1. 2012 Fall Conference Program Audits
CMS logo
2012 Fall Conference Program Audits
Tawanda Holmes, Director
&
Jonathan Blanar, Deputy Director
Division of Compliance and Policy Operations
Program Compliance and Oversight Group
Center For Medicare
September 5, 2012
Image of smiling family of 6

2. Objectives High Level Walk Through of Audit Process
Immediate Corrective Action Required Process – New Since Spring Conference
Preparation Tips for Audit
2012 Best Practices and Common Findings
2013 Audit Planning 2

3. Audit Process 3

4. Immediate Corrective Action Required (ICAR)
Definition of ICAR:
Deficiencies identified that have the potential to cause significant beneficiary harm (whether medical or financial) in the areas of:
Part D coverage determinations, appeals, and grievances (CDAG);
Part D prescription drug formulary administration (FA);
Part C organization determinations, appeals, grievances; or
Part C access to care (ODAG) 4

5. Immediate Corrective Action Required (ICAR)
(continued)
Significant beneficiary harm exists if the identified deficiency resulted in the plan’s failure to provide medical services or prescription drugs, causing financial distress, or posing a threat to enrollee health and safety due to non-existent or inadequate policies & procedures, systems, operations or staffing
Problems identified as needing immediate corrective actions are not issues that have already been resolved, but are current vulnerabilities 5

6. Examples of Deficiencies Requiring ICAR
Part D Prescription Drug Formulary Administration
Disruption of care for beneficiaries with drugs in the protected classes or other critical medications
Beneficiary access problems related to the use of clinically inappropriate and unapproved utilization management criteria
Transition issues that prohibit beneficiaries from receiving a temporary supply of prescribed Part D drugs when they are eligible for a transition benefit
 Part D Coverage Determinations, Appeals, and Grievances
Misclassifying coverage determinations or appeals as grievances or failure to effectuate overturns or approvals
Failure to auto-forward cases to the IRE as required 6

7. Examples of Deficiencies Requiring ICAR
Part C Organization Determinations, Appeals. and Grievances and Part C Access to Care
Failure to follow National Coverage Determinations (NCDs)/Local Coverage Determinations (LCDs) or other CMS coverage policy when making coverage decisions on any medical or other health service that is covered by Medicare
Misclassifying organization determinations or appeals as grievances or failure to effectuate overturns or approvals
Failure to auto-forward adverse reconsideration cases (including cases that are not adjudicated within the required timeframe) to the IRE as required 7

8. ICAR Onsite/Webinar Process
Onsite/Webinar Audit
TLs must identify and document access issues and/or systemic issues that have the potential to cause significant beneficiary harm
Audit team will immediately inform CMS management and communicate verbally to the sponsor when identified
The PCOG AL will send an to the plan’s compliance officer the same day, detailing the immediate corrective action issue and requesting the plan fix it immediately
The sponsor will be made aware of the seriousness of the issue(s) and our expectations for immediate resolution (i.e. immediately stop inappropriate action(s) and/or initiate manual intervention)
The TL will reiterate immediate corrective action issues at the exit conference 8

9. ICAR Post Audit Process
Within a few days of the exit conference, the AL will send the immediate corrective action request via to the plan’s compliance officer
The AL will have a call with the plan after sending the to describe CMS’ expectations
The corrective action plan and confirmation must be received by the AL, from the Sponsor, within 72 hours of receipt of the immediate corrective action request 9

10. ICAR Post Audit Process
Post Audit (continued)
Once the response is received from the plan, it will either be accepted or denied by PCOG
Accepted: It is reasonable as long as the plan had measurable responses describing actions taken to immediately ensure the potential for significant beneficiary harm has been eliminated
Denied: If the responses are not reasonable or complete, PCOG will reject the submission and have the plan resubmit within 1 business day
The AL will let the plan know whether or not the submission is accepted via 10

11. Validation of ICAR by CMS
For Formulary Administration – The sponsor will submit a 3 day universe of rejected claims starting the day after all corrections are implemented by the sponsor
For ODAG and CDAG - The sponsor will submit a 30 day universe for both CDAG/ODAG starting the day after all corrections are implemented by the sponsor
The validation for the remainder of the areas audited and findings that were not immediate needs will be handled through the normal audit report process (90 days)
Once validation is complete, the DCPO representative will communicate to the sponsor via the results of the validation within 3 days of finalizing the results (Pass or Fail and why) 11

12. Preparation Tips for Audit
Pre-Audit
BEFORE receiving an audit start notice, review the HPMS memo (date), discuss the requirements internally, and conduct mock audits
AFTER receiving an audit start notice, discuss requirements internally and forward questions to CMS before the audit start notice follow-up call
Notify your PBMs and other delegated entities who would be needed to assist with pulling universes
During the follow-up call, ask questions about the universe templates, inform CMS of other audit efforts, etc 12

13. Preparation Tips for Audit
Pre-Audit (continued)
Since CMS will audit all areas simultaneously, plan staffing requirements and discuss scheduling needs with audit lead
Provide CMS with a contact for access to SFTP and test the access upon receiving username and password
Contact the audit lead if universes would be delayed and for any other clarification or concerns
For Enrollment/Disenrollment, LEP and Agent/Broker areas, clearly label documents to support samples. Highlight areas that prove you are compliant. Ensure cases are complete and available for review after the entrance conference 13

14. Preparation Tips for Audit
Samples are provided during the entrance conference. Be ready to show supporting documentation for samples in your systems live via webinar
Be prepared to discuss how samples are compliant
Feel free to ask questions if you are unclear on why a sample is considered “failed”
Provide screenshots of documents as requested by the CMS team lead and upload to the SFTP daily
Provide audit team with items requested within the deadlines provided. If unable to meet a deadline, please notify the CMS team members as soon as you can to propose a new deadline 14

15. Preparation Tips for Audit
Immediate issues should be addressed as directed by CMS. Track other failed samples to assist in planning for corrective action
During the exit conference, ask questions
Begin developing corrective action plans in anticipation of final audit report
Post Audit
Review the draft report and provide comments timely
Upon receiving the final report, prepare your corrective action plan for submission to CMS
Respond to the audit questionnaire to assist CMS in improving the audit process 15

16. 2012 Best Practices and Common Findings
Refer to HPMS memo 16

17. 2013 Audit Planning Finalize the 2013 audit strategy – October 2012
Release 2012 audit lessons learned – December 2012
Release 2013 protocols via HPMS – January 2013
New audit module in HPMS will go live – January 2013
2013 Audits will begin – late January/early February 2013
Developing PCOG Webpage 17

18. Q&A 18

19. Jonathan.Blanar@cms.hhs.gov Tawanda.Holmes@cms.hhs.gov
Contact Information