Appeals and IRE Data Issues Can Impact Audit Scores, Star Ratings and CMPs  

By March 6, 2018CDAG, CMPs, ICARs, IRE, ODAG

Whether deficiencies are discovered as part of a CMS program audit or a Timeliness Monitoring Project (TMP) review, issues with appeals and Independent Review (IRE) data can impact a plan’s Star Ratings and result in CMS enforcement actions, including Civil Money Penalties (CMPs).

Program Audit Impact

Examples of appeals and IRE deficiencies found during CMS program audits include:

  • Sponsor failed to process expedited pre-service reconsiderations with 72 hours (Organization Determinations, Appeals and Grievances (ODAG)).
  • Sponsor did not appropriately auto-forward coverage determinations and/or redeterminations (standard and/or Expedited) for review and disposition within the CMS-required timeframe (Coverage Determinations, Appeals and Grievances (CDAG)).

These conditions are almost always cited as Immediate Corrective Actions Required (ICARs) by CMS, and at 2 points each, can quickly increase a plan’s overall audit score. The CDAG condition has been a common condition the past 5 of 7 years, and as such, can add to the total program audit CMPs levied on a plan. CMS considers common conditions to be an aggravating factor when calculating CMPs. Aggravating factors are levied per determination at a base of $25,000, adjusted upward annually. The adjusted amount for aggravating factors per determination in 2017 was $34,794.

Star Ratings Impact

CMS began the TMP in 2017 as a way to measure timeliness, IRE auto-forwards and data integrity for related Star Ratings measures, outside of the standard program audit.

The specific Star Ratings measures that rely on data collected by CMS during TMP and program audits are weighted at a value of 1.5 each and include:

  • Part C Domain 5: Health Plan Customer Service
    • C32 – Plan Makes Timely Decisions About Appeals
    • C33 – Reviewing Appeals Decisions
  • Part D Domain 1: Drug Plan Customer Service
    • D02 – Appeals Auto-Forward
    • D03 – Appeals Upheld

CMS’ policy is to reduce a contract’s measure rating to 1 Star If CMS finds the measure score to be based on inaccurate or biased data. Inaccurate or biased data can result from inappropriate processing, such as a plan’s error in processing coverage and organization determinations and appeals. As mentioned in the “Highlights of CMS-Proposed Changes in Draft 2019 Call Letter” article in this newsletter, CMS proposes to employ a scaled Star Rating reduction, based on the degree of missing IRE data from the TMP review, to the appeal measures.

Plans in the 2018 third and final wave of the TMP have until March 26 to submit their subset of CDAG and ODAG universe data to CMS. Two plans received CMPs totaling $63,200 ($59,600 and $3,600) for deficiencies found during the 2017 TMP.

BluePeak conducts mock TMP reviews and provides support for clients during actual TMP reviews. We also assist clients with strategies to improve their Star Ratings. Contact us today to learn more.