CMS Program Audits - ICEForHealth.org Program Audits ODAG - Are You Prepared? Carol Wanke, Sharp HealthCare Todd DeYoung, Humana Darlene Black, SCAN Health Plan ... Determinations

1

CMS Program AuditsODAG – Are you Prepared?

CMS Program AuditsODAG – Are you Prepared?

2015 Annual ICE Conference

Ann Duarte

November 13, 2015

• Goal: Audit sponsors enrolling 95% beneficiaries over five‐year period

• 2010‐2014: Audited 100 (45%) sponsors covering 39.3m (96%) beneficiaries

CMS Audit Strategy Goal

• Data‐driven risk assessment includes:

– Star Ratings

– Sponsor‐reported Data

– Sudden enrollment growth

– Large‐scale formulary changes

– PBM changes

– Audit Referrals

• Final selection includes low‐ and high‐risk

Annual Sponsor Selection

3

2

• Revised and released annually

• 2016 Strategy & Protocols released on October 20, 2015 via HPMS memo and posted to CMS website

– Updates to 2015 protocols with no additional changes for 2016

– Sponsors should share this information with delegated entities

Audit Strategy & Protocols

4

• Focus on transparency since 2010

• Industry solicitation for feedback on protocols, processes and operational areas

• Sharing protocols

• Encouraging self‐audits, self‐reporting

• Common findings, recommendations and best practices memos

• October 20, 2015 release of 2014 Annual Report

Process Improvements

5

• Technical guidance via audit mailbox: [email protected]

• CMS Audit Team

– Set group of Team Leads

– Focus on single audit protocol

– Program Audit Consistency Teams (PACT)

More Process Improvements

6

3

• Additional week to submit universes

• Improvements to universe record layout:

– Deleted extraneous / duplicative fields

– New headers

– Direction on what to include / exclude

– Updated data dictionaries, including how to report certain data


7

• Scoring adjustment to weight conditions with greatest potential to impact beneficiary access to care


8

• Improved overall performance 2010 to 2014

• Largest overall improvement 2013 to 2014

• Program area improvement varied:

– CDAG 37%

– FA 27%

– CPE 24%

– ODAG 5%

Improvements in Audit Outcome

9

4

• Overall, ODAG scores second to lowest (just behind CDAG)

• For 5‐Star sponsors, ODAG is lowest

• Many opportunities for improvement

ODAG Performance

10

• Begins with CMS’ audit start notice or engagement letter

• Within 5 days: Sponsor submits Pre‐Audit Issue Summary

– Sponsor‐disclosed issues

– Self‐reported issues (includes those previously identified by CMS)

– Issue remediation status

Audit First Steps

11

• If CMS can validate correction during audit, marked as observation (no audit points)

• If audit identifies issue that was reported as corrected, CMS will cite those conditions (audit points)

Pre‐Audit Issue Summary

12

5

• Due to CMS within 15 days following date of audit start notice

• Prior to 2015 – single combined universes

• Starting in 2015 – 13 separate universes to facilitate universe‐level timeliness tests

ODAG Audit Universes

13

1. Standard Pre‐Service Org Determinations

2. Expedited Pre‐Service ODs

3. Requests for Part C Payment ODs

4. Direct Member Reimbursement Requests

5. Standard Pre‐Service Reconsiderations

6. Expedited Pre‐Service Reconsiderations

7. Requests for Payment Reconsiderations


14

8. Pre‐Service IRE Cases Requiring Effectuation

9. IRE Payment Cases Requiring Effectuation

10. All ALJ, MAC Cases Requiring Effectuation

11. Part C Oral and Written Std Grievances

12. Part C Oral and Written Expedited Grievances

13. Dismissals

ODAG Universes

15

6

• Separating the universe presenting significant challenge to sponsors

• Late 2015/2016 – Clarification and/or simplification of some data requests


16

• Goal: Verify that data (dates / times) in universe record layout matches cases in sponsor’s systems and mailing policy

• First determine universe accuracy

• CMS selects 5 cases from each (13) universe

• If more than 1 of the 5 doesn’t match, CMS requests replacement universe

Universe Timeliness Test

17

• Allowed three chances to submit accurate universe

• Starting 2016 – After three failed attempts, CMS cites sponsor with Invalid Data Submission (IDS) condition


18

7

• If universe accurate, review for case timeliness:

– Number of late cases divided by total number of cases

• Timeliness Threshold = 100% ‐ Late %

• Apply timeliness against three pre‐determined compliance thresholds


19

• Timeliness at or above first threshold = No Conditions

1ST THRESHOLD

• Between first and second = Corrective Action Required (CAR)

2ND THRESHOLD

• Under third threshold = Immediate Correction Action Required (ICAR)


20

• All other reviews (FA, ODAG, CDAG, etc.) performed concurrently via webinar

• Webinars allow CMS remote access to sponsor’s / delegate’s systems to walk through sample cases

Audit Schedule – Week 1

21

8

• Compliance Program Effectiveness (CPE)

– Only on‐site portion of audit

– Interviews depend upon issues found

• Continuation of other protocols as necessary

Audit Schedule – Week 2

22

Audit Area

Monday, January 4, 2016

Tuesday, January 5, 2016

Wednesday, January 6, 2016

Thursday, January 7, 2016

Friday, January 8, 2016

Entrance Conference

CO Participants: 6‐3100; Other participants: 877‐267‐1577; Meeting ID: XXXXXXXXX Time: 0:00 am/pm ‐ 0:00 am/pm

F

O

R

M

U

L

A

R

Y

Dial in number

CO Participants: 6‐3100; Other participants: 877‐267‐1577; Meeting ID: XXXXXXXXX





Webinar link ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HEREENTER WEBINAR LINK

HERE

Morning Session

ENTER: Specific Formulary Area under Review

ENTER: Time: 0:00 am/pm ‐0:00 am/pm









LunchENTER: Time: 0:00 am/pm ‐

0:00 am/pm ENTER: Time: 0:00 am/pm ‐




0:00 am/pm

Afternoon session











O

D

A

G

Dial in number






Webinar link ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HEREENTER WEBINAR LINK

HERE

Morning Session

ENTER: Specific ODAG Area under Review










LunchENTER: Time: 0:00 am/pm ‐





0:00 am/pm

Afternoon session











23

Sample Audit Schedule – Week 1

Audit Area






Pre Exit Conference (Delete if held in Week 1)

CO Participants: 6‐3100; Other participants: 877‐267‐1577; Meeting ID:XXXXXXXXX Time: 0:00 am/pm ‐0:00 am/pm Enter: 0:00 AM/PM ‐ 00:00 AM/PM

C

O

M

P

L

I

A

N

C

E

Welcome MeetingENTER: Time: 0:00

am/pm ‐ 0:00 am/pm

Tour of OperationsENTER: Time: 0:00

am/pm ‐ 0:00 am/pm

Interview ‐ Compliance Officer

ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm

Employee Interviews(As needed)


24


9

Audit Area






C

O

M

P

L

I

A

N

C

E

Interview ‐ SIU/FWA Oversight


Tracer Sample Review 1ENTER: Time: 0:00 am/pm

‐ 0:00 am/pm

Tracer Sample Review 2ENTER: Time: 0:00 am/pm

‐ 0:00 am/pm

Tracer Sample Reviews 3‐5


Exit Conference (indicate if scheduled

after Week 2)

CO Participants: 6‐3100; Other participants: 877‐267‐1577; Meeting ID:XXXXXXXXX Time: 0:00 am/pm ‐ 0:00 am/pm Enter: 0:00 AM/PM ‐ 00:00 AM/PM

25


• CMS identifies ODAG samples one hour in advance of the scheduled webinar regardless of delegation.

• Samples grouped by provider

• Sponsor can decide order of review

• Each delegate joins webinar for specific sample review

ODAG Sample Review –Clinical Decision Making

26

• Cases reviewed against specific criteria (e.g., timeliness, notice requirements, etc.)

• For each element / universe, CMS will cite Observation, CAR or ICAR depending upon nature of failures

• For failed cases, CMS requests case documentation, due within 24 hours

ODAG Sample Review –Clinical Decision Making

27

10

Invalid Data Submission 1 point per failed universe

Observation 0 points

Corrective Action Required (CAR)

1 point per condition

Immediate Corrective Action Required (ICAR)

2 points per condition

Audit Scoring

28

• Audit score = sum of points / number of audit elements tested

• Allows for cross‐sponsor comparison regardless of sponsor type and # of elements

Audit Scoring

29

• Audit processes have been effective

• Requires sponsor’s close coordination with delegates

• CMS encourages regular audit tests to ensure delegates are capable of process (let alone compliance with program requirements!)

Delegated Model

30

11

• Ensure delegates have CMS audit instructions and protocols

• Require weekly universe submissions in advance of audit

• Perform two mock audits including testing access to delegates’ systems via webinar

Delegated Model Best Practices

31

• CMS audit process effective in driving improvements

• Still work to be done

• Look forward to continued collaboration with industry on improving the audit process

Summary

32

1

2015 Annual Conference

CMS Program AuditsODAG - Are You Prepared?

Carol Wanke, Sharp HealthCareTodd DeYoung, Humana

Darlene Black, SCAN Health PlanJean Diaz, SCAN Health Plan

November 13, 2015

2015Annual

ConferenceAgenda

Introductions CMS Program Audit Scope and Timeline Part C Organization Determinations and

Appeals and Grievances (ODAG) Universe Tables #1- 4 ODAG Universe Reminders & Submissions ICE Templates for ODAG Tables #1- 4

Audit Readiness Efforts with Delegates & Plans Issues & Concerns for Delegates

2

2015Annual

ConferenceCMS Program Audit Scope

Part D Formulary and Benefit Administration Part D Coverage Determinations, Appeals and

Grievances Part C Organization Determinations, Appeals and

Grievances Special Need Plans– Model of Care (SNP-MOC) Part C and Part D Compliance Program Effectiveness Medication Therapy Management (PILOT) Provider Network Adequacy (PILOT)

3

2

2015Annual

ConferenceCMS Program Audit Timeline

4

Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Week 7

Week 8

Universe Submission

Webinar

Audit Notice

F/U Call

On-Site

Audit Starts

1 to 2 Days After Notice to Discuss Audit Scope

Validation Webinar

Universe Request Call Prior to Upload of Universe to Answer Any ?s

Due Within 15 Business Days of Audit Notice

Pre-Audit Audit

Audit Schedule

After Upload to Verify Dates

Sent 6 Weeks Before Audit Start Date

Sent Before Start

2015Annual

Conference

Part C - ODAG Universe Tables #1 - 4

Table 1 – Standard Pre-Service Organization Determinations (SOD)

Table 2 – Expedited Pre-Service Organization Determinations (EOD)

Table 3 – Requests for Payment Organization Determinations (Claims)

Table 4 – Direct Member Reimbursement Requests (DMR)

5

2015Annual

Conference

Part C - ODAG Universe Tables #1, 2, 3 & 4

6

TABLE#

RECORD LAYOUT

UNIVERSE COMPLIANCE STANDARD TO APPLY

TEST

1 SOD Standard Pre- service ODs

No later than 14 days, plus 14 days (totaling 28 days) if

an extension is used.

Decision-Making

Notification

2 EOD Expedited Pre- service ODs

No later than 72 hours, plus 14 days (totaling 17 days) if

an extension is used.

Decision-Making

Notification

3 Claims

Requests for Part C payment ODs-

Claims (designate if the request was a clean claim or an unclean claim)

95% in 30 days for clean claims and 60 days for

unclean claims.

Effectuation

Notification

4 DMR

Requests for Payment ODs- Direct

Member Reimbursement

Requests

No later than 60 days.Effectuation

Notification

3

2015Annual

ConferenceODAG Universe Reminders

• All dates and times should be submitted in the manner prescribed in the audit process documents (CCYY/MM/DD and HH:MM:SS). If seconds are not captured, enter “00” Example: 2015/01/01 and 23:59:00

• Diagnosis Field should reflect ICD- 9/ICD-10 codes related to this request. If the ICD codes are unavailable, provide a description of the diagnosis. Multiple diagnoses should be separated by (,) Diagnosis codes MUST include the decimal point Example: J20.6

7

2015Annual

Conference

ODAG Universe Reminders (cont.)

Field – “Issue Description and Type of Service”

Provide the description of the service requested issue and type of service why it was requested (if known). For denials, also provide an explanation of why the claim or request was denied.Use comma (,) to separate multiple values within

one field if there is more than one piece of information for a specific field.

8

2015Annual

Conference

ODAG Universe Reminders (cont.)Field – “Issue Description and Type of Service” (cont.)

If denied, Plans/delegates should include a brief description of the denial reason such as “lack of medical necessity”, “service not covered”, and “no-referral”.

9

4

2015Annual

Conference

ODAG Universe Reminders (cont.)Field – “Issue Description and Type of Service” (cont.)

Denial codes should not be used as a description for the denial. However, ICD-9 and ICD-10 codes are acceptable in the diagnosis field.Denial Example: office visit,denied,lack of

authorizationApproved Example: office visit

10

2015Annual

Conference

ODAG Universe Reminders (cont.)

N/A is NOT acceptable; NA is acceptable only when specified in a Table Description.

Delegates - Blank Fields are NOT acceptable* (*exceptions in tables 1- 4, Plans to populate fields Contract ID & Plan ID)

Plans should populate all fields in each table.

Delegates should submit their universes in Excel (.xlsx) format.

Plans should submit the tables through HPMS in an Excel (.xlsx) or Comma Separated Value (.csv) format rather than a tab delimited text file (.txt). 11

2015Annual

Conference

ODAG Universe Submissionsfor Tables 1 & 2: SOD & EOD

Include all requests processed as standard or expeditedpre-service organization determinations, including all supplemental services, such as dental and vision, and include all approvals and denials.

Exclude payment requests

Submit cases based on the date the Plan or delegate’s decision was rendered, or should have been rendered (the date the request was initiated may fall outside of the review period).

12

5

2015Annual

Conference

ODAG Universe Submission for Table 3: Claims Include all requests processed as both contract and non-

contract provider denied claims and only non-contract provider paid claims.

Exclude all requests processed as direct member reimbursements, duplicate claims and payment adjustments to claims; claims denied for invalid billing codes; claims for beneficiaries who are not enrolled on the date of service; and claims due to recoupment of payment.

If a claim has more than one line item, include all of the claim’s line items in a single row and enter the multiple line items as a single claim.

13

2015Annual

Conference

ODAG Universe Submission for Table 3: Claims (cont.)

After removing excluded records for multiple line claims: If all of remaining line items are paid/allowed, the

claim should be included in the Claims Universe (if applicable) and marked as “approved”.

If all of the remaining line items are denied, the claim should be included in the Claims Universe as “denied.”

14

2015Annual

Conference

ODAG Universe Submission for Table 3: Claims (cont.)

After removing excluded records for multiple line claims: If any of the remaining line items are denied and

the rest of the line items in the claim are approved, the entire claim should be included in the Claims Universe and considered partially favorable. For purposes of these program audits, a partially favorable decision is considered denied. Therefore the claim should be included in the Claims Universe as “denied”.

15

6

2015Annual

Conference

ODAG Universe Submission for Table 4: DMR

Include all requests processed as direct member reimbursements, including approvals, denials and partial approvals.

Exclude all requests processed as contract and non-contract provider claims.

16

2015Annual

Conference

ODAG Universe Submission for Table 4: DMR (cont.)

Submit cases based on the date the Plan or delegate’s decision was rendered, or should have been rendered (the date the request was initiated may fall outside of the review period).

If a claim has more than one line item, include all of the claim’s line items in a single row and enter the multiple line items as a single claim.

17

2015Annual

Conference

ICE ODAG Templates Table # 1 ‐ 4

Field Name:

Field Type & Requirements:

MAX Field Length:

CMS Field Description:

FORMAT Example Use of NA

Validation Rules

DiagnosisCHAR Always Required

20 Provide the enrollee diagnosis/diagnoses ICD-9/ICD-10 codes related to this request. If the ICD codes are unavailable, provide a description of the diagnosis.

ICD- 9/ICD-10 Diagnosis Code (alpha numerical).

J20.6 NA is not acceptable in this field

Provide primary diagnosis and any diagnosis codes you can reasonably provide. Separate each diagnosis code with a comma(,).

18

2015 CMS Audit Process & Data Request

ICE Format Aides

7

2015Annual

Conference

Audit Readiness Efforts With Plans & Delegates

Recommendations for ODAG Tables# 1 - 4 Fields: “Contract ID” and “Plan ID”- Delegates may not

have this information; therefore, recommend the following:Delegates populate the Fields “Cardholder ID” and

“Beneficiary Date of Birth” (new ICE field added) Based on the above 2 fields, allows Plans to

populate the Fields “Contract ID”, and “Plan ID”

In addition to CMS fields, ICE added fields “Date of Birth” and “Date of Service” or “Date of Authorization” for delegates to populate.

19

2015Annual

Conference

Audit Readiness Efforts With Delegates

Reminding, notifying and conducting universe educational webinars with our delegates

Mock universe pulls with our delegates and providing feedback with lessons learned

Working with ICE to collaboratively request the same data from delegates amongst all the Plans to reduce the burden on delegates

20

2015Annual

Conference

Audit Readiness Efforts With Plans

Are Plans Ready for an Audit Today? Have all processes, systems and data been assessed to

maximize compliance and minimize potential risk? Have test universes been created, and are these

universes accurate and complete? What type of errors exist (i.e., formatting, missing data)? Is there enough data received from delegates on claims,

determinations and denials? Do Plan staff know what to say and when?

21

8

2015Annual

Conference

Issues and Concerns for Delegates

If a staff person entered information for the referral inaccurately, it needs to be corrected. The original and correct date/time of the receipt of the referral should be used unless a new referral is used.

If a referral (OD) is not clean and additional information is needed, what date/time should be used as receipt date/time?

Oral notifications- time tracking and compliance issues Portal transmission- delays causing date and time

mismatch What date and time should be used for letters that are

automated and released in a queue?

22

Documents

CMS Program Audits - ICEForHealth.org Program Audits ODAG - Are You Prepared? Carol Wanke, Sharp HealthCare Todd DeYoung, Humana Darlene Black, SCAN Health Plan ... Determinations