Transcript Document
1 Confidential | Copyright © 2014 TriZetto Corporation Are You Prepared for a CMS Audit? Steve Arbaugh, CEO, ATTAC Consulting Group Christine Turner, COO Soundpath Health Jim Foss, Services Overlay Executive 2 Confidential | Copyright © 2014 TriZetto Corporation CMS Audit Trends What are the highlights of the Soundpath Mock Audit story? 3 Confidential Soundpath Overview Why an audit? The “Audit Prep” The Audit experience What we learned What we did after | Copyright © 2014 TriZetto Corporation Soundpath Health Formed in 2007 under the name of Puget Sound Health Partners in Washington State to serve Medicare beneficiaries First MA members became effective 1/1/2008 Formed by 2 IPA’s & 1 PHO who had a history of managing capitated, delegated business Catholic Health Initiatives (CHI) became majority shareholder in March, 2013 Currently serve 16,700 members in 9 counties In the process of implementing QNXT for a 10/1/14 go-live date 4 Confidential | Copyright © 2014 TriZetto Corporation Soundpath Health Challenges faced Disparate systems weren’t meeting increased CMS requirements/expectations Delegated model without agreement on data standards constantly causes data challenge Investments in plan resources were delayed during due diligence Reason for Mock CMS Audit Soundpath Health had never been selected for a CMS Plan audit Catholic Health Initiatives wanted an independent assessment of health plan to identify Compliance and operational risks Required critical investments 5 Confidential | Copyright © 2014 TriZetto Corporation Soundpath Health What was Learned? Stumbling Blocks Scheduling challenges are significant Pulling universes in an accurate and timely manner was difficult – particularly when coordination was required with delegated entities File preparation was challenging and made presenting information during webinars “clunky” in certain areas Critical Issues Identified Improvements/Enhancements were needed in compliance program G & A was particularly challenging Need to improve all aspects of FDR relationships Contract language Service Level Agreements Establishing & Monitoring Standards Increased Communications Need to increase vigilance in testing ourselves 6 Confidential | Copyright © 2014 TriZetto Corporation CMS Audit Trends What audit trends are the most important? Targeted audits Self-audits Audit Audit Audit 7 Confidential | Copyright © 2014 TriZetto Corporation CMS Audit Findings What are the biggest audit challenges? Number of Organizations with Enforcement Actions by Area Since 2012 12 11 10 9 8 8 7 6 6 4 2 2 2 0 Formulary Coverage Org Annual Notice Enrollment Administration Determination, Determination, of Change & & Transition Appeals, Appeals, Evidence of Benefit Grievances Grievances Coverage… HEA Mastering the CMS Program Audit Process, April 2012 Michael DiBella, Director, Division of Compliance Enforcement Medicare Parts C & D Oversight & Enforcement Group 8 Confidential | Copyright © 2014 TriZetto Corporation PACE Services Premium Billing The “Fear” of CMS Audits What happens when your CMS audit fails? 9 Confidential | Copyright © 2014 TriZetto Corporation Data Requirements Why are the data requirements so complicated when the regulations and data elements are well-defined for a CMS Audit? 10 Confidential | Copyright © 2014 TriZetto Corporation Oversight of entities How do downstream entities affect CMS Compliance? ACO Multispecialty physician group Clinical vendors Health Plan FMO Clinically integrated networks Clinical review IPA 11 Confidential | Copyright © 2014 TriZetto Corporation PBM Components of an Audit What are the audit components? Audit Components ODAG Organizational Determinations, Appeals & Grievances CDAG Coverage Determinations, Appeals & Grievances Formulary & Benefit Administration Enrollment Verification Enrollment Agent Oversight Compliance Effectiveness 12 Confidential | Copyright © 2014 TriZetto Corporation You are done – Now what? What happens after the Mock Audit COMPLIANCE 13 Confidential | Copyright © 2014 TriZetto Corporation Culture of Compliance What are the business operations implications? 14 Confidential | Copyright © 2014 TriZetto Corporation Why Now? Does it cost more to do it now vs later? 15 Confidential | Copyright © 2014 TriZetto Corporation Session Survey We would like to extend you an opportunity to provide candid feedback. During the workshop you should’ve received an e-mail notification for you to take an on-line survey. If you could take a few minutes to complete at this time, we would greatly value your feedback. For your convenience, the survey will be available throughout the remainder of the conference should you not be able to complete immediately. 16 Confidential | Copyright © 2014 TriZetto Corporation Thank You! 17 Confidential | Copyright © 2014 TriZetto Corporation