Compliance Highlights of the CY 2017 Draft Call Letter

According to the Centers for Medicare & Medicaid Services (CMS), the Call Letter activities follow four major themes: improving bid review, decreasing costs, promoting creative benefit designs, and improving beneficiary protections. This means implementing creativity and doing more with less while enhancing the beneficiary experience.  To borrow from one of the earliest reality shows, this is the time when CMS stops being nice and starts getting real.  There are some of the key items of which your Compliance Department needs to be aware outlined below; however, it is not all inclusive and a thorough read of the document is required.

Compliance Impact on Stars

Something that is highly detrimental to an organization is CMS’  reduction of a Star measure to 1 Star if any compliance-related issues are identified with a measure’s data.  We have seen that applied repeatedly this year to a variety of measures.  This Data Integrity initiative is not new; unfortunately, CMS notes in the Call Letter that the agency continues to identify new vulnerabilities where inaccurate or biased data could exist.  You will hear more from my colleague, Melissa Smith, on the proposed Star Ratings changes here in this blog.

Program Audit Protocols and Enforcement Actions

In an effort to allow sponsors more time to implement new protocols, CMS is proposing to release the following year’s protocols by the end of July, starting this year.  How does this change impact an organization?

  • An earlier release means industry feedback received at certain times this year will most likely inform the 2018 protocol updates.  Since the Medication Therapy Management and Provider Network Adequacy (PNA) pilots are scheduled to be released “a few months into” the pilot audit period, comments won’t be received in time to inform 2017 protocol. Therefore, CMS proposes to extend the pilot into 2017.
  • CMS notes the PNA protocol will not be administered during the same time as the program audits.  This is not surprising for two reasons. First, the current program audit schedule is jam-packed.  It’s tough to envision adding another layer of operational audits to an already taxing schedule.  Second, CMS reminds sponsors that this is only one piece of their larger scale efforts at reviewing adequacy. Consider the provider directory requirements memo released on November 13, 2015. CMS will actually be using the PNA pilot to validate corrections required as part of monitoring completed by the Medicare Drug and Health Plan Contract Administration Group (MCAG).

Some of these changes may mean more impact to your Compliance staff day to day.  Gorman Health Group (GHG) notes our sponsor partners are quick to dive into published protocols to update tools and programming.  Oftentimes they identify unclear items and immediately contact CMS for clarification, so this change should not create a significant impact to those who follow suit.

Since CMS is focusing on network, this should drive renewed focus and monitoring as part of a risk assessment and current oversight activities.  GHG is aware of at least one consistently rated five star plan that has conducted full network assessments on a quarterly basis for quite some time now.  In addition, CMS, in working with a contractor, has developed what they believe is a comprehensive process for monitoring provider directory accuracy. Interpret as such: your focus on this area pays off.  Our Network team will dive deeper into this area here in the GHG blog.

CMS plans to release a memo describing their interpretation of applicable rules in the methodology for civil money penalties and will provide a comment period to the industry.  Compliance should distribute this memo and collect comments as the calculation is often questioned on user calls and during enforcement discussions.

The agency is also seeing no significant reduction in the volume of Part D auto-forwarded coverage determinations and redeterminations.  For this reason, they plan to increase the level of severity of compliance and enforcement actions.  This is an area of the program with direct impact on a beneficiary’s ability to access his or her Part D benefit. It is hoped that turning up the heat in this area may encourage plans to implement changes to reduce that volume and start meeting time frames more regularly.

CMS also proposes to consider the findings of noncompliance from the one-third financial audits for potential enforcement actions.  In the past, sponsors were required to implement a corrective action plan, but they have had this authority under 422.752 and 423.752.

Sensing a theme here?  CMS has reached a tipping point, and as our Founder and Executive Chairman, John Gorman, has recently noted, it appears 2016 is the year they drop the gloves.  If you’ve ever played hockey, that’s when it starts getting good.  We hope to see you at our webinar on March 1!



Join John Gorman, GHG Executive Chairman, and colleagues, Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG’s Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed “methodology changes” could mean for your organization and its partners, and the steps you can take to soften the impact on Tuesday, March 1 from 2:30-3:30 pm ET. Register now >>

Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our websiteRegister now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>

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

  1. Hi Regan,
    I was wondering is there any more and any Medicare Compliance Manager training seminars coming up that you know of. We are just now seeing and viewing your site. It has a lot of great information.
    Thank you,

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