The CMS Fall Conference: 4 Ways to Solve the Preparedness Problem

The Centers for Medicare & Medicaid Services (CMS) held their Fall Conference and Webcast on September 10 in Baltimore.  The presentations and videos from the event are found on the Compliance Training, Education & Outreach site here.  CMS covered various aspects of the Medicare Advantage Prescription Drug (MA-PD) program, but here I’ve focused on four lessons I heard loud and clear: work with CMS, prepare ahead of time, seek continuous improvement, and don’t wait until the last minute.

Linda Anders from CMS hosted two Aetna representatives who discussed lessons learned in beneficiary and pharmacy outreach stemming from strategic network changes taking place over 2014 to 2015.  They had developed a communication strategy but soon understood a lack of clarity and misinformation caused significant beneficiary and pharmacy confusion.  Ms. Anders stressed there is much to be learned from Aetna for any plan contemplating changes to their program.  Aetna recognized their Part D network configuration was “generally consistent” with CMS requirements.  It is recommended any plan contemplating program changes not tested in the industry work closely with CMS on these initiatives.

Gregory Woods gave valuable information regarding the Value-Based Insurance Design (VBID) Model Test.  Things will move quickly for the VBID model.  While they are beginning this test for 1/1/2017 effectives, the Request for Application (RFA) responses will be due sometime this November or December.   This is new, so Compliance and Product teams, prepare yourself for a new onslaught of questions from Clinical and Actuarial, because they are coming.

As a lead-in to a presentation from MAXIMUS Federal Services, CMS confirmed they are working with a small number of plans on point of sale rejections. They hope to share more information about that in the 2017 call letter.  Some helpful reminders were then provided regarding appeals going to MAXIMUS.  Make sure your organization is referring to the most updated process manuals provided by MAXIMUS for Part C and Part D appeals.  Additionally, there is a significant amount of appeals data dating back to 1997 showing your plan’s percentage of upholds and overturns.  Organizations can compare to other plans to benchmark or simply leverage to spark internal process improvements.  Cathleen MacInnes, Project Director, also addressed the development of a submission portal for electronic upload of case info to MAXIMUS.  If your organization is interested in participating, contact either her or her Part D counterpart.  From an operational perspective, that should make sharing case info much easier, so long as it is secure, secure, secure.

The icing on this conference cake was the update from Jennifer Smith, Director, Division of Analysis, Policy and Strategy, Medicare Parts C and D Oversight and Enforcement Group, on 2015/2016 program audit protocol, processes, and activity.  The changes she outlined are exciting — here are some, and since I’ve already written plenty, you can either watch the video or contact me for more details and my thoughts.

  • Edits to record layouts will include not only those outlined during June’s Oversight and Enforcement conference but also additional edits based on plan and auditor feedback. Extraneous fields will be gone, headers will be added to record layouts, and more clear instruction will be incorporated as to what should be included and excluded.
  • Beneficiary Impact Analyses (BIAs) will not be requested at the time of the self-identified and self-disclosed issue reporting.  Organizations should still anticipate a BIA request if an issue is found during an audit.
  • CMS is also revising their policy on the “three strikes” for universe submission.
  • The two anticipated pilot audit areas are being moved to 2016.
  • Compliance Program Effectiveness (CPE) will be conducted either onsite or virtually.

“It is also important to remember the audit protocols are more like a pop-quiz than a final exam,” says Charro Knight-Lilly, Senior Vice President of Client Relations.   Don’t lose sight of the need to comply with all requirements and testing performance through monitoring, auditing, and annual risk assessment.  Ms. Smith said something that resonated with me and likely others in the industry:  Don’t wait until the audit notice to practice universe pulls and activities.  If you do, you are behind the 8-ball.



CMS outlined areas of poor performance within the release of the Outlier Notification in August.  In addition to audits and Corrective Action Plans (CAPs), this notice also referenced Compliance Letters (C and D) and Star Ratings (C and D) as areas of concern and indicators of poor performance.  Both of these areas require advance planning, preparation, and coordination in order to make an impact a minimum of one full year later.  Don’t exhale as we head in to the 2016 Annual Election Period (AEP) — now is the time to plan strategy for 2017.  Contact us to learn more.

Join John Gorman, Founder and Executive Chairman at GHG, and colleague, Nancy Djordevic, Senior Consultant in Healthcare Analytics & Risk Adjustment Solutions, for our upcoming webinar on MA-VBID Model plan requirements, needed strategies for data analysis and benefit development, as well as what you need to be doing now to prepare for January 2017 on Tuesday, September 29, from 1-2 pm ET.  Register here

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Regan Pennypacker
Regan Pennypacker

Regan is Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). She leads the Compliance Solutions practice, responsible for multidisciplinary projects such as Part C and Part D audits, new applications, marketing material reviews, risk assessments, and training engagements. As a member of this team, she has provided compliance direction and insight on industry best practices to many GHG clients. Regan brings GHG clients 19 years of experience in the healthcare industry. Read more

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