Transcript Document
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Confidential
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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
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CMS Audit Trends
What are the highlights of the Soundpath Mock Audit story?
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Soundpath Overview
Why an audit?
The “Audit Prep”
The Audit experience
What we learned
What we did after
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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
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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
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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
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CMS Audit Trends
What audit trends are the most important?
Targeted audits
Self-audits
Audit
Audit
Audit
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CMS Audit Findings
What are the biggest audit challenges?
Number of Organizations with Enforcement Actions by Area Since 2012
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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
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PACE
Services
Premium
Billing
The “Fear” of CMS Audits
What happens when your CMS audit fails?
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Data Requirements
Why are the data requirements so complicated when
the regulations and data elements are well-defined for
a CMS Audit?
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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
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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
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You are done – Now what?
What happens after the Mock Audit
COMPLIANCE
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Culture of Compliance
What are the business operations implications?
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Why Now?
Does it cost more to do it now vs later?
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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.
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Thank You!
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