Avoiding a Perfect Storm-Proactive Testing and Claims Oversight is Key

By November 24, 2020December 18th, 2020Compliance

The most effective way for any plan to avoid member disruption and compliance risks for the new plan year is to establish a process to validate the accuracy of the formulary and benefit areas prior to the start of the new plan year and to continue testing into the new plan year.  However, the first quarter of 2021 could present unique challenges for Part D plans. First quarter is always a critical time for Plans to validate benefit set-up, but this year presents some unique challenges that warrant extra oversight.

There are two big components that may lead to additional member disruption in 2021.

Remote Monitoring and Oversight

Many plans and PBMs cannot return back into their office settings due to COVID-19 restrictions.  Traditionally, plans and PBMs closely collaborate in-person on strategies around year-end testing and ongoing monitoring and oversight.  However, these types of efforts will need to happen via webinar or phone.  Although most plans will still conduct some form of testing and monitoring and oversight, many plans have struggled collaborating with all business units to develop an effective annual testing strategy.   Even if your year-end testing strategy has not been as robust as in prior years, it is not too late to develop a robust post 1/1 oversight strategy.

Increase in Member Disruption

A reduction in monitoring and oversight increases the potential for the beneficiary to be disrupted at the pharmacy from an undetected benefit, formulary, or medication access issue.  Additionally, due to call center staff being displaced, plans are challenged with meeting call center metrics and accurately classifying member complaints appropriately.  Incorrect management of member calls coupled with the increased potential for member disruption can have a domino effect and cause additional CMS Complaint Tracking Module (CTMs) to be created.  CTMs will need to be thoroughly researched and resolved timely, pulling staff away from operationally needs, and also count against a plan’s Star Ratings calculations.

It’s not unusual for plans to struggle with balancing day-to-day operations with an increased focus for claim monitoring and oversight.  Plans have challenges determining the best approach and the appropriate resources needed to effectively manage claim oversight from a formulary and benefit perspective.  However, a failure to effectively manage either of these areas will increase member disruption, staff needed to remediate any issues, along with the possibility of increased CMS compliance action.  BluePeak Advisors strongly recommends for plans to dedicate resources to validate the accuracy of their formularies, benefits, and transition of care logic on a daily basis.

Increased CMS Activity

Industry experts are expecting an uptick in CMS audits this season, based on historical trends. In CMS’ last audit cycle, they conducted an average of 34 program audits each year.  For the first two years of this four year audit cycle, CMS has conducted less than 10 program audits each year.  If CMS was looking to administer the same volume of program audits in this audit cycle, they would need to administer 60 audits in the next two years.  Although it’s unlikely they’ll hit this number, many experts agree it’s a real possibility that CMS will significantly increase the volume of program audits starting next year.  As a result, plans who were not audited in the last two years, have a greater chance of being selected for a program audit next year or 2021.

Concerned about the 2021 audit season?  BluePeak can help.

BluePeak Advisors has a trained staff of seasoned Medicare analyst to perform ongoing testing and validation continued monitoring and oversight throughout the year.  We collaborate with our internal auditors on CMS audit trends and ensure our testing and monitoring approach captures any high-risk areas and will mitigate compliance risk during a CMS program audit.  Allow BluePeak Advisors to be your calm within this storm and don’t hesitate to contact us with any questions.