Updated: Aug 12, 2022
CMS Program Audits are in full swing this summer, but are you truly prepared? If you are a Special Needs Plan (SNP) and you are not quite sure how to measure your readiness, here are a few suggestions:
Care management case review: Remember, the true intention of the SNP is to assist those Medicare beneficiaries who are chronically ill, vulnerable, frail or dually eligible above and beyond what traditional Medicare Advantage (MA) plans do. Too many plans believe they have implemented a care management program without truly ever conducting an in-depth annual evaluation or measuring the program’s success or failures. One true test for the care management program’s effectiveness is to review your members’ cases against what your plan’s program and Model of Care (MOC) say you do. Look at each case to identify if that Health Risk Assessment (HRA) has been translated to the care plan and if the Interdisciplinary Care Team (ICT) occurred with the correct members to support that care plan’s implementation. Many plans go through the actions or quite literally “check the box” of activities under the MOC but do not truly provide quality, individualized care plans that are oversighted by an ICT.
Care management case note: The notes within any care management platform are an additional opportunity to tell the story to an auditor of exactly how the care manager effectuated the care plan and interacted with the member. If your care management team’s notes are not checked for content or appropriateness to the task being documented, you may be at risk during an audit. Especially, if your Care Management (CM) platform is not configured with smart technology to auto populate tasks or clinical criteria to support your CM team’s activities.
Member preferences in the care plan: Too many plans state in their MOC they include member preferences in the care plan only to find they are system generated and the same for many members, despite having individual needs. Care managers need to tailor educational material for the members goals, add members to the ICT to support behavior changes to meet these goals or offer coaching to provide to the member if needed.
Allowing the CM platform to auto populate associated interventions does not quality for an
individualized care plan nor does it recognize the ever-changing needs of our most vulnerable Medicare beneficiaries.
Institute quality oversight of the content of your plan’s CM documentation and system use
for better audit outcomes. If you are unsure of where to start or how to develop such a program, contact us today.