Topic: Compliance

2016 CMS Application Season Begins

Regan Pennypacker

Yesterday CMS released the 2016 Part D application, and this afternoon the 2016 Medicare Advantage (MA) application was released.  Despite the applications’ release dates, potential and current Plan Sponsors should be well under way in the preparation of the upload that is due on February 18th.  Aspects of the application that require significant lead time to accomplish include the establishment of an adequate network and the acquisition of the required state licensure.

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ICD-10 Transition – Ready or Not?

Mae Regalado

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Annual Compliance Program Audit: Your Organization’s Achilles Heel?

Betsy Seals

When it comes to auditing throughout the Organization, the truth is that much of the responsibility often falls directly on the Compliance Department. This can be due to many factors, such as lack of resources or lack of cross-functional expertise. However, one of the CMS Compliance Program requirements is that the Compliance Program itself is audited annually. Fulfilling the requirement to annually audit the Compliance Program can present an issue for some Organizations due to the fact that Compliance Department self-auditing does not fulfill the requirement, and there may be no other department within the Organization with the expertise to conduct the review.

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Rewards and Incentives: Are We There Yet?

Betsy Seals

Yes, Medicare Advantage is finally catching up to the rest of the health care industry, and we are now permitted to offer enrollees Rewards and Incentives.

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Medicare and Exchange Risk Adjustment: Data Quality Matters

Janet Fina

Plans/Issuers participating in the Exchange may think they have dodged a bullet because HHS has stated payments will not be adjusted during the first two years of the program as a result of RADV audits. However, other remedies such as prosecution under the False Claims Act may still be applied to non-compliant issuers (health plans).

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CMS Validation Process: The Silver Lining

Betsy Seals

We’ve seen quite a few changes over the past few years in the way that the Centers for Medicare & Medicaid Services (CMS) is approaching the program audit and audit validation process. The most notable trend this year is continued push back of responsibility onto the Organization. In recent sanction reports, CMS states that it will require the Organization “to hire an independent auditor to conduct validation in all operation areas cited in this notice and to provide a validation report to CMS.” In addition, CMS presenters at the CMS Fall Conference, which took place on September 11, 2014, stated that “The onus of correction overall is on the sponsor. Therefore, CMS this year will not request universes to conduct sample testing unless the sponsor is unable to demonstrate through its presentation and from the responses to CMS questions, that it has not corrected the findings.”

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The Good, the Bad and the Ugly in Medicare Advantage

John Gorman

In the last two weeks there’s been good, bad and ugly news for Medicare Advantage (MA) plans.  On one hand, the program has never been stronger and quality metrics are surging in the right direction; on the other, the industry is sucking it up on following the rules of its biggest customer, the Centers for Medicare and Medicaid Services (CMS).

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