It’s time to start thinking about CMS audits

By Yvonne Zachman Fiedler
Tue, Dec, 18, 2018

As rules and regulations are continuously changing, health plans must navigate a complex and confusing framework to stay in compliance with CMS audits. While the Centers for Medicare and Medicaid Services hasn’t always been clear on certain aspects of Part C and Part D, the consolidation of two guide chapters into one comprehensive guidance document may soon offer more clarity in appeals guidance.

The final document isn’t expected to be released until the spring, but the draft CMS released in October hints to some changes that may be coming. Health plans should start reviewing the guidance now to see where their policies may fall short and how they may adjust them to ensure compliance in the coming year.

New Part C and Part D Appeals Guidance Coming from CMS

A memo issued by Centers for Medicare and Medicaid Services in October noted the federal agency is consolidating Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one comprehensive guidance document. CMS said the purpose is to better align and provide a clearer, more straightforward, non-repetitive interpretation of the Part C and Part D appeals policy. The agency also included updated guidance based on the Contract Year 2019 Policy and Technical Changes to the Medicare Advantage and Medicare Prescription Drug Program Benefit Regulation.

CMS eliminated much of the duplicate language found in both chapters to reduce the volume and implemented universal terminology that is applicable to both Part C and Part D. The new chapter is now only 100 pages, easier-to-understand and less redundant, compared to a combined 211 pages in the previous ones.

The agency sought feedback on the guidance and is now in the process of reviewing comments. It’s likely that the final version of the chapter will be released before or during May 2019 to coincide with the 2019 CMS Medicare Advantage and Prescription Drug Plan Spring Conference.

Clearer Interpretation

CMS noted plans’ internal policies may remain the same until the final version is released. Yet because these manuals are the reference for setting policies related to appeals, grievances and authorizations, it could have a significant impact on how plans conduct their business and prepare for CMS audits.

While we can’t yet know what the final rules will be, there are some things we can expect in the final version. Some of these changes are positive and could reduce administrative complexities and simplify processes, while others could create new burdens and responsibilities.

Here are some of the most important changes:

Calculation of days for assessing plan timeliness
For the purpose of assessing a grievance, initial determination or reconsideration, “day one” will now be considered the day after the request, not the day of the request.

Good Faith Attempts
There is now more clarity about what constitutes a good faith attempt regarding notifications about coverage decisions. Plans may now satisfy a notification requirement by first providing verbal notices as long as there is written notice thereafter.

Delegation Responsibilities
The plan must have a comprehensive and on-going monitoring and auditing process to ensure compliance with the applicable CMS requirements.

Appointment of Representatives
If the representative form is maintained by the plan, a photocopy of the form will no longer need to be filed with future grievances, appeals or coverage requests made on behalf of an enrollee. Unless revoked, a representative form is valid for one year.

Handling of Grievances
A plan may, but is not required to, accept and process a grievance filed after the 60-day deadline. If a verbal grievance can be resolved by customer service, the plan must document the details of the resolution and log the call as a grievance.

Part C dismissal notice
If an MS plan dismisses a reconsideration request, it must send a written notice of the dismissal to the parties at their last known address at the end of the applicable adjudication timeframe.

Outreach Attempt Requirements
When outreach is necessary to make a coverage or appeal decision, a minimum of one attempt to obtain additional information is now sufficient. If no additional information can be obtained, the plan should make the best decision based on information available.

Start planning and look for a consultant in 2019

While internal policies and procedures won’t need to be amended until the final version is released, it’s wise to get ahead of any potential changes to see where your plan may fall short. Health plans have all received the same memos and many compliance departments are reviewing the draft rules. A new cycle of audits starting in 2019 means that every single plan will come up for audit review in the next three to four years.

Bringing in a trusted health plan compliance specialist will help ensure your plan will work within the new guidance framework.