Industry-Wide ODAG and CDAG Monitoring Activity

By Jen Sousa
If you have been through a CMS program audit in 2015 or 2016, you have gone through the rigors of a timeliness review of your Part C review-audit pngOrganization Determinations, Appeal, and Grievances (ODAG) and Part D Coverage Determinations, Appeals, and Grievances (CDAG) universes.  CMS incorporated the timeliness review into the audit protocols (referred to TODAG and TCDAG) to validate the accuracy of data universes and to measure timeliness in each of the audit areas.
Now, all Medicare Advantage and Prescription Drug Plans will experience the TODAG and TCDAG reviews, regardless of whether they are selected for a CMS audit this year.  CMS announced on November 28, 2016 that they are implementing an industry-wide timeliness monitoring activity related to Part C organization determinations and appeals and Part D coverage determinations and appeals.  They also sent an email to all plans on December 2, 2016 addressing common questions from the industry.  The goal of the monitoring activity is twofold: to evaluate the integrity and completeness of the Independent Review Entity (IRE) data, and the to improve the overall monitoring of compliance with ODAG and CDAG timeliness requirements.  Data integrity for appeals is of particular importance because all four Star Rating appeal measures use data reported by Sponsors to the IRE.  CMS considers data integrity issues, if identified, as an indicator that a contract’s measure data are invalid and cannot be used in the Star Ratings program.
Beginning January 9, 2017, CMS started collecting seven ODAG universes and ten CDAG universes from each contract to assess sponsors’ timeliness in processing both Part C and D requests, as well as sponsor compliance with forwarding cases to the IRE.  This monitoring activity will apply only to sponsors with active contracts in both 2016 and 2017.
So…what’s next?
First, if you haven’t yet been contacted by one of CMS’ contractors, you soon will be, with a request to submit the universes within 15 business days of the request.  Pay close attention to the universe instructions found in the 2016 CMS Audit Protocols, including the 2016 Audit Protocols Addendum, and make sure that each of the universes is completed according to the protocols.  The universe descriptions include specific instructions for field type, length, and description, as well as how to determine the dates for date fields.  Be sure to include all relevant data from your delegated entities in your universes as applicable.  If your organization went through a CMS Program Audit in 2016 and your universe review period included more than 30 days of 2016 data, it is only necessary to submit universes that were subject to an Invalid Data Submission (IDS) condition for this monitoring activity.
Once data are received, CMS’ contractors will review the data and schedule a validation webinar to ensure that the data provided in the universes match the data in the sponsor’s systems. If data are found to be invalid, sponsors will be required to resubmit data and undergo another validation. Failure to successfully submit universes may result in compliance actions by CMS.
Does this process sound familiar?  If you have been through a 2015 or 2016 program audit, you are probably experiencing deja-vu.  If you have not been through a CMS program audit in the past two years but have been routinely practicing universe preparation and validating your data, you are likely a tad nervous, annoyed that this activity will occur during a very busy time of year, but pretty confident you will get through the process relatively unscathed.  And if you haven’t been through a recent CMS program audit and also have not routinely practiced universe preparation and data validation, you are most likely in a state of panic and praying that CMS doesn’t select your plan for a while.   But there is a better way.  Call us.  Medicare Compliance Solutions can answer your questions, assist with universe preparation and validation, and conduct mock validation webinars to help you prepare for the real thing.  Don’t wait until it’s too late!

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