MA, Part D Plans Face Uncertainty as Audit Season Begins

Reprinted with AIS Health permission from the March 5, 2020, issue of RADAR on Medicare Advantage.

Medicare Advantage, Medicare-Medicaid Plan and Part D sponsors selected for 2020 program audits will start receiving engagement letters this month, but they face some uncertainty as CMS has yet to finalize a set of proposed changes unveiled last August. While the bulk of those changes were aimed at reducing plan sponsors’ burden, plans are advised to closely monitor the data CMS may no longer collect through the audit process but may obtain from other sources, while continuing to conduct mock audits.

“Audit season is here, and March Madness means something different in the MA-PD world,” remarks Tina Bailey, vice president of compliance solutions with Gorman Health Group, LLC (GHG). “But this year the timing is odd as we’re waiting on new protocols…and we’re not sure what pieces of the proposed changes are going to be finalized and implemented this audit cycle.”

The current program audit protocols approved by the Office of Management and Budget (OMB) are set to expire on April 30. CMS in August 2019 issued a Health Plan Management System (HPMS) memo seeking comments on proposed changes for the next audit cycle, but the agency at press time had not finalized them.

Many of the changes proposed for 2020 appear to be aimed at streamlining data collection, especially as it pertains to appeals and grievances. But while it looks like CMS is “reducing a little bit of the burden” on plan sponsors as far as providing data to CMS, “it doesn’t mean they’re reducing the scrutiny,” Bailey warns. For example, CMS can still obtain critical information such as auto-forwarded appeals from the independent review entity (IRE), Maximus, she points out.

“We continue to communicate to plan sponsors that even though an element may not be part of the audit protocol process going forward, it does not mean you should discontinue those universes and [not] monitor that information internally,” Bailey tells AIS Health.

CMS Aims to Up Grievance Sample Sizes

Specifically, CMS proposed removing several tables for collecting data under Part D Coverage Determinations, Appeals and Grievances (CDAG) and Part C Organization Determinations, Appeals and Grievances (ODAG), and increasing the grievance sample sizes for each from 10 to 20.

Bailey explains that the latter change is related to the suspension of call logs that CMS proposed in a 2018 HPMS memo, in which CMS stated it would delay implementation of new protocols until audit year 2020. Program audits for years have been turning up issues related to plans’ misclassification of Part D coverage/organization determinations, redeterminations or grievances as customer service inquiries. Most recently, Humana Inc. was fined by CMS in part for its failure to properly classify such requests, according to the latest round of civil monetary penalty notices.

“What plans struggle with…is that when a member is calling customer service, there could be a gap in identifying and classifying grievances, so they never make their way through the grievance process,” remarks Bailey. Although call logs were one mechanism for identifying grievances that might not have been classified appropriately, CMS in its 2018 memo said it would continue to monitor this issue through other avenues such as Compliance Program Effectiveness (CPE). By doubling the sample sizes for Part C and Part D grievances, CMS is in effect making up for the removal of call logs from the data universes, which has yet to be cleared through the OMB approval process, observes Bailey.

Other noteworthy proposals identified by GHG include reducing the data integrity sample size from 75 to 65 for CDAG, and removing Organization Determination approved cases from the Clinical Decision Making section, effectively reducing the sample size from 40 to 35.

Proposal Included Fewer Questionnaires

CMS also proposed doing away with the CPE self-assessment questionnaire and the ODAG/CDAG supplemental questions that follow the engagement letter to plans that are selected for audit. Again, Bailey says this is likely to avoid duplication since CMS can get much of that information during the audit process.

In the meantime, GHG is advising clients that may be subject to audits this year to expect to be audited against current protocols. That way, if CMS implemented the updated protocols prior to April 30, most changes plans would face may not be too difficult to accommodate. “CMS pushed this out early enough to communicate what potential changes could be. A lot of this is not adding data sets, so it may be less burdensome for plans to remove tables versus adding data,” suggests Bailey.

“That said, there will be some IT work on the back end if you have automated systems that produce the universes,” she continues. For example, under ODAG, if a plan’s system is automatically capturing an appointment of representative, “and CMS is telling you to exclude those cases, it’s easy to filter those out if there’s an auto-generation of that data.”

Some Changes Could Complicate Process

ATTAC Consulting Group (ACG), however, points out that CMS proposed some significant additions to the protocols and that some of the changes to existing tables will require reworking. For example, under CPE, CMS proposed adding a question to the Compliance Officer Questionnaire about overseeing the call routing process to ensure that incoming requests are properly classified and processed as required, observes Darlene Dulac, senior consultant with ACG. And the removal of the “Level of Service” column from two ODAG tables may make it more difficult to target certain claims or request types, she says.

In addition, CMS proposed adding the phrase “if the decision was favorable” to two ODAG tables reflecting notification dates, which may limit “the way to measure unfavorable decision notification timeliness as the date the unfavorable case was forwarded to the IRE,” says Dulac in an email to AIS Health.

Meanwhile, CMS on Dec. 6, 2019, issued a Paperwork Reduction Act request seeking feedback on new protocols for program audits and the industry-wide Part C Timeliness Monitoring Project for 2021. The comment period for those proposals closed on Feb. 4, and generated 38 comments.

“Due to the timing of the 2020 changes and the upcoming 2021 changes which will require significant preparation time by Sponsors,” ACG suggested that CMS not implement the 2020 changes and include all changes in the 2021 directive, according to an email from ACG’s vice president of compliance solutions, Ken Nuñez. “The rework of the 2020 universes requires time for data production and testing by [plans]. With the anticipated 2020 program audit notices to be issued shortly…it will likely be difficult for Sponsors to have enough time to make the necessary changes. By eliminating the 2020 changes, it will help to reduce the burden on the Sponsors to prepare for the upcoming 2020 audits and to focus on the more significant changes for 2021.”

View the new CMP notices at

Contact Bailey at

by Lauren Flynn Kelly

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