Topic: Compliance

CMS Clarifies Key Audit Terminology

Regan Pennypacker

Immediate Corrective Action Required (ICAR), Corrective Action Required (CAR), and Observation. These terms have become part of the vocabulary for Compliance specialists, auditors, analysts, managers, directors, and Compliance Officers who so often field questions from Operations. Let’s consider the following scenario: Compliance has just completed an internal audit of Claims Operations and has identified findings. This leads the Ops team to ask, “Are these findings CARs or ICARs?”

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Evolution of Validation: Selecting an Independent Auditor

Regan Pennypacker

The Centers for Medicare & Medicaid Services (CMS) audit validation process has evolved over the past few years. Here is what you should know about the changes and how to best prepare to contract with an Independent Auditor, or IA.

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2016 Readiness Review Smaller Size, Bigger Punch.

Julie Billman

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Readiness Checklist on Monday, November 9, 2015. The 20-page checklist is full of items CMS is expecting plan sponsors to review and validate it will be compliant for the 2016 calendar year. While CMS won’t have an official website for plan sponsors to attest to the readiness this year, they will use other methods to validate compliance. No matter the validation method, CMS’ expectations are clear: Part C and Part D plan sponsors should review and validate compliance for each item.

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Proposed Changes to the CMS-HCC Risk Adjustment Model

Daniel Weinrieb

Policy changes governing risk adjustment in plans for Medicare-Medicaid dual eligibles may soon be coming.

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Is Your Customer Service Ready? Top 5 Lessons Learned in 2015 Rolling into 2016

Julie Billman

It’s only a few months until we ring in a new year.  Time flies, but there is still enough time to ensure we put our best foot forward as we begin 2016.  Here are the top 5 lessons learned in 2015 as we roll into 2016 to ensure Customer Service is ready for the New Year: Read more

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2015-2016 CMS Program Audit Protocols Update

Regan Pennypacker

It’s Christmas in October (and Hanukkah, too) if you’ve been waiting for the revised 2015-2016 Program Audit process and protocols. Let’s get right down to it!

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Considering Network Expansion? The Role Network Adequacy, Risk Adjustment, and Star Ratings Play

Elena Martin

The leaves are changing colors, pumpkins are out on every front stoop, and the brisk weather signifies fall is in full swing.  It also means we are in the midst of application season for health plans wanting to expand their geographic footprint.  The Centers for Medicare & Medicaid Services (CMS) has put provider networks front and center under the bright spotlight, and Medicare Advantage (MA) plans need to be even more vigilant in managing their largest asset.  Regardless of the size and scope of the organization, your plan’s network adequacy and accessibility is a cornerstone of any new initiative.

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