STATE OF COMPLIANCE REGAN PENNYPACKER SENIOR VICE PRESIDENT, COMPLIANCE SOLUTIONS APRIL 2016

Transcription

1 STATE OF COMPLIANCE REGAN PENNYPACKER SENIOR VICE PRESIDENT, COMPLIANCE SOLUTIONS APRIL 2016

2 AND YOU ARE 2

3 TODAY S AGENDA CMS Program Audits o Current State o GHG Insight on Conditions Readiness Reviews Compliance Reviews Compliance s Place in Innovation 3

4 CMS PROGRAM AUDITS Scope October Changes Layout clarifications still a ways to go CAR/ICAR definitions Focus on fairness Call Letter Protocol release in PRA PNA occurring separately Clarification of CMP calculation Increased enforcement actions Pilots Provider Network Accuracy one small step MTM one giant leap 2014 Part C and Part D Program Audit Annual Report Innovations Process improvements Part C and Part D Program Audit Roundtables 4

5 PROGRAM AUDIT CONDITIONS Common Conditions and Low-Hanging Fruit FA CMS Non-approved QLs Max daily doses which are not supported in FDA labeling Formulary files posted on website differ from formulary files in HPMS QLs which equate to less than one unit (tablet/capsule) per day B vs D crossover drugs which reject at point of sale with no member outreach and no subsequent adjudication for either Part B or Part D IV and compound drugs which reject inappropriately CDAG Handling grievances in a compliant manner Lack of understanding of universe validation activities Misclassification of coverage determinations as grievances Lack of meaningful and effective processes for the identification of nonrespondent participating providers and the escalation to Medical Director and Provider Relations ODAG Not developing denied claims; outreach at least twice; best practice is to reach out 3 times Letters easily understood by members Having right people in the roles but not trained Non-par provider appeal language Misclassification of organization determinations as grievances Misclassification of appeals as re-openings 5

6 PROGRAM AUDIT CONDITIONS Common Conditions and Low-Hanging Fruit SNP-MOC Staffing desire and case loads Ensuring MOC is implemented The challenge of an ICP MOC 4 Plan Performance: struggle to identify meaningful and attainable measures Regular monitoring Embracing automation, dashboards any opportunities for info to be pre-populated? CPE Newer staff in Compliance roles Disconnect with monitoring and auditing functions Connection between risk assessment and how a Sponsor s audit plan is informed Lack of understanding of the goals of tracers Documentation sharing and presentation what works? 6

7 CONSEQUENCES What s the Penalty if I Choose Not to Seen: Financial penalties, halt of enrollment, published enforcement actions, Star Ratings impact, individual accountability* o CMS reduction of a Star measure to 1 Star if any compliance-related issues are identified with a measure s data o CMS program audits will soon include review of Part D sponsors MTM programs. CMS intends to review and apply any relevant MTM program audit findings that could demonstrate sponsors MTM data were biased, outside of the Data Validation results, thus impacting Star Ratings Star Ratings measure members quality of care and the plan s customer experience, while the audits look at operational areas that impact beneficiary access to drugs and services. *US Department of Justice, Individual Accountability for Corporate Wrongdoing (Washington, DC: Yates, 2015) 7

8 CONSEQUENCES What s the Penalty if I Choose Not to Unseen: Fire-drill focus; derailment of day-to-day operations; months of meetings, monitoring revision, testing and retesting; stress, finger-pointing; increased anxiety, staff turnover How does this impact your beneficiaries? CMS Audit Roundtables 8

9 SPOTLIGHT ON ENFORCEMENT Part C and Part D Enforcement Actions: 2016 CMPs $62,950 $30,000 $153,850 $127,200 $458,250 Centers for Medicare & Medicaid Services Part C and Part D Enforcement Actions, iance-and-audits/part-c-and-part-d-compliance-and-audits/partcandpartdenforcementactions-.html (April 8, 2016) 9

10 FOCUS ON READINESS New Contracts, MMPs, Annual Readiness 10

11 READINESS OF NEW APPLICANTS CMS determination to conduct desk or onsite review Organizations new to the market may be subject to review Existing organizations with other active lines of business choosing to re-enter a market may be subject to review What can be expected during a readiness review? How can applicants best prepare? 11

12 MEDICARE AND MEDICAID COORDINATION MODEL 13 Tools released for 10 States Assessment processes, care coordination/idts, network development, staffing, quality improvement beneficiary focused People, systems, and processes must demonstrate coordination, preparation for Medicare-Medicaid Plan (MMP)-specific data Future state-specific readiness review tools will be completed and posted after CMS and the states have signed MOUs Centers for Medicare & Medicaid Services Financial Alignment Initiative, Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination- Office/FinancialAlignmentInitiative/FinancialModelstoSupportStatesEffortsinCareCoordination.html (March 22, 2016) 12

13 ANNUAL READINESS CHECKLIST Assessment Requires All Hands on Deck Key operational requirements: systems, data, customer service, marketing, membership, claims, grievances and appeals Should you identify areas where your organization needs assistance or is not/will not be in compliance, your organization must report those problems to your Account Manager directly by in a timely manner Centers for Medicare & Medicaid Services, Contract Year (CY) 2016 Medicare Requirements Readiness Checklist for Medicare-Medicaid Plans (MMPs) (Baltimore, MD: Donovan, 2015); Revised 2016 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, and Cost Plans (Baltimore, MD: Larrick, Coleman, 2015) 13

14 STRONG SUGGESTIONS 2016 Readiness Checklist We strongly encourage sponsors to place beneficiary-level PA requirements on the four categories of drugs that are always used for ESRD treatment. In addition, we strongly encourage sponsors to remove the beneficiarylevel PA edits on the seven categories of prescription drugs that may be used for ESRD treatment. CMS strongly suggests that compliance officers incorporate these courses [Part C and Part D G&A courses] into their existing in-house training and use the certificate to track course completion within the organization. Review the checklist for the more than a dozen shoulds before they become musts these are expectations. 14

15 FEDERALLY-FACILITATED MARKETPLACE (FFM) COMPLIANCE REVIEWS 15

16 FFM ISSUER COMPLIANCE REVIEWS Report Released 12/16/15 Notification of selection may be at any time May be desk review or onsite review Targeted reviews and/or expedited reviews may have shorter turnaround time for submission of documentation Casework (Health Insurance Casework System) barometer for complaints Delegated/downstream entities (including affiliated agents/ brokers) Enrollment periods, enrollment processes, health plan applications, and notices Record retention, marketing and benefit design, network adequacy, issuer participation standards, rating variations, termination of coverage, and compliance plans 16

17 FFM ISSUER COMPLIANCE REVIEWS See 2017 Letter to Issuers Good faith policy ended at the close of 2015 this means CMPs can be leveraged this year, and past performance will be taken into account. Maximum penalty is $100 per day per issuer for each individual adversely affected by the non-compliance. Centers for Medicare & Medicaid Services, 2017 Letter to Issuers in the Federally-facilitated Marketplaces (Washington, DC: CCIIO, 2016) 17

18 ISSUER COMPLIANCE REVIEWS Most common result incomplete policies Many did not confirm affiliated agents/brokers completed their FFM training and registration requirements o 83% had no policy Delegated and downstream entities do not include FFM-specific language in contracts; no formal procedure for oversight o 61% had operational findings regarding vendor contracts 18

19 ISSUER COMPLIANCE REVIEWS Enrollment periods not adequately defined SEPs for triggering events o 1/3 had no P&P or incomplete P&P 70% Enrollment notices missing taglines ADA and LEP Network access, no OON policy, no procedure for maintaining directory Moral of the story Leverage Issuer Compliance Review results to other lines of business 19

20 ISSUER COMPLIANCE State Agency Involvement in FFM Example of Non-Compliance On February 11, the North Carolina Dept. of Insurance (DOI) said it had launched an examination of the state s largest health insurer after receiving more than 1,000 formal customer complaints and thousands of calls. Many of the complaints are related to overbilling and an inability to confirm coverage, particularly among those who signed up for coverage through the state s federally run insurance exchange. Plan experienced a massive software failure when it attempted to transfer about 400,000 members off of a legacy platform to Facets. Steve Davis, Wave of Complaints Prompts DOI to Launch Examination of BCBSNC, The AIS Report on Blue Cross and Blue Shield Plans, March,

21 INNOVATION Reinforcement of Commitment 21

22 INNOVATION What We Are Seeing in the Field Dashboard of key metrics for PBM overall dashboards supplemented with delegatespecific reporting that rolls up to cumulative data Implementation of survey technology in order to collect information from FDRs track OIG/GSA screening attestations, training attestations Visual presence of Compliance Hotline information posters, trifolds, badges Reinforcement of no tailgating reminder signs on doors support the culture, eliminating potential stigma of just let me in 22

23 INNOVATION What We Are Seeing in the Field Provider groups evaluating their compliance programs, preparing for adequacy and accuracy The Power of Chocolate Leveraging existing internal resources when you can t purchase a gold standard solution Monthly test module for Sales staff Includes in the field examples Recent industry items of awareness Requirement to pass the monthly test to sell Increasing sales agent and broker awareness re: their impact on complaint volume and customer service 23

24 READING THE TEA LEAVES 24

25 REGAN PENNYPACKER Senior Vice President, Compliance Solutions T (401) E rpennypacker@gormanhealthgroup.com Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance Marketplace opportunities. For nearly 20 years, our unparalleled teams of subject-matter experts, former health plan executives and seasoned healthcare regulators have been providing strategic, operational, financial, and clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and compliant operations within our client s reach. GHG offers software to solve problems not addressed by enterprise systems. Our Valencia software reconciles membership of more than 10 million members in Medicare, Medicaid and the Health Insurance Marketplace. Over 3,000 compliance professionals use the Online Monitoring Tool (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 33,000 brokers and sales agents are certified and credentialed using Sales Sentinel. In addition, hundreds of health care professionals are trained each year using Gorman University training courses. We are your partner in government-sponsored health programs 25