Document 6498972

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
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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
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Scope of CMS Audits
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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
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Scope of CMS Audits
• Focused Audits
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Compliance program effectiveness
Agent/broker activities
Appeals and Grievances
SNP enrollment eligibility audits
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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
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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
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Compliance Program Effectiveness
• Preparing for a Compliance Effectiveness Audit
– 42 CFR 422.503(b)(vi)
– Ch. 15 of the Universal Audit Guide
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Corporate Responsibility and Compliance Program
Mission:
Ensure operational accountability for compliance with the
obligations that govern our government business. This will be
done through:
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Clear outcome measures
Standardized processes, tools and accountabilities
Governance process and structure
Tracking and oversight
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Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.
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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
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Any use, copying or distribution without written permission from UnitedHealth Group is prohibited.
Corporate Responsibility & Compliance
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Medicaid Compliance Program
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Medicare Compliance Program
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Program Evaluation
Compliance Scorecard
Measurement Framework:
Structure x Process x Outcome =
Effectiveness
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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
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Scorecard
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Preparing for the Audits
• Operational End-to-End Audits
• RADV Audits
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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
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Corrective Action Plans
• Tips to accelerate CMS acceptance and implementation of CAP
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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
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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
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