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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