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MOCK DATA – DOES NOT INDICATE REAL INFORMATION
MEDICARE COMPLIANCE REPORT
1
CMS Past Performance Methodology (PPM) Current Predicted PPM Scores for 2016 Application Cycle – December 1, 2014
Overview of PPM
- Past Performance scores impact Plan Sponsors ability to continue to grow our business (service area expansions, new contracts/plans).
- Legal Entities are outliers when a certain number of past performance points are assessed for Part C or Part D:
Part C = 4 past performance points Part D = 5 past performance points
- There are 11 categories in PPM; the following 2 categories are Plan Sponsors main areas of focus: Performance Area Negative Performance Points Value
Compliance Letters (Notices of Non-Compliance, Warning Letters, and Corrective Action Plans (CAPs))
1-2 points
Performance Metrics (Star Ratings) 2 points for each contract with 2.5 Stars or below
Current Predicted Legal Entity Outliers & Watch List - 1 Legal Entity currently predicted to be PPM outlier due to Star Ratings & LPI Designation. - 2 Legal Entities currently “at risk” to become a PPM outlier and are high priority. - 1 Legal Entities on our internal “watch list” due to points being assessed in one category. - 18 Legal Entities total, we are monitoring all but remaining are not currently predicted or considered high
risk for PPM outlier status. Current Legal Entities Predicted for Past Performance Methodology Outlier Status
(Based on 2015 Star Ratings these entities have low Star Ratings for at least 3 years and are automatically a PPM outlier)
Legal Entity Contracts Impacted
Total Members
PPM Category resulting in Negative Points Assessed
Reason for Assessment of Negative Points
Predicted PPM Score
ABC HXXX 12,000 Compliance Letters Performance Metrics (Star
Ratings)
Receipt of Ad Hoc CAPs (2 pts)
2.5 Part C Star Rating for 2015 (2 pts)
4/4
Current Legal Entities Predicted AT RISK for Past Performance Methodology Outlier Status (Based on Compliance assessment of known issues/risks, these entities could become a PPM outlier if additional CMS Compliance
Notices are received prior to 2/28/15)
Legal Entity Contracts Impacted
Total Members
PPM Category resulting in Negative Points Assessed
Reason for Assessment of Negative Points
Predicted PPM Score
DEF HXXX 80,000 Performance Metrics (Star
Ratings) 2.5 Part C Star Rating for
2015 (2 pts) 2/4
3 Compliance Notices received YTD; predicting 4 Notices of Non Compliance could be received. If all predicted are received, entity would be PPM outlier.
GHI HXXX 130,000 Compliance Letters Multiple NONCs received YTD. 2/4
Current Legal Entities on WATCH LIST for Past Performance Methodology Outlier Status (Based on Compliance assessment of known issues/risks, these entities are not likely to become a PPM outlier unless we experience
significant unanticipated compliance issues or CMS changes the scoring methodology)**
Legal Entity Contracts Impacted
Total Members
PPM Category resulting in Negative Points Assessed
Reason for Assessment of Negative Points
Predicted PPM Score
JKL SXXX 95,000 Compliance Letters Multiple NONCs received YTD 2/5
CMS 2016 Application Cycle Past Performance Review Methodology: Review Period 1/1/14-2/28/15
Part C Performance Area Negative
Performance
Points
HXXX1
State
HXXX2
State
HXXX3
State
HXXX4
State
HXXX5
State
HXXX6
State
HXXX7
State
HXXX8
State
HXXX9
State
Compliance Letters
Notice of Non-Compliance 1 0 1 0 1 2 0 0 1Warning Letter 3 3
Warning Letter with a Business Plan 4CAP – Ad hoc compliance event 6
sub-total 0 1 0 1 5 0 0 1 0
Compliance Letter Scores:
90th -100th percentile: 2 pts
80th - <90th percentile: 1 pt
Current Part C thresholds:
90th percentile – 7
80th percentile – 5
Max 2 pts 1
Performance Metrics C/D: A summary star
rating score of less than 3.0 is automatically 2
pts.
Max - 2 pts. 2
Multiple Ad Hoc CAPs Max - 1 pt
Ad Hoc CAPs with Beneficiary Impact - 1
pt. per CAPNo Max
Financial Watch List Max 1 pt.
One-Third Financial Audits (Adverse
Opinion or Disclaimed Results) Max 1 pt.
Program audit Max 1 pt.Exclusions Max 4 pts 0 0 0 0 0 0 0 0 0
Medicare & You Handbook 1On-Line Enrollment Center 1
Formulary Update 1 or 2
LIS Reassignments/Auto-Enrollees:
Subsequently lifted: 2 points
Ongoing: 3 points
N/A
Enforcement Actions Intermediate
Sanctions Civil Money Penalties (CMP)
Immediate: 3 points lifted/7 points ongoing
a. Non Immediate: 2 points lifted/6 points
ongoing
b. CMP of any amount: 1 point
No Max
Terminations
a. CMS-Imposed: 8 points
b. Disruptive Mutual: 4 points
c. Non-Disruptive Mutual: 1 point
Max 8 pts
Outstanding Compliance Concerns Not
Otherwise Captured Max 5 pts
Contract Totals
Part C Threshold: 4 = Outlier0 0 0 0 1 2 0 0 0
MOCK DATA -- FOR EXAMPLE ONLY
10/1/14: (2 Points) Part C Stars < 3.0 - HXXX6
1/15/14: NONC (1 point) HXXX2, HXXX4, HXXX5, & HXXX8 Part C&D Event Upload. Failure to notify CMS of scheduled marketing events timely (7 calendar
days).
Note: Thresholds are based on percentiles published in the 2015 Application Cycle PPM and are likely to change when recalculated for the current review period.
Medicare Compliance 12-9-2014
MOC
ICARs - 0
CARs - 2
Obs - 1
FA
ICARs - 2
CARs - 0
Obs - 2CDAG
ICARs - 0
CARs - 4
Obs - 2
ODAG
ICARs - 0
CARs - 0
Obs - 3
CPE
ICARs - 0
CARs - 3
Obs - 0
Audit Readiness Dashboard
Q4 2014
As of December 21, 2014
MOCK DATA – EXAMPLE ONLY
Medicare Compliance Q3 Audit Readiness ReportMOCK DATA – For Example Only
1
Issue Brief description of issue/root cause Remediation Opened Status
1
CMS Audit
Readiness –
Summary
(Update)
Status of previous Internal Mock Audit CAPs totaling 6 (Update)
• 1 findings was an ICARs in xxxx and was remediated within 1
week
• 2 of the 5 CARs are in-process of being remediated and
should be fully implemented in Q4
Internal Compliance Mock Audits (New)
5 CARs identified through Mock Audits
• XYZ Dept (2) -- Issues with……………………………………..
• ABC Dept (1) – Issues with………………………………………..
• ZZZ Dept (2) – timely processing of member notification
1 CAR – identified through validation audit procedures for xxxxx
department
KPIs/Monitoring – Compliance Issues (New)
• AAA Department – failed to …………………………– repeat issue
• Compliance substantially achieved in October
Previously Reported Mock Audits (Update)
• 2 of the 5 findings have been
remediated as per department
management (validation audit to be
scheduled)
Internal Compliance Mock Audits (New)
• Technical consultants engaged by
Medicare Operations to assist in
testing processes and implementing
revisions in XYZ department to achieve
sustainable compliance
• ABC Dept – CAPs in progress
• ZZZ Dept – CAPs in progress
KPIs/Monitoring (New)
• Corrective actions implemented; issue
has been fully remediated.
Ongoing Ongoing
Audit Readiness ICARs and CARs
• CMS audits always result in findings. CMS audit findings are categorized as either a Corrective Action Required (CAR) or Immediate Corrective Action
Required (ICAR). The main difference is ICARs are considered to have potential or actual member impact.
• ICARs are the most significant findings. Plans with 3 to 4 (or more) ICARs in 2012 audits received civil monetary
penalties or sanctions; CMPs started at $50,000.
• Best performing plan in 2012 had 19 CARS and 0 ICARs.
CMS Program Audit - UHC Audit Readiness ProgramDashboard of ResultsAs of December 1, 2015 - DRAFT
MOCK DATA USED - INFORMATION PROVIDED IS NOT REAL. 1
Overall UnitedHealthcare Medicare & Retirement 1.64
Audit Elements ICAR CAR OBSV Total UHC Business Area(s) FDRPart D Formulary & Benefit Administration
Formulary Administration 0 1 1 1
Transition Benefit 1 1 0 3Part D Website 0 0 0 0P&T Committee 0 0 1 0
1.25
Part D Coverage Determinations, Appeals & Grievances
Effectuation Timeliness 0 3 2 3
Clinical Decision Making 1 1 3 3
Grievances 0 2 1 2 N/A
2.67Part C Organization Determinations, Appeals & Grievances Effectuation Timeliness 0 0 2 0
Clinical Decision Making 0 1 0 1Dismissals 0 3 2 3Grievances 1 0 1 2
1.50
Special Needs Plans - Model of Care Implementation
Population to be Served - Enrollment Verification 0 1 0 1 Operations N/A
Health Risk Assessment (HRA), Interdisciplinary Care Team (ICT), Implementation of the Individualized Care Plan (ICP) and Use of Evidence-Based Clinical Guidelines
0 4 3 4 Clinical N/A
Plan Performance Monitoring and Evaluation of the MOC 0 1 2 1Quality
N/A
2.00
Compliance Program Effectiveness
Written Policies & Procedures 0 0 0 0Compliance Officer, Compliance Committee & High Level Oversight
0 0 0 0
Effective Training & Communication 0 1 1 1Effective Lines of Communication 0 0 1 0Enforcement of Well-Publicized Disciplinary Guidelines
0 0 0 0
Effective System for Routine Monitoring, Auditing, and Identification of Compliance Risks 0 1 2 1
Procedures and System for Promptly Responding to Compliance Issues
0 1 3 1
Sponsor Accountability and Oversight of FDRs 0 1 5 1Effectiveness Measure 0 0 1 0
0.78
Corrections in ProgressExpected Completion: Q1 2015
CPE Executive Owner: Kathy Kline
Compliance Program Effectiveness Audit Score (Industry average 1.11)
N/ACompliance
OperationsClinical
N/A
Pharmacy PBM
(Industry average 2.92)
(Industry average unknown; piloted in 2013)Special Needs Plans - Model of Care Audit Score
SNP MOC Executive Owner: Bob NelsonCorrections in Progress
Expected Completion: Q1 2015
PharmacyOperations
2014 Audit Readiness Dashboard - Sample Review Results in CMS Audit Scoring Methodology
Part D Coverage Determinations & Verbal Grievances Audit Score
Part D Formulary & Benefit Administration Audit Score
Part C Organization Determinations Area Audit Score
PBM
Findings Corrected FBA Executive Owner: John Smith
Various
Corrections in ProgressExpected Completion: Q1 2015
ODAG Executive Owner: Mary BrownFindings Corrected
(Industry average 2.14)
CDAG Executive Owner: Smith Johnson
(Industry average 2.15)
(Industry average 4.7)
Metrics Examples – Overall Compliance
Note: example data only
Metrics Examples – Overall Compliance
2 Note: example data only
25 28 23
30 35
40 45
50
15 12 18
16 13
20 18
17
11 10 8
13 10
9 11
8
4 5 5
6 8
10
12 14
2 1 3
5 7
9
10
15
0
20
40
60
80
100
120
2012 Q2 2012 Q3 2012 Q4 2013 Q1 2013 Q2 2013 Q3 2013 Q4 2014 Q1
1-30 Days 31-60 Days 61-90 Days 91-120 Days 121+ Days
Metrics Examples – Overall Compliance
Note: example data only
Metrics Examples – Health Plan Compliance
Note: example data only
Metrics Examples – Health Plan Compliance
Note: example data only
Metrics Examples – Health Plan Compliance
Note: example data only
Metrics Examples – Health Plan Compliance
Note: example data only
Metrics Examples - Privacy
8
Note: example data only
MEDICARE COMPLIANCE REPORT Monthly Executive Summary of Activity As of December 1, 2014
MOCK DATA – INFORMATION SHOWN IS NOT REAL 1
Type Title/Description Status / Concerns Business Executive
Compliance Officer
New Activity UHC
Communication with CMS
CTM – Member Specific Case
CMS requesting information on member CTM history.
Johnson Nelson
Updated Activity Regulatory Audit (CMS)
CMS Part D Recovery Audit Contractor (RAC) Unauthorized Prescriber Audit Review for Plan Year 2010
Contracts selected for review. Smith Brown
Regulatory Audit (CMS)
CY 2012 1/3 Financial Audit Sample selections were provided to Contractor.
Anderson Thompson
Regulatory Monitoring
(CMS)
CMS CY2015 Monitoring of Marketed Comprehensive Formularies
Annual monitoring of marketing formularies has kicked off.
Smith
Brown
CMS Compliance Letters – Year to Date Summary Notice of Non Compliance
(NONC) Title Compliance Lead Received
Date # of
Contracts
NONC 1 Sales 10/19/2014 1
NONC 2 Operations 4/22/2014 10
Warning Letter 1 Pharmacy 1/13/2014 3
CMS Self Reported Issues – Year to Date Summary
Self Report Title
Compliance Lead Submit Date # of Contracts
Self Report 1 Operations 10/1/2014 6
Self Report 2 Clinical 9/11/2014 50
Self Report 3 Finance 4/18/2014 46
Self Report 4 Pharmacy 1/2/2014 10
1
10
3 0 0 0
2
4
6
8
10
12
# o
f CM
S C
ompl
ianc
e Le
tter
s
CMS Compliance Letters # of Contracts Impacted by Compliance Area
1 1 1 1
0 0
0.2
0.4
0.6
0.8
1
1.2
# of
Sel
f Rep
orte
d Is
sues
Medicare Self Reported Issues by Compliance Area
Operations
Clinical
Finance
Pharmacy
Sales