CMS Oversight Goes into Hyperdrive

In recent weeks, CMS has sent word to plans of two extraordinary changes in their audit practices.
The first is a notice to certain low-rated (plans with contracts <  3 stars) indicating that they expect the plans to develop a corrective action plan to address the low rating: “CMS is requesting that your organization develop and implement a corrective action plan designed to ensure that it will achieve at least a “good” plan rating.”
They do so with the following rationale: “CMS considers a low Part C or D Summary Plan Rating to be evidence that the sponsor has in place insufficient administrative and management arrangements to meet its obligations as a Medicare plan sponsor.”  CMS is also taking care to mention that organizations with a < 3 star rating for three consecutive years may also have its contract terminated, a statement it made first in this year’s Call Letter.
Second, in an extraordinary development, it has come to our attention that certain Regional Offices are initiating monitoring reviews of health plans, independent of Central Office activity. While the reasons for this can only been speculated, it certainly will add to the already challenging environment for plans, particularly those that are already at risk for a bad audit.
It is absolutely critical that plans ensure that they 1) have a plan of action for their star ratings and 2) ensure that they are audit-ready at a moment’s notice.

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