CMS Medicare Part C Plan Reporting Requirement Changes
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1 WEBINAR CMS Medicare Part C Plan Reporting Requirement Changes April 22 nd Updates Sponsored by June 23, 2016, 11:00 am 11:30 am PST
2 Today s Speaker Gabriel Viola 31 Years of experience in Healthcare Operations o Government Programs (MEDICAID, MAPD, PDP) o Commercial Large Accounts o Small Group and Individual plans Past 12 years focused in Government Programs (Medicare and Medicaid) o Enrollments, Claims, Customer Service, Delegated Oversight, Appeals and Grievances, and Compliance Key Accomplishments o Achieved a 100% score in the CMS Validation Audit for ODAG and CDAG in 2014 o Achieved the highest Audit Rating from CMS on the OEV process
3 Discussion Topics What reports are Suspended No Longer required Summary of the Major changes from 2015 CMS 2016 Part C Reporting changes General discussion affecting Grievances and Organization Determinations and Reconsiderations Review of the additional guidance provided by CMS Make sure the math adds up
4 What Reports are Suspended
5 What Reports are Suspended Reporting sections o o o o o o # 1 - Benefit Utilization # 2 - Procedure Frequency # 3 - Serious Reportable Adverse Events # 4 - Provider Network Adequacy #10 - Agent Compensation Structure #11 - Agent Training and Testing
6 Summary of Major Report Changes Three reporting sections were updated to include additional data elements. o Reporting Section # 6 (Organization Determinations/Reconsiderations), The dues dates for Grievances and Employer Group Plan Sponsors were also changed to the first Monday in February. o Reporting Section #13 (Special Needs Plans Care Management), and o Reporting Section #14 (Enrollments/Dis-enrollments) The due dates for Enrollment/Disenrollment were changed to last Monday of August and February.
7 Summary of Major Report Changes In addition three new reporting sections were added: o Rewards and Incentives Programs, o Mid-Year Network Changes, and o Payments to Providers. Reporting Section # 12 Plan Oversight of Agents was changed to Sponsor Oversight of Agents The data due date was also changed to the first Monday in February of the following year.
8 Part C Report Changes Affecting Appeals and Grievances (A&G) Process
9 Part C Reporting Changes for A&G - Definitions Let First Review a few of the Reporting Rules and definitions: A grievance is defined in the CMS Managed Care Manual as Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services. Part C reporting, grievances are defined as those grievances completed during the reporting period.
10 Part C Reporting Changes for A&G Must Report Only those grievances processed in accordance with the grievance procedures outlined in 42 CFR Part 422, Subpart M (i.e., Part C grievances). Report grievances involving multiple issues under each applicable category. Report grievances if the member is ineligible on the date of the complaint or notification to the plan but was eligible on the date the incident occurred.
11 Part C Reporting Changes for A&G Do Not Report
12 Organization Determinations / Reconsiderations Reporting Now due on the Last Monday of February of the following year still requires a breakdown by quarter Two new data elements have been added: o #6.10, Number of Requests for Organization Determinations Dismissals o #6.20, Number of Requests for Reconsiderations Dismissals
13 Organization Determinations / Reconsiderations Reporting Dismissal A dismissal is an action taken when an organization determination or reconsideration request lacks required information or otherwise does not meet CMS requirements to be considered a valid request. The most common reasons for a Medicare plan s dismissal are: Lack of proper appointment of representative Failure of the enrollee or other party to file a timely appeal request No waiver of liability submitted with an appeal filed by a non-contract provider Failure to exhaust the prior level of adjudication
14 Organization Determinations / Reconsiderations Reporting Must Report Organization Determinations/Reconsiderations Reporting must Report: Completed Org Determinations. & Reconsiderations All Part B drug claims processed & paid by PBM are reported as org. determinations or reconsiderations. Re-openings across multiple reporting periods are reported in each applicable reporting period. Claims with multiple line items at the summary level. A request for payment as a separate and distinct org determination, even if a pre-service request for that same item or service was also processed. A denial of a Medicare request for coverage of an item or service as either partially favorable or adverse, Report denials based on exhaustion of Medicare benefits. In cases where an extension is requested after the required decision making timeframe has elapsed, the plan is to report the decision as non-timely. Dismissals
15 Organization Determinations / Reconsiderations Reporting Do Not Report Independent Review Entity (IRE) decisions. Re-openings requested or completed by the IRE, Administrative Law Judge (ALJ), and Medicare Administrative Contractor (MAC). Concurrent reviews during o Concurrent hospitalization o review of Skilled Nursing Facility (SNF) o Home Health Agency (HHA) or o Comprehensive Outpatient Rehabilitation Facility CORF care Duplicate payment requests concerning the same service or item. Payment requests returned to a provider/supplier in which a substantive decision (fully favorable, partially favorable or adverse) has not been made. Enrollee complaints only made through the CMS Complaints Tracking Module (CTM).
16 Review of Additional Guidance Provided by CMS
17 Additional Guidance
18 About Inovaare
19 Confidential: Internal use only
20 Inovaare A leader in Compliance and A&G Software Offers highly configurable software solutions exclusively for the healthcare industry. Inovaare solutions are built on a flexible and integrated platform that supports application areas including risk assessment, internal control, Internal audit, compliance management and incident management. Compliance and Quality Management System (CQMS) is a unified platform to plan and manage compliance and quality requirements. Users of CQMS platform have the option of building their own application or, choosing from among ready-to-go solutions from Inovaare, when quick implementation is required. Inovaare s A&G software provides a powerful business improvement solution that reduces cost and effort needed to proactively manage risk, quality, and sustainability.
21 Question & Answer
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23 for attending our webinar! We trust you found the information useful. The Presentation archive and PowerPoint Presentation will be available for downloading on within the week We hope to see you on another webinar soon! If you would like to obtain additional information or are interested in discussing how Inovaare can help you with your compliance needs, please feel free to us at Or Visit 23
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