Case Study
During the course of a Medicare Program Audit the plan struggled with being able to generate accurate and compliant universes in a timely manner. The plan had experienced a change in the IT Department which further impeded their ability to pull compliant universe and complete a quality review of the universes within the prescribed timeframe. Additionally, the plan had certain universes that required specific fields be manually populated as a result of the system limitations. These issues, combined with the stresses of undergoing a CMS Program Audit, caused the plan to be in a compromised situation and unable to quickly review the generated universes manually to validate accuracy and compliance.
Background:
The plan is a Medicare Advantage (MA) plan that offers Preferred Provider Organization (PPO) options as well as a Health Maintenance Organization (HMO) Special Needs Plans (SNP) for Dual Eligibles with multiple contracts and uses several First-Tier Downstream Entities (FDRs). As a result of staff turnover and insufficient structure and processes, the plan struggled with being able to pull compliant universes and did not have the tools needed to adequately and quickly generate clean universes. This client became overwhelmed with managing data mining techniques, and simply filtering a universe to ensure accuracy and compliance was not an effective quality review process as specific issues were overlooked. In an effort to avoid data paralysis, this client needed to take an holistic approach to the universe review, have a clear understanding of the CMS Audit Protocols and obtain access to tools that eliminate manual intervention. Manually reviewing universe transaction details was an onerous task subject to items being missed and subjectivity in the interpretation of requirements. This is where BluePeak stepped in and was able to provide the client with our Universe Monitoring Service to assist with identifying universe data technical and clerical issues and isolating underlying operational issues of non-compliance.
To effectuate meaningful outcomes, BluePeak utilized our Universe Monitoring Tool to provide timely, accurate and meaningful information to allow the plan to understand issues and gaps identified in the universe prior to uploading to CMS. In addition to the tool, a BluePeak Subject Matter Expert (SME) with experience in universe review analyzed the universe data to look for potential non-compliance concerns that the plan should review.
Outcomes:
BluePeak was able to help the plan successfully navigate and submit universes for their CMS Program Audit and avoid the pitfalls of dealing with an Invalid Data Submission (IDS) condition.
These changes included:
- Avoid common universe submission errors
- The plan was experiencing the most common formatting/clerical issues that can be easily identified by CMS and would result in immediate rejection by CMS without further review.
- Universe Exclusions
- Blank Spaces
- Incorrect values per the audit protocol
- Duplicate lines submitted
- Illogical dates in terms of order which indicates at least one of the dates is incorrectly reported
- Incorrectly populating universe data fields (not in accordance with the CMS Audit Protocol)
- Decrease the risk for Invalid Data Submission (IDS)
- Provided fast results and feedback in order to allow the plan time to remediate issues prior to submitting universes to CMS
- Reduced the risk of having the universe fail CMS Data Integrity review, which would result in a need for universe resubmission
- Reduced the risk of receiving a IDS audit condition for not being able to produce an accurate universe, thereby avoiding the potential cost of Civil Monetary Penalties associated with CMS assessment of the IDS condition.
- Eliminate Wasted Time
- Improved operational efficiency
- Reduced administrative burden
- Enhanced the ability to identify potential non-compliant cases in a quick and consistent manner
- Streamlined the results in a comprehensive summary that allowed the plan to target the specific issues identified
- Eliminated Non-Utilized Talent due to misinterpretation of CMS Audit Protocol rules
- Eliminated Extra-Processing due to manual universe review
- Reduced the time it takes to compile complete and accurate universes to include plan and FDR data, ensuring the plan’s ability to meet CMS program audit universe submission deadlines.
The plan that BluePeak partnered with was able to timely submit universes during their CMS program audit. Additionally, the plan team members were afforded the opportunity to focus on important preparatory items other than detailed universe review to prepare for the audit. We estimate that we saved the plan a minimum of 40 hours of manual universe review and the additional time it would take to re-pull universe(s) during the audit review period, and expect at least this amount of time would be saved on future audit universe pulls due to knowledge transfer and improved processes.
- Development of Data Dictionary
- Allowed the plan the ability to create an accurate universe data dictionary that has all of the universe pull data requirements clearly documented and cross-walked to core systems to ensure the ability to accurately and systematically pull universes.
- Ensured reliable, consistent and dependable data is populated every time a universe is pulled
- Avoided the need for manual entry and saved time with pulling universes.
Consultative Opportunities
- BluePeak Universe Review SMEs reviewed all feedback provided by the tool and provided the plan a Universe Review Summary that allowed for quick and easy identification of potential issues including specific lines to be reviewed, pivots with counts of impacted cases broken down by FDR and a summary of the percentage of total cases impacted.
- The BluePeak SME provided a summary of potential non-compliance issues that could be targeted in a live CMS Program Audit that the plan should focus on reviewing, expeditiously remediating, and/or preparing scripts for CMS audit discussion. Some examples include:
- Erroneous denials
- Plan Directed Care cases
- Cases denied for lack of medical necessity but were not reviewed by a physician or other appropriate health care professional
- Untimely Non-Contracted Provider, Paid Claims that were processed and Late Payment Interest was not applied correctly
- Pre-Service cases that were not downgraded correctly from an expedited case to a standard case. The plan did not follow the CMS guidance outlined Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance
- Inappropriate adjudication timeframe extensions taken
- Inappropriately processing Non-Contracted Provider Appeals without a Waiver of Liability
- Inappropriately processing Beneficiary Representative cases without an Appointment of Representative form or equivalent documentation on file
- Grievances Misclassified
- Failure to recognize Quality of Care grievance scenarios
- A clear and concise summary of issues was provided and the plan had an opportunity to discuss any questions and points of clarification needed to ensure complete understanding. This was a great opportunity for BluePeak to partner with the plan and teach them how to effectively interpret the universe data but more importantly identify issues of potential non-compliance.
- BluePeak provided recommendations on how to remediate or explain the identified issues.
- BluePeak partnered with the plan to conduct a ‘mock’ data integrity session to ensure the universes were compliant and matched the source systems. This allowed the opportunity to coach the client on how to successfully present during a live CMS Program Audit and the opportunity to do a “dry-run” audit session. This really allowed the plan to build up their confidence and identify areas of opportunity that they could work on to ensure positive data integrity results and successful webinars with CMS.
The plan became more proficient at pulling universes and completing their own quality review process. The process also provided an opportunity for the plan to build a knowledge-base and fundamental understanding of the CMS Audit Protocol that is needed to establish an ongoing monitoring process and universe creation process that can be easily repeated. Lastly, it allowed the plan to go through a ‘mock’ audit data integrity session to understand what is expected, how to navigate through a case successfully and identify areas of opportunity to be able to proactively prepare for the CMS webinars.
