CMS Best Practices Review

September 5, 2012

Renee Wroth, Esq.Director of Compliance & Accreditation

CMS Best Practices Review

AGENDA

• About Health New England

• HNE’s “Best Practices”

• Preparing for a CMS Audit

• Lessons Learned

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About Health New England• Provider owned health plan in Western

Massachusetts

• Incorporated in 1985

• Lines of Business:o Commercial (FF/ASO)o Medicareo Medicaid

• Covering approximately 127,000 members

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HNE’s “Best Practices”• Strong culture of Quality, Accountability,

and Compliance • Dedicated Commitment to our Members• Dedicated Commitment to our

Employees• Dedicated Commitment to Improvement

(OFI and LEAN)

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HNE’s Commitment to Quality●1991 – First HMO in the nation to undergo

accreditation review by the National Committee for Quality Assurance (NCQA)

●2008 – HNE is ranked a Top 10 Commercial health plan in the annual ranking by NCQA (Status maintained in 2009, 2010, and 2011)

●2009 – HNE enters the Medicare Advantage Market

●2012 – HNE earns 5-Star designation from CMS

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HNE’s Commitment to Compliance

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HNE Medicare Workgroup Structure

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HNE’s Commitment to Members

• Transparent Sales Process• Employed sales staff with strict testing

requirements• Easy to Understand Plan Designs• Trend analysis on grievances and appeals• Focus on clear communication and ease of

useo Part D authorization extension processo Part D grievance responses in writingo Inclusion of clinical criteria, LCDs and/or lists of

available providers in denial letters8

HNE’s Commitment to Employees

• Selective Hiring Process (Integrity and Trust is a “price of admission” competency)• Opportunities for advancement and

transfer• High Performance Coaching Culture• Employee Engagement• Investment in training

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Preparing for a CMS Audit• Practical Matters

Space Computer and Phone Access/Support

• Preparing Your Documentation Follow the universe specifications precisely More is not always “better” Entrance presentation Scanned documents

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Preparing for a CMS Audit• Preparing Your Team

SMEs CEO and Executive Team Board Members PBM Late nights

• Preparing Your Organization Walk through Impromptu interviews Coverage for daily work Compliance reminders

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Lessons Learned•Preparation is key

•Always be in an “audit ready” state – use the universes!

•Compliance dashboards are important

• “NCQA” readiness is helpful but not enough

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