Ensuring CMS Compliance for Medicare Advantage Plans

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Case Overview

An established Midwestern commercial health insurer added a new line of business, a Medicare Advantage (MA) plan that went live on January 1, 2020. The client lacked experienced Medicare Advantage internal resources to perform the functions required for a MA plan. Similar to other health plans, the client decided to delegate many operational functions to external vendors. They engaged Change Healthcare Consulting—which routinely oversees this process for both new and existing plans—to provide delegation oversight and monitoring and auditing support for all contracted functions. The client wanted to ensure it had proper oversight of its delegated entities, and requested that the consulting team perform its annual compliance program effectiveness assessment.

Challenges

CMS requires both new and existing plans to perform ongoing oversight of any delegated function. Since the client had not yet conducted an audit of functions delegated to the vendors, the consultants reviewed dozens of delegated policies and procedures. Additionally, CMS requires an annual evaluation of the effectiveness of an MA plan’s compliance program. Due to a lack of internal resources, the client needed the consulting team’s assistance to review the performance of its delegates and perform the compliance program assessment.

Solutions

The consulting team evaluated all the operational policies of the client’s delegated entities to ensure compliance with CMS regulations. Many of the policies were outdated and contained inaccurate references to CMS regulations. The consultants then evaluated the client’s delegation oversight policies and structure, and recommended best practices.

The team performed a CMS-style mock audit of the client’s Organization Determinations Appeals and Grievances (ODAG) and Coverage Determinations Appeals and Grievances (CDAG)-delegated functions, and identified compliance issues that required corrective action plans. Lastly, the consulting team performed the annual compliance program effectiveness audit and identified additional areas for improvement.

Results

The team presented the client with several recommendations for correcting the delegation oversight policies and procedures. The team also provided a final mock audit report that identified compliance issues, turnaround time challenges, and Medicare operational process recommendations. They then trained the client’s internal resources on how to conduct oversight of delegated entities for future audits. The client immediately began corrective actions with its vendors to address these issues and help ensure CMS compliance.

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