Prepare for Strategic Conversations with CMS

Updated January 10, 2024

The Centers for Medicare & Medicaid Services (CMS) released the 2024 Oversight Activities HPMS memo on October 24, 2023, to inform Medicare Advantage Organizations (MAOs) that Account Managers would conduct having strategic conversations in November. These conversations focused on validating that plans understand and have implemented the new utilization management (UM) rules that are effective January 1, 2024.

In addition to this memo, CMS published an update to the Program Audit Process on December 19, 2023, that outlined the new expectations surrounding audits and when plans should expect to receive engagement letters to help them prepare for audits.

Explore the background around these strategic conversations, how to prepare for an audit and when to start submitting information to CMS.

Recommendations to CMS

In September 2018 the Office of Inspector General (OIG) published Medicare Advantage Appeal Outcomes and Audit Findings Raise Concerns About Service and Payment Denials in which they stated that “high numbers of overturned denials upon appeal, and persistent performance problems identified by CMS audits, raise concerns that some beneficiaries and providers may not be getting services and payment that MAOs are required to provide.”

At that time, OIG made three recommendations to the CMS: “(1) enhance its oversight of MAO contracts, including those with extremely high overturn rates and/or low appeal rates, and take corrective action as appropriate; (2) address persistent problems related to inappropriate denials and insufficient denial letters in Medicare Advantage; and (3) provide beneficiaries with clear, easily accessible information about serious violations by MAOs.” 

Key Takeaway

According to the OIG’s findings, MAOs denied prior authorization and payment requests that met Medicare coverage rules by:

• Using MAO clinical criteria that are not contained in Medicare coverage rules.
• Requesting unnecessary documentation.
• Making manual review errors and system errors.

Four years later, the OIG had similar findings in their April 2022 report Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care in which they clearly identified their concerns and the areas in which plans should improve their processes. It suggested CMS take the following actions:

• Issue new guidance on the appropriate use of MAO clinical criteria in medical necessity reviews.
• Update its audit protocols to address the issues identified in this report, such as MAO use of clinical criteria and/or examining particular service types.
• Direct MAOs to take additional steps to identify and address vulnerabilities that can lead to manual review errors and system errors.

The evidence of continuing challenges prompted CMS to incorporate the OIG suggestions into the Medicare Program; Contract Year 2024 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly and to intensify their oversight of how plans deliver benefits to members and guarantee beneficiaries receive appropriate care when and where needed.

What should you expect from a strategic conversation with your plan’s CMS Account Manager and a potential audit?

Prep for Strategic Conversations and Audits

Know what changed and the impact to your organization. Be prepared to provide:

• Updated policies and procedures.
• Staff training materials and attestations of completed training.
• Staff monitoring, oversight, and feedback to prevent, detect, and correct potential manual and system errors.
• Provider training and communications reflecting updated authorization requirements and processes.
• Documentation of any necessary system updates.
• Results from internal oversight/audits validating compliance.
• Internal corrective action plans implemented.

Julie Mason, President at Integritas Medicare did a great job in her article New Medicare Advantage UM audits are coming...are you ready? describing the how to identify gaps in your UM processes in preparation for being audited.

Engagement Letters and Lookback Periods

In the December 19 update to the Program Audit Process, CMS stated they expect to evaluate the performance of plans serving 88% of the Medicare Advantage population. CMS will begin sending letters in January to plans that will be audited.

These audits will include a lookback period wherein a plan will need to submit information to CMS based on a specific time period. The normal lookback period is two to three months, so if you’re one of the earlier plans to receive your engagement letter, the time to execute the changes may be past.

The projected timeline for lookback periods is based on enrollment size and include:

• Less than 50,000 enrollees: Submit the 12-week period preceding, and including, the date of the audit engagement letter.
• Great than or equal to 50,000 but less than 250,000 enrollees: Submit the 8-week period preceding, and including, the date of the audit engagement letter.
• Greater than or equal to 250,000 but less than 500,000 enrollees: Submit the 4-week period preceding, and including, the date of the audit engagement letter.
• Greater than or equal to 500,000 enrollees: Submit the 2-week period preceding, and including, the date of the audit engagement letter.

Simply preparing for an audit isn’t sufficient. CMS requires plans to establish sustainable operational processes that are both efficient and compliant, guaranteeing timely access to care for all members. To accomplish this, it’s crucial to take intentional steps, establish clear expectations, utilize data, and secure leadership support. Adapting to change can be difficult, but embedding compliance and understanding within your team’s culture can be helpful. Encourage an environment in which asking questions and seeking understanding are the standard, and equip your team with the essential knowledge, training, and information to empower them and foster their professional development.

Healthmine has a team of subject matter experts with extensive operational and compliance expertise, ready to assist you in navigating these changes. We can provide real-time coaching, education, support, and training to help hardwire best practice workflows, activities, and interventions into your routine operations and infrastructure for continuous, sustainable success. For more information, please contact me at Cherie.Shortridge@healthmine.com.