CMS Audits Aim For “Real Time” Reviews

In years past, the norm for CMS has always been to conduct retrospective audits – essentially a review of data from prior months’ (EX. CMS would arrive at the plan in October to review data from January through June).

Audits were primarily focused their efforts on universe pulls and standard operating procedures along with any known escalated events that came through their jurisdiction such as CTMs.

Moving forward CMS will be conducting audits of plans on a more "real time" basis. They are conducting more "focused" audits and they are keeping a tight view of all plan CTMs and their occurrences.

Also, MA plans are now directed to report more in-depth information to CMS beginning with HEDIS and other metrics. With this increased scrutiny of plans and Medicare Improvements for Patients and Providers Act's arrival in 2008, the theme of tighter monitoring continues to resonate throughout regulation for 2010.

As such, better procedures and business processes are no longer discussion points, but key elements in maintaining quality and compliance (see: The 2010 Call Letter, Marketing Guidelines, and Enrollment and Dis-enrollment Guidance).

As with any guidance and changes from CMS, the first step is indentifying what’s new, then moving forward with an analysis of how it will change your business; what it could add, change or remove for your processes.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.

Are You Ready? Updates From AHIP Conference

With Annual Enrollment (AEP) soon to be here are you ready?

As with prior years, CMS has issued an extensive readiness check list for plans to follow and guide them in preparation of the upcoming 2010 plan year. 

This year, with the multiple changes in regulation and continued scrutiny of marketing activities (see early post blog post from today), it is apparent there is much to do to ensure readiness on all fronts.  

CMS recommends plans self-audit so there are no surprises. 

While CMS has not provided the timeline for reporting readiness, as always, the sooner you begin the more confident you will feel. 

Support materials are from CMS available for download here. 

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.   

Improving Results, Everyday

Improving results, everyday. It's a pretty straight-forward goal.

As a member of the Merrill Corp. team, I've worked with customers both large and small in interpreting Healthcare and Insurance regulations, meeting CMS requirements and improving processes to make compliance a simple part of the process and not a "trip to the dentist" (nothing against dentists', mine is quite good!).

In this blog, I'll be talking about just those things. And hopefully providing a few good insights and things to consider along the way.

I'll hope you'll join me in discussing CMS Compliance, Healthcare and Insurance regulations, and meeting and improving operating goals. It's not exactly a movie review, but it does impact companies, their customers, and you everyday.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.