cms best practices review
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CMS Best Practices Review. September 5, 2012 Renee Wroth, Esq. Director of Compliance & Accreditation. AGENDA. About Health New England HNE’s “Best Practices” Preparing for a CMS Audit Lessons Learned. About Health New England. Provider owned health plan in Western Massachusetts - PowerPoint PPT PresentationTRANSCRIPT
September 5, 2012
Renee Wroth, Esq.Director of Compliance & Accreditation
CMS Best Practices Review
AGENDA
• About Health New England
• HNE’s “Best Practices”
• Preparing for a CMS Audit
• Lessons Learned
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About Health New England• Provider owned health plan in Western
Massachusetts
• Incorporated in 1985
• Lines of Business:o Commercial (FF/ASO)o Medicareo Medicaid
• Covering approximately 127,000 members
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HNE’s “Best Practices”• Strong culture of Quality, Accountability,
and Compliance • Dedicated Commitment to our Members• Dedicated Commitment to our
Employees• Dedicated Commitment to Improvement
(OFI and LEAN)
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HNE’s Commitment to Quality●1991 – First HMO in the nation to undergo
accreditation review by the National Committee for Quality Assurance (NCQA)
●2008 – HNE is ranked a Top 10 Commercial health plan in the annual ranking by NCQA (Status maintained in 2009, 2010, and 2011)
●2009 – HNE enters the Medicare Advantage Market
●2012 – HNE earns 5-Star designation from CMS
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HNE’s Commitment to Compliance
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HNE Medicare Workgroup Structure
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HNE’s Commitment to Members
• Transparent Sales Process• Employed sales staff with strict testing
requirements• Easy to Understand Plan Designs• Trend analysis on grievances and appeals• Focus on clear communication and ease of
useo Part D authorization extension processo Part D grievance responses in writingo Inclusion of clinical criteria, LCDs and/or lists of
available providers in denial letters8
HNE’s Commitment to Employees
• Selective Hiring Process (Integrity and Trust is a “price of admission” competency)• Opportunities for advancement and
transfer• High Performance Coaching Culture• Employee Engagement• Investment in training
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Preparing for a CMS Audit• Practical Matters
Space Computer and Phone Access/Support
• Preparing Your Documentation Follow the universe specifications precisely More is not always “better” Entrance presentation Scanned documents
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Preparing for a CMS Audit• Preparing Your Team
SMEs CEO and Executive Team Board Members PBM Late nights
• Preparing Your Organization Walk through Impromptu interviews Coverage for daily work Compliance reminders
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Lessons Learned•Preparation is key
•Always be in an “audit ready” state – use the universes!
•Compliance dashboards are important
• “NCQA” readiness is helpful but not enough
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