Raising the Stakes in 2018, CMS Continues Focus on Appeals and Grievances

Debra Faulkner Debra Faulkner
Senior Product Manager, Government Solutions


Now, more than ever, it is crucial to be able to comprehensively track, manage and document appeals and grievances to CMS specifications so that you are ready for increased audits and avoid corrective actions on all non-compliant reporting and validation.

On average, 35 percent of a government-sponsored plan’s population will have an appeal and/or grievance (A&G). Resolution of these complaints causes a huge drain on resources, especially because many reach Level 3 status annually. Also at stake are Star Ratings because 40 percent of the criteria involve A&G and revenue loss due to penalties.

In 2018, the stakes will be even higher. CMS announced on December 12, 2017, that they will be conducting an industry-wide monitoring project, collecting data to evaluate the timeliness of processing Medicare Advantage (Part C) organizational determinations and reconsiderations and Medicare Prescription Drug (Part D) coverage determinations and redeterminations. Effective appeals processes by sponsors are a key focus area of the Part C and D programs. Both programs provide key beneficiary protection to access essential medical and/or prescription medication. The audits performed in past years have consistently identified performance issues in these areas.

So, who will be included in the audit review? Only those organizations with active contracts in both CY 2017 and CY 2018. All Pace, Medicare-Medicaid Plans (MMP), MSA, Employer/Union-only Direct (“E” Contracts) and 1833 Health Care Prepayment Plans (HCPP) will be excluded. This data collection will be a retrospective of 2017. Sponsors who underwent a program audit in 2017 will not have to resubmit data for this request if they successfully submitted the Coverage Determination, Appeals and Grievance (CDAG) and Organizational Determinations, Appeals and Grievance (ODAG) universes without any Invalid Data Submission (IDS) conditions and had at least one month of 2017 data for each of the universes listed.

Organizations will receive a data request email from CMS that will include all instructions, data submission processes and a list of the universe data sets that will be required within 15 business days (excluding federal holidays) after receiving the request.

Once data sets are received, CMS 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 system. If invalid data is found, sponsors will be required to resubmit data and undergo other validations. Failure to successfully submit universes may result in compliance actions by CMS.

If sponsors do not have adequate reporting and the ability to pull the requested compliance universes, they may face corrective actions early in 2018. Sponsors need to start planning now for this data event and ensure all their systems are able to pull data from March 2017 through May 2017 in the compliant formats.

Medecision’s Appeal and Grievance app and advisory services can help you automate processes for maximum effi­ciency, enabling proactive alignment with CMS regulations, while driving operational improvements, increasing cost savings and enhancing Star Ratings.

Request a demo today!

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