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Medicare Parts C and D Data Validation Trends and Challenges October 29, 2013 Presented by: Jim Casurella Rob Shelley Sadie Zarnoth
Medicare Parts C and D Data Validation Trends and ChallengesOctober 29, 2013
Presented by:Jim CasurellaRob ShelleySadie Zarnoth
Today’s Agenda
•Data Validation Overview•Why do we do this?•Who are PSRx and MetaStar?
Introductions
•2013 Results, What happened last year?•Common Challenges
2013 Experience
•2014 Summary and Changes•DV Standards•Automation possibilities
To the Future!
Disclaimer: Off-season we are restricted by CMS from “consulting”. We can’t answer your specific questions about measures, but we can pass them along to CMS and share with you their response.
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•MetaStar specializes in HEDIS® audits and External Quality Review validation, both of which support the assessment of DV deliverables•PSRx Advisors offers advanced PBM oversight support for Medicare Part D compliance and financial management
The Team
2013 Data Validation
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
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2013 Data Validation
•Within the Code of Federal Regulations (CFR), the Centers for Medicare and Medicaid Services (CMS) identify the reporting requirements for Medicare Advantage Organizations (MAOs)•CMS requires that MAOs submit certain data reports which began with measurement year 2010•Specific data reports must be validated by an independent data validation contractor•CMS stipulated the requirements for the data validation contractor•Both PSRx and MetaStar meet all CMS requirements for an independent experienced data validation contractor
Overview
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2013 Data Validation
•608 Total contracts underwent Data Validation, 530 for Part C •The average Part C score was 98.1%•Nearly 1/3 (32.8%) scored 100%
2013 ResultsPart C Data
ValidationDisclaimer: These statistics were excerpted from CMS Memo dated August 2, 2013, subject line was “Results of the 2013 Part C and D Reporting Requirements Data Validation”.
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•608 Total contracts underwent Data Validation, 603 for Part D•The overall average Part D score was 99%•Why such a high score?•Nearly ½ scored 100% on the Part D Reporting Sections•Per CMS, the results of this Data Validation indicate an overall level of high performance of Medicare standards
2013 ResultsPart D Data
ValidationDisclaimer: These statistics were excerpted from CMS Memo dated August 2, 2013, subject line was “Results of the 2013 Part C and D Reporting Requirements Data Validation”.
2013 Data Validation
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2013 Data Validation
• Standard 1g: Recalculation narrative that
matches the process • Standard 1g: Keep manuals, policies, and
procedures updated• Standard 1g: Consolidation and centralize
documentation• Standards 2d and 2e: Consistent categorization
to data elements• Standard 3a: Quality assurance process for data
entry to ensure accuracy• Standard 7: Sufficient oversight of all vendors •Various Standards: Continuous training
Challenging Standards
For current DV specifications and documentation, go to cms.gov
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Contract Year 2013 Measures2013 Part C Part D
Reported Measures 11 15
Validated Measures 4* 5
• Two Part C measures from Contract Year 2012 will also be validated in this year’s cycle.
2014 Data Validation
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2014 Data Validation
•No validation of Plan Oversight of Agents for Part C or Part D
•Serious Reportable Adverse Events (SRAE): Validating two years rather than one
•Special Needs Plan (SNP): Validating two years rather than one
2014 Changes
Part C
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2014 Data Validation
2014
Changes
Part D
•Grievances Part D: Plan submits once instead of four times; two additional data elements validated
•Coverage Determinations/Exceptions: Plan submits once rather than four times; number of data elements increased to 29
•Redeterminations: Plan submits once rather than four times
• Long-Term Care Utilization: Two files instead of previous three (one year instead of two)
•Medication Therapy Management Programs (MTMP): Increased from 19 to 26 data elements
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2014 Data Validation
StandardsValidation
•CMS is available for questions.•Source data must be available!•The 2014 Data Validation Manual and Appendix B, the Data Validation Standards must be used to evaluate your practices.
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Can It Be Automated?
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What’s on the horizon?
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Providing Informed Pharmacy Decisions
