CMS Audit (Finding) Validation Process Focus on Appeals and Grievances

Transcription

1 CMS Audit (Finding) Validation Process Focus on Appeals and Grievances Sponsored by Inovaare Corporation About Webinar: About Inovaare: 1 1

2 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 2

3 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 3

4 The Audit and Findings A brief history of the process : 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 4

5 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. 5

6 Auditors and Oversight Auditors 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. 6

7 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 7

8 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 8

9 The Numbers Part D Coverage Determinations and Appeals General Focused Areas % sponsors had finding Areas % sponsors had finding Appropriateness of Clinical Decision Making & Compliance with Processing Requirements 80% Effectuation Timeliness 70% Failed to timely process redeterminations Failed to timely forward the coverage redetermination request to the IRE 65% 85% Failed to appropriately process coverage determination requests 75% 9

10 The Numbers Part D Grievances Specific areas of concern and oversight: Failed the issue totally (meaning more than an acceptable # of findings): 60% (2011) 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. 10

11 The Numbers Most egregious of all: Many sponsors failed simply because they couldn t produce the required samples! 11

12 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. 12

13 Part D Coverage Determination and Appeals Examples of/typical Findings for Appropriateness of Clinical-Decision Making 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 (f); 42CFR (g); Medicare Prescription Drug Benefit Manual, Ch 18, Sec,

14 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. 14

15 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. 15

16 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. 16

17 CAP Validation Scope: Not a second full audit Focus on Conditions Validate by reviewing and testing the corrective action. 17

18 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. 18

19 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. 19

20 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. 20

21 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. 21

22 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. 22

23 TracX by Inovaare Software to Solve A&G Process Challenge 23

24 Healthplan Challenges External stake holder CMS NCQA CCIIO Internal stakeholder MEMBER SERVICE A&G Physician Compliance Information Case info Letters Member correspondence Provider correspondence Multiple data sources Readiness Process in place Information in Silos AM Monitoring process Enforcement of compliance rules 24

25 Healthcare BYOD TracX: Appeals and Grievances Solution A & G Process Process Manager Compliance Compliance oversight Monitor Manager Grievances workflow Audit Support Audit support Audit Manager Support Quality Support Appeal and Grievances processes Part D Appeal workflow Part C Pre service Appeal workflow Post Service workflow Digital platform Inovaare s application platform Infrastructure Case Document HIPAA Compliant Datacenter 25

26 Appeal and Grievances process with TracX Web Portal Case coordinator Physician Member Phone/ Call Ctr Case Intake Investigation Decision IRE processing Physician Fax Compliance monitoring Process oversight Case data Documents Letters Audit support AM support Quality management 26

27 TracX: Benefits for Healthplans Efficient process Get CMS Compliant Centralized Information Reduced turn around time Enforcement of operational polices Timeliness of case processing Letter generation Appropriate case review Key goal CMS Compliant Customer satisfaction Improve quality rating Foundation for CCIIO Reduce manual oversight Audit Ready Quality Improvement CMS audit support AM Monitoring support Internal audit support NCQA measure tracking CMS Star rating Trend analysis 27

28 Process Manager End to End Case processing platform Audit Su Compliance oversight Manager 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 All information in one place Ability to manage workload during peak period Easy to use Customer Comments 28

29 Compliance Monitor & Oversight Timeliness monitoring Appropriate processing Part C and D Reporting Built-in compliance data model Pre-built dashboard based on CMS measures is a great feature Customer Comments 29

30 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 Designed based on CMS AM s monitoring model 4 CCIIO support 30

31 Inovaare TracX Process owner action portal Action Portal Process dashboard Case workflow Compliance dashboard 31

32 Thank You Contact About Webinar: About Inovaare: