CMS Discusses Draft 2019 Audit Protocols and More at Conferences

1. The Draft 2019 Program Audit Protocols universe submissions will require significant programming by plans’ information technology (IT) departments, as the number of tables have been reduced through consolidation of previous universes in the Compliance Program Effectiveness (CPE); Organization Determinations, Appeals and Grievances (ODAG); and Coverage Determinations, Appeals and Grievances (CDAG) areas. CMS will conduct integrity testing on all universes in 2019. CMS is currently reviewing comments received from the 60-day comment period, which ended June 1, and will release changes to the draft protocols, based on comments received, for another 30-day comment period, before finalizing the protocols for the 2019 program audit cycle. Plans should work with their programming areas now to determine the amount of time and effort needed to revise data pulls to adhere to the proposed revised protocols.Other proposed changes include:

• Audit process and data request documents will be separate for each audit area, and impact analysis formats will be consistent with universe layouts.
• The Special Needs Plan-Model of Care (SNP-MOC) will be renamed the SNP-Care Coordination and Quality Improvement Program Effectiveness (SNP-CCQIPE), which aligns with the Medicare-Medicaid Plan (MMP) CCQIPE universe.
• As with CPE, CMS will employ tracer methodology to test SNP-CCQIPE compliance.
• Supplemental questionnaires will be removed for CDAG and ODAG and added to Formulary Administration (FA) and SNP-CCQIPE.
• A new universe, Unprocessed Cases (UC), will be added to CDAG. CMS will remove Website as an FA audit element.For more details, refer to the Updated Program Audit Data Collection in the April 6 Federal Register and “New Approach to 2019 Audits and Universes” presentation from the May 10 CMS MA and PDP Audit & Enforcement Conference.

2. In addition to discussing a new Independent Validation Audit (IVA) Work Plan template, effective 2019, CMS also provided clarification around conflict of interest and use of consultants as IVA auditors. Plans can use the same consultants for an IVA as those who conducted their mock and annual CPE audits and data validation, as long as the consultants did not participate in any remediation efforts. The timeframe for completion of the IVA has been extended from 150 to 180 days, effective 2018. For more details, refer to the 2019 Call Letter and “New Approach to 2019 Audits and Universes” presentation from the May 10 CMS MA and PDP Audit & Enforcement Conference.

3. CMS is revising 2019 member communications, such as the “Medicare & You” Handbook, Initial Enrollment Period (IEP) Direct Mail Package, and both the Medicare.gov and MyMedicare.gov websites, to give members more access and control over their healthcare information. Plans will benefit from these revisions through increased member satisfaction. CMS is adding an icon-based coverage chart to the IEP materials; information on the MA Open Enrollment Period (OEP), Plan B premium buy down, plan-directed care and pre-authorizations to the 2019 Medicare & You Handbook; along with an out-of-pocket costs (OOPCs) calculator to the Medicare.gov and MyMedicare.gov websites.

Since the launch of CMS’ Blue Button in 2010, an application programming interface (API) that enables Medicare beneficiaries to connect their claims data to the applications, services and research programs they trust, over 1.5 million beneficiaries have been able to download up to 3 years of hospital, physician and prescription drug claims data through MyMedicare.gov. CMS is strongly encouraging plans who have yet to do so to offer the Blue Button 2.0 or similar application to members. For more details, refer to the 2019 Call Letter and the “Talking to Beneficiaries about their Plan Choices” and “Medicare’s Blue Button 2.0” presentations from the May 9 CMS MA and PDP Spring Conference.

4. Classification of Part C and Part D Grievances and Coverage Requests was the subject of a session at the CMS MA and PDP Audit & Enforcement Conference, as well as a 2017 CMS Program Audit common condition. BluePeak highly recommends listening to the audio from this session to get the answers to the six scenarios CMS presented. CMS is working on updates to the Medicare Managed Care Manual, Chapter 13 and Prescription Drug Benefit Manual, Chapter 18 and is considering including these scenarios in the updated chapters. For more details, refer to the aforementioned session and the May 8 CMS 2017 Part C and Part D Program Audit and Enforcement Report.

5. CMS provided more detail around analysis and calculation of CMPs. The Division of Compliance Enforcement (DCE) reports to the Medicare Parts C and D Oversight and Enforcement Group and is responsible for investigating referrals from Annual Notice of Change (ANOC)/Evidence of Coverage (EOC) reviews; Independent Review Entity (IRE) Auto-Referrals; and Program, 1/3 Financial and Programs of All-Inclusive Care for the Elderly (PACE) Audits. CMS expects PACE referrals to increase. Two PACE organizations received enrollment suspensions, one of which also received a $37,396 CMP, in 2017. CMS indicated last year that it would begin issuing CMPs for certain 1/3 Financial Audit findings, and BluePeak observed in May the first 1/3 Financial Audit CMPs levied on two plans, totaling $287,600 ($243,200 and $44,400), on the CMS Part C and Part D Enforcement Actions website.

DCE reviews documentation, conducts outreach to the audit team and sponsor, performs the Impact Analysis (IA) validation and makes a determination on whether to issue a CMP based on whether there was a regulation failure, a substantial violation (number or percent of enrollees impacted, number of cases that failed, and/or root cause), adverse effect or substantial likelihood of adverse effect (delay or denial of access to drugs or services, impeded access to appeal process, and/or financial impact), and other considerations. For more details, refer to the “Enforcement Analysis Process” presentation from the CMS MA and PDP Audit & Enforcement Conference, CMS Part C and Part D Enforcement Actions website, and the June 28, 2017 HPMS memo, “2017 One-Third Financial Audit Civil Money Penalties.”