deconstructing the cms program audit - … the cms program audit ... we are your partner in...

DECONSTRUCTING THE CMS

PROGRAM AUDIT

Audit Cases

APRIL 2016

Copyright © 2016 Gorman Health Group, LLC

Government Programs

Leading enterprise of national consulting services and software solutions

for payers and providers.

Our Mission

Our mission, as the industry’s most active professional services consultancy and

provider of technology-based solutions, is to empower health plans and providers

to deliver higher quality care to beneficiaries at lower costs, while serving as

valued, trusted partners to government health agencies.

Washington, DC

Headquartered in Washington, DC, with more than 200 staff and contractors

nationwide with over 2,000 combined years of Government Programs experience.

Leadership

Deep payer and provider knowledge coupled with Centers for Medicare & Medicaid

Services (CMS) regulatory expertise.

Privately Owned

Founded in 1996

Gorman Health Group is the leading solutions and consulting firm

for government-sponsored health programs.

WHO IS GORMAN HEALTH GROUP?

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Our clients have one-stop access to expert advice, guidance, and support,

in every strategic and operational area for government-sponsored programs, across seven verticals.

CLINICALChanging how you approach Medical Management,

Quality and Stars.

PROVIDER INNOVATIONSSupporting network design and medical

cost control implementation.

OPERATIONSBringing excellence to every aspect of your

implementation from enrollment to claims payment.

COMPLIANCEOffering guidance and support in every strategic and

operational area to ensure alignment with CMS.

PHARMACYLeading experts in Part D, PBM, formulary

and pharmacy programs.

HEALTHCARE ANALYTICS & RISK

ADJUSTMENT SOLUTIONSImplementing cross-functional risk adjustment

programs for medical trend management and quality

improvement.

STRATEGY & GROWTHDriving profitable growth and member retention

through strategic marketing, sales, and product

development.

BROAD SERVICES

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• Scenario

o Mrs. K attempts to fill a prescription for Adacel prefilled syringe and is

told by the pharmacist this vaccine is not covered by her insurance.

o Mrs. K’s health plan’s marketed formulary shows Adacel is covered at

Tier 3.

• What factors need to be assessed to determine if the scenario

is compliant with CMS regulations?

AUDIT CASES

Case 1

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• Scenario

o Your organization has outsourced dental grievances and dental claims,

but your dental appeals are handled in-house.

• What issues can you expect to encounter when gathering your

universes, conducting universe validation, and during your

audit?

AUDIT CASES

Case 2

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• Scenario

o Health Plan A reviews daily rejected claims file provided by the PBM on

a daily basis.

o Member AB had claims reject at the point of sale on 3/24/16, 3/25/16,

and 3/26/16 for Missing Invalid National Provider Identifier (NPI).

o The claim was paid on 3/27/16.



AUDIT CASES

Case 3

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• Scenario

o Your Special Needs Plan Model of Care (SNP MOC) was approved by

NCQA.

o The MOC does not require you to do an Individualized Care Plan (ICP)

for every member, only those with multiple conditions.

• What factors need to be assessed to determine if your MOC is

compliant with CMS’ SNP MOC requirements?

• What is the best way to approach this with CMS after your audit

notice has been received?

AUDIT CASES

Case 4

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• Scenario

o JL is a renewing member with Plan X. He attempts to fill a prescription

on 1/1/2016 for Drug BB prefilled syringe at his retail pharmacy and is

told he must get an authorization.

o Drug BB is not on the CMS FRF.

o Drug BB is listed on the comprehensive formulary with a PA indicator.



AUDIT CASES

Case 5

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• Scenario

o Your Member Services Manager has determined the latest group of

employees to be hired into the Member Services Department were not

granted access to all of the call codes. Several individuals were missing

the “GR” code, which allows them to designate a member complaint as a

grievance.

• Now that the problem is identified, what should you do?

o CMS sends notice of a Program Audit, and the plan decides there isn’t a

risk associated with this issue.

• Is this scenario compliant with CMS regulations?

AUDIT CASES

Case 6

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• Scenario

o BB attempts to fill phenobarbital 30 mg tab, and it is rejected for PA at

the point of sale.

o BB has filled phenobarbital 15 mg the month prior without needing a PA.



AUDIT CASES

Case 7

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• Scenario

o Mrs. L calls Customer Service and expresses her dissatisfaction with

her doctor for refusing to prescribe an antibiotic for her chronic sinus

infections. She stated she didn’t want the plan to contact her doctor

regarding this, she simply wanted to complain, and she requested that

no one contact her about this.

o The plan honors the member’s request and does not officially file a

grievance, but since it is a potential Quality of Care issue, it is referred

to the Quality Department for investigation. No final letter is sent to the

member, per her request.

• Should this be listed as a grievance in the universe? If so, what

are the potential issues CMS may have with the way the plan

handled this situation?

AUDIT CASES

Case 8

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• Scenario

o Type of request: Coverage Determination Non-formulary Exception

o Drug Requested: Seroquel 25mg

o Date request received: 2/14/16 at 03:00 pm. Prescriber supporting

statement received 2/15/16 at 08:52 am.

o Clinical Decision: Case was denied due to lack of medical necessity.

o Notification: Oral notification was made 2/15/16 at 09:15 am. Written

notification sent 2/16/16 at 09:00 am.

o Prescriber: Dr. HS, Neurology

AUDIT CASES

Case 9

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• Relevant Case Information:

o Diagnosis: Psychosis NOS, Alzheimer’s, Confusion, dementia with

behavior disturbance and hallucinations

o Request does not state trial and failure of formulary agents

o Physician request stated:

Alternate drug previously tried but with adverse outcome. Patient is

complex with one or more chronic conditions, and patient is stable on

current drug with a high risk of significant adverse clinical outcome with

medication change.


AUDIT CASES

Case 9

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• Scenario

o Type of request: Expedited Non-formulary Exception

o Drug Requested: Depakote ER 500 mg tab

o Date request received: 2/19/16 at 11:01 am. Prescriber supporting

statement received 2/20/16 at 01:00 pm.

o Clinical Decision: Case was denied due to lack of medical necessity.

o 2 attempts were made to obtain additional information from the

prescriber (2/19/16 at 1:00 pm and 2/20/16 at 08:30 am).

o Notification: Oral notification was made 2/20/16 at 02:00 pm. Written

notification sent 2/20/16 at 04:00 pm.


AUDIT CASES

Case 10

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• Scenario

o Type of request: Standard coverage determination

o Drug requested: Megace Oral Suspension

o Diagnosis: Anorexia

o Plan X has approved PA criteria for megestrol oral suspension

o Based on the CMS-approved criteria for megestrol oral suspension,

member does not meet the PA criteria, and Plan X denies coverage

o Denial notification was timely and language appropriate indicating PA

criteria was not met

• Is this Scenario compliant with CMS regulations?

AUDIT CASES

Case 11

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• Is this denial language compliant with CMS regulations?

AUDIT CASES

Case 12

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• Scenario

o Type of request: Standard Coverage Determination

o Drug requested: Cyclosporine 100 mg caps

o Date request received: 2/12/16 at 11:06 am

o Time of plan decision: 2/15/16 at 08:52 am

o Clinical Decision: Case was denied due to coverage under Medicare

Part B for a Medicare-covered transplant


AUDIT CASES

Case 13

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Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including

Medicare managed care, Medicaid and Health Insurance Marketplace opportunities. For nearly 20 years, our unparalleled teams of subject-

matter experts, former health plan executives and seasoned healthcare regulators have been providing strategic, operational, financial, and

clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and

compliant operations within our client’s reach.

GHG offers software to solve problems not addressed by enterprise systems. Our Valencia™ software reconciles membership of more than 10

million members in Medicare, Medicaid and the Health Insurance Marketplace. Over 3,000 compliance professionals use the Online

Monitoring Tool™ (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 25,000 brokers and sales agents

are certified and credentialed using Sales Sentinel™. In addition, hundreds of health care professionals are trained each year using Gorman

University™ training courses.

We are your partner in government-sponsored health programs

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WAYNE MILLER

Senior Director, Pharmacy Services

18

570.244.6859

[email protected]

CARON WINGERCHUK

Senior Director, Pharmacy Services

480.492.3852

[email protected]


Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including

Medicare managed care, Medicaid and Health Insurance Marketplace opportunities. For nearly 20 years, our unparalleled teams of subject-

matter experts, former health plan executives and seasoned healthcare regulators have been providing strategic, operational, financial, and

clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and

compliant operations within our client’s reach.

GHG offers software to solve problems not addressed by enterprise systems. Our Valencia™ software reconciles membership of more than 10

million members in Medicare, Medicaid and the Health Insurance Marketplace. Over 3,000 compliance professionals use the Online

Monitoring Tool™ (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 25,000 brokers and sales agents

are certified and credentialed using Sales Sentinel™. In addition, hundreds of health care professionals are trained each year using Gorman

University™ training courses.

We are your partner in government-sponsored health programs

T

E

T

E

BETH MATEL

Senior Director, Compliance Solutions

19

520-237-2508

[email protected]

LIZ BROWNING

Senior Consultant, Compliance

Solutions202-657-7919

[email protected]

deconstructing the cms program audit - … the cms program audit ... we are your partner in...

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