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CMS’ Audit (Finding) Validation Process
Focus on Appeals and Grievances
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Sponsored by Inovaare Corporation
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About Inovaare: http://www.inovaare.com
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HELLO from Derek
Board Certified
– Fraud Examiner (CFE): Association of Certified Fraud Examiners
– Medical Investigator (CMI-V): American Board of Forensic Medicine
– Healthcare Compliance (CHC): Health Care Compliance Association
In the past 37 years:
– Special Investigator
– Provider/Administrator
– Auditor/Consultant/Author
– Founder/Principal x3
– Speaker/Trainer
D. Derek Jansen-Jones, PhD, MHA
• Fellow - American Board of Forensic Examiners
• Association of Certified Fraud Examiners Advisory
Council
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Today’s Topics
The Audit and Findings
– Brief history of the process
– Auditors and Oversight
– Examples of/Typical Findings for 2012
CAP Validation
– From Contractor to AM
– The “Reasonableness” measure
Value added
Appeal and Grievances process using Inovaare’s TracX
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The Audit and Findings
A brief history of the process 2010 – 2012:
– Early oversight (over reach) of/by contractors was not consistent during
and after audits;
– Responsibilities for follow-up (validation) were less than clear –
messages to Plan murky;
– Scoring process was dynamic until late 2011;
– Audit scoring = OIG OAS
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Audit Scoring = OIG OAS
Finding =
– Criteria – What should be (The regs)
– Condition – What is
– Cause – of the difference between above
– Effect – Consequence of the difference
– Corrective Action Required to fix it.
The important result for plans is that it allowed for better
training of contractors and CMS lead staff.
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Auditors and OversightAuditors and Oversight
Audit Teams are a mixed bag:
– Smaller CMS contingent, but large numbers overall;
– PCOG/MOEG Audit Lead, with Central Office SME’s in functional areas;
– Some Account Managers, usually out-of-region;
– Compliance Lead (usually experienced) with contractor auditors;
– All acting on contractor-generated intelligence.
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Examples of/Typical Findings for 2012
Generally:
– Part D Coverage Determinations and Appeals
Effectuation Timelines
Appropriateness of Clinical Decision Making & Compliance with Processing
Requirements.
– Part D Grievances
– Part D Organization Determination and Appeals
Timeliness
Clinical Decision Making
– Part C Grievances/Dismissals
– Access – Misclassified Grievances
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Examples of/Typical Findings for 2012
Part C and Part D Compliance Program Effectiveness (Four
Horsemen of Compliance Apocalypse):
– Effective Training and Education
– Systems for Monitoring and Auditing
– Promptly Responding to Compliance Issues
– FDR oversight
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The Numbers
Part D Coverage Determinations and Appeals
Areas % sponsors
had finding
Appropriateness of Clinical
Decision Making & Compliance
with Processing Requirements
80%
Effectuation Timeliness 70%
General
Areas % sponsors
had finding
Failed to timely process
redeterminations
65%
Failed to timely forward the
coverage redetermination
request to the IRE
85%
Failed to appropriately
process coverage
determination requests
75%
Focused
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The Numbers
Part D Grievances
Failed the issue totally
(meaning more than
an acceptable # of
findings): 60% (2011)
Specific areas of concern and oversight:
– Failure to timely resolve grievances and notify the beneficiary of the disposition of the grievance.
– Failure to properly resolve grievances. (70% failure rate) This is tied closely to “Appropriateness of Clinical Decision Making & Compliance with Processing Requirements”, meaning that CMS will be looking more closely at the clinical aspect of determination and redetermination.
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The Numbers
Most egregious of all:
Many sponsors failed simply because
they couldn’t produce the required samples!
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Examples of/Typical Findings for 2012
Specific Example:
– Part D Coverage Determination and Appeals
Appropriateness of Clinical-Decision Making –
The Plan was non-compliant with CMS regulations
regarding appropriateness of clinical decision-making in
26 of 30 cases reviewed. The nature and extent of
operational deficiencies identified in this section are
indicative of ineffective compliance oversight of this
specific program area.
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Part D Coverage Determination and Appeals
- Appropriateness of Clinical-Decision Making
Condition: The SO issued a denial letter that included incorrect
information specific to the individual in (many) cases.
Criteria: 42CFR 423.568(f); 42CFR 423.568(g); Medicare
Prescription Drug Benefit Manual, Ch 18, Sec, 40.3.4
Examples of/Typical Findings for 2012
Appropriateness of Clinical-Decision Making
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Part D Coverage Determination and Appeals
Appropriateness of Clinical-Decision Making
Cause: SO does not have an adequate process in place to
ensure that denial letters contain correct information.
Effect: …due to the errors, there is potential for beneficiary
harm.
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Part D Coverage Determination and Appeals
Appropriateness of Clinical-Decision Making
Corrective Action Required: The S.O. must ensure that denial
letters provide specific information to the denial that is complete
and accurate.
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CAP Validation
• From Contractor to AM – Very Important
– Remember:
Audit conducted by Contractor with some CMS oversight (AL and SME’s,
with assist from out of region AMs)
May, or may not, have MOEG/PCOG (policy) participation
May, or may not, have DCPO (enforcement) participation.
– CAP validation conducted and managed by your RO, AMs, CMHPO
SMEs with little Contractor input and PCOG oversight.
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CAP Validation
Scope:
– Not a second full audit
– Focus on “Conditions”
Validate by reviewing and testing the corrective action.
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CAP Validation
“Reasonableness” of Plan
– Does corrective action plan describe in
Sufficient detail &
Sufficient specificity
– That CMS/AM can be reasonably assured.
Reasonable, it may be, but test to be sure –
– Test for dates “after” the deficiencies were to have been corrected.
Compare to other information, i.e. ICARs or NONC. Hx with the
Region.
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CAP Validation
Remember?
– Corrective Action Required: The SO must ensure that denial letters
provide specific information to the denial that is complete and accurate.
– Corrective Action Plan: The SO has licensed (a ubiquitous compliance
software that seems to surround the problem) that has a component to
ensure specific information to the denial that is complete and accurate.
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CAP Validation
Corrective Action Plan:
– The SO has purchased X, that has a component to ensure specific
information to the denial that is complete and accurate.
Is that sufficient and specific enough?
– Procedures?
– Would implementation actually fix the problem?
– How do you know?
This is not an unimportant question, because it is asked of the AM. The
AM’s performance is measured, in part, by their monitoring of the plan.
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Post CAP Validation
AM Monitoring tools
– All functional areas, plus Compliance
– Ongoing process
As accreditation organizations changed from every 3 years to continuous;
– Don’t recreate the wheel
– Speaking the same monitoring language makes understanding simpler.
– Don’t confuse the monitors.
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Value Added
It simplifies internal auditing and monitoring for both the
business function and compliance.
It helps manage the day-to-day relationship with the CMS AM.
Audit prep and readiness. Don’t FAIL due to the inability to
locate the requested samples.
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TracX by Inovaare
Software to Solve A&G Process Challenge
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Healthplan Challenges
Case
infoLetters
Member
correspondence
Provider
correspondence
Readiness
Process in place
× Information in Silos
× AM Monitoring process
× Enforcement of compliance rules
CMS NCQA
MEMBER
SERVICE
A&G Physician Compliance
CCIIOExternal stake holder
Internal stakeholder
Information
Multiple data sources
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TracX: Appeals and Grievances Solution
A & G Process
He
alth
care
BYO
D
Part C Pre service Appeal workflow
Post Service workflow
Inovaare’s application platform
HIPAA Compliant Datacenter
Appeal and Grievances processes
Digital platform
Infrastructure
Audit Support Quality Support
Grievances workflow
Compliance oversight Manager
Audit support Manager
Part D Appeal workflow
Process
Manager
Compliance
Monitor
Audit
Support
Case Document
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Case data
Documents
Letters
Compliance
monitoring
AM support
Process
oversight
Audit support
Web Portal
Phone/
Call Ctr
Fax
Case Intake Member
Quality
management
Investigation Decision IRE processing
Physician
PhysicianCase coordinator
Appeal and Grievances process with TracX
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Efficient
process
• Centralized Information
• Reduced turn around time
• Enforcement of operational polices
Get CMS
Compliant
• Timeliness of case processing
• Letter generation
• Appropriate case review
Audit Ready
• CMS audit support
• AM Monitoring support
• Internal audit support
Quality
Improvement
• NCQA measure tracking
• CMS Star rating
• Trend analysis
TracX: Benefits for Healthplans
Key goal
CMS Compliant
Customer satisfaction
Improve quality rating
Foundation for CCIIO
Reduce manual oversight
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Process Manager
End to End Case processing platform
Process dashboard: Role based collaborative
portal to monitor and take action on various cases
CMS rule based workflow: Built-in workflow for
various Appeal and Grievances incidents
Configurable centralized database: Centralized
database, documents and letters.
Automated letter generation: Automated letter
generation bases on type of cases
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“All information
in one place”
“Ability to
manage
workload during
peak period”
“Easy to use”
Customer Comments
Audit Support
Compliance oversight Manager
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Compliance Monitor & Oversight
Timeliness monitoring
Appropriate processing
Part C and D Reporting
Built-in compliance data model
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“Pre-built dashboard
based on CMS measures
is a great feature”
Customer Comments
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Audit and Quality Management
Internal audit : Enables to perform internal
audit
AM audit support: CMS audit support
based on AM tool approach
NCQA Measures : Information reporting
and monitoring for trend analysis
CCIIO support
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Designed based
on CMS AM’s
monitoring
model
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Process owner action portal Action Portal
Process dashboard
Compliance dashboardCase workflow
Ino
vaar
eTr
acX
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Thank You
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Contact
Email: [email protected]
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About Inovaare: http://www.inovaare.com