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Past Performance, Encounters and Misclassifications, Oh My!

By September 15, 2017September 25th, 2017Audits, CMS, Compliance, Part C, Part D, Past Performance, Uncategorized

CMS denies applications due to Past Performance scores, encounter data volume is growing, and misclassification of appeals and grievances continues to be an issue. BluePeak tells you what you need to know from the CMS 2017 MA & PDP Fall Conference webinar held Sept. 7. 

Parts C and D Performance Analysis

CMS denied three applications for both 2017 and 2018, while no applications were denied in 2016 – signaling the agency is making good on its intent to use Parts C and D Past Performance scores as a predictor when making contractor decisions.

An outlier Past Performance score would be 4 or more points for Part C and 5 or more points for Part D across the 11 performance categories: Compliance Letters, Performance Metrics, Multiple Ad Hoc Corrective Action Plans (CAPs), Ad Hoc CAPs with Beneficiary Impact, Fiscal Soundness, One-Third Financial Audits, Program Audits, Exclusions, Enforcement Actions, Terminations/Non-renewals and Outstanding Significant Compliance.

CMS conducts the Past Performance Analysis twice a year, in the spring and fall. The fall analysis is used as a predictor for the spring analysis, and CMS utilizes the spring analysis to make contract determinations. CMS will release an HPMS memo on the spring analysis for comment in the near future.

Encounter Data

The volume of encounter data submitted to CMS is growing, forecasting to reach 775 million records this year. Despite the increase in volume, the edit rate has decreased.

The most frequent edits are:

  • Front End Edits – Diagnosis Code
  • Back End Edits Professional – Chart Review Duplicate
  • Back End Edits Institutional – Exact Inpatient Duplicate Encounter
  • Back End Edits DME – Enrollment

CMs expects the Chart Review Duplicate edit frequency to decrease, following a modification to the edit effective September 29.

Plans can expect more site visits from CMS, as part of the agency’s efforts to increase communication around encounter data, and monitoring Report Cards will be released in Excel format this month.

Encounter Data Services: BluePeak can help plans prepare for the upcoming changeover from the current Risk Adjustment Payment System (RAPS) to the Encounter Data Processing System. Our team can review internal and external encounter data processes for accuracy, effectiveness, oversight and monitoring. We can also help you find missed opportunities, that left unattended, result in lost revenue.

Appeals, Grievances and Complaints

CMS indicated at the conference that misclassification of appeals and grievances continues to be a common finding during program audits. Through audit support and validation audits, BluePeak has found that CMS consistently scores a misclassification condition as an Immediate Corrective Action Required (ICAR).

CMS recommends the following on processing misclassifications:

  • Coverage request misclassified as a grievance – forward to appropriate department and notify enrollee in writing that it was misclassified.
  • Grievance misclassified as a coverage request – same as above; however, if the plan issues a denial, and the case is forwarded to the Independent Review Entity (IRE), the IRE will dismiss the case and return it to the plan for proper processing.

The number of complaints logged into the Complaint Tracking Module (CTM) continues to decrease. The top complaint is enrollment/disenrollment. Over 70 percent of complaints come from 1-800-MEDICARE, after individuals have looked for resolution elsewhere. CMS reminds plans that even if they are able to resolve a complaint during a phone call, it should still be classified as a grievance.

Independent Call Log Review: BluePeak’s seasoned consultants will review your call logs as CMS would during a program audit to ensure grievances are appropriately classified, member notification properly addressed the issue(s) raised in the grievance, and incoming calls were appropriately classified as either organization or coverage determinations or grievances.

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