Document 6498972

CMS Audits of Health Plans:
How to Avoid the Crisis
David Orbuch
Steve Lokensgard
Agenda
• Scope of CMS Audits of Health Plans
• Preparing for an audit
– Compliance Effectiveness Audits
– RADV Audits
– Operational End-to-End Audits
• Drafting successful Corrective Action Plans
2
1
Scope of CMS Audits
• One-third of plans must be audited every year
– Medicare Modernization Act of 2003 (MMA), Pub. L. 108-173
– Section 1857(d)(1) of the Social Security Act
• GAO Report in July of 2007
– CMS not hitting its target
– Required audits of limited value
– CMS not adequately funded for audits
3
Scope of CMS Audits
4
2
Scope of CMS Audits
• 2010
– CMS continues its operational end-to-end audits, but shifts audit
approach to more focused audits
– CMS has begun auditing the effectiveness of compliance programs
5
Scope of CMS Audits
• Focused Audits
–
–
–
–
Compliance program effectiveness
Agent/broker activities
Appeals and Grievances
SNP enrollment eligibility audits
6
3
Scope of CMS Audits
• Risk Adjustment Data Validation (RADV) Audits
• New Risk Adjustment Process fully implemented in 2007
• Expanded RADV Audits began in 2008
– 200 records
– Increased number of Hierarchical Condition Categories (800)
• Requirement to Extrapolate Error Rates
7
Preparing for the Audits
• Consult references to help prepare for the CMS Audits
• Medicare Part C and Part D Universal Audit Guide
– Published in October of 2009
– Incorporates various source materials:
• Applicable Federal Regulations
• Medicare Managed Care Manual
• Prescription Drug Benefit Manual
– Ch. 4 – Marketing
– Ch. 9 – Privacy
– Ch. 15 – Compliance Plan
8
4
Compliance Program Effectiveness
• Preparing for a Compliance Effectiveness Audit
– 42 CFR 422.503(b)(vi)
– Ch. 15 of the Universal Audit Guide
9
Corporate Responsibility and Compliance Program
Mission:
Ensure operational accountability for compliance with the
obligations that govern our government business. This will be
done through:
•
•
•
•
10
Clear outcome measures
Standardized processes, tools and accountabilities
Governance process and structure
Tracking and oversight
10
Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.
5
Guiding Principles
• Our program translates our values into actions
• Business operational leaders are responsible for compliance
• We will develop a strategy for effective compliance and
support business leaders in implementing that strategy
• Our regulatory relationships are fundamental for our
organization’s success
• We will create clear accountability around compliance and
foster open, honest and clear communications about our
outcomes
11
11
Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.
Corporate Responsibility & Compliance
12
12
6
Medicaid Compliance Program
13
Medicare Compliance Program
14
14
7
Program Evaluation
Compliance Scorecard
Measurement Framework:
Structure x Process x Outcome =
Effectiveness
15
Measurement Framework
• Structure measures refer to the capacity of a health care
organization to ensure compliance
• Process measures refer to the manner in which an
organization actually provides compliance coverage
• Outcome measures refer to observable, measurable
compliance outcomes
16
8
Scorecard
17
Preparing for the Audits
• Operational End-to-End Audits
• RADV Audits
18
9
Corrective Action Plans
• GAO Report (GAO-10-36) issued December of 2009 relating to
marketing noted shift in timelines relating to Corrective Action
Plans (CAPs)
• Between 1/2006 and 4/2008
– Days to CMS acceptance of CAP = 90 days
– Days to implementation of CAP = 128 days
• Between 5/2008 and 2/2009
– Days to CMS acceptance of CAP = 145 days
– Days to implementation of CAP = 29 days
19
Corrective Action Plans
• Tips to accelerate CMS acceptance and implementation of CAP
–
–
–
–
–
–
Address Deficiency Cited
Timetable for Correction
Process for Validating Correction
System for Ongoing Monitoring
Progress Reports to CMS RO
Involve RO Plan Manager Before Submitting Through HPMS
• Further Applications of Corrections
20
10
Presenter’s Contact Information
David Orbuch
Chief Compliance Officer
Public and Senior Markets
Group
UnitedHealth Group
(952) 931-5958
Steve Lokensgard
Special Counsel
Faegre & Benson
(612) 766-8863
[email protected]
[email protected]
21
11