Data Universes – Friend not Foe

Data universes are not new in the Medicare Advantage and Part D space. The Centers for Medicare & Medicaid Services (CMS) requires data universes for a variety of purposes, including program audits and timeliness monitoring. Gorman Health Group has communicated time and time again the importance of pulling accurate universes as well as continuous review of that data. Universes tell a story often not heard via other monitoring efforts.

Whether you are from a health plan or a first tier, downstream, and related entity (FDR), universes are critical to your organization’s success. During a CMS program audit or timeliness monitoring effort is not the time to realize your organization cannot pull the data or the data is inaccurate. CMS imposes strict penalties and fines when health plans cannot produce data – $25,000 for an invalid data submission (IDS) per violation/contract. IDS issues, if identified, can also have a negative impact to a health plan’s Star Ratings. Conversely, health plans can impose corrective action plans and monetary penalties on their FDRs for the same problem.

Ask yourself the following:

  • Can our organization produce all applicable data universes?
  • Is the data pulling from the correct source?
  • Has the data been tested for accuracy?
  • If a health plan, can our FDRs produce accurate universes? Have they been validated?

These activities can be time consuming for any organization and compete with other monitoring and auditing activities. Gorman Health Group offers customizable universe review services for both health plans and FDRs, including:

  • Automated review utilizing Gorman Health Group’s proprietary analytics/algorithms
  • Subject matter expert review in order to identify any risks and/or compliance concerns
  • Timeliness testing of CDAG and ODAG universes
  • Validation testing of the data conducted via webinar

Clients can tailor these services to fit their specific needs, e.g., monthly, quarterly, annually. Contact us today to learn more!

 

 

Resources:

Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

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Tina Bailey
Tina Bailey

Tina Bailey is Vice President of Compliance Solutions at Gorman Health Group (GHG). In this role, she assists health plans in preparing for and undergoing Centers for Medicare & Medicaid Services (CMS) audits, directs onsite and remote focused audits, assesses new and existing plan readiness, produces Part C and Part D delegation oversight programs, leads large-scale member/marketing material review, assists with CMS/state applications, and creates and conducts focused trainings.

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