Co-Authored by Jennifer Young and Wendy Karsten
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Medicare Advantage is a complex business with numerous regulations. CMS provides plans with an annual Readiness Checklist as a reminder of what can go wrong at the beginning of a new benefit year without the proper preparation. As plans attract new members and roll out new benefits and services (and potentially new product), success is found in the details.
The Readiness Checklist is all about accountability. This includes accountability to the Board of Directors, internal staff, CMS, and members. It helps to identify areas of risk and readiness across the organization. Review of the checklist is also a great operational overview for any new staff members. While the checklist can be overwhelming initially, with a divide and conquer approach, it can be manageable and provide confidence in the organization’s readiness for the upcoming contract year.
To begin, the checklist should be converted into a working document complete with prioritization, due dates, and responsible parties. On a biweekly basis between now and January 31st, this checklist should be updated with the progress on every item and shared with the entire team. This is the time for the team to raise challenges, especially items at risk, so mitigation strategies can be developed. High priority items should include those things that, if they aren’t running smoothly, will generate CTMs, NONCs, and/or and grievances. Medium priority should include any items that will reflect poorly on the organization but are not likely to cause the issues in the high priority list. Finally, low priority should include everything else.
Our Rebellis experts recommend looking at three factors to evaluate the compliance of the elements:
What documentation exists to support the operationalization of the element?
How is the documentation accessed by staff and have the staff of the department(s) impacted by the element reviewed the documentation this year?
What systems and reports are in place to support the end-to-end compliance, stability, and scalability of the element?
Documentation of existing processes, whether in the form of workflows, policies, job aids, or desk level procedures, is critical. Documentation should establish what is being done and who is accountable. It is the organization’s opportunity to ensure that institutional knowledge is not lost with attrition, which could create future compliance gaps. The documentation should also be used for internal audit and monitoring to validate that the process is working as intended. Documentation should be reviewed annually to identify changes or general updates and distributed to the staff. Staff should be provided the time to review documentation annually, even for processes they perform daily. This also ensures that staff are performing work steps in a consistent, compliant manner. An evaluation of systems and reports should identify where there are manual steps, where there is automation, and anytime there is a hand-off between departments and/or systems. Are there controls and active monitoring in place that will prevent and detect non-compliance?
Not all readiness elements are worded in a way that identifies the compliance evaluation. For example, “Ensure that services are provided in a culturally competent manner to all enrollees, including those with limited English proficiency (LEP) or reading skills and diverse cultural and ethnic backgrounds” should be evaluated by questioning how compliance is evidenced by the organization. To do this, one should ask: “Have we defined cultural competency for our population? Have we trained our staff and provider community on cultural competency? What tools do we have available to monitor to show that we are compliant with this element?” Key words in the readiness element can be used to identify the questions that should be asked to assess compliance.
Performing this evaluation can then be included in the organization’s risk assessment and internal audit schedule. For example, a process may be compliant, but the documentation has not been updated in five years, only one staff member is trained on the process, and it is highly manual. Those factors equal risk that should be included in additional audits. If the compliance readiness box is just checked, an opportunity to identify risks and how to create a plan to mitigate those risks in the coming year may be missed.
There are always challenges in performing comprehensive reviews during the busy open enrollment period. However, while the Readiness Checklist does change annually, the changes are usually minor. Rebellis recommends performing a comprehensive readiness review in September prior to AEP using the prior year’s readiness checklist. Upon receipt of the updated readiness checklist for the upcoming contract year, the changes can be identified, and a supplementary readiness and risk assessment performed on the new items. Using the readiness review as part of the global risk assessment will create visibility into items CMS believes are critical to compliance monitoring of health plan operations.
Is your plan’s readiness review where it should be? For a free download of our best practice readiness checklist in an easy to operationalize format, click the link below to sign up for our newsletter. The CMS readiness review is an important review tool but does not cover all compliance requirements of an organization. Rebellis Group offers comprehensive compliance and operational assessments that evaluate all CMS requirements, including the readiness elements, into one organizational compliance dashboard. Contact us for a free consultation on how our expertise can provide you with valuable insight into your organization.