cms five star best practice review

CMS Five Star Best Practice ReviewKaiser Foundation Health Plan

Marcella Jordan, Vice President

Medicare & Compliance Programs

September 5, 2012

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Overview

Background

Review Process & Protocols

Compliance Program Best Practices

Background

• For 2012, four of KFHP’s Medicare health plans were awarded an overall rating of 5 stars

– California, Colorado, Hawaii, and Northwest – Combined membership of over 900,000– Integrated health systems inclusive of health plan,

hospitals, and affiliated medical groupOperations largely decentralizedNational Compliance Program in place

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Review Process & Protocols: Approach

Formal notification received February 6, 2012 Conducted in two phases Compliance Program was only area reviewed on-site

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Phase 1 Phase 2Formulary and Benefit Administration Agent/Broker OversightPart D Coverage Determinations & Appeals

Late Enrollment Penalty (LEP)

Part C Organization Determinations & AppealsGrievancesPart C AccessCompliance Program Effectiveness

Review Process & Protocols: Timeline

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Review Process & Protocols: Preparation

• Universe/supporting documentation request included with engagement letter

• Samples received just a few days in advance or on same day depending on element– Moving forward, sample selection to be provided on day of

audit• Reviews conducted via webinar– Live “walk-though” of systems

• All documents uploaded through secure File Transfer Protocol (FTP)

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Review Process & Protocols: Challenges

• Short turnaround times to produce:– Universes, supporting documentation

• Coordination (i.e. ensuring right people available at the right times)– Securing necessary information/files from vendors

• Technical difficulties– Viewing/opening large files via webinar– Navigating complex data systems in real-time– Playing audio recordings (e.g. OEV calls) over webinar

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Review Process & Protocols: Lessons Learned

• Secure leadership support to ensure adequate resources

• Have WebEx savvy people available to facilitate meetings

• Ensure electronic versions of documents are available for quick retrieval and effective archiving

• All hands on deck! 8

Compliance Program Best Practices

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• KFHP passed all eight Compliance Program elements– Seven OIG elements and

FDR

• Compliance Program was previously audited in Fall 2010

• Numerous best practices cited by CMS

Compliance Program Best Practices

Data Mining

• Analytic team dedicated to data mining

• Identifies patterns that suggest FWA; refers cases as appropriate

• Conducts ad-hoc studies based on tips

• Monitoring of claims paid in CMS-designated “high-risk Counties”

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Compliance Program Best Practices

Tracking of FDR Training

• Training for our Medical Groups:– Offered through web-

based modules– Completion tracked at

individual level

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Compliance Program Best Practices

Compliance Hotline

• Receives 7,000 calls per year

• Integrated with case tracking system– System also tracks all CAPs

and disciplinary actions– Controls allow for triaging

and active monitoring of open cases

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Compliance Program Best Practices

New CMS Issuance process

• Regulatory guidance is reviewed and internally disseminated• Implementation of new requirements tracked in a database

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Compliance Program Best Practices

Code of Conduct • Interactive website that allows employees to add comments or pose questions

• Site showcases policies, procedures, and compliance toolkits

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Contact Information

Marcella Jordan, VP- Medicare & Compliance Programs

Kaiser Foundation Health Plan, Inc.2101 East Jefferson Street, 2WRockville, MD 20852Office: (301) 816-7178Mobile: (202) 744-0233marcella.jordan@kp.org 15

Questions & Answers

Thank you!

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