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- Gorman Health Group on Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight
- Liz Robinson on Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight
- Gorman Health Group on Industry Ducks Bullets in 2016 Medicare Advantage Rate Proposal
- Jessica K on Industry Ducks Bullets in 2016 Medicare Advantage Rate Proposal
- Daniel on 2016 CMS Applications: Highlights and Basics
This week’s CMS industry training on applications was quite informative, and contained many audience questions that you will want to hear. The recording is already available to registrants for those who missed it. There was way too much information for me to summarize, so I have included here a few highlights from the call and some basics that are easily overlooked.
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.
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.
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.
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).
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.”