4 Points to Ponder from CMS’ Oversight and Enforcement Conference

On June 26, CMS hosted their MA-PD Oversight and Enforcement conference. Not one of the topics was less relevant to the audience than another — they prepared ahead of time to present current, critical information related to their data-driven approach to oversight, best practices and common findings, preparing for an audit and enforcement actions. I was glad to see CMS invite plan sponsor staff to share their experiences. They included Todd Meek of SilverScript Insurance Company; Margaret Drakeley of Kelsey Care Advantage; Shannon Trembley of Martin’s Point Health Care; Marcella Jordan of Kaiser Permanente, and Jenny O’Brien of UnitedHealthCare. Their first-hand accounts are worth your full attention.

The webinars and materials are all available to the public and I encourage you to watch them and encourage your staff to watch. Of all of the things said, the following should be enough to kick your compliance efforts into high gear:

  • Jerry Mulcahy shared that the improvement is not what CMS had hoped, and that organizations are still not testing effectively. That should warrant a hard look in the mirror to ensure your “trust but verify” methods are working. Put another set of eyes on your validation. Leverage staff with auditor experience. If the improvement is not what CMS has expected, especially after having shared their protocol and numerous best practice/common findings memos over the past few years, then consider this a red flag.
  • Statutes and regulations expect nothing but 100% timeliness. Too often we are asked for the acceptable threshold for compliance of a measure. Unless otherwise published, the expectation is 100%. Kady Flannery stressed this while explaining the 2014 method for checking CDAG and ODAG universe timeliness.
  • LCDR Lorelei Piantedosi communicated an additional best practice that didn’t make the slides, and that’s a 100% rejected Part D claims look-back. Seeing as how all five of the Formulary Administration common findings have been common findings published in the past, it is a wonder when an organization does not dedicate resources to this activity. (She also communicated a best practice near and dear to our hearts, but I’ll leave that for another blogger.)
  • “Be transparent!” Todd Meeks says he would often times get asked about how transparent to be. Based on the fact that he shared how collaborative CMS was in aiding his organization, at times providing easier, cleaner ways to correct something, then the answer should be simple.

Think about it this way: if you draw the short straw this year for a CMS Program Audit (and I use ‘short straw’ in the most lovingly way possible, CMS), then everything you add to your Self-Assessment Questionnaire should already be known by your Account Manager. We can be broken-record about this, but a Medicare Compliance Officer should know what’s going on well before CMS does — it’s arguably just as important to your organization that your Account Manager knows about it before Central Office.



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Regan Pennypacker
Regan Pennypacker

Regan is Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). She leads the Compliance Solutions practice, responsible for multidisciplinary projects such as Part C and Part D audits, new applications, marketing material reviews, risk assessments, and training engagements. As a member of this team, she has provided compliance direction and insight on industry best practices to many GHG clients. Regan brings GHG clients 19 years of experience in the healthcare industry. Read more

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