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Best Practices for CMS Audit Preparedness by Health New England**

This presentation by Renee Wroth, Esq., reviews effective strategies and best practices for preparing for a CMS audit at Health New England (HNE), a leading provider-owned health plan in Western Massachusetts. Established in 1985, HNE emphasizes a strong culture of quality, accountability, and compliance, along with a commitment to its members and employees. The discussion includes lessons learned from past audits, insights into documentation and team preparation, and HNE's commitment to quality and compliance, as well as the significance of effective communication in member relations.

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Best Practices for CMS Audit Preparedness by Health New England**

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Presentation Transcript

  1. CMS Best Practices Review September 5, 2012 Renee Wroth, Esq. Director of Compliance & Accreditation

  2. AGENDA • About Health New England • HNE’s “Best Practices” • Preparing for a CMS Audit • Lessons Learned

  3. About Health New England • Provider owned health plan in Western Massachusetts • Incorporated in 1985 • Lines of Business: • Commercial (FF/ASO) • Medicare • Medicaid • Covering approximately 127,000 members

  4. 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)

  5. 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

  6. HNE’s Commitment to Compliance

  7. HNE Medicare Workgroup Structure

  8. 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 use • Part D authorization extension process • Part D grievance responses in writing • Inclusion of clinical criteria, LCDs and/or lists of available providers in denial letters

  9. 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

  10. 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

  11. 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

  12. 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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