ANNUAL RISK ASSESSMENT
Sponsors are required to conduct a formal baseline assessment of their major compliance and FWA risk areas and this is one of the key compliance activities CMS reviews in program audits. Our best-in-class Medicare annual risk assessment ensures that your compliance program includes all of the required components, and that processes can be implemented within your unique organizational structure.
Engaging our team of seasoned Medicare Advantage and Part D experts allows you to identify and address issues before they lead to corrective action plans, validation audits, or even enforcement actions such as civil monetary penalties or suspension of marketing and enrollment.
APPLICATIONS FOR MA-PD
The CMS application process is time and labor-intensive, requiring laser attention to detail. Many entrants in the Medicare Advantage and Part D market find the process overwhelming, but it doesn’t have to be.
MCS provides an organized and efficient application process, creating a work plan specific to the type of contract(s) you plan to offer. We’ll manage everything from collection or creation of the required documents, to the review, completion, and submission to CMS.
We know the answers to even the hardest questions. If an issue does arise for which there isn’t a ready answer, we’ll contact our colleagues at CMS, with whom we have strong and trusted relationships.
In the many years that the experts at MCS have been preparing and assisting with applications, not one of those applications has been denied.
Enforcement actions by CMS have doubled since 2012. Civil monetary penalties are getting larger, and more and more plans are subject to suspension of marketing activity and enrollment.
While CMS has been publishing its audit protocols, requirements and expectations for the past five years, essentially giving out the answers to the test, many Medicare Advantage and Part D plans still receive poor CMS audit results. This is because many don’t have the resources or experience to create viable internal audit programs themselves.
Based on your structure, performance and budget, MCS will work with you to create a highly effective audit program from the ground up, or from your existing program. We can conduct the auditing and monitoring activities while training your team to execute independently in the future, or simply provide the program for your team to implement on its own.
CMS AUDIT PREPARATION SERVICES
The CMS audit process is complex and dynamic. Although CMS releases its updated audit protocol to the industry each year, many organizations still don’t know what to expect or how to prepare.
The MCS team has years of experience participating in CMS audits, either as CMS regulators in charge of conducting audits, or as seasoned Medicare health plan veterans who have successfully navigated through CMS audits. Our deep experience and direct knowledge will result in a smoother audit and a more successful outcome.
Let MCS guide your compliance and operational staff through the audit preparation process to make sure they are well informed and ready. We provide a range of targeted services to help you and your team prepare:
• Training on the CMS audit process
• How to compile universes for the audit
• Reviewing and revising operational policies and procedures and other documentation that CMS requests prior to, or during, the audit
• Mock webinars with operational and compliance staff to review and discuss sample cases prior to the CMS live webinars
• Mock interviews with operational staff to prepare them for possible questions from the CMS audit team
• Onsite, behind-the-scenes help and guidance responding to CMS’ questions during the webinars and on site compliance portion of the CMS audit.
Medicare Advantage and Part D organizations are required by CMS to audit and monitor the First Tier, Downstream and Related Entities (FDRs) involved in the administration or delivery of Medicare Part C and Part D benefits. This has been an increasing area of scrutiny by CMS in recent years.
We will create and implement FDR oversight programs that fully document your compliance to present to your Board of Directors and CMS. At the end of the project you’ll have a comprehensive program that includes monitoring, auditing, and other oversight activities at all levels (operational, compliance and executive oversight) as well as review tools, policies and procedures.
Losing a key staff member in Medicare Advantage and Part D operations or compliance is disruptive and leaves your organization at risk. Given the complexity of the Medicare Advantage and Prescription Drug programs, it can be hard to find replacement candidates who can hit the ground running.
Let MCS fill the gap by embedding a subject matter expert into your organization for as long as you need, on site or virtually. We can also help interview replacement candidates and train them once hired. We’ll work to ensure a smooth and effective transition from our seasoned professional to your new colleague.
Our experts have served as interim Medicare Compliance Officers, Directors of Enrollment, and Directors of Appeals and Grievances, among other positions, for periods of a few weeks to many months. Our Medicare industry veterans bring a wide variety of expertise:
• Appeals and grievances
• Claims processing
• Delegation oversight
• Medicare compliance and FWA
• Member services
• Medicare Advantage operations
• Part D operations
• Process reengineering
• Project management
• Systems training
• Utilization management and quality assurance
Non-compliant marketing materials continue to be a hot spot for CMS and have been cited in many enforcement actions over the past few years. Medicare marketing material requirements started as a 36-page set of guidelines in the 1990s, but have since ballooned into more than 120 pages of sometimes arcane guidance on everything from disclaimers to testimonials. And in 2018 the marketing guidelines were changed to distinguish between marketing and communications materials.
Many organizations feel ill-equipped to develop materials that can pass muster with CMS given such broad and complex requirements. Add to that the seasonal time crunch of creating and distributing materials in the fall for the coming benefit year and you have a recipe for high stress at best - enforcement actions at worst.
Let MCS ease the stress by helping you develop and review your marketing materials for compliance during AEP and throughout the year.
CMS requires organizations to conduct ongoing monitoring to determine whether their internal Medicare Advantage and Part D operations are compliant with requirements.
Your organization has a considerable amount of data –much of which is accessible by CMS– which is the first line of sight into operational and accessibility issues. Without a comprehensive monitoring program in place, however, the advantage of identifying non-compliance early is lost. Small problems can become serious deficiencies that remain undetected until an audit.
Let the experts at MCS help. We have experience creating monitoring programs and compliance dashboards that harness the information necessary to provide compliance status at-a-glance to your compliance officers and senior management.
NEW MEDICARE ADVANTAGE PLAN IMPLEMENTATION
It’s only after an initial or service area expansion application has been submitted to CMS that the real work begins. It takes knowledge, experience and an investment of considerable resources to implement a compliant Medicare Advantage and Part D program.
At MCS, we have extensive experience managing the implementation process from CMS contract award to go-live and beyond. We will create a work plan based on the specific needs of your organization, providing a detailed account of the requirements, costs, expected risks, and schedules necessary to successfully implement your new program or expansion.
POLICIES AND PROCEDURES
A strong operation is built on detailed and compliant policies and procedures (P&Ps). Whether you’re creating new P&Ps, or it’s simply time to elevate your current practices to best in class, we have the expertise you need in all operational areas of Medicare Advantage and Prescription Drug Plans.
Let MCS review your current P&Ps to determine whether they meet CMS requirements. Our experts can then help you to refine or create new practices based on HPMS memos, CMS manual chapters, and regulatory guidance. Finally, we’ll work with your staff in all functional areas to ensure the new or revised P&Ps are implemented efficiently, without redundancy or inconsistency between departments.
PRESCRIPTION DRUG PLAN (PART D) SERVICES, SUPPORT AND SURVEILLANCE
A constantly changing maze of requirements makes the Part D program exceptionally challenging to manage. We can demystify Part D administration and regulation, and provide you with industry best practices to make sure you’re compliant.
MCS can decipher the barrage of data from CMS for Coordination of Benefits (MARxCOB), FIR/ATBT, Nx transactions, and High-Risk Pharmacy and PDE responses. We can also de-construct and translate Part D-related HPMS memoranda into actionable procedures.
Part D activities performed by Pharmacy Benefit Managers (PBMs) are not transparent. Their formulary administration test plans aren’t tailored to your benefit plan design. PBMs make mistakes with rebate allocation and pricing adjudication, while fraud, waste and abuse surveillance is often minimal. Issues like these require diligent and robust oversight.
Let MCS help. We offer a menu of Part D operational and PBM oversight services:
• Assistance with the PBM procurement process, including writing the request for proposal, scoring PBM capabilities, and negotiating pricing and performance guarantees. This provides you with insight into the strengths and weaknesses of the PBM.
• Pre-implementation due diligence and post-implementation oversight, should the client decide to change PBMs.
• Training of health plan staff to identify anomalies that may put your program in jeopardy of non-compliance by reviewing and testing claims.
• Coaching health plan staff on management and interpretation of Part D related data, whether the source is CMS or your PBM.
• Train staff on coverage determinations and formulary management.
• Meticulous preparation of your staff for a CMS audit.
Because CMS bombards our industry with frequent, sometimes daily, changes to requirements, organizations must be able to implement guidance quickly and effectively. The experts at MCS can refine, reengineer and streamline your processes to achieve greatly improved quality, efficiency, compliance and profitability.
The MCS approach:
• Organize around outcomes, not tasks;
• Identify all processes, then prioritize in order of redesign urgency;
• Integrate information into the real work that produces the information;
• Treat geographically dispersed resources (the new virtual world) as though they were centralized;
• Put the decision point where the work is performed, and build control into the process;
• Capture information once and at the source;
• Base changes on industry best practices.
Ongoing training of new and experienced employees is crucial for organizational growth and success. It is also the starting point to achieve and maintain regulatory compliance. MCS offers training in all areas of the Medicare Advantage and Prescription Drug programs.
Our curricula can be delivered in person, via webinar, or in electronic format for upload to your in-house training software for self-directed learning. Our content is continually updated to reflect requirements related to Medicare Advantage and Part D job functions, including but not limited to:
• Medicare Advantage Basics
• Enrollment and Disenrollment
• Medicare Sales and Marketing, basic and advanced
• Call Center Basics
• Classifying Inquiries, Grievances, Determinations and Appeals
• CMS Payment Basics
• Medicare Compliance and Fraud, Waste and Abuse
• Medicare Advantage: Provider Compliance
• Medicare Advantage: Provider Networks
• Medicare Advantage: Quality Management and Utilization Management
• Medicare Health Plan and PDP: Fraud, Waste, and Abuse
• Medicare Part D: Bid and Benefit Package
• Medicare Part D: Coordination of Benefits and True Out-of-Pocket Facilitation
• MAPD: Risk Adjustment and Data Validation