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Medicare Parts C and D Data Validation Trends and Challenges October 29, 2013 Presented by: Jim Casurella Rob Shelley Sadie Zarnoth.

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Presentation on theme: "Medicare Parts C and D Data Validation Trends and Challenges October 29, 2013 Presented by: Jim Casurella Rob Shelley Sadie Zarnoth."— Presentation transcript:

1 Medicare Parts C and D Data Validation Trends and Challenges October 29, 2013 Presented by: Jim Casurella Rob Shelley Sadie Zarnoth

2 Today’s Agenda Data Validation Overview Why do we do this? Who are PSRx and MetaStar? Introductions 2013 Results, What happened last year? Common Challenges 2013 Experience 2014 Summary and Changes DV Standards Automation possibilities To the Future! Disclaimer: Off-season we are restricted by CMS from “consulting”. We can’t answer your specific questions about measures, but we can pass them along to CMS and share with you their response.

3 3 MetaStar specializes in HEDIS® audits and External Quality Review validation, both of which support the assessment of DV deliverables PSRx Advisors offers advanced PBM oversight support for Medicare Part D compliance and financial management The Team 2013 Data Validation HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

4 Data Validation Within the Code of Federal Regulations (CFR), the Centers for Medicare and Medicaid Services (CMS) identify the reporting requirements for Medicare Advantage Organizations (MAOs) CMS requires that MAOs submit certain data reports which began with measurement year 2010 Specific data reports must be validated by an independent data validation contractor CMS stipulated the requirements for the data validation contractor Both PSRx and MetaStar meet all CMS requirements for an independent experienced data validation contractor Overview

5 Data Validation 608 Total contracts underwent Data Validation, 530 for Part C The average Part C score was 98.1% Nearly 1/3 (32.8%) scored 100% 2013 Results Part C Data Validation Disclaimer: These statistics were excerpted from CMS Memo dated August 2, 2013, subject line was “Results of the 2013 Part C and D Reporting Requirements Data Validation”.

6 6 608 Total contracts underwent Data Validation, 603 for Part D The overall average Part D score was 99% Why such a high score? Nearly ½ scored 100% on the Part D Reporting Sections Per CMS, the results of this Data Validation indicate an overall level of high performance of Medicare standards 2013 Results Part D Data Validation Disclaimer: These statistics were excerpted from CMS Memo dated August 2, 2013, subject line was “Results of the 2013 Part C and D Reporting Requirements Data Validation” Data Validation

7 7 Standard 1g: Recalculation narrative that matches the process Standard 1g: Keep manuals, policies, and procedures updated Standard 1g: Consolidation and centralize documentation Standards 2d and 2e: Consistent categorization to data elements Standard 3a: Quality assurance process for data entry to ensure accuracy Standard 7: Sufficient oversight of all vendors Various Standards: Continuous training Challenging Standards For current DV specifications and documentation, go to cms.gov

8 8 Contract Year 2013 Measures 2013Part CPart D Reported Measures1115 Validated Measures4*5 Two Part C measures from Contract Year 2012 will also be validated in this year’s cycle Data Validation

9 9 No validation of Plan Oversight of Agents for Part C or Part D Serious Reportable Adverse Events (SRAE): Validating two years rather than one Special Needs Plan (SNP): Validating two years rather than one 2014 Changes Part C

10 Data Validation 2014 Changes Part D Grievances Part D: Plan submits once instead of four times; two additional data elements validated Coverage Determinations/Exceptions: Plan submits once rather than four times; number of data elements increased to 29 Redeterminations: Plan submits once rather than four times Long-Term Care Utilization: Two files instead of previous three (one year instead of two) Medication Therapy Management Programs (MTMP): Increased from 19 to 26 data elements

11 Data Validation Standards Validation CMS is available for questions. Source data must be available! The 2014 Data Validation Manual and Appendix B, the Data Validation Standards must be used to evaluate your practices.

12 12 Can It Be Automated?

13 13 What’s on the horizon?

14 14 In Closing…

15 15 Providing Informed Pharmacy Decisions


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