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As we are heading into April, hopefully the dust is settling on your post-AEP activities. The largest amount of retroactivity in your plan systems and CMS reports will be in January – March, and we see the discrepancies across the industry normalizing heading into April. We love the small window for Operations before AEP ramp-up begins once again in the summer because it provides the opportunity to step back and double check that the I’s are dotted and the T’s are crossed. Here are some new focus areas from CMS that we think Medicare organizations should be taking the time to look at end to end.
CMS completed a review of 54 MAO Online Provider Directory that identified 45% were inaccurate resulting in 31 Notices of Non-compliance. The most common issues identified were:
The second review is underway for another 64 MAO. Have you taken the necessary steps to ensure your Online Provider Directory is accurate?
A security area that can be overlooked is member credit card and bank account information. The information can be in various forms: applications, inbound correspondence, authorization forms or verbally. Review your processes to confirm that there are reasonable and appropriate safeguards for protecting credit card information received from its members per the Payment Card Industry Data Security Standard (PCI DSS) and the HIPAA rules.
CMS has routinely discussed their expectation to look at your data to continually identify opportunities for improvement. We are huge fans of data analytics and the value of quantitative and qualitative data to develop a work plan to drive cross-functional improvements. Your plan should include:
CMS notified plans in the March 2017 payment letter that a data clean up identified and corrected missing 10/16 and 11/16 payments. Look for Adjustment Reason Code 94 with a clean up ID of RT6993395. If you are using your MMR for full plan monthly reconciliation, these may have created discrepancies that the staff ignored because MARx was showing the accurate enrollment span. Use this clean up as a training to your staff on the identification of ‘payment only’ discrepancies that should be reported to your plan leadership & accounting teams as well as the MAPD help desk. CMS addressing data issues are largely driven by plans identifying and reporting these issues.
CMS has updated the Complaint Tracking Module (CTM) with a new function to allow MAOs to submit request for assistance with member’s LIS status when member cannot provide Best Available evidence (BAE). The cases should be entered within 1 day of being notified of LIS eligibility using lead category “Premiums and Costs-Beneficiary needs assistance with acquiring Medicaid eligibility information (EX)” and sub-category “CMS review/action”. These cases will not be included in the CTM metrics.
CMS will notify MAOs of results via CTM . MAO is responsible for updating systems to reflect correct LIS status and send attachment A or B from the 2/17/2017 HPMS memo Best Available Evidence Process Update. If MARx is not correct the CTM can be used as documentation when submitted to RPC. If member can provide BAE documentation, the existing BAE process from PDBM Chapter 13 Premium and Cost-Sharing Subsidies for Low-Income Individuals section 70.5 should be used. Make sure you have a copy of the new User Guide distributed via HPMS on 3/14/16.
Make sure your organization understands the eRpt system and process changes.