CMS Five Star Best Practice Review Kaiser Foundation Health Plan Marcella Jordan, Vice President...

CMS Five Star Best Practice ReviewCMS Five Star Best Practice ReviewKaiser Foundation Health Plan

Marcella Jordan, Vice President

Medicare & Compliance Programs

September 5, 2012

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OverviewOverview

Background

Review Process & Protocols

Compliance Program Best Practices

BackgroundBackground

• For 2012, four of KFHP’s Medicare health plans were awarded an overall rating of 5 stars

– California, Colorado, Hawaii, and Northwest – Combined membership of over 900,000– Integrated health systems inclusive of health plan,

hospitals, and affiliated medical groupOperations largely decentralizedNational Compliance Program in place

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Review Process & Protocols: ApproachReview Process & Protocols: Approach

Formal notification received February 6, 2012 Conducted in two phases Compliance Program was only area reviewed on-site

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Phase 1 Phase 2Formulary and Benefit Administration Agent/Broker OversightPart D Coverage Determinations & Appeals

Late Enrollment Penalty (LEP)

Part C Organization Determinations & AppealsGrievancesPart C AccessCompliance Program Effectiveness

Review Process & Protocols: TimelineReview Process & Protocols: Timeline

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Review Process & Protocols: Preparation

Review Process & Protocols: Preparation

• Universe/supporting documentation request included with engagement letter

• Samples received just a few days in advance or on same day depending on element– Moving forward, sample selection to be provided on day of

audit

• Reviews conducted via webinar– Live “walk-though” of systems

• All documents uploaded through secure File Transfer Protocol (FTP)

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Review Process & Protocols: Challenges

Review Process & Protocols: Challenges

• Short turnaround times to produce:– Universes, supporting documentation

• Coordination (i.e. ensuring right people available at the right times)– Securing necessary information/files from vendors

• Technical difficulties– Viewing/opening large files via webinar– Navigating complex data systems in real-time– Playing audio recordings (e.g. OEV calls) over webinar

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Review Process & Protocols: Lessons Learned

Review Process & Protocols: Lessons Learned

• Secure leadership support to ensure adequate resources

• Have WebEx savvy people available to facilitate meetings

• Ensure electronic versions of documents are available for quick retrieval and effective archiving

• All hands on deck! 8

Compliance Program Best PracticesCompliance Program Best Practices

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• KFHP passed all eight Compliance Program elements– Seven OIG elements and

FDR

• Compliance Program was previously audited in Fall 2010

• Numerous best practices cited by CMS

Compliance Program Best PracticesCompliance Program Best Practices

Data Mining

• Analytic team dedicated to data mining

• Identifies patterns that suggest FWA; refers cases as appropriate

• Conducts ad-hoc studies based on tips

• Monitoring of claims paid in CMS-designated “high-risk Counties” 10

Compliance Program Best PracticesCompliance Program Best Practices

Tracking of FDR Training

• Training for our Medical Groups:– Offered through web-

based modules– Completion tracked at

individual level

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Compliance Program Best PracticesCompliance Program Best Practices

Compliance Hotline

• Receives 7,000 calls per year

• Integrated with case tracking system– System also tracks all

CAPs and disciplinary actions

– Controls allow for triaging and active monitoring of open cases 12

Compliance Program Best PracticesCompliance Program Best Practices

New CMS Issuance process

• Regulatory guidance is reviewed and internally disseminated• Implementation of new requirements tracked in a database

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Compliance Program Best PracticesCompliance Program Best Practices

Code of Conduct • Interactive website that allows employees to add comments or pose questions

• Site showcases policies, procedures, and compliance toolkits

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Contact InformationContact Information

Marcella Jordan, VP- Medicare & Compliance Programs

Kaiser Foundation Health Plan, Inc.2101 East Jefferson Street, 2WRockville, MD 20852Office: (301) 816-7178Mobile: (202) 744-0233marcella.jordan@kp.org

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Questions & AnswersQuestions & Answers

Thank you!

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