CMS Audits of Health Plans: How to Avoid the Crisis David Orbuch Steve Lokensgard Agenda • Scope of CMS Audits of Health Plans • Preparing for an audit – Compliance Effectiveness Audits – RADV Audits – Operational End-to-End Audits • Drafting successful Corrective Action Plans 2 1 Scope of CMS Audits • One-third of plans must be audited every year – Medicare Modernization Act of 2003 (MMA), Pub. L. 108-173 – Section 1857(d)(1) of the Social Security Act • GAO Report in July of 2007 – CMS not hitting its target – Required audits of limited value – CMS not adequately funded for audits 3 Scope of CMS Audits 4 2 Scope of CMS Audits • 2010 – CMS continues its operational end-to-end audits, but shifts audit approach to more focused audits – CMS has begun auditing the effectiveness of compliance programs 5 Scope of CMS Audits • Focused Audits – – – – Compliance program effectiveness Agent/broker activities Appeals and Grievances SNP enrollment eligibility audits 6 3 Scope of CMS Audits • Risk Adjustment Data Validation (RADV) Audits • New Risk Adjustment Process fully implemented in 2007 • Expanded RADV Audits began in 2008 – 200 records – Increased number of Hierarchical Condition Categories (800) • Requirement to Extrapolate Error Rates 7 Preparing for the Audits • Consult references to help prepare for the CMS Audits • Medicare Part C and Part D Universal Audit Guide – Published in October of 2009 – Incorporates various source materials: • Applicable Federal Regulations • Medicare Managed Care Manual • Prescription Drug Benefit Manual – Ch. 4 – Marketing – Ch. 9 – Privacy – Ch. 15 – Compliance Plan 8 4 Compliance Program Effectiveness • Preparing for a Compliance Effectiveness Audit – 42 CFR 422.503(b)(vi) – Ch. 15 of the Universal Audit Guide 9 Corporate Responsibility and Compliance Program Mission: Ensure operational accountability for compliance with the obligations that govern our government business. This will be done through: • • • • 10 Clear outcome measures Standardized processes, tools and accountabilities Governance process and structure Tracking and oversight 10 Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. 5 Guiding Principles • Our program translates our values into actions • Business operational leaders are responsible for compliance • We will develop a strategy for effective compliance and support business leaders in implementing that strategy • Our regulatory relationships are fundamental for our organization’s success • We will create clear accountability around compliance and foster open, honest and clear communications about our outcomes 11 11 Any use, copying or distribution without written permission from UnitedHealth Group is prohibited. Corporate Responsibility & Compliance 12 12 6 Medicaid Compliance Program 13 Medicare Compliance Program 14 14 7 Program Evaluation Compliance Scorecard Measurement Framework: Structure x Process x Outcome = Effectiveness 15 Measurement Framework • Structure measures refer to the capacity of a health care organization to ensure compliance • Process measures refer to the manner in which an organization actually provides compliance coverage • Outcome measures refer to observable, measurable compliance outcomes 16 8 Scorecard 17 Preparing for the Audits • Operational End-to-End Audits • RADV Audits 18 9 Corrective Action Plans • GAO Report (GAO-10-36) issued December of 2009 relating to marketing noted shift in timelines relating to Corrective Action Plans (CAPs) • Between 1/2006 and 4/2008 – Days to CMS acceptance of CAP = 90 days – Days to implementation of CAP = 128 days • Between 5/2008 and 2/2009 – Days to CMS acceptance of CAP = 145 days – Days to implementation of CAP = 29 days 19 Corrective Action Plans • Tips to accelerate CMS acceptance and implementation of CAP – – – – – – Address Deficiency Cited Timetable for Correction Process for Validating Correction System for Ongoing Monitoring Progress Reports to CMS RO Involve RO Plan Manager Before Submitting Through HPMS • Further Applications of Corrections 20 10 Presenter’s Contact Information David Orbuch Chief Compliance Officer Public and Senior Markets Group UnitedHealth Group (952) 931-5958 Steve Lokensgard Special Counsel Faegre & Benson (612) 766-8863 SLokensgard@Faegre.com David.Orbuch@uhc.com 21 11