CMS Program Audits ODAG – Are you Prepared?

2015 Annual ICE  Conference Ann Duarte November 13, 2015

CMS Audit Strategy Goal • Goal: Audit sponsors enrolling 95%  beneficiaries over five‐year period • 2010‐2014: Audited 100 (45%) sponsors  covering 39.3m (96%) beneficiaries

Annual Sponsor Selection • 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 3

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Audit Strategy & Protocols • 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 4

Process Improvements • 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 5

More Process Improvements • 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)

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More Process Improvements • 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

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

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Improvements in Audit Outcome • Improved overall performance 2010 to 2014 • Largest overall improvement 2013 to 2014 • Program area improvement varied: – CDAG 37% – FA 27% – CPE 24% – ODAG 5%

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ODAG Performance • Overall, ODAG scores second to lowest (just  behind CDAG) • For 5‐Star sponsors, ODAG is lowest • Many opportunities for improvement

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Audit First Steps • 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 11

Pre‐Audit Issue Summary • 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)

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ODAG Audit Universes • 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

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ODAG Audit Universes 1. 2. 3. 4. 5. 6. 7.

Standard Pre‐Service Org Determinations Expedited Pre‐Service ODs Requests for Part C Payment ODs Direct Member Reimbursement Requests Standard Pre‐Service Reconsiderations Expedited Pre‐Service Reconsiderations Requests for Payment Reconsiderations 14

ODAG Universes 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 15

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ODAG Audit Universes • Separating the universe presenting  significant challenge to sponsors • Late 2015/2016 – Clarification and/or  simplification of some data requests

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Universe Timeliness Test • 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 17

Universe Timeliness Test • Allowed three chances to submit accurate  universe • Starting 2016 – After three failed attempts,  CMS cites sponsor with Invalid Data  Submission (IDS) condition

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Universe Timeliness Test • 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

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Universe Timeliness Test • 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

Audit Schedule – Week 1 • 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

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Audit Schedule – Week 2 • Compliance Program Effectiveness (CPE) – Only on‐site portion of audit – Interviews depend upon issues found

• Continuation of other protocols as  necessary

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Sample Audit Schedule – Week 1 Audit  Area

Monday,  January 4, 2016

Entrance Conference

F O R M U L A R Y

Dial in number Webinar link

O D A G

Wednesday,  January 6, 2016

Thursday,  January 7, 2016

ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm 

Morning Session Lunch Afternoon session 

Dial in number

Tuesday,  January 5, 2016

Friday,  January 8, 2016

CO Participants: 6‐3100;           Other participants: 877‐267‐ 1577; Meeting ID:  XXXXXXXXX                             Time: 0:00 am/pm ‐ 0:00  am/pm  CO Participants: 6‐3100;          CO Participants: 6‐3100;        CO Participants: 6‐3100;        CO Participants: 6‐3100;        CO Participants: 6‐3100;      Other participants: 877‐267‐ Other participants: 877‐267‐ Other participants: 877‐267‐ Other participants: 877‐267‐ Other participants: 877‐ 1577; Meeting ID:  1577; Meeting ID:  1577; Meeting ID:  1577; Meeting ID:  267‐1577; Meeting ID:  XXXXXXXXX                            XXXXXXXXX                          XXXXXXXXX                          XXXXXXXXX                          XXXXXXXXX                         ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm 

ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm 

ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm 

ENTER WEBINAR LINK  HERE ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm   ENTER:  Specific Formulary  Area under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm 

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

Webinar link Morning Session Lunch Afternoon session 

ENTER:  Specific ODAG Area  under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm 

ENTER WEBINAR LINK  HERE ENTER:  Specific ODAG Area  ENTER:  Specific ODAG Area  ENTER:  Specific ODAG Area  ENTER:  Specific ODAG Area  under Review  under Review  under Review  under Review  ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm  0:00 am/pm  0:00 am/pm  0:00 am/pm  ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm  0:00 am/pm  0:00 am/pm  0:00 am/pm 

ENTER:  Specific ODAG Area  under Review  ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm 

ENTER:  Specific ODAG Area  ENTER:  Specific ODAG Area  ENTER:  Specific ODAG Area  ENTER:  Specific ODAG Area  under Review  under Review  under Review  under Review  ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ ENTER: Time: 0:00 am/pm ‐ 0:00 am/pm  0:00 am/pm  0:00 am/pm  0:00 am/pm 

ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE ENTER WEBINAR LINK HERE

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Sample Audit Schedule – Week 2 Audit  Area

Monday,  January 11, 2016

Tuesday,  January 12, 2016

Wednesday,  January 13, 2016

Thursday,  January 14, 2016

Friday,  January 15, 2016

CO Participants: 6‐ 3100;                                 Other participants:  877‐267‐1577;  Pre Exit Conference (Delete if Meeting ID: XXXXXXXXX                    held in Week 1) 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 Meeting

ENTER: Time: 0:00  am/pm ‐ 0:00 am/pm 

Tour of Operations

ENTER: 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)

ENTER: Time: 0:00 am/pm  ‐ 0:00 am/pm

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Sample Audit Schedule – Week 2 Audit  Area C O M P L I A N C E

Monday,  January 11, 2016

Tuesday,  January 12, 2016

Interview ‐ SIU/FWA  Oversight

ENTER: Time: 0:00 am/pm  ‐ 0:00 am/pm 

Tracer Sample Review 1

ENTER: Time: 0:00 am/pm  ‐ 0:00 am/pm 

Tracer Sample Review 2

Tracer Sample Reviews  3‐5

Wednesday,  January 13, 2016

Thursday,  January 14, 2016

Friday,  January 15, 2016

ENTER: Time: 0:00 am/pm  ‐ 0:00 am/pm 

ENTER: Time: 0:00 am/pm  ‐ 0:00 am/pm 

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   

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ODAG Sample Review – Clinical Decision Making • 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 26

ODAG Sample Review – Clinical Decision Making • 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 27

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Audit Scoring Invalid Data Submission Observation Corrective Action  Required (CAR) Immediate Corrective  Action Required (ICAR)

1 point per failed universe 0 points 1 point per condition 2 points per condition

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Audit Scoring • Audit score = sum of points / number of  audit elements tested • Allows for cross‐sponsor comparison  regardless of sponsor type and # of  elements

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Delegated Model • 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!) 30

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Delegated Model Best Practices • 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

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Summary • CMS audit process effective in driving  improvements • Still work to be done • Look forward to continued collaboration  with industry on improving the audit  process

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2015 Annual Conference

CMS Program Audits ODAG - Are You Prepared? Carol Wanke, Sharp HealthCare Todd DeYoung, Humana Darlene Black, SCAN Health Plan Jean Diaz, SCAN Health Plan November 13, 2015

Agenda   

 

2015 Annual Conference

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

CMS Program Audit Scope       

2015 Annual Conference

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)

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2015 Annual Conference

CMS Program Audit Timeline Week 1

Week 2

Week 3

Week 4

Week 5

Week 6

Audit Notice F/U Call

Week Week 7 8 Sent 6 Weeks Before Audit Start Date

1 to 2 Days After Notice to Discuss Audit Scope

Universe Request Call Universe Submission

Prior to Upload of Universe to Answer Any ?s Due Within 15 Business Days of Audit Notice Validation Webinar

After Upload to Verify Dates

Audit Schedule

Sent Before Start Audit Starts Webinar On-Site

Pre-Audit

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Audit

Part C - ODAG Universe Tables #1 - 4

2015 Annual Conference



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



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



Table 3 – Requests for Payment Organization Determinations (Claims)

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Table 4 – Direct Member Reimbursement Requests (DMR) 5

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

UNIVERSE

COMPLIANCE STANDARD TO APPLY

2015 Annual Conference

TEST Decision-Making

1

SOD

2

EOD

3

Claims

4

DMR

Standard Pre- service No later than 14 days, plus 14 days (totaling 28 days) if Notification ODs an extension is used. Decision-Making Expedited Pre- service No later than 72 hours, plus 14 days (totaling 17 days) if Notification ODs an extension is used. Effectuation Requests for Part C payment ODs95% in 30 days for clean Claims (designate if claims and 60 days for the request was a Notification unclean claims. clean claim or an unclean claim) Effectuation Requests for Payment ODs- Direct No later than 60 days. Member Notification Reimbursement Requests

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ODAG Universe Reminders

2015 Annual Conference

•

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

ODAG Universe Reminders (cont.)

2015 Annual Conference

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.

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ODAG Universe Reminders (cont.)

2015 Annual Conference

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”.

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ODAG Universe Reminders (cont.)

2015 Annual Conference

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 authorization  Approved Example: office visit

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ODAG Universe Reminders (cont.)

2015 Annual Conference



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 11 a tab delimited text file (.txt).

ODAG Universe Submissions for Tables 1 & 2: SOD & EOD

2015 Annual Conference



Include all requests processed as standard or expedited pre-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

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ODAG Universe Submission for Table 3: Claims

2015 Annual Conference

Include all requests processed as both contract and noncontract 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. 

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

2015 Annual Conference

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

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

2015 Annual Conference

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

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ODAG Universe Submission for Table 4: DMR

2015 Annual Conference

 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.

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

2015 Annual Conference

 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

ICE ODAG Templates Table # 1 ‐ 4  2015 CMS Audit Process & Data Request

2015 Annual Conference

ICE Format Aides

Field Field Type & MAX CMS Field FORMAT Example Use Validation Name: Requirements: Field Description: of Rules Length: NA J20.6 NA Provide ICD- 9/ICDDiagnosis CHAR Always 20 Provide the primary is 10 Diagnosis Required enrollee not diagnosis diagnosis/diagn Code (alpha acce and any numerical). oses ICDptabl diagnosis 9/ICD-10 codes e in codes you related to this this can request. If the field reasonably ICD codes are provide. unavailable, Separate provide a each description of diagnosis the diagnosis. code with a comma(,). 18

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Audit Readiness Efforts With Plans & Delegates

2015 Annual Conference

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

Audit Readiness Efforts With Delegates

2015 Annual Conference



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

Audit Readiness Efforts With Plans

2015 Annual Conference

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?

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Issues and Concerns for Delegates 



  

2015 Annual Conference

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

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