The ProviderTrust team spent a few days in Florida at the 2019 HCCA Managed Care Compliance Conference. During the event, we had the chance to talk with health plan leaders and attend helpful sessions on the industry’s latest hot topics.

This year’s conference had some great speakers from a variety of health plan compliance professionals to government administrators from the Centers for Medicare and Medicaid Services (CMS). We had such a great time and would like to walk through some of the key themes and takeaways from this year’s conference, and hopefully, open up the conversation for your thoughts and experiences.

For a full list of all of the presenters from this year’s conference visit the following site – HCCA 2019 Managed Care Compliance Conference.

Combating Fraud, Waste, and Abuse in Managed Care – Megan Tinker, Senior Advisor for Legal Affairs, HHS OIG

The conference started off with a great session from Megan Tinker from HHS OIG. She began by introducing some of the basics about the Office of Inspector General and helped explain OIG’s role in eliminating fraud, waste, and abuse and the supporting the integrity of HHS programs.

Megan walked through some identified risks from OIG and laid out their plan for tackling top priorities such as opioids, home and community-based services, home health, personal care services, and more.

Pertaining to managed care specifically, she explained some of the top management challenges including the following:

  • Combatting provider fraud and abuse
  • Fostering compliance by managed care organizations
  • Ensuring comprehensive data
  • Law enforcement referrals
  • Ensure access to care
  • Enhancement of oversight of MCO contracts

To conclude her presentation, the Senior Advisor expressed the determination and success of HHS OIG to combat fraud, waste, and abuse by healthcare providers billing managed care plans. She also expressed the importance of ensuring the integrity and compliance by managed care plans and Part D sponsors is fully optimized.


CMS Compliance and Enforcement Update – Kimberly Brandt, Principal Deputy Administrator for Operations, CMS

Kimberly Brandt CMS HCCA Compliance InstituteAnother great session involved hearing from Kimberly Brandt, representing the Centers for Medicare and Medicaid Services (CMS)Always well spoken, Kimberly delivered an entertaining presentation filled with some helpful information on how CMS is working to make quality care the priority and reduce the burden of paperwork on providers.

Kimberly addressed three main topics during her presentation:

  • Patients Over Paperwork
  • Addressing the Opioid Epidemic
  • Program Integrity

CMS is committed to reducing confusing requirements and processes for providers to ensure they are delivering the best quality care. Through document consolidation and providing more access to resources, CMS has seen improvement in provider relations for many everyday activities.

As it relates to combating the opioid epidemic, CMS is delivering a three-pronged strategy. The following CMS Opioid Roadmap was released on June 11, 2018.

2018 CMS Opioid Strategy

Program Integrity Focus Areas for CMS include the following:

  • Data and analytics investment to support fraud detection and prevention efforts and recover improper payments
  • Stronger collaboration with all partners
  • Medicare Advantage and Part D efforts
  • Enhanced Medicaid oversight

CMS continues to work on modernizing Medicare Advantage and Part D programs. A new rule was released last fall – Policy and Technical Changes to Medicare Part D Programs and is currently seeking public comments until April 30, 2019.

The CMS Preclusion List was another important topic discussed during this presentation. Starting in April 2019 the list will go into effect for Medicare Advantage and Part D.

Kimberly Brandt CMS Preclusion List


HCCA Managed Care Conference Takeaways

Medicare Advantage Organization (MAO) Provider Directories

A report – CMS Online Provider Directory Review brought visibility to an interesting challenge for health plans – inaccurate provider network directories. According to the Centers for Medicaid and Medicare Services (CMS), “Provider directories are an important tool MA enrollees use to select and contact their physicians and other contracted providers who deliver medical care.”

In 2018, CMS reported data from 52 Medicare Advantage Organizations (MAOs), including 5,602 providers from 10,504 locations. The review found that 48.74% of the provider directory locations listed had at least one inaccuracy.

CMS calculated the percentage of locations with inaccuracies for each MAO directory, which ranged from 4.63% to 93.02%. The average MAO inaccuracy rate by location was 44.97%. The majority of the MAOs (28 out of 52) had between 30% and 60% inaccurate locations.

Common Issues with Provider Data Inefficiencies

  1. Group practices continue to provide data at the group level rather than at the provider level. Provider directories conveyed an inflated number of locations where the provider practices.
  2. A general lack of internal audit and testing of directory accuracy. Medicare Advantage health plans must implement internal oversight of their processes for data validation.
  3. Too many instances where providers were deceased or retired for several years. Medicare Advantage health plans must proactively reach out to providers for updated information on a routine basis.

The Centers for Medicare and Medicaid Services (CMS), since 2016, has implemented a 3-year cycle for sending out surveys and reviewing the accuracy and effectiveness of MAO provider directories. At ProviderTrust, we are always seeking to help health plans build more complete profile information to ensure each provider is in good standing with Medicare, and their required documentation for online directories is accurate.

One of the ways that we help fill in the gaps is with smarter tools with NPI verification and supplementing data from primary sources to build a clear picture of provider history and current status. In this way, provider and network operations managers have more information for decision making and special investigators have more insight into claims processing and recoupment.

CMS Preclusion List

There certainly was a lot of buzz around the new CMS Preclusion List, which goes into effect on April 1, 2019. This requirement will affect both Medicare Advantage (Part C) and Prescribers (Part D Sponsors).

What is the CMS Preclusion List?

The Preclusion List from the Centers for Medicare and Medicaid Services (CMS) is a list of providers and prescribers who are precluded from receiving payment for Medicare Advantage (MA) items and services or Part D drugs furnished or prescribed to Medicare beneficiaries.

Why was the CMS Preclusion List Created?

  • To replace the Medicare Advantage (MA) and prescriber enrollment requirements
  • To ensure patient protections and safety and to protect the Trust Funds from prescribers and providers identified as bad actors

In the April 2018 release of the Federal Register Rules and Regulations, the Department of Health and Human Services released policy and technical changes to a variety of Medicare programs included in the CMS-4182 Final Rule document. It will be interesting to see how health plans, providers, pharmacies, and others adjust to this new policy and perform routine screening against this new federal healthcare dataset.

Would you like to learn more about the CMS Preclusion List? Would love to connect! Easily sign up for a quick discussion with one of our team members – here.

Health Plan Special Investigations Units

We really enjoyed one of the sessions involving SIUs – “Building an SIU that is Nimble and Audit Ready”. In this session, attendees were given great examples of how an effective special investigations team is assembled and managed.

Building a Nimble and Audit Ready SIU Key Takeaways

  • Integrate systems
  • Form strong partnerships
  • Select great people with experience

The session helped provide insights into how to integrate systems and processes for building crucial partnerships with legal teams, pharmacy benefit managers, HR departments, and more. Another main focus of the presentation was how to create an agile work environment with enhanced training, referrals, risk assessments, and workflows.

The group presented a clear framework for how to prepare efficiently for a CMS audit.

SIU CMS Audit


ProviderTrust for Health Plans

We had a great time at the 2019 HCCA Managed Care Compliance Conference and look forward to continuing to build great partnerships with health plan professionals. Our mission is to assist in ongoing provider network monitoring, claims processing and recoupment, provider directory accuracy, and more. Please reach out if you have any questions – we would love to discuss!

In order to help build a better managed care community, we have started an ongoing monthly webinar series to discuss the latest topics and hear from industry experts.

To sign up for our webinar series – please click here.


Check out our latest resources for health plans!

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Written by Michael Rosen, Esq.

ProviderTrust Co-Founder, mrosen@providertrust.com

Michael brings over 20 years of experience founding and leading risk mitigation businesses, receiving numerous accolades such as Inc. Magazine’s Inc. 500 Award and Nashville Chamber of Commerce Small Business of the Year.

 Connect with Michael on LinkedIn