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CMS Best Practices Review

CMS Best Practices Review. September 5, 2012 Renee Wroth, Esq. Director of Compliance & Accreditation. AGENDA. About Health New England HNE’s “Best Practices” Preparing for a CMS Audit Lessons Learned. About Health New England. Provider owned health plan in Western Massachusetts

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CMS Best Practices Review

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  1. CMS Best Practices Review September 5, 2012 Renee Wroth, Esq. Director of Compliance & Accreditation

  2. AGENDA • About Health New England • HNE’s “Best Practices” • Preparing for a CMS Audit • Lessons Learned

  3. About Health New England • Provider owned health plan in Western Massachusetts • Incorporated in 1985 • Lines of Business: • Commercial (FF/ASO) • Medicare • Medicaid • Covering approximately 127,000 members

  4. 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)

  5. 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

  6. HNE’s Commitment to Compliance

  7. HNE Medicare Workgroup Structure

  8. 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 use • Part D authorization extension process • Part D grievance responses in writing • Inclusion of clinical criteria, LCDs and/or lists of available providers in denial letters

  9. 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

  10. 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

  11. 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

  12. 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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