Health Plan Insurer Blog

CMS offers clarification related to grievance investigation timelines

Posted on Fri, Oct, 23, 2015

When reviewing our clients’ 2014 data in the pre-assessment and audit periods, we discovered confusion regarding the 30 calendar days that a health plan has to investigate a grievance. Some health plans interpreted CMS specifications to include the time stamp on the date received and the time stamp on the date closed. For example a grievance received at 10:00 am on January 1 and resolved at 1:00 pm on January 31 would be untimely if the time stamp was taken into account.

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Topics: CMS

Data Validation: What to Expect in the 2015 Reporting Year Audit

Posted on Thu, Oct, 01, 2015

Changes to CMS Technical Specifications will affect the 2015 reporting year audit. The good news is that there are not as many changes as there were for the 2014 reporting year. Make sure you understand the data elements as early as possible so your operations capture all the data needed to report in 2015.

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Topics: CMS

Don’t overlook CMS’ 2015 program audit modifications

Posted on Wed, Apr, 01, 2015

Each year CMS makes changes to protocol for program audits and the elements it measures. If you haven’t already read the 2015 CMS release published in February, do so soon to make sure your plan is prepared for the new requirements.

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Topics: CMS, 2015 CMS guidance, CMS guidance, data elements

Odds are high your plan faces a CMS program audit in 2015

Posted on Thu, Mar, 26, 2015

Since program audits first started in 2010, CMS has reviewed Medicare Part C and Part D plan sponsors representing 96 percent of Medicare Advantage and Prescription Drug enrollees. 2015 kicks off a new cycle of CMS program audits.

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Topics: CMS program audit, new CMS requirements

CMS call letter sets high bar for performance, penalties for failure

Posted on Wed, Mar, 04, 2015

CMS released a draft of its annual call letter for Medicare Part C and Part D managed care plans on February 20. The letter lays the road map for the next year and sets expectations for what is to come.

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Topics: prescription drug plan, CMS, data validation

Receive full value from your PBM rebates

Posted on Thu, Nov, 20, 2014

Rebate reviews and audits regularly surface PBM mistakes and contractual underperformance. Small miscalculations can easily impact your rebates and not in a good way. An independent rebate audit can make sure your plan receives what the PBM promised and that all rebates are passed back to you accurately.

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Topics: Rebate Audit, PBM rebates, PBM underperformance, PBM audits

Don't let CMS timeliness standards hurt your data validation score

Posted on Tue, Nov, 11, 2014

Burchfield's Guide to CMS timeliness standards

CMS has plenty of timeliness standards and keeping them all straight can be confusing. Use our handy guide to help stay on top of the days or hours needed to complete a decision or payment. CMS measures timeliness down to the minute, so keep vigilant records and remember to factor in time zone changes.

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Topics: data validation, 2015 CMS guidance, CMS timeliness standards

Complex 2014 Determinations reporting section challenges plans

Posted on Wed, Sep, 24, 2014

Even though Medicare data validation is in its fifth year of audit, the validation standards remain complex and continue to evolve. The Coverage Determinations and Redeterminations reporting section, formally known as Coverage Determinations and Exceptions, went through many changes between 2013 and 2014. Some of these changes added additional reporting sections and others consolidated some of the elements.

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Topics: prescription drug benefits, CMS, data validation

Poor scores posted for 2013 data validation SNP reporting

Posted on Thu, Sep, 11, 2014

Special needs plan (SNP) care management reporting is one of the most difficult data validation standards. The average SNP score in 2013 was only 96.4, the worst scoring section by a wide margin. (Part C Grievances was next at 98.)

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Topics: CMS, data validation, special needs plan, SNP

Align data validation stakeholders to avoid last minute mistakes

Posted on Mon, Aug, 18, 2014

Management and oversight of data validation varies between health plans. Different plans may use an audit department, a compliance unit or a Medicare oversight department. However your plan is structured, having a centralized business unit in charge of data validation reporting can ensure clear and effective communication to all stakeholders. Consider the following ideas to help make your 2015 review a success.

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Topics: prescription drug plan, prescription drug benefits, data validation, 2015 CMS guidance, CMS guidance