According to Author Stephen Covey, in his book The Seven Habits of Highly Effective People, you should “begin with the end in mind.” This means to start with a clear understanding of your destination so you know where you’re going and understanding where you are now so the steps you take are always in the right direction.
Many department leaders have said, “I wasn’t trained to be a compliance manager. I was just a good individual contributor managing my practice area, and someone asked me to take on this role.” A powerful first step in becoming successful in a new role is to understand your organization’s “End in Mind,” which is usually described in the mission statement.
As Medicare Part D plan sponsors approach the 2017 Readiness season, this advice would be well taken. The Centers for Medicare & Medicaid Services (CMS) has intensified its program audit schedule, making it much more likely for a plan to receive the dreaded audit notice from CMS in 2017. Working from the point of view your plan will be one of those receiving an audit notice next year, you should approach the 2017 Readiness process as compliance audit preparation. In other words, the end in mind requires a critical review of the processes downstream from the Readiness Attestation.
Are your policies current with the latest regulatory requirements and guidance? Do your procedures match the actual processes in place? Can you demonstrate you comply with your stated processes? This is the approach CMS will take in a Compliance Program Audit. By attesting to the end point in the Readiness Checklist, you are in effect stating the processes on which the end is predicated are also functional and compliant.
Since most plan sponsors rely on first-tier, downstream, and related entities (FDRs) to help meet the operational and compliance requirements, it is also time to evaluate their performance. An FDR audit for delegation oversight is a critical part of the compliance plan for all plan sponsors. Any delegated function performed by an FDR is ultimately the responsibility of the plan sponsor. In the event of an audit, one of the greatest risks to a plan sponsor is from its FDRs. Since the Pharmacy Benefit Manager (PBM) is usually the largest, most impactful FDR, close attention should be paid particularly to regulatory changes that have been made in 2016 and need to be implemented in 2017.
Strategies that will ultimately improve the Compliance Readiness for 2017:
- PBM delegation oversight audits
- Mock program compliance audits
- Targeted audits (coverage determinations, formulary administration)
- Operational gap assessments
- Benefit administration testing
These represent key methodologies that can be used to discover deficiencies in functionality which translate to audit deficiencies Gorman Health Group can assist plan sponsors with as we approach the 2017 plan year.
The Centers for Medicare & Medicaid Services (CMS) audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more about our audit services >>
On Tuesday, September 13, 2016, from 1:00 — 2:00 pm ET, join colleagues Diane Hollie, Senior Director of Sales & Marketing Services, and Carrie Barker-Settles, Director of Sales & Marketing Services, as they outline the keys to building an integrated member experience program that will deliver a significant and positive impact on health plan enrollment, retention, and revenue generation. Register now >>
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