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Want to know what you missed if you didn’t receive an audit notice in 2022?

By October 17, 2022October 19th, 2022Consultant Corner
carmen winters
Carmen Winters, a BluePeak senior consultant, provided 2022 CMS program audit support to many clients. Read about her observation regarding CMS auditor focus on Quality of Care during the 2022 Program Audits.

Quality of Care (QOC) allegations are always an area of concern for Medicare Advantage and Prescription Drug Plan Sponsors.  Questions arise, such as:

  • How much information can you share with the enrollee?
  • How do you demonstrate a substantive review while maintaining information on a need to know basis?
  • How many departments are involved in the process?
  • Who is responsible for documenting and maintaining the outcome?

With this year’s program audit support of health plans, I experienced a different focus from the CMS auditors.  In some audits, the reviewer asked to trace the end-to-end process by speaking with the staff who conducted the quality review process or investigation.  The CMS reviewers asked the Sponsor to explain its ranking process (e.g., Do you score them numerically; Did you confirm them as substantiated, or unsubstantiated; Did you take disciplinary action or perform a peer to peer discussion?).  The Sponsor was required to show its resolution letter with the Quality Improvement Organization (QIO) contact information.  In other reviews, the CMS auditor asked the Sponsor to show the clinical records received, the Sponsor’s analysis, and final quality review determination.

This departure in review understandably raised both discomfort and concern.  CMS does not generally include a physician reviewer in the grievance sessions because the cases are reviewed for accurate classification versus processing coverage requests.  Historically, the appeal and grievance team will speak to the Sponsor’s process, including the hand-off to the quality team for their review and investigation.  The grievance team is able to show the closure notification and demonstrate the member was afforded their rights to contact the Quality Improvement Organization (QIO).  Most Sponsors address the non-quality related complaints and provide assurance that the allegation has been investigated and appropriate action taken.  Through this process, the Sponsor is able to timely close the grievance with the beneficiary, afford them their rights, as well as allowing the quality team the time necessary to ensure a comprehensive investigation occurs.

You may be asking

  • Does CMS have the right to inquiry about the quality review process? Yes, they do!
  • Is the Sponsor required to show the investigation? In theory, yes.  However, I want to remind Sponsors that they must protect privileged information and honor the need-to-know limitations outlined under Health Information Privacy and Accountability Act (HIPAA).

In talking to my peers, BluePeak’s recommendation is that the grievance representative/audit lead speak with its quality team before an audit.  Advise them that someone should attend the audit session who is able to speak to the full process, including outreach attempts, clinical review, external peer review and how the Sponsor scores allegations and takes remedial action when required.  During the Classification of Requests (grievance) audit session, if the CMS reviewer wants to dive into additional details, we recommend the Sponsor share its determination regarding whether the allegation was substantiated or unsubstantiated.  No further detail should be provided during this session, since the grievance review is truly intended to ensure the Sponsor has correctly identified all items in a complaint, addressed each of those items under the correct process (initiate an organization determination, process an appeal, and/or process a grievance).  CMS reviewers must be able to confirm the Sponsor is correctly identifying and processing complaints.  Other than that, the Sponsor has to ensure it is following all the state and federal regulations that apply as a contracted Sponsor – including limiting information to only that necessary for the job.