How CMS Data Validation Scores Impact Star Ratings

By Jason Hoyme
Tue, Nov, 06, 2018

Since the inception of the CMS Data Validation (DV) program, Burchfield has provided services both as a DV auditor and for DV pre-assessment reviews. Over the past few years, Burchfield has gotten several questions regarding how the new Star Ratings protocols are impacted by DV scores. We would like to highlight a few of the most important things to remember during your next review and how Burchfield can help.

The independent DV audit is required by Medicare plans by CMS. It currently includes three Part C sections and four Part D sections, though CMS updates the requirements every year. The audit reviews the reliability, validity, completeness, and comparability of the reporting submitted by the plan to CMS. Today we are focusing on the Part D section – the Medication Therapy Management Program (MTMP).

CMS has also created a Star Ratings program that provides each plan a score ranging from 1 – 5 in order to summarize the plan’s performance as a whole. The scores are displayed on the Medicare Plan Finder so members can consider both quality and cost in enrollment decisions.

Plans with the highest Star Ratings scores receive extra financial and enrollment benefits. Plans with 5-stars can market year-round and beneficiaries can join these plans any time via a special enrollment period. Plans with at least a 4-star rating also receive a quality bonus payment from CMS. There are 34 separate Part C measures and 14 different Part D measures, each with a weight between 1-3. The average 2018 score for MA-PD contracts was 4.03 and 44% of MA-PD plans scored at least 4 stars.

One of the 14 Part D measures includes “D13 – the MTMP Completion Rate for CMRs”. The MTM program was implemented by CMS to ensure optimal therapeutic outcomes for beneficiaries through improved medication use. CMS requires an upload of the MTMP data for the DV audit and is now using this data to help determine Star Ratings scores.

The completion rate for CMRs is based on the calculation of how many Comprehensive Medication Reviews (CMRs) the plan completes compared to the number of members in the MTM program that met the targeting criteria during the calendar year (excluding those enrolled less than 60 days or in hospice). The higher the ratio the better the plans score.

The CMR ratio is only counted and applied to Star Ratings if the MTMP data was determined to be valid during the DV audit. CMS has determined that the CMR ratio is invalid if the plan scores less than 95% on the MTMP section of the DV audit or the plan scores below a 4 (as part of the 1-5 Likert scale) on any of these specific MTMP DV elements:

HICN (B), Met Targeting Criteria (G), MTM Enrollment Date (I), Met Targeting Criteria Date (J), Opt-Out Date (K), CMR Received (O), or CMR Received Date (Q)

The plan will also score 1-star if they fail to submit their MTMP data for the DV audit. Only if the data is valid, will the CMR ratio get incorporated as part of the plans Star Ratings score (aggregated as part of the 14 Part D measures and 34 Part C measures).

Here are the MTMP CMR ratio cut-points from the 2018 Star Ratings specifications. The 2019 rates are not yet finalized (based on the DV submission from the 2017 plan year).

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If the plan does not have valid MTM data, these ratios do not matter, and the plan will automatically score a 1-star for this measure. Having a strong DV program is very important to a Medicare plan’s overall health. Plans want to make sure they are getting credit for all the hard work in having their members complete CMRs.

Here is an example of a finding that caused a plan have 1-star for MTM: A 2017 DV client had all MTM data elements correct except for the Opt-Out Date (K). The client reported 12/31/2017 dis-enrollments as opt-outs, which was incorrect and resulted in a finding.

Since the Opt-Out-Date (K) is one of the Star Rating elements, the plan received a score of 1 for measure D13-MTM.

Even if your plan delegates this section to an MTM vendor, the plan is ultimately responsible for the reporting. Some ideas for plans that Burchfield incorporates during our pre-assessment reviews include:

  • Trending and ratio review
  • Review of enrollment / dis-enrollment
  • Sample review
  • Data integrity checks (including dates within acceptable ranges)

Hopefully we have provided a few ideas for your reporting team. Let us know if you have any questions or if Burchfield can help you navigate any aspect of DV reporting.

The Data validation reporting submission deadline for MTMP is 2/25/2019.