After Good Faith Compliance: Incorporating Exchange Compliance into Your Overall Government Program Compliance Structure

Transcription

1 After Good Faith Compliance: Incorporating Exchange Compliance into Your Overall Government Program Compliance Structure Michael S. Adelberg Senior Director Ann B. Kinsella Medicare Operations Compliance Officer Exchange Compliance Lead Today s Topics 1) CCIIO s Approach to QHP Oversight 2) Integrating QHP Requirements into Overall Compliance Program 3) Practical Steps to Prepare for Exchange Audits 4) Likely Hot Topics for 2016 QHP Audits OUT OF SCOPE Market wide Requirements 3Rs 2 1

2 12/31/15: The End of Good Faith Compliance In 2013, CMS announced it would oversee QHP issuers based on the Good Faith Compliance Standard CMS assumes QHP issuers are acting in good faith to meet Federal Exchange requirements Refrains from enforcement actions Two-year mutual learning period for CCIIO and issuers Good Faith Compliance Standard ends 12/31/15 CCIIO enforces requirements CCIIO assumes issuers have had time to learn program requirements 3 Going Forward: Progressive Compliance Approach Seek to solve problems at the lowest possible level Progressive Notices Notice of Non-Compliance Warning Letter CAP Enforcement Actions Civil Money Penalty Decertification Other Actions Plan Suppression SEP 4 2

3 QHP Oversight Tactics? Compliance Reviews/Audits Focused vs. General / Off-site vs. On-site Little manualized guidance Collaborating with States Past Performance Data Analysis Plan-caused HICs and SEPs Compliance Reviews and Monitoring Activities Notices of Non-Compliance, Warning Letters Plan data errors requiring suppressions and/or data corrections Account Manager feedback Significant regulatory actions from other entities Quality ratings and transparency data (?) 5 Federalism in Overseeing QHPs CCIIO sets broad requirements for all exchanges Significant latitude for SBMs to set and enforce their own requirements Significant latitude for partner states to enforce FFM requirements CCIIO is enforcer of FFM requirements in remaining states State DOI continues to enforce non-exchange requirements For example: California (SBM): assures QHPs meet requirements Delaware (Partner): indicates to CCIIO that it will assure that QHPs meeting requirements: otherwise CCIIO will enforce Texas (non-partner FFM): CCIIO enforces 6 3

4 Unique Challenges for QHP Compliance New Program, New Requirements Lack of manualized guidance Guidance disaggregated across thousands of FAQs, PPTs, etc. Continued reliance on workarounds (i.e., HICS) Federalism concerns (i.e., consumer notices) 3 Tips for Coping with the End of Good Faith Compliance QHP-Specific Compliance Plan P&Ps, SIU, etc. Mock or Internal Audits Secret Shopping of Call Center, Providers, Agent/Brokers 7 Integrating QHP Regs into Overall Government Programs Compliance Program Whether an insurer is focused on the Exchange market specifically or has broader products: leverage your existing compliance structure. Understand your business partners: are they familiar with government program compliance and federal regulatory landscape or is their experience more in line with commercial products? THE COMPLIANCE MODEL FOLLOWS THE BUSINESS MODEL Oversight structure and committees: what exists that can work? CMS has very specific Medicare compliance requirements: although not yet there for Exchanges, they likely won t re-invent the wheel. 8 4

5 It all goes back to the elements... Seven Elements of an Effective Compliance Program Standards and procedures Involvement of high-level personnel Discretionary authority carefully delegated Standards and procedures communicated to employees Monitoring and auditing Standards consistently enforced Response and prevention PREVENTION ACTIVITIES How best to align or establish Exchange Policies and Procedures Some policies will be keyed to federal requirements, others to state or more general NCQA requirements CMS audits will likely continue P&P focus but also move to more outcome-based review of transactions (HICs complaints, claims, network adequacy, ECP contracting, etc.) Consider your governance structure: Exchange reporting to your Compliance Committee (consider sub-committee or business forums that focus specifically on Exchanges to accomplish the goal of clear lines of communication and documentation) Reporting Tools and Scorecards Risk Assessment: is an Exchange sub-review needed? Do you know your risks? Document 3-5 risks you can reasonably address and make progress on. 10 5

6 DETECTION Business Monitoring for reporting to leadership (examples) Complaints: HICS complaints, DOI complaints, trends across both complaint types, timeliness of responses Enrollment: reports on enrollment timeliness (from receipt of CMS transaction to effectuation in system) Billing: reports on payment processing (how are payments received, how fast are they processed) Provider Data Accuracy (spot checking of provider directories/monitoring): a focus for CMS and States Claims review of denial trends Sales: how many agents, training logs, oversight Lots of opportunity to focus/target to your risks Compliance Oversight: add Exchange reviews to your Compliance monitoring work plan (CMS will ask) 11 CORRECTION How are you documenting identified issues? What are your policies and practices in Medicare or otherwise? Apply them to Exchanges specifically documenting differences, if needed, but keeping it simple How are you identifying issues? Engage with your business leaders through their existing business forums to learn the issues and drive understanding of reporting to compliance; review the reporting you have agreed that your business leaders will submit (detection activities) Document corrective actions: Consider having a compliance issue log again, leveraging existing system with a tab or space for exchanges 12 6

7 Practical Steps for Preparing for Exchange Audits Identify business leaders at a senior level to take accountability for audit deliverables and interviews. Ensure their leadership is on board with the time commitment: have agreement this is a priority Good Faith exception no longer there! Identify risks based on document requests; review published notes on CMS playbook. Involve your legal and regulatory partners and start preparing for an audit now: what is on track or behind in terms of CMS requirements implementation? What do business monitoring reports show? Prepare for the interviews: have leaders in the interview chair and senior leaders available for opening and exit. 13 Hot Topics Heading into 2016 Audit Season Provider Directories Consumer Notices (accurate, timely, comprehensive) SEPs Network Changes Consistent de minimus Policy on Premiums HICs Closure Rate Accumulators Out of Network Provider / In Network Facility Individual Inside a Family Access to Drugs Compliance Plan 14 7

8 After Good Faith Compliance: Incorporating Exchange Compliance into Your Overall Government Program Compliance Structure Michael S. Adelberg Ann B. Kinsella Questions? Thank you! 8