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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) [email protected]
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Questions & AnswersQuestions & Answers
Thank you!
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