mock data – does not indicate real information …...mock data – does not indicate real...

MOCK DATA – DOES NOT INDICATE REAL INFORMATION

MEDICARE COMPLIANCE REPORT

1

CMS Past Performance Methodology (PPM) Current Predicted PPM Scores for 2016 Application Cycle – December 1, 2014

Overview of PPM

- Past Performance scores impact Plan Sponsors ability to continue to grow our business (service area expansions, new contracts/plans).

- Legal Entities are outliers when a certain number of past performance points are assessed for Part C or Part D:

Part C = 4 past performance points Part D = 5 past performance points

- There are 11 categories in PPM; the following 2 categories are Plan Sponsors main areas of focus: Performance Area Negative Performance Points Value

Compliance Letters (Notices of Non-Compliance, Warning Letters, and Corrective Action Plans (CAPs))

1-2 points

Performance Metrics (Star Ratings) 2 points for each contract with 2.5 Stars or below

Current Predicted Legal Entity Outliers & Watch List - 1 Legal Entity currently predicted to be PPM outlier due to Star Ratings & LPI Designation. - 2 Legal Entities currently “at risk” to become a PPM outlier and are high priority. - 1 Legal Entities on our internal “watch list” due to points being assessed in one category. - 18 Legal Entities total, we are monitoring all but remaining are not currently predicted or considered high

risk for PPM outlier status. Current Legal Entities Predicted for Past Performance Methodology Outlier Status

(Based on 2015 Star Ratings these entities have low Star Ratings for at least 3 years and are automatically a PPM outlier)

Legal Entity Contracts Impacted

Total Members

PPM Category resulting in Negative Points Assessed

Reason for Assessment of Negative Points

Predicted PPM Score

ABC HXXX 12,000 Compliance Letters Performance Metrics (Star

Ratings)

Receipt of Ad Hoc CAPs (2 pts)

2.5 Part C Star Rating for 2015 (2 pts)

4/4

Current Legal Entities Predicted AT RISK for Past Performance Methodology Outlier Status (Based on Compliance assessment of known issues/risks, these entities could become a PPM outlier if additional CMS Compliance

Notices are received prior to 2/28/15)


Total Members



Predicted PPM Score

DEF HXXX 80,000 Performance Metrics (Star

Ratings) 2.5 Part C Star Rating for

2015 (2 pts) 2/4

3 Compliance Notices received YTD; predicting 4 Notices of Non Compliance could be received. If all predicted are received, entity would be PPM outlier.

GHI HXXX 130,000 Compliance Letters Multiple NONCs received YTD. 2/4

Current Legal Entities on WATCH LIST for Past Performance Methodology Outlier Status (Based on Compliance assessment of known issues/risks, these entities are not likely to become a PPM outlier unless we experience

significant unanticipated compliance issues or CMS changes the scoring methodology)**


Total Members



Predicted PPM Score

JKL SXXX 95,000 Compliance Letters Multiple NONCs received YTD 2/5

CMS 2016 Application Cycle Past Performance Review Methodology: Review Period 1/1/14-2/28/15

Part C Performance Area Negative

Performance

Points

HXXX1

State

HXXX2

State

HXXX3

State

HXXX4

State

HXXX5

State

HXXX6

State

HXXX7

State

HXXX8

State

HXXX9

State

Compliance Letters

Notice of Non-Compliance 1 0 1 0 1 2 0 0 1Warning Letter 3 3

Warning Letter with a Business Plan 4CAP – Ad hoc compliance event 6

sub-total 0 1 0 1 5 0 0 1 0

Compliance Letter Scores:

90th -100th percentile: 2 pts

80th - <90th percentile: 1 pt

Current Part C thresholds:

90th percentile – 7

80th percentile – 5

Max 2 pts 1

Performance Metrics C/D: A summary star

rating score of less than 3.0 is automatically 2

pts.

Max - 2 pts. 2

Multiple Ad Hoc CAPs Max - 1 pt

Ad Hoc CAPs with Beneficiary Impact - 1

pt. per CAPNo Max

Financial Watch List Max 1 pt.

One-Third Financial Audits (Adverse

Opinion or Disclaimed Results) Max 1 pt.

Program audit Max 1 pt.Exclusions Max 4 pts 0 0 0 0 0 0 0 0 0

Medicare & You Handbook 1On-Line Enrollment Center 1

Formulary Update 1 or 2

LIS Reassignments/Auto-Enrollees:

Subsequently lifted: 2 points

Ongoing: 3 points

N/A

Enforcement Actions Intermediate

Sanctions Civil Money Penalties (CMP)

Immediate: 3 points lifted/7 points ongoing

a. Non Immediate: 2 points lifted/6 points

ongoing

b. CMP of any amount: 1 point

No Max

Terminations

a. CMS-Imposed: 8 points

b. Disruptive Mutual: 4 points

c. Non-Disruptive Mutual: 1 point

Max 8 pts

Outstanding Compliance Concerns Not

Otherwise Captured Max 5 pts

Contract Totals

Part C Threshold: 4 = Outlier0 0 0 0 1 2 0 0 0

MOCK DATA -- FOR EXAMPLE ONLY

10/1/14: (2 Points) Part C Stars < 3.0 - HXXX6

1/15/14: NONC (1 point) HXXX2, HXXX4, HXXX5, & HXXX8 Part C&D Event Upload. Failure to notify CMS of scheduled marketing events timely (7 calendar

days).

Note: Thresholds are based on percentiles published in the 2015 Application Cycle PPM and are likely to change when recalculated for the current review period.

Medicare Compliance 12-9-2014

MOC

ICARs - 0

CARs - 2

Obs - 1

FA

ICARs - 2

CARs - 0

Obs - 2CDAG

ICARs - 0

CARs - 4

Obs - 2

ODAG

ICARs - 0

CARs - 0

Obs - 3

CPE

ICARs - 0

CARs - 3

Obs - 0

Audit Readiness Dashboard

Q4 2014

As of December 21, 2014

MOCK DATA – EXAMPLE ONLY

Medicare Compliance Q3 Audit Readiness ReportMOCK DATA – For Example Only

1

Issue Brief description of issue/root cause Remediation Opened Status

1

CMS Audit

Readiness –

Summary

(Update)

Status of previous Internal Mock Audit CAPs totaling 6 (Update)

• 1 findings was an ICARs in xxxx and was remediated within 1

week

• 2 of the 5 CARs are in-process of being remediated and

should be fully implemented in Q4

Internal Compliance Mock Audits (New)

5 CARs identified through Mock Audits

• XYZ Dept (2) -- Issues with……………………………………..

• ABC Dept (1) – Issues with………………………………………..

• ZZZ Dept (2) – timely processing of member notification

1 CAR – identified through validation audit procedures for xxxxx

department

KPIs/Monitoring – Compliance Issues (New)

• AAA Department – failed to …………………………– repeat issue

• Compliance substantially achieved in October

Previously Reported Mock Audits (Update)

• 2 of the 5 findings have been

remediated as per department

management (validation audit to be

scheduled)

Internal Compliance Mock Audits (New)

• Technical consultants engaged by

Medicare Operations to assist in

testing processes and implementing

revisions in XYZ department to achieve

sustainable compliance

• ABC Dept – CAPs in progress

• ZZZ Dept – CAPs in progress

KPIs/Monitoring (New)

• Corrective actions implemented; issue

has been fully remediated.

Ongoing Ongoing

Audit Readiness ICARs and CARs

• CMS audits always result in findings. CMS audit findings are categorized as either a Corrective Action Required (CAR) or Immediate Corrective Action

Required (ICAR). The main difference is ICARs are considered to have potential or actual member impact.

• ICARs are the most significant findings. Plans with 3 to 4 (or more) ICARs in 2012 audits received civil monetary

penalties or sanctions; CMPs started at $50,000.

• Best performing plan in 2012 had 19 CARS and 0 ICARs.

CMS Program Audit - UHC Audit Readiness ProgramDashboard of ResultsAs of December 1, 2015 - DRAFT

MOCK DATA USED - INFORMATION PROVIDED IS NOT REAL. 1

Overall UnitedHealthcare Medicare & Retirement 1.64

Audit Elements ICAR CAR OBSV Total UHC Business Area(s) FDRPart D Formulary & Benefit Administration

Formulary Administration 0 1 1 1

Transition Benefit 1 1 0 3Part D Website 0 0 0 0P&T Committee 0 0 1 0

1.25

Part D Coverage Determinations, Appeals & Grievances

Effectuation Timeliness 0 3 2 3

Clinical Decision Making 1 1 3 3

Grievances 0 2 1 2 N/A

2.67Part C Organization Determinations, Appeals & Grievances Effectuation Timeliness 0 0 2 0

Clinical Decision Making 0 1 0 1Dismissals 0 3 2 3Grievances 1 0 1 2

1.50

Special Needs Plans - Model of Care Implementation

Population to be Served - Enrollment Verification 0 1 0 1 Operations N/A

Health Risk Assessment (HRA), Interdisciplinary Care Team (ICT), Implementation of the Individualized Care Plan (ICP) and Use of Evidence-Based Clinical Guidelines

0 4 3 4 Clinical N/A

Plan Performance Monitoring and Evaluation of the MOC 0 1 2 1Quality

N/A

2.00

Compliance Program Effectiveness

Written Policies & Procedures 0 0 0 0Compliance Officer, Compliance Committee & High Level Oversight

0 0 0 0

Effective Training & Communication 0 1 1 1Effective Lines of Communication 0 0 1 0Enforcement of Well-Publicized Disciplinary Guidelines

0 0 0 0

Effective System for Routine Monitoring, Auditing, and Identification of Compliance Risks 0 1 2 1

Procedures and System for Promptly Responding to Compliance Issues

0 1 3 1

Sponsor Accountability and Oversight of FDRs 0 1 5 1Effectiveness Measure 0 0 1 0

0.78

Corrections in ProgressExpected Completion: Q1 2015

CPE Executive Owner: Kathy Kline

Compliance Program Effectiveness Audit Score (Industry average 1.11)

N/ACompliance

OperationsClinical

N/A

Pharmacy PBM

(Industry average 2.92)

(Industry average unknown; piloted in 2013)Special Needs Plans - Model of Care Audit Score

SNP MOC Executive Owner: Bob NelsonCorrections in Progress

Expected Completion: Q1 2015

PharmacyOperations

2014 Audit Readiness Dashboard - Sample Review Results in CMS Audit Scoring Methodology

Part D Coverage Determinations & Verbal Grievances Audit Score

Part D Formulary & Benefit Administration Audit Score

Part C Organization Determinations Area Audit Score

PBM

Findings Corrected FBA Executive Owner: John Smith

Various

Corrections in ProgressExpected Completion: Q1 2015

ODAG Executive Owner: Mary BrownFindings Corrected


CDAG Executive Owner: Smith Johnson



Metrics Examples – Overall Compliance

Note: example data only


2 Note: example data only

25 28 23

30 35

40 45

50

15 12 18

16 13

20 18

17

11 10 8

13 10

9 11

8

4 5 5

6 8

10

12 14

2 1 3

5 7

9

10

15

0

20

40

60

80

100

120

2012 Q2 2012 Q3 2012 Q4 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1

1-30 Days 31-60 Days 61-90 Days 91-120 Days 121+ Days

Metrics Examples – Health Plan Compliance


Metrics Examples - Privacy

8


MEDICARE COMPLIANCE REPORT Monthly Executive Summary of Activity As of December 1, 2014

MOCK DATA – INFORMATION SHOWN IS NOT REAL 1

Type Title/Description Status / Concerns Business Executive

Compliance Officer

New Activity UHC

Communication with CMS

CTM – Member Specific Case

CMS requesting information on member CTM history.

Johnson Nelson

Updated Activity Regulatory Audit (CMS)

CMS Part D Recovery Audit Contractor (RAC) Unauthorized Prescriber Audit Review for Plan Year 2010

Contracts selected for review. Smith Brown

Regulatory Audit (CMS)

CY 2012 1/3 Financial Audit Sample selections were provided to Contractor.

Anderson Thompson

Regulatory Monitoring

(CMS)

CMS CY2015 Monitoring of Marketed Comprehensive Formularies

Annual monitoring of marketing formularies has kicked off.

Smith

Brown

CMS Compliance Letters – Year to Date Summary Notice of Non Compliance

(NONC) Title Compliance Lead Received

Date # of

Contracts

NONC 1 Sales 10/19/2014 1

NONC 2 Operations 4/22/2014 10

Warning Letter 1 Pharmacy 1/13/2014 3

CMS Self Reported Issues – Year to Date Summary

Self Report Title

Compliance Lead Submit Date # of Contracts

Self Report 1 Operations 10/1/2014 6

Self Report 2 Clinical 9/11/2014 50

Self Report 3 Finance 4/18/2014 46

Self Report 4 Pharmacy 1/2/2014 10

1

10

3 0 0 0

2

4

6

8

10

12

# o

f CM

S C

ompl

ianc

e Le

tter

s

CMS Compliance Letters # of Contracts Impacted by Compliance Area

1 1 1 1

0 0

0.2

0.4

0.6

0.8

1

1.2

# of

Sel

f Rep

orte

d Is

sues

Medicare Self Reported Issues by Compliance Area

Operations

Clinical

Finance

Pharmacy

Sales

mock data – does not indicate real information …...mock data – does not indicate real...

Documents