The Bridge – Volume 2

Highlights of Proposed 2020 Audit Protocols

CMS started proposing changes to the 2020 Program Audit protocols in August 2019. The revised protocols are now being finalized by CMS. Sponsoring organizations should expect routine program audit engagement letters from March through July 2020.

In general, CMS simplified and provided greater clarity in the five protocols by removing unnecessary columns within the universes to promote consistency across the program-area instructions. Throughout, Cardholder ID was renamed Enrollee ID and defined as the Medicare Beneficiary Identifier (MBI).

Protocol-specific changes include updated language and tables, removed tables, and other changes to compliance standards. CMS also removed the CPE Self-Assessment Questionnaire, and clarified that all files must be in Excel format.

You can see a summary of changes here.

To help you cope with the sheer number of changes, Madena can help you with:

  • Universe Design Development – we perform systems review to help design universes, making sure you to get the right data out of your system(s) and into the right universe. We can help map data from your systems and database tables to the universes for reliable data pulls.
  • Universe Validation – we can help evaluate universes for adherence to instructions. We load your files into our analytic tools that provide detailed accuracy and quality checks. We advise on any necessary data clean up and recheck your results as many times as it takes to get it right.
  • Universe Compliance Review – Our analytic tools perform checks for timeliness against compliance standards. We provide a detailed report of results and recommended corrective actions. Our actionable lists can be used by your team or Madena can assist with process enhancements.

Get the supporting statement and related forms for the proposed collection summarized in this notice.

Service Spotlight

Madena BPO Services – Providing scalable staffing solutions to help your company achieve optimal operational efficiency, profitability, and member satisfaction.

Madena Membership Suite™ EDV Module – Create EDV packets to ensure streamlined submission of data from EDV worksheets and supporting documentation. Meet monthly Medicare audit requirements and track audit success or failure to implement internal coaching and process improvement.

Madena Membership Suite™ RPC Module – Reduce errors and RPC rejections by the systematic creation of archivable RPC packets, cover letter, and submission sheets. Upload FDRs to close out items or identify rejections requiring resubmission. Generate RPC reporting to allow inventory management, oversight, and to identify trends.

Madena & Industry News

CMS Wants to Know …

The 2021 Advance Notice proposal has been published and is available for comment until March 6, 2020.

Some of the notable proposed changes are as follows:

  • Remove the restrictions for ESRD beneficiaries and allow them to enroll in MA plans starting 2021.
  • When ESRD beneficiaries enroll in a MA plan starting 2021, the organ acquisition costs for kidney transplants will be excluded from MA benchmarks and covered under the FFS program starting 2021.
  • STAR Rating changes for Part C and D are focused on patient experience and access by increasing the weighted scoring from 2 to 4, removing current measurements and adding new measures.
  • Calculation of Risk Scores for 2021 would be based on 75% of the encounter data-based risk score and 25% of the RAPS-based risk score.
  • Allow a “Preferred” Specialty tier to help reduce prescription drug costs.
  • Require Part D plans to implement a Beneficiary Real Time Benefit Tool (RTBT), providing members the ability to view patient-specific, real-time formulary and benefit information by January 1, 2022.
  • Several provisions related to Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act including education on opioid risks, alternate pain treatments, safe disposal of opioids, and expansion of drug management programs and medication therapy management programs to help prevent opioid overuse.
  • Strengthen network adequacy rules for MA plans with new policies to improve access in rural areas and encourage the use of telehealth in all areas. Including telehealth providers for Dermatology, Psychiatry, Cardiology, Otolaryngology, and Neurology. Let CMS know if you feel additional specialties should be included.
  • MA plans that are not designated as D-SNP are at risk for CMS renewing their contract for 2021. These “look alike” plans are identified if 80% of the membership is dual eligible or the MA plan is under a year old and has less than 200 members. Members will be allowed to transition to an existing D-SNP plan if qualified.

Use this link to provide your opinion to CMS on this and other proposed changes.

A fact sheet for the 2021 proposed changes can be found here.

View/download a PDF of the February 2020 newsletter.