New CMS Industrywide Appeals Timeliness Monitoring ‒ What You Should Do Today

There are some surprises that are good, like winning the lottery or getting a promotion. There are other surprises that are not so good. These include things like a leaking roof or an unexpected bill. At the office, a negative surprise is someone finding out about a problem in your department before you do. It is even worse when it is identified by a Centers for Medicare & Medicaid Services (CMS) regulator.

Do you know how compliant you are with CMS timeliness for prior authorization, claims payment, and reconsiderations? Hopefully you do, because soon you will be sharing with CMS all the data needed to identify this. On November 29, 2016, CMS published a Health Plan Management System (HPMS) memo, “Industrywide Appeals Timeliness Monitoring,” introducing a new monitoring program. This new program, utilizing the CMS audit protocol universes, will evaluate health plan timeliness in processing Part C organization determinations and reconsiderations and Part D coverage determinations and redeterminations. These universe data sets have large amounts of information about how your organization, delegates, and Pharmacy Benefit Manager approve and deny services for your members.  “Now that CMS will have access to key data files from every sponsor, they will more easily be able to review timeliness on a level playing field,” says Regan Pennypacker, Senior Vice President of Compliance Solutions.  “This may impact current internal thresholds used for timeliness evaluation during audits, and may result in a bevy of outlier notices. Sponsors need to remember if a timeliness threshold is not defined by statute, the requirement is 100%.”

At Gorman Health Group (GHG), we have been recommending health plans utilize audit universes to monitor and audit their internal and delegated functions. If your plan has been using audit universes, you are ahead of the curve. Regardless of whether or not your plan has been doing this, here are four things you should do immediately to prevent negative surprises during the new CMS monitoring:

  1. Contact Your Delegates – Inform your delegates of the monitoring event and timeline. Health plans often assume delegates have more experience with CMS universes and can pull them quickly. This is often not the case. In many instances, delegates are not able to easily and accurately pull universes. Health plans should work closely with their delegates to pull and validate audit universes to ensure accuracy. Additionally, if you aren’t already reviewing these delegate universes on a routine basis, you may be in for a very unpleasant surprise. This is a great tool to enhance your delegation oversight program and detect and correct non-compliance.
  2. Pull Sample Universes Now – It is surprising how often health plans and delegates find some of the fields in the universe are not stored within their system. To fulfil the universe request, the data may need to be pulled manually and/or parsed and cleaned to provide the requested data elements. This manual activity can take a significant amount of time depending on the sample volume. It is critical any manual modifications be identified now.
  3. Complete a Thorough Validation – During almost every audit, there are issues with the data in a universe. It could be the wrong field was pulled, or it could be the formatting is not correct. Each data field entry needs to be validated for formatting and data integrity; then go farther to validate the information against the data in your system. Any discrepancies need to be investigated as they may point to a much larger data integrity issue. The CMS contractor will complete a similar data validation with each health plan, and you don’t want to identify the data is incorrect at that time.
  4. Take Action on Identified Issues – Every health plan identifies issues when reviewing their data. Review past CMS audit memos and common findings to see how they may apply to your organization. Don’t stop at timeliness concerns! Your universes show CMS much more data than just timeliness. You will see things in the data that may surprise you or raise questions. Those same issues may surprise CMS as well, and CMS may choose to follow up on that potential concern. Mitigating the issue now will protect your members and improve your program.

In years past, CMS has refined their audit protocol universes. CMS is now able to identify problems that seriously impact members through review of universes and follow up on targeted sample reviews. This is a valuable tool used by CMS and savvy health plans. Hopefully the surprise here is that your plan is already using this tool to understand your operations and compliance. This will only benefit your organization during the new monitoring process. If not, this is one negative surprise you need to remedy today.

GHG’s subject matter experts are familiar with CMS audit universes. We assist our clients in reviewing audit universes for accuracy as well as identifying potential operational non-compliance. If your health plan needs support in validating universes, identifying potential non-compliance, or mitigating identified concerns, GHG can help. For more information on how GHG can support your organization, please contact me at We can help you prevent future negative surprises!



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

No Comments Yet

Leave a Reply

Your email address will not be published.