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

Vice President, Compliance Solutions

Tina Bailey began her tenure at GHG in 2011 and was appointed Vice President, Compliance Solutions in August 2018. In this capacity Tina leads the Compliance Solutions team and its engagements to ensure optimum solutions. Tina brings GHG clients more than 25 years of experience, providing them a knowledgeable resource in Medicare Advantage and Part D with an emphasis on Special Needs Plans (SNPs). Her areas of expertise include compliance, applications, audits, readiness, delegation oversight, marketing materials, bid development, new plan implementation as well as appeal and grievance expertise. Prior to her role at GHG, Tina held a management position with a SNP where she was responsible for the organization's day-to-day Medicare operational compliance. Tina has also held management positions with several MAOs in the greater Los Angeles and Orange County markets. In her previous roles, Tina was responsible for compliance interpretation and implementation, member/marketing material review and submission, bid development and submission, internal audits and CMS audit preparation, implementing internal corrective action plans, and creating detailed trainings. Tina is certified in Compliance and Ethics from the Health Care Compliance Association.

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