Giving Back through Governance

The holidays are over, but I want to talk about a form of giving, that unlike last month, won’t put a dent in your wallet, and will actually pay you back in ways you might not expect. I’m referring to joining a local, not-for-profit, board of directors.

Governance can be both incredibly rewarding and challenging at the same time. On the board of directors of a nonprofit organization, you support a cause you value, find networking opportunities, and, when comprised of the right mix of people, you learn from colleagues across many industries and walks of life. Sounds good, right?

However, when it comes to major decisions, that same mix is bound to disagree, and disagree hard. Don’t fret – professional discourse and disagreement can result in great decisions, once a decision is reached. Don’t let tough times make you throw in the towel. What you may not realize are the added benefits to participating on such a group. You aren’t just giving back to your community, you are giving back to yourself. As it relates to volunteering, best-selling author and personal finance guru Suze Orman says, We really need to start putting on different-colored glasses to see not only how we help the world but also help ourselves as well.”

So what does she mean, to “help ourselves”? I look at it this way: do you want to be a more valuable employee, a generous leader, a better friend? Volunteering on a board can benefit you personally and professionally by exercising these skills on a regular basis:

  • Patience: if you are not naturally gifted with this trait, being on a board will help you dial in your temperament, and fast. You may not understand fully how the world sees you until your patience is tested in a smaller group on a regular basis. The more hands in the cookie jar, the longer some decisions may take, so patience becomes one of your greatest virtues.
  • Compromise: You may not realize how unyielding you are until you are challenged by a roomful of people you aren’t related to. That stubbornness may work at home, but not here.
  • Strategic planning: One of the most important responsibilities of a board is to keep an organization on track with a strategic plan. What are the short term and long term goals and how to we achieve them? Regular practice of formulating priorities and objectives is a part of strategic planning. Furthermore, managing risk and capitalizing on open opportunities not only benefits the organization, but also your own activities in work and life.

You must be collaborative and open to new ideas in order to gain new perspectives. When giving time to a mission you believe in, you are bound to be a vocal contributor, wholeheartedly working toward that mission. As we enter a new year, let’s continue to give of our time to local causes important to us. Find local opportunities to serve at the following sites, or contact organizations you value directly:


The Bridgespan Group

LinkedIn board positions

The ExecRanks Inc.

Breaking: 2019 Program Audit Protocol

Let’s get right into it. Last night, the Centers for Medicare & Medicaid Services (CMS) provided detailed information regarding changes to the 2019 Program Audit process. Here, I break down the memo and briefly explain impact.

  • CMS incorporated validation audit updates to the Program Audit Validation-Close Out document. No surprises here as this information was previously communicated in the Call letter of the 2019 Final Announcement.
  • Audit notices are scheduled to be sent between the months of March and July, 2019. This window is two months shorter than the 2018 window, which ended in September. While teams can plan accordingly based on this information, CMS may issue an ad hoc or unplanned audit notice based on a tip, allegation, or newly identified risk. Do not let July pass by and start breathing a sigh of relief. Talk to your Compliance Officers: CMS account managers continually request information regarding plan performance and significant issues. These matters may be referred to the Central Office for further action.
  • The agency is suspending the collection of Supplemental Questionnaires for Coverage Determinations, Appeals, and Grievances (CDAG), Part C Organization Determinations, Appeals, and Grievances (ODAG), and Medicare-Medicaid Plan (MMP) Service Authorization Requests, Appeals, and Grievances (SARAG). They note the info is relevant when conducting root cause or pulling together impact analyses, so best bet is to still have them ready.
  • Arguably the most significant change, modifications are being made to the methodology to review misclassification of beneficiary calls, including the suspension of collecting the Call Log tables. Instead, CMS will review a sponsor’s oversight of the call routing process during its review of Compliance Program Effectiveness (CPE). In my recent experience, the collection of call log data as well as the classification of calls continued to frustrate sponsors. However, the targeting of call log samples was one of the most eye-opening and direct avenues to identify misclassification. It also shed light on opportunities to improve customer service overall, especially when it came to listening to calls handled by a vendor. Shifting from targeted samples to a review of process appears to be a step backwards. Since processes vary sponsor to sponsor, listening to targeted calls was a consistent method to uniformly measure a sponsor’s compliance.
  • Speaking of CPE, CMS will suspend some data collection including the Self-Assessment Questionnaire and some universe data points in the review of the compliance program. The agency realized some of this information was either covered in tracer samples, not pertinent to identifying increased risk of non-compliance or no longer required. It is not expected this will significantly reduce sponsor burden, however it does demonstrate the agency is continually evaluating methodology to make it more meaningful.
  • Additional program audit elements suspended to reduce overlap include the Website Review, previously conducted in Formulary Administration, and Enrollment Verification in Special Needs Plan – Model of Care.
  • Part D, take note: CMS will be evaluating the implementation of the Comprehensive Addiction and Recovery Act (CARA) of 2016 through the program audit process. How so? CARA allows sponsors to limit “at risk beneficiary” access to coverage for frequently abused drugs via drug management (DM) programs starting next year. The agency is clarifying that these decisions made under DM programs are not defined as coverage determinations, and therefore will not be collected in data universes. However, at-risk redeterminations (appeals) will be collected as part of the appeals tables 6 and 8 (Standard and Expedited Redeterminations, respectively).
  • Timing is everything, and sponsors should welcome the anticipation of the February, 2019 release of the final appeals guidance. While CMS acknowledges they do not anticipate significant changes from the draft to the final, they note they will provide opportunity to the industry to implement the updates before auditing these changes to compliance standards. Once the final guidance is released, CMS notes they will communicate how and when any audit standards will be affected. Keep in mind, audit review periods are retrospective. Ideally, CMS would provide a future effective date for the appeals guidance so that sponsors can fully evaluate and implement changes. This is done in the annual enrollment guidance as well as for many provisions in the Marketing Guidelines, so why not for key appeals guidance? Time will tell.

We still wait for the 2020 Program Audit Protocol 30-day notice for public comment to be released. All in all, reduction of burden on sponsors and focus on patient care seem to be a factors in implementing these changes.

What to do next: Sponsors should evaluate what changes need to be made to current audit preparation processes. While some items are easily implemented (such as the suspension of data collection), questions remain. Will CMS be reviewing the call routing process desktop procedures only, or will they solicit training tools and other procedures? Will vendor call routing processes be collected and reviewed, or will vendors be required to explain their processes during CPE week? Will the appeals chapter really be released in February? Contact me to schedule a call to discuss what these changes mean for your own audit planning and general oversight. I’ll be caffeinated and ready!

Readiness: A Year-Round Effort

A solid, compliant sponsor isn’t perfect, but they know how to react swiftly when the unexpected arises, and it will come up year-round. Take it from recent enforcement notices issued by the Centers for Medicare & Medicaid Services (CMS).

Within a matter of days, the agency first imposed and then lifted an immediate suspension of enrollment and marketing sanction on a Prescription Drug Plan (PDP) sponsor new to the market. Operated by a highly reputable organization with over 100 years in the finance and insurance industries, the enrollment and marketing freeze was imposed due to the sponsor not providing CMS with evidence of a valid license within the state of Florida. The sponsor had disclosed to the agency that the state had recently informed them an amendment was required for their license to be complete. Therefore, based on what was in effect with the state, the sponsor was not in compliance with the Part D regulation 42 C.F.R. § 423.401(a) which requires each PDP sponsor have a license under state law as a risk bearing entity eligible to offer health insurance or health benefits coverage.

The issue was quickly remedied when the Office of Insurance Regulation provided notice to CMS it had approved the additional line of business on the sponsor’s license. As a result, CMS lifted the sanction. The requirement to be properly organized and licensed under state law is confirmed upon submission of a Part D application, unless a waiver is requested and approved. That should generally be the end of it, but in this sponsor’s case, there was more to come.

As illustrated by this recent enforcement action, things you think are in place might not be, and no checklist can prepare you for those instances. Those most successful in administering government programs are honest about what they know, unafraid to pick up the phone and verify, and driven to implement effective corrections.

Draft Part C and Part D Appeals Guidance for Industry Comment

On October 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released consolidated draft chapter guidance based on Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual.

CMS requests comment on the revisions, structure and format by close of business, Monday, October 22. In a new publication, I summarize notable revisions and provide suggestions and points to ponder based on my experience with this beneficiary-impacting area of plan operations.

Whether you are a new or experienced in your role – be it Compliance Officer, VP of Operations, Appeals Director – and whether you are at a plan sponsor or entity delegated to perform these functions, my summary provides key considerations to supplement your review.

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Crushing Deductibles Affect RI Families

Many employer group plans today have higher than normal deductibles. In my experience (and under past employment), benefit plans generally did not have an in network deductible, and my out-of-pocket costs included either copayments of flat dollar fees, or coinsurance, percentages of a total. Deductibles were saved for out of network benefits, and even then we were talking only $500 or $1000, on a generous plan. Nowadays, a family has to meet so many out of pocket costs.  I have two anecdotes to provide in this regard.

A family member experienced a glitch, and was not able to change her plan as of January 1 of this year. A new plan with a new deductible was in effect February 1.  Unfortunately, her out-of-pocket costs incurred in January do not offset her February plan with a new organization. She has filed appeals requesting exceptions, which hopefully will be approved because the Summary of Benefits and Coverage (SBC) has been arguably watered down to incompletion. This is a great difficulty for someone self-employed and raising a family.

A close friend has been helping her sister financially as she undergoes treatment for a serious illness. Her sister was diagnosed a few months ago, and has a plan your benefit which includes a $6000 deductible starting June 1. She works for a major pharmacy benefit manager in a warehouse position, and has so for years, but barely makes a living wage considering she is single, taking care of her disabled son as well as a granddaughter. My friend is self employed herself and is now hustling as best she can to help her sister pay participating physicians who are demanding cash upfront.

These anecdotes illustrate a couple examples of how our current system is causing great financial harm to working families. More refinement is needed to make sure people don’t delay care and providers do not refuse care due to cost.

Passed the Test!

This past week I completed and passed the exam to be a Certified Compliance & Ethics Professional, or CCEP. This certification is administered by the Compliance Certification Board.  Continued education is something I personally value and in all instances of my professional activities, it enhances not only my client work but also my decision-making as a manager of staff and as a board member of a health center. I recommend anyone in this field to pursue this or a similar certification.

In other news, 2018 seems to be flying by. I am keeping busy not only with career obligations but also with my volunteer efforts. We are seeking a new CEO for our health center, as our current leader is retiring. He has some pretty big shoes to fill, so if you know anyone with some HRSA experience and a penchant for New England living, don’t hesitate to send them my way. Really, is it almost March?


January Imperatives

A few thoughts during this quiet Sunday in a temperate January come to mind that I hope all readers consider:

  • Yes everyone has their feelings about the flu shot. I’m not here to preach about the vaccination as it’s a personal decision you make with your medical professional. However, as a human, it’s not only flu season we are dealing with but also a very miserable virus. It’s scary the number of reported casualties this season. If you or a family member is under the weather, get checked out. Here are some helpful tips on choosing the right setting for your medical care.
  • The first State of the Union Address delivered by President Trump will be this coming Tuesday, January 30. Anticipated themes include tax reform, border security, immigration, and the stock market. Tune in at 9PM Eastern.
  • On the local front, while Q4 2017 data is not finalized, I am hoping that accidental drug-related overdose deaths are on the decrease for our tiny state. Every live saved is a blessing and a gift that has slipped through another family’s fingers. Continue educating yourself and promoting recovery options for all.

Looking forward to a prosperous and healthy 2018 for everyone.

New Year, What is Next?

…one of my favorite phrases that I picked up during Spiritual Exercises in college is so fitting for a new year.

It’s the first Saturday of  2018, truly one of the first days with some time to breathe after the planning and excitement of the last month.

There’s not much to love in the news lately but there are glimmers of hope if you can find them. Sarah Silverman has done an act of kindness instead of choosing escalation and inflammation. On the same platform there are bullies and moms and reporters and megalomaniacs, so it is nice when something so positive gets attention.

And then?

  • Spent the end of the year in a chilly city; kept warm with great people.
  • Reading a book that is totally outside my wheelhouse but my brain is thanking me for it.
  • Planning work travel and sharpening those time management skills.
  • Getting involved in community events and sharing the intel forward.

Be Antibiotics Aware

Far be it from me to provide medical advice. This place is about my personal perspective and experience, and this topic includes an important message for our community, especially now that the holiday season is coming. Families will be getting together, and oftentimes, someone at the dinner table feels under the weather.

The Rhode Island Department of Health (RIDOH) issued a press release today to remind Rhode Islanders to be “antibiotics aware”. It seems there is a special week for everything!  Last week was Corporate Compliance and Ethics week, but this week, apparently, is U.S. Antibiotic Awareness Week and World Antibiotic Awareness Week (November 13th -19th). These drugs are super helpful in the treatment of bacterial infections. However, according to the press release, the overuse of antibiotics and the use of these drugs when not appropriate have contributed to 2 million+ people falling ill with antibiotic-resistant bacteria.

Remember: antibiotics do not work on viruses. There is a distinction between viruses and bacteria that make us ill. Take it from an experienced patient: Let your physician properly diagnose your illness. Finish your prescription medication as directed. Alert your physician if you experience any significant side effects of antibiotics (as I have done; some of them pack quite a punch!) and safely discard any unused medication.

The End of Oklahoma’s In-Home Support Waiver

Buried in my newsfeed today is an article from earlier this month regarding the state of Oklahoma’s decision to cut funding for a significantly needy population.  Families who care for developmentally disabled adults often require additional support, otherwise, working a full-time job would be difficult.

The Oklahoma Health Care Authority describes the In-Home Support Waiver as follows: In-Home Supports for Adults serves the needs of individuals 18 years of age and older with intellectual disabilities who would otherwise require placement in an ICF/IID [Intermediate Care Facilities for Individuals with Intellectual Disabilities].

According to the OHCA website,  services include: Respite, Nursing Services, Adaptive Equipment, Nutritional Services, Audiology, Occupational, Physical, & Speech Therapies, Habilitation Training Specialists (in-home care), Psychological Counseling, Medical Supplies and Services, Employment Services, and Transportation. Funding for these and more services will end December 1, forcing families to make some key decisions in the next few weeks.

I hope state lawmakers responsible for informing the budget can find something else to cut besides these valuable sevices. Parents and caretakers may need to choose between caring for these loved ones or keeping their jobs. From the article:

“We are still hopeful, still optimistic that the legislature will not allow these cuts to take place,” said DHS spokeswoman Sheree Powell. “There’s still time to pass funding bills, to make sure that the funding is available for these services. But come December 1, these programs will end and there will be nothing DHS can do about it.”