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 that the Independent Review Entity (IRE) data is correct and valid for use in the Part C Star Ratings to be posted for 2024.
Who can get monitored? Part C sponsors that have active contracts in both CY2022 and CY2023.
- The sponsoring organization will be excluded if, within the current year they had a program audit and successfully submitted the ODAG universes with no Invalid Data Submission (IDS) conditions and had at least one month of current-year data for each required universe.
- If a sponsoring organization had an IDS on any of the required universes, they only have to resubmit the affected universe.
- If a sponsoring organization is going through an audit validation in the current year, they will not be exempt.
- An organization will be excluded from the data submission if they are a standalone Prescription Drug Plan, Program of All-Inclusive Care for the Elderly, Medicare-Medicaid Plan (MMP), Medicare Medical Savings Account, Employer/Union Direct (“E” contracts), and 1833 Health Care Prepayment Plan.
What is being monitored? Starting in the fall of 2022, plans will be notified to submit their first quarter CY2022 Part C data. CMS will collect data to evaluate the timeliness of processing Medicare Part C reconsiderations, including ODAG Tables 2: Standard and Expedited Pre-service Reconsiderations (RECON) and Table 3: Payment Organization Determinations and Reconsiderations (PYMT_C). Please note that Table 3 will be limited to data for payment reconsideration only. The request universe period begins January 1. This is dependent on the size of the sponsoring organization:
- 500,000 or more enrollees will submit two weeks of data
- 250,000 to 499,999 enrollees will submit four weeks of data
- 50,000 to 249,999 enrollees will submit eight weeks of data
- Less than 50,000 enrollees will submit 12 weeks of data
Like the collection for program audits, universe submissions must include data processed in-house and by all First Tier, Down-stream, and Related entities (FDRs) on your behalf. Additionally, all universes will be submitted at the Parent Organization level; therefore, one universe submission may include data for multiple contracts.
When will the monitoring activities begin? CMS will conduct this collection in three waves, with the first wave’s data request letters issued in September. Sponsors will receive a request from the TimelinessMonitoring@cms.hhs.gov mailbox with additional instructions on the time period being tested, how to submit data via the Secure File Transfer Protocol, deadline for submission (10 business days), and schedule information on validation webinars.
CMS will run a timeliness analysis on all validated universes and determine a rate-of-timeliness for each case type. Once the findings are reviewed, compliance actions may be necessary and may have implications for the Star Ratings data-integrity reviews for the two appeal measures.
It is imperative that sponsoring organizations have effective universe preparation processes in place to ensure valid data submissions. Data integrity continues to be a priority for CMS not only for Star Ratings and IRE data accuracy, but also for required Part C and D reporting.
We’re here to help you prepare—CODY’s expert guidance, monitoring support, and best practices for universe development helps address quality and identify potential risks. We also support clients by:
- Performing systems review to design universes: We have experience with HSP, QNXT, and many others. We can help map your data from your GUI to the backend tables and then to the universes.
- Evaluating universes for adherence to instructions: Our analysis tools provide detailed accuracy and quality checks of your universe files. We advise on data clean-up and recheck the files as many times as it takes to get it right.
- Reviewing timeliness standards: While your universes are in our analysis tool, we perform checks for timeliness against compliance standards and provide a detailed report of the results.
- Conducting mock webinars for accuracy: We act as CMS to ensure confidence when the actual webinar happens. We’ll share our tips for a successful webinar and make certain any problems are corrected before CMS reviews.
- Guiding FDRs in the timeliness monitoring requirements: We’ll work with your FDRs, review their data, and perform mock webinars with them as well.
CODY® has the team, expertise, and state-of-the-art technology to support health plan operations, improve performance, and ensure compliance with industry and regulatory standards. To learn more, contact us today for a consultation.
About CODY: CODY® works with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft® and Synchronicity™, our proprietary suites of software, are designed specifically for health plans. www.codyconsulting.com