HCCA Managed Care 2019: CMS Regulation and Program Updates

By Yvonne Zachman Fiedler
Wed, Apr, 10, 2019

So far, 2019 has been a very busy year for CMS regulations and activities with some of the highlights being:

  • New CMS Program audit cycle starting 3/1/2019
  • CMS releasing the combined Medicare Advantage Chapter 13/18 in February 2019, with an effective date of January 1, 2019
  • Plans prepping and still waiting on the updated 2020 protocols to be released
  • CMS is preparing for the 2019 spring conference, of note to mention is that the Audit Conference will NOT be occurring.

At the end of January, The Burchfield team attended the 2019 HCCA Managed Care Conference. During the sessions at the conference, both health plans and regulators spoke about the current regulatory environment. The overwhelming theme of the 3-day conference was that health plans continue to receive more CMS regulation oversight activities from all levels of the government, both state and federal.

Many of the presentations were focused on individual audits and how the plans effectively managed the process and worked towards a positive outcome. There was a big focus on preparing for the next CMS audit cycle that begins on April 1, 2019, since all plans are eligible to be selected in the new cycle.

This conference provides excellent examples of how plans of different sizes and focus manage through the regulatory environment. There was a lot of discussion about resources and how plans utilized both internal and external resources to keep all the balls in the air.

There were several regulators who spoke, one from the OIG and several others from CMS. The narrative was clear, both organizations are working to make audits more focused and on point to identify problem areas. The organizations look for audits and activities that generate results.

Finally, there was an underlying theme of oversight of Fraud, Waste and Abuse (activities). Both CMS and Health Plans are working to improve the oversight of these activities. Opioids continue to be a focus, and this is going to be an even bigger bullseye in the future.

One of the key items that CMS eluded to is the timing on the new combined Chapter 13/18 chapters of the Medicare Advantage Manual. This rewrite is significant and provides both clarity and confusion. This document was published on February 22, 2019. Due to the timing (3 weeks after the completion of HCCA) of the release, CMS was unable to provide much visibility into the document. They did, however, share that the industry had provided thousands of pages of responses to the draft document that was released last fall.

As always, the conference provided a great window into the industry, current concerns and the best practices of how health plans successfully manage them.

With all the changes, many plans have been asking what activities they should be doing to ensure CMS compliance in the future:

  • Conduct mock audits. With the updated guidance, it is important to make sure that your plan is following the regulations.
  • Come up with a plan for implementing the new audit protocol. Although it is only in draft format we know it will be out soon.

For additional questions or inquiries on how The Burchfield Group can assist your compliance efforts, please contact yzachmanfiedler@burchfieldgroup.com .