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Remember, your plan must be operating from an approved Model of Care (MOC).
The off-cycle submission process allows for substantial changes such as fundamental organizational changes essential to the MOC process and functions; for example, changes to an organization’s MOC narrative that occur between approval periods (e.g., year 2 of a three-year approval) and have not expired.
It’s impossible to achieve reasonable and prudent member care management in a vacuum. The three-legged stool supporting care management includes medical management, risk assessment, and medication therapy management. The care manager cannot make reasonable decisions about a member’s care unless he or she has knowledge of the member’s medical management history and current status, medication history and current status, and diagnostic history and current status based on risk assessment.
In sports, a good coach will tell you, “Practice like you play, because you will play like you practice.” Well, the same can be said for case sampling. My colleague, Anita McCreavy and I advise plans, “You can use an audit practice run of your Model of Care’s Special Needs Plan Enrollees (MOC-SNPE) universe to tell you if your operations are ready for a Centers for Medicare & Medicaid Services (CMS) audit.” Additionally, there is opportunity to add to the universe fields to assist management in further prioritizing potential gaps.