How CMS Data Validation Scores Impact Star Ratings

By Jason Hoyme
Fri, Sep, 13, 2019

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 received 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 be of assistance to your teams.

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. This article will focus on the Part D section – the Medication Therapy Management Program (MTMP) and the Part C section – Special Needs Plan (SNP) Care Management.

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. From the 2020 First Plan Preview, there are 32 separate Part C measures and 14 different Part D measures, each with a weight between 1-3. The average 2019 score for MA-PD contracts was 4.06 and 46% of MA-PD plans scored at least 4 stars.

Part D - MTMP

One of the 14 Part D measures includes “D12 – 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, in hospice, or under the age of 18). 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 32 Part C measures).

Here are the MTMP CMR ratio cut-points from the 2016-2019 Star Ratings specifications. The 2020 rates are not yet finalized (based on the DV submission from the 2018 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 D12-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)
  • The CMS Data validation reporting submission deadline for MTMP is 2/24/2020.

Part C – SNP

One of the 32 Part C measures includes “C08 – Special Needs Plan (SNP) Care Management”. SNP plans are unique Medicare plans that limit membership to people with specific diseases or characteristics. Medicare SNPs tailor their benefits, provider choices, and drug formularies to best meet the specific needs of the groups they serve and require the completion of a health risk assessment (HRA). This DV section only relates to SNP plans and is not required for other types of Medicare Advantage plans.

As part of the DV audit, CMS requires the submission of eight data elements related to the count of SNP plan membership and completed HRAs. CMS is now using the DV SNP information to help determine Star Rating scores and to make sure members are getting the care they need.

The HRA completion ratio used for Star Ratings is based on the calculation of how many HRAs the plan completes compared to the total number of eligible members during the calendar year. The higher the ratio the better the plans score.

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

  • 13.1 – Number of new enrollees due an initial HRA
  • 13.2 – Number of enrollees eligible for an annual HRA
  • 13.3 – Number of initial assessments (HRAs) performed on new enrollees
  • 13.6 – Number of annual reassessments (HRAs) performed on eligible enrollees

Currently, CMS is not incorporating the unable to reach or member refusal elements into the HRA completion ratio.

Only if the data is valid, will the HRA ratio get incorporated as part of the plans Star Ratings score (aggregated as part of the 14 Part D measures and 32 Part C measures).

Here are the SNP HRA ratio cut-points from the 2016-2019 Star Ratings specifications. The 2020 rates are not yet finalized (ratios on the DV submission from the 2018 plan year)

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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 members complete HRAs.

Burchfield has found that the SNP section is perhaps the most difficult out of all the DV reporting sections for plans to accurately complete. The specifications provided by CMS are nuanced and can be interpreted in many ways.

Many SNP plans are now working to try to minimize the likelihood of receiving a finding while maximizing their Star Ratings score. This has been difficult due to the specifications from CMS and as each DV audit firm can have different interpretations of the requirements. Burchfield has developed multiple models for reviewing SNP data and is able to quickly identify reporting risks and provide expertise through our pre-assessments.

Burchfield recommends having the necessary resources in place and a strong review team to validate your SNP counts. Expertise will likely be needed from operational and technical areas to properly code the requirements. It is also important that plans can justify any potentially disputable methodology based on the published specifications or from CMS emails.

  • The CMS Data validation reporting submission deadline for the SNP reporting section is 2/24/2020.

We hope your organization finds the above tips and updates helpful in your CMS Data Validation preparation. Should you have any questions, please don’t hesitate to reach out to Burchfield for additional clarification on your DV reporting requirements.

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