Posts by Annie
Provider Directory Accuracy—Why is it Important?
The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to post an online provider directory that is up-to-date and accurate. Beneficiaries must be able to use the online provider directory to find contracted providers they can see to receive covered services. Inaccurate provider directories pose risks to beneficiaries. Because members rely on…
Read MoreCMS Program Audit Findings & Key Preparation Tips
CMS released the 2021 Part C and Part D Program Audit and Enforcement Report on June 7, 2022. Highlights of the report indicate the average audit scores increased over the last report, stating 2020 average overall audit score of 0.15 to 2021 average overall audit score of 0.44. It’s worth noting, there were 27 plans…
Read MoreThe Medicare Timeliness Monitoring Project (TMP)—What to Expect?
CMS continues to conduct an industry-wide Timeliness Monitoring Project (TMP). This project is a retrospective review of 2022 data. It allows CMS to collect data to evaluate the timeliness of processing Medicare Part C reconsiderations, using the new TMP and audit protocols in place for 2022. As a reminder, this data is used to verify…
Read MoreCMS Model Materials—Significant Changes for CY23
Wow! The CMS model materials were released weeks earlier than previous years, and we’re thankful for that! There are significant changes for CY23: most notably the reduction in length, reorganization, and reduction of tables and language. View the CY23 Models here: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/MarketngModelsStandardDocumentsandEducationalMaterial CMS Model Materials Notable Changes Annual Notice of Change (ANOC)—Notable Changes (applies to…
Read MoreNew CMS Guidelines for Individuals Not Lawfully Present—Are Your Systems Ready?
Ensuring Member enrollment records are accurate is no easy task. The Centers for Medicare and Medicaid Services (CMS) makes policy changes regularly, and it is up to the individual Health Plans to keep up. Last November, CMS announced in an HPMS memo they would make updates to their policy for Individuals Not Lawfully Present. Effective…
Read MoreHow to Ensure a Successful Triennial Network Adequacy Review
CMS monitors compliance with Network Adequacy Standards on a triennial basis. Every three years CMS requires a plan to upload its full-contract-level network into the Network Management Module (NMM) in Health Plan Management System (HPMS). When selecting contracts for the triennial review period, CMS pulls from the list of active contracts—primarily based on when the…
Read MoreWhy Consolidating COB & MSP Data Collections Are Crucial for Health Plan Revenue Recovery & Compliance
The Centers for Medicare and Medicaid Services (CMS) requires MA and PDP health plans to update systems timely and accurately. Consolidating and analyzing COB & MSP data collections while maximizing recovery options and complying with CMS regulations is a challenging task. Incorrect data sets can easily contribute to non-compliance and lead to inaccurate claims payments,…
Read MoreMedicare Communications & Marketing Guidelines (MCMG)—CMS Updates Warrant a Thorough Review
Last month, CMS published a new MCMG, and it looks quite different! Not only is it much shorter, 51 pages compared to the previous 84 pages, it now has CFR references for all sections. Upon review, CMS has removed several details, seemingly anything without a CFR reference which accounts for the slimmed-down version, and it…
Read More2023 Star Rating Changes—CMS Advanced Notice for Review & Comment
CMS released the “Advance Notice of Methodological Changes for Calendar Year (CY) 2023 for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies” on February 2, 2022, with feedback accepted until March 4, 2022. Some changes may impact Star Ratings for CY 2023. To submit comments or questions electronically, go to…
Read MoreAre You Prepared for Your Next CMS Program Audit?
Preparation is critical to produce accurate universes and achieve successful CMS Program Audit results. In November 2021, CMS announced they will send program audit engagement letters to sponsors, starting in February through July 2022. If you ask yourself when should your readiness for a program audit begin? The answer is NOW! CMS made several significant…
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