed below.
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MMP Care Coordination and Quality Improvement Effectiveness (MMP-CCIPE)
The review period for the two MMP-QIPE universes is 13 months preceding and including the date of the audit engagement letter.
Along with the universes, the MMP will submit the following documentation:
- Health Risk Assessment (HRAs) tool
- Policies and Procedures (P&Ps)
- Performance Monitoring/Evaluation Reports
- Relevant First-Tier, Downstream or Related Entities (FDRs)
- Relevant Model of Care (MOC) documents
MMP-CCIPE includes the following audit elements and number of samples:
- Care Coordination
- 30 samples from the Medicare Medicaid Plan Members (MMPM) universe
- Quality Improvement Program Effectiveness (QIPE)
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MMP Service Authorization Requests, Appeals and Grievances (MMP-SARAG)
The review period for the following 12 MMP-SARAG universes is 3 months preceding and including the date of the engagement letter.
MMP-SARAG includes the following audit elements and number of samples:
- Timelines
- Five (5) samples will be chosen from Tables 1-11, for a total of 55 samples to test the data integrity of the universes. Note: Tables 8 and 9 are not applicable to NY MMPs.
- Timeliness calculations are performed on each universe (except Tables 3 and 6) after data integrity webinar.
- Clinical Decision-Making: 40 samples
- 10 service authorization requests (denied)
- 10 plan-level appeals (denied)
- 2 provider payment requests
- 5 IRE/ALJ/MAC overturns
- 5 State Fair Hearings overturns
- 4 service authorization request approvals (standard and expedited
- 4 plan-level appeal approvals (standard and expedited)
Notes: For sponsors with multiple MMP contracts, CMS may sample cases from any of the MMP contracts and will select a total sample of 40 cases. The IRE and ALJ are not part of the NY MMP appeal process. If the NY MMP does not have 5 MAC overturns, CMS will select up to 5 additional State Fair Hearings overturns to reach the total 40 cases sampled for this element.
- Grievances and Misclassification of Requests: 20 samples
- 7 standard grievances
- 3 expedited grievances
- 10 calls from MMP Call Log universe
Note: If the MMP does not have enough expedited grievances, the auditors will sample additional cases from the standard grievance universe. For sponsors with multiple MMP contracts, CMS may sample cases from any of the MMP contracts.
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Some Similarities Between Program Audit Protocols and Audit Protocols for MMP
- The MMP has 5 business days from the receipt of the audit engagement letter to submit a Pre-Audit Issue Summary (PAIS) of disclosed issues.
- The MMP has 15 business days from receipt of the audit engagement letter to submit universes.
- The MMP has 3 attempts to provide complete and accurate universes. If the MMP is unable to provide an accurate universe, the MMP will be cited an Invalid Data Submission (IDS) condition relative to each element that cannot be tested, grouped by the type of case.
- Impact Analysis (IAs) must be submitted as requested by CMS during the audit.
- The points per condition (ICAR = 2 points; CAR and IDS = 1 point; and Observation = 0 points) and calculation of audit score is the same as for a program audit.
- MMP-SARAG protocols mirror program audit’s Organization Determination, Appeals and Grievances (ODAG) protocols.
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Differences Between Program Audit Protocols and Audit Protocols for MMP
- MMPs will have up to 10 business days to complete requested IAs.
- CMS will likely extend audit field work from 2 to 3 weeks to audit both the Medicare Advantage (MA) and MMP lines of business.
- CMS auditors will evaluate MMPs according to state-specific compliance standards and requirements set forth in the contract between the MMP, State and CMS.
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- Breathing a sigh of relief because you didn’t get a request from CMS for Appeals Timeliness Monitoring? Don’t relax yet… CMS’ requests for Appeals Timeliness Monitoring data began in January, and sources at CMS confirm that the data requests will continue throughout the year. Let BluePeak review your data before you submit it to CMS, because...
- The Civil Money Penalty (CMP) for being unable to submit complete and accurate universes went from $25,000 to $34,794 per contract in 2017 and will increase every year thereafter.
- The nominal value of marketing gift(s) has increased from $50 to $75 per person per year.
- There’s more than one new Integrated Denial Notice (IDN) in town. CMS released a Spanish IDN in March, a revised IDN for Sponsors, and an IDN model for MMPs in February.
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Got the latest in CMS guidance?
BluePeak’s CMS Guidance Monitor can help ensure you weren’t just reading about the alerts above for the first time.
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BluePeak’s Member Material Review
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It’s almost that time of year when CMS releases the Model Marketing Materials, and the clock starts counting down to Sept. 30, when those materials need to be in members’ hands. CMS released last year’s Model Marketing Materials in late April.
Plans face at least a couple of challenges in ensuring the annual required materials (Summary of Benefits (SB), Annual Notice of Change (ANOC), Evidence of Change (EOC), Provider/Pharmacy Directories, etc.) are adequately proofed:
- Changes in CMS guidance
- HPMS no longer produces the SBs, but rather provides a memo to Plans, advising what elements to include in the SB.
- The multi-language insert will be replaced by a Section 1557 document in 2018.
- In past years, changes in the Model Marketing Materials have been posted to the CMS website without the benefit of an HPMS memo.
- Lack of time and resources
- A Plan may need to produce several versions of the annual required materials, depending on how many Plan Benefit Packages (PBPs) a Plan intends to offer in 2018. Some of these materials are over 100 pages in length.
- Coordination among the Plan’s departments to populate the required materials with PBP information takes time, and PBP information may change while the Plan awaits approval of its bids from CMS in June.
- ANOCs/EOCs must still be printed, mailed and in members’ hands by Sept. 30. Print production and mail time can take 2 weeks or more.
Member materials containing inaccurate information can result in Notices of Non-Compliance (NONCs) and CMPs, as well as the added cost of producing and distributing the subsequent errata. A quick glance at CMS’ Enforcement Actions web page shows failure to provide clear and accurate benefit information to enrollees in the ANOC/EOC documents as one of two reasons Plans receive CMPs. The other reason? Results from program audits (see top story).
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Don’t get caught with inaccurate Member Materials!
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BluePeak’s consultants have experience reviewing member materials from their work at Plans and for CMS. We can help you populate and/or review the annual required materials, as well as other member communications, such as Explanations of Benefits (EOBs), transition letters, denial notices, etc., that, if in error or not easily understood, could potential result in program audit conditions.
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Come See Us at One of Our Events!
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Mini Summit #16: What can Medicare Advantage Plans do to Optimize Medication Use:
Price is Only a Piece of the Puzzle
Babette Edgar, Principal
April 5-7, 2017 :: Arlington, VA
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Keynote Address: Making the Most of Your Mock-Audit Programs
Babette Edgar,
Principal
Session: Keys to Operating Your MTM Program to Ensure Compliance
Babette Edgar,
Principal
and Melissa Whitley, VP, Client Services
May 1-3, 2017: Chicago, IL
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Booth # 309
Sherry Pound, Principal, Donna Powers, Sr Consultant and Greg Miller, Sr Consultant
May 8-10, 2017 :: Scottsdale, AZ
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