Medicare Advantage, v. 1.0 -- Audit Processes

As I blogged about in early Summer 2006, the Centers for Medicare and Medicaid Services (“CMS”) has approved URAC as an Accreditation Organization (“AO”) that has “deemed status” under the Medicare Advantage (“MA”) program. What this means is that a Medicare Advantage Plan operating under an “H” contract can take care of many of its regulatory requirements by tacking the “Medicare Advantage Health Plan Module v. 2.0” onto its Health Plan accreditation. I refer you to that blog for the history of that issue. Today’s blog are simply some of my notes from a high-level overview of the URAC program given by URAC’s Director of Accreditation, Christine Leyden.

There’s no way, however, to capture all of what we covered in a readable blog. We spent hours going over details of the standards. So, my comments will focus more on the review process itself, rather than the standards. With regard to the standards, I would simply suggest that applicants read very closely the Program Guide (which CMS just approved on September 19, 2006) and the Scoring Tool and take seriously the specific requirements you find there. And, of course, if you have questions, give me a call.

The key distinction throughout is that URAC’s MA module is substituting for regulations, so some of the “wiggle room” you might find in any accreditation program are not to be found here.

An excellent example of this lack of wiggle room can be found it the –

New audit rules
Typically, in a URAC audit, you can have one or two files out of compliance without raising an eyebrow (e.g., noncompliant provider contracts or credentialing files). That is not the case here – all files reviewed must comply with the requirements. If not, CMS will find out about it. Typically, the URAC reviewer will pull 30 files for each of its onsite audit “pulls”.

The MA Module Scoring Sheet
Usually, URAC applicants do not get to see the URAC reviewers’ scoring tool. This program is the exception – you get the entire scoring tool, including the onsite interview questions. The reviewers will have to follow this more closely than they would in the other accreditation programs.

Reports to CMS

All issues will be reported to CMS, even those caught in the desktop review process. If there is an issue, there will be a teleconference between the URAC reviewer, the applicant, and CMS about the issue before the application goes to the URAC Accreditation Committee. In fact, CMS has to see the desktop review summary (DRS) before URAC can do its onsite review. You will get a separate DRS for your MA program than for your commercial program.

Also note that this whole accreditation report will be available to the public on the CMS web site, also unlike the other URAC accreditation programs.

Be ready to back up what you say

As we have told our clients for years, practice "Tell and Show" during the onsite review. In other words, when you are being interviewed during the onsite review, be prepared to haul out a document to back up what you are telling the reviewer.

Intensity of the review

Depending on your plan, the Medicare review alone will be between one and three days. It is unlikely to be one day -- more likely two or three. Three reviewers are involved, and will review your MA documents separately -- on separate days -- from your commercial documents.

Monitoring onsite

The Monitoring Onsite does not apply to the MA module.

As I said, these are just my thoughts about the review MA review process and how it differs from the other reviews URAC conducts. The big differences, though, are in the standards themselves. A much closer examination of the URAC Program Guide, the Medicare regulations, and your "H" contract will be essential as you dive further into your Medicare Advantage review process.