If you did not have the pleasure of being part of a Centers for Medicare & Medicaid Services (CMS) Program Audit in 2017, don’t be caught off guard if you receive your invitation this year.
Audit engagement letters will start going out this month.
CMS has made few changes to the 2018 CMS program audit protocol from 2017. However, one change was for the Call Log submission for Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG). With the exception of Medicare-Medicaid Plans (MMPs), the number of call days required to be submitted varies based on the plans sponsors’ enrollment.
While helping plans survive the CMS program audits last year, Gorman Health Group observed one standout area of struggle: call logs. The addition of call logs to the audit protocol relates back to ensuring plan sponsors are appropriately classifying and handling grievances, coverage determinations (Medicare Part C and Medicare Part D), and member notifications. It really boils down to customer service and proving your representatives are handling the cases appropriately. The importance of customer service cannot be stressed enough. At the heart of every business is good customer service. Within the Medicare space, any opportunity to make the member experience a positive one is important from both a quality of care and Star Ratings perspective. Call logs are a means to assess current service levels and to identify training and improvement opportunities. There are now vendors who utilize artificial intelligence to detect the emotions of the caller and how to handle the call appropriately—if the caller is frustrated, they may need to be handled as a grievance.
If you have not established an oversight program or performed a universe pull for call logs, don’t wait any longer! Identifying any issues with data integrity and the service/information provided by your customer service representatives is crucial. Pay particular attention to how the calls are being documented and the reliance on vendor or inter-departmental communications. You want to ensure call transcripts are entered into your system and notes would easily walk an auditor through the case from the time the call was answered through to resolution and that it has been sufficiently documented. If there is a gap in your current process, it is time to put a plan in place.
Gorman Health Group can assist your plan with mock audit services ranging from a complete program audit to a specific, targeted audit of your call logs. The time to act is now to avoid getting caught with your pants down.
Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now
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