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1/26/2015
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Effective Policies, Processes, and Oversight for the Preparation and Certification of Plan Reports and Bids
HCCA Managed Care Compliance Conference
– February 15, 2015
� Patrick Braley
� Partner
� Bennett Thrasher LLP
Blair Todt
SVP, Chief Legal & Administrative Officer
WellCare Health Plans, Inc.
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� Understand how to quarterback program reporting and bid submission processes including the gathering, corroboration, and certification of data from multiple sources
� Define the role of the Compliance Department in report and bid preparation and review
� Review common pitfalls and practical tips for implementing policies, procedures, systems, and controls to help mitigate the risk of audit failures if/when an audit is requested
� Program reporting and bids are two ways in which regulators assess the credibility of an MCO
� Reimbursement rates are establish and/or substantiated through information provided in reports and bids
� Inaccurate or incomplete reporting and bid submissions can have detrimental consequences to the reputation and financial conditions of an organization
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� Program-mandated submission of information pertaining to a plan or the MCO that
� Demonstrates plan performance
� Validates encounter data provided separately
� Allows for the performance of quality improvement analysis
� Reconciles plan data to program-level data
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� Program-mandated submission of information pertaining to a plan or the MCO that
� Communicates benefit packages and related modifications from year to year
� Substantiates rates or usage of capitation payments
� Discloses key assumptions behind actuarially-determined estimates and projections
� Cost / expenditure reports
� Rate-setting reports
� Encounter data reports
� Reconciliation reports
� Pharmacy claims and PDE reconciliation reports
� Fraud, waste, and abuse reports
� Other program-specific special reports
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� Financial performance details
� Medical loss ratios (MLR)
� Utilization metrics
� Encounter data
� Prescription drug event (PDE) data
� Actuarial projections and estimates
� Market
� Actuaries
� Health analytics department
� Encounters / claims processing
� Finance and accounting
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� Information technology
� Pharmacy department
� Third parties
� Sponsoring agency
� Healthcare consultant studies
� CMS
� Does the organization managed several plans?
� Do your plans have complex reporting requirements?
� Are financial, performance, and encounter data maintained in databases across multiple departments?
� Are the data gathering and report preparation and approval processes performed by different employees across different departments?
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To Ensure…
� Reports are reviewed, validated, certified, and approved prior to submission
� Accuracy, completeness, timeliness of submission, compliance with requirements
� Reasons for any conflicting data are documented
� Retention protocols are satisfied
� Regular training is administered
� Questions and issues are addressed promptly
� Regulatory Owner
� Data Source Providers
� IT Preparer
� Report Preparer
� Data gathering procedure audits
� Recognition of disciplinary actions upon non-compliance
� Executive level approval
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� Lack of or incomplete documentation of data gathering procedures
� Resolution of automated report “errors” and “warnings” not sufficiently documented
� Ineffective linkage of report data to report requirements
� Inability to recreate data sets in the future
� Utilization of outdated data gathering queries
� Data entry errors and inconsistencies
� Review and define requirements
� Define responsible parties
� Identify and define data sources and parameters
� Establish expectations for data preparation and review
� Review and obtain approval from responsible parties for previously specified data and representations
� Report certification and approval
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� Start as early as possible, e.g., plan negotiation stage
� Read report instructions
� Seek and document additional regulatory guidance / clarification, as necessary
� Document internal, interpretive guidance and decisions
� Identify Report Preparer as soon as possible
� Delegate data preparation and review responsibilities
� Communicate internal and external deliverables / deadlines, including interdependencies
� Involve appropriate departments to expedite and ensure accurate and complete data is gathered
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� Delegate data preparation and review responsibilities
� Define data sources and parameters
� Establish written protocols for obtaining and preparing data, e.g., business requirements
� Communicate expectations / deadlines
� Use a report template when possible
� Utilize written protocols to document how data was obtained and prepared, e.g., business requirements (Roadmap back to requirements and supporting documentation)
� Document internal reviews; Follow up on exceptions, as applicable
� Retain documentation to evidence what, how, and by whom information was prepared (Include approvals / signoffs)
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� Sub-certifications at data gathering level
� Ultimate certification by the responsible party
� Utilization of standard certification forms Confirmation of accuracy and completeness
� Early analysis of reporting requirements
� Roadmap of reporting requirements
� Sub-certifications of data
� Proactive communication of requirement changes
� Periodic assessment of propriety of queries
� Training and accountability measures
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� Document retention
� Quality control reviews
� Documentation of data gathering steps
� Centralized repository for reporting requirements, deadlines, responsible persons, sign-offs, etc.
� Documentation of reviews and certifications
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� Bids or responses to requests for proposals (RFPs) submitted to program sponsors for one or more of the following purposes:
� Market penetration
� Market expansion
� Plan renewal
� Substantiate rates
� Responses to RFPs
� Technical / Benefit Package Proposals
� Cost Proposals
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� Plan benefit package details
� Financial projection details
� PMPM build-up / substantiation
� Non-benefit expense extrapolation
� Quality performance narratives and scores
� Historical and projected utilization metrics
� Actuarial projections and estimates
� Promises
� Market
� Actuaries
� Health analytics department
� Encounters / claims processing
� Finance and accounting
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� Information technology
� Pharmacy department
� Third parties
� Sponsoring agency
� Healthcare consultant studies
� CMS
� Does the organization bid on plans frequently (both time and volume)?
� Are financial, performance, and encounter data maintained in databases across multiple departments?
� Are the actuarial analyses, data gathering, and report preparation and approval processes performed across multiple departments?
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To Ensure…
� Bids are reviewed, validated, certified, and approved prior to submission
� Accuracy and completeness of data and representations
� Timeliness of submission, compliance with laws, regulations, and other requirements
� Fair and ethical business/proposal practices are followed throughout bid submission process
� Regular training is administered
� Contracting Executive
� Protocol re: Preparation of the Covered Benefit Package
� Presentations and Interviews
� Post-Submission Practices
� Interacting with Government Customers
� Expense Exclusions
� Interacting with Third Party Consultants
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� Reference to outdated processes or practices
� Informal retention practices, e.g., documents / information retained by each department on separate shared drives instead of centrally retained
� Inconsistent responses, e.g., cross-referenced information or statements not updated
� Inability to subsequently demonstrate accuracy or support of narrative or performance-based statements
� Use of outdated data-gathering queries or utilizing queries / preparation activities designed for alternative purposes
� Ensuring timely review of relevant components and affording ample opportunity to research and address qualifying statements of business owner attestations / certifications
� Subject matter expertise
� Establishing and enforcing accountability
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� Consideration of Requirements
� Planning and Data Gathering
� Preparation and Review
� Bid Certification and Approval
� Read RFP in its entirety
� Participate in Q&A phase
� Internal assessment of economics and ability to deliver
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� Identify Contracting Executive as soon as possible
� Identify Bid Preparation Project Manager
� Delegation of data gathering responsibilities
� Documentation of specific steps to gather data
� Data compiled by Bid Project Manager
� Internal consistency reviews
� Roadmap back to RFP requirements and supporting documentation
� Legal and third-party consulting reviews
� Regular communication with and among Contracting Executive and data gatherers
� Executive review and sign-off
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� Sub-certifications at data gathering level (SME’s and their managers)
� Ultimate certification by the Contracting Executive
� Utilization of standard certification forms
� Confirmation of accuracy and completeness
� Early analysis of RFP requirements
� Roadmap of RFP requirements and responsible personnel
� Sub-certifications of data
� Proactive communication of policy, process, and procedure changes
� Evaluation of the propriety of established queries
� Training and accountability measures
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� Document retention
� Quality control reviews
� Documentation of data gathering steps
� Centralized repository for RFP requirements, deadlines, responsible persons, sign-offs, etc.
Questions???
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� Patrick Braley, Bennett Thrasher LLP
� pbraley@btcpa.net
� (678)218-1407
� Blair Todt, WellCare Health Plans, Inc.
� Blair.todt@wellcare.com
� (813)206-6833
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