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CMS Begins ODAG and CDAG Timeliness Monitoring in 2017
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In an effort to improve the agency’s monitoring of compliance with organization determinations and reconsiderations and coverage determinations and redeterminations timeliness and appropriate appeal decisions, the Centers for Medicare & Medicaid Services (CMS) is launching a large-scale monitoring project.
All plans, with the exception of those who were audited in 2016 and had no Invalid Data Submission (IDS) conditions in their preliminary draft audit report, must submit Organization Determinations, Appeals and Grievances (ODAG) universes, Tables 1-7, and Coverage Determinations, Appeals and Grievances (CDAG) universes, Tables 1-10, to CMS. CMS will begin to request data on January 9, 2017.
Plans should follow the 2016 CMS Medicare Parts C and D Program Audit Protocols for populating the universes and submit data at a Parent Organization level. The time period for the universe data is February-April 2016. Universe size will be based on total enrollment across all contracts at the end of November 2016:
- Enrollment over 250,000 members – 1 month of data
- Enrollment of 50,000-250,000 members – 2 months of data
- Enrollment less than 50,000 members – 3 months of data
Once the data is received, CMS will review the data and schedule a validation webinar. If the data are found to not be valid, the plan will be required to resubmit the universes and undergo another validation. Failure to successfully submit universes that are accurate and complete may result in compliance actions by CMS.
Once the universes are validated, CMS will conduct timeliness calculations on all universes. Plans will be given 5 business days to rebut any areas of disagreement. Findings may result in compliance actions and may impact the plan’s Star Ratings data integrity review for the four appeals measures. Additional information on the Star Ratings integrity review will be included in the draft 2018 Call Letter for public comment.
In Related News
CMS recently announced a threshold for compliance and enforcement actions relative to a plan’s Part D Independent Review Entity (IRE) auto-forward rate, based on quarterly analyses of plan data (see table below). All 10 CDAG universes that CMS will review as part of their appeals timeliness monitoring effort contain IRE auto-forward data. CMS is also effectuating a compliance-to-enforcement escalation process in 2017. Plans who received a Notice of Non-Compliance (NONC) for exceeding the IRE auto-forward thresholds in the fourth quarter of 2016 and who exceed the threshold in the first quarter of 2017 may be issued a Letter of Warning (LOW). A plan who receives compliance notices over multiple quarters may ultimately face a CMP and enforcement action.
Table of Potential Compliance and Enforcement Actions
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A note from BluePeak: As part of our Universe Monitoring Service, BluePeak utilizes the same methodology as CMS will for the ODAG and CDAG Timeliness Monitoring. BluePeak can review your universes and conduct validation webinars prior to your data submission to CMS.
For more information, refer to HPMS memos:
- November 28, 2016, Industry-wide Appeals Timeliness Monitoring
- December 2, 2016, email, Revisions to Industry-wide Appeals Timeliness process
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CMS Revises Draft 2017 Audit Protocols
On Nov. 8, CMS released a revised version of the 2017 draft Medicare Parts C and D Program Audit Protocols for a 30-day comment period. In August, BluePeak provided a summary of significant changes from the 2016 CMS audit protocols to the initial draft 2017 CMS audit protocols. Below is a summary of significant changes from the initial to revised draft CMS 2017 audit protocols.
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Compliance Program Effectiveness
- Daily monitoring and auditing activities excluded from universes
Formulary Administration
Coverage Determination, Appeals and Grievances
- Call Logs Part D (CLD) universe –audit review period varies, depending on organization’s size
- Appointment of Representative (AOR) added to majority of CDAG universes to be more consistent with ODAG universes
- New value to denote approved Direct Member Reimbursements (DMRs) with no reimbursement due
Organization Determinations, Appeals and Grievances
- Call Logs Part C (CLC) universe –audit review period varies, depending on organization’s size
- Excluded cases (notice of admit, continued care decisions, etc.) language excluded from Table 1: Standard Organization Determinations (SOD) and Table 2: Expedited Organization Determinations (EOD) universes
- Receipt date and time for standard organization determinations that become expedited organization determinations clarified to be receipt of the request to expedite (for timeliness of expedited processing calculation)
Special Needs Plan – Model of Care
- Medicaid Medicare Plans (MMPs) removed, as MMP will have its own audit protocol in 2017.
Medication Therapy Management Pilot
- Elements II and III were combined into a single element; Element III was deleted.
- Deleted MTM-2015 universe
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Be Ready When the CMS Audit Bell Rings with
BluePeak’s Independent Call Log Review
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Weighing in at just 10 columns each, the Part C and Part D Call Logs universes have the potential to deliver a knockout punch to your CMS Program Audit score.
Prior to CMS adding the Call Logs universes to the Organization Determinations, Appeals and Grievances (ODAG) and Coverage Determinations, Appeals and Grievances (CDAG) universes in the 2017 Program Audit Protocols, CMS would request call logs to supplement small ODAG and/or CDAG universes.
CMS’ intent remains the same – to review the call logs to determine that:
- Grievances were appropriately classified;
- Member notification properly addressed the issue(s) raised in the grievance; and
- Incoming calls were appropriately classified as either organization or coverage determinations or grievances
Historically, responding to impromptu requests from CMS for call logs universes during a program audit, plans had difficulty pulling the necessary information from their systems and reviewing thousands of lines of data in a short timeframe.
BluePeak developed the Independent Call Log Review in response to:
- Seeing these difficulties firsthand, while assisting clients through actual CMS program audits;
- The inclusion of the ODAG and CDAG Call Logs universes in the CMS audit protocols; and
- CMS citing multiple Grievances conditions in recent audit reports.
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BluePeak’s seasoned consultants will thoroughly review your call logs against the most recent CMS Program Audit Protocols and guidance, as CMS would, while also streamlining thousands of lines of data down to hundreds of lines or less.
In addition to performing an Independent Call Log Review, BluePeak offers follow-up services to the plan, such as improving processes, developing and providing training, and monitoring. Interested plans can engage BluePeak to conduct an Independent Call Log Review as a singular project or as part of BluePeak’s Universe Monitoring Service or mock CMS Program Audit.
Don’t be down for the count when it comes to generating Call Logs universes. BluePeak’s Independent Call Log Review will help ensure your universes are ready when the CMS Program Audit bell rings.
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Come See Us at One of Our Events!
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Booth #11
Kim Mullins, Sr Consultant
January 29 - February 1, 2017 :: Scottsdale, AZ
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Babette Edgar,
Principal
and
Kim Mullins,
Sr Consultant
March 6-8 :: Nashville, TN
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Looking for your Free Consultation?
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