Evaluating the Effectiveness of Your Compliance Program Closing the Gap between Expectations and Reality

1. Evaluating the Effectiveness of
Your Compliance Program
Closing the Gap between Expectations and Reality
About Inovaare: http://www.inovaare.com
November 8, 2017
10:00 am PST – 11:00 am PST

2. Agenda
• Who has Expectations for Your Compliance Program?
• Does Your Current Reality Match Expectations?
• A Vision for a New Reality – Compliance in Real Time
• How Do You Get There from Here?
Stuff We’re Going To Think About Today…
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3. Who Has Expectations
for Your Compliance Program?
Evaluating the Effectiveness of Your Compliance Program –
Closing the Gap between Expectations and Reality
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4. Who Has Expectations for
Your Compliance Program?
• Regulators have expectations…
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5. …Regulators expect Compliance to have its arms around the entire organization.
…Regulators know how much data your organization collects across all facets of the
operation, and they think Compliance has access to it all.
…Regulators don’t understand the complexities of data management in a modern
health care organization; they expect Compliance to marshal that all that data into
meaningful, timely oversight.
…In short, Regulators think Compliance should be able to see everything that’s
happening, as it’s happening.
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State and Federal Regulators have high expectations for your Compliance
Program. Some are reasonable, some not so much. In General…
Who Has Expectations for
Your Compliance Program?

6. Who Has Expectations for
Your Compliance Program?
• Senior Management / BOD has expectations…
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7. …Senior Management expects Compliance to keep the company open for business,
and keep them out of jail.
…Senior Management expects Compliance to ensure good external audit
performance.
…Senior Management expects Compliance to ensure the company keeps its hard-
earned money, rather than sending it to the State or Federal Government in the
form of fines or civil monetary penalties.
…Like your Regulators, Senior Management may sometimes believe Compliance can
see further and deeper into the organization than is actually possible.
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Senior Management also has high expectations for your Compliance
Program. In General…
Who Has Expectations for
Your Compliance Program?

8. Who Has Expectations for
Your Compliance Program?
• You have expectations…
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9. …Most compliance professionals didn’t start their careers as compliance
professionals. But however you ended up in compliance, you’ve almost
certainly developed a real heart for the beneficiary if you’ve been in it for
any length of time. You probably see yourself as something of a guardian
or protector. And when things happen that cause harm to beneficiaries, it
bothers you on a personal level. So you, too, expect your Compliance
Program to be as effective as possible at protecting beneficiaries, as well
as your organization.
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As a Compliance Professional, what are your expectations for your
Compliance Program? In General…
Who Has Expectations for
Your Compliance Program?

10. Does Your Current Reality
Match Expectations?
Evaluating the Effectiveness of Your Compliance Program –
Closing the Gap between Expectations and Reality
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11. Does Your Reality Match Expectations?
• Can you depend on the timeliness and accuracy of the
monitoring / performance data you routinely gather within
your organization?
• Do you have line of sight into all facets of your organization?
• Is the process by which information is reported to you
transparent?
• Do you rely heavily on IT and/or functional areas to report
data to you?
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Food for Thought:

12. Does Your Reality Match Expectations?
• Bad Situation – Have you (or your boss) ever had to answer the
following question from a Regulator or Senior Management:
“Why did it take so long for Compliance to find out about this?”
• Worse Situation – Have you (or your boss) ever had to answer
the following question from a Regulator:
“How come we knew about this, but you didn’t?”
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More Food for Thought:

13. Does Your Reality Match Expectations?
CMS 2016 Part C and Part D Program Audit and Enforcement Report
• ODAG Most Common Conditions
Condition Language
Citation
Frequency
2011-Present
Percentage of
Sponsors
Affected in 2016
Denial letters did not include adequate rationales, contained incorrect/incomplete information
specific to denials or were written in a manner not easily understandable to enrollees.
6 out of 6 80%
Sponsor did not notify enrollees and providers if the providers requested the services, of its
decisions within 72 hours of receipt of expedited organization determination requests.
5 out of 6 51%
Sponsor did not take appropriate actions, including full investigations, and/or appropriately
addressing all issues raised in grievances.
3 out of 6 49%
Sponsor did not demonstrate sufficient outreach to providers or to enrollees to obtain
additional information necessary to make appropriate clinical decisions.
6 out of 6 31%
Sponsor did not notify beneficiaries of its decisions within 60 days of receipt of payment
reimbursement requests.
1 out of 6 29%
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14. Does Your Reality Match Expectations?
CMS 2016 Part C and Part D Program Audit and Enforcement Report
• Most Common ICAR Conditions from 2015 and 2016 Audits – ODAG
Condition Language
Number of
ICAR Citations
Sponsor did not notify beneficiaries and providers if the provider requested the services, of its decisions within
72 hours of receipt of expedited organization determination requests.
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Sponsor did not notify enrollees and providers if the provider requested the service, of its decisions within 14
calendar days of receipt of standard organization determination requests.
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Sponsor did not demonstrate sufficient outreach to providers or to enrollees to obtain additional information
necessary to make appropriate clinical decisions.
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Sponsor did not prepare written explanations and send case files to the Independent Review Entity (IRE) in a
timely manner upon affirming its adverse decisions on standard pre-service reconsiderations.
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Sponsor inappropriately denied services to beneficiaries and/or payments to providers for services rendered to
beneficiaries.
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15. Does Your Reality Match Expectations?
Some Examples from Our Attendees:
• Provision of 1915(c) Waiver Services – A State audit revealed the Plan had not been
providing monthly HCBS services, as required, for numerous waiver enrollees. Some clinical
staff members knew this, but Compliance was unaware prior to the State audit.
• KPI Report: EOD Timeliness – Due to internal data lag, an EOD timeliness issue was
90 days old and had impacted dozens of beneficiaries by the time it showed up on the Monthly
KPI Report. Compliance regularly shares the KPI Report with their CMS Account Manager, who
put the Plan on immediate Corrective Action.
• Clean Claims Payment to Contracted Nursing Facilities – Quarterly Claims Report to the
Plan’s Medicaid Contract Manager showed 30-day clean claims timeliness for contracted NFs
was 71%, against a required standard of 90%. Compliance was unaware of the deficiency prior
to the report.
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16. Does Your Reality Match Expectations?
Some Examples from Our Attendees:
• Members with First Follow-up Visit within 30 Days of Hospital Discharge – State-specific
MMP measurement. Compliance was unaware of poor performance on this metric until it was
submitted in a quarterly report, 45 days after the quarter ended.
• Timely Completion of Annual Reassessment (HRA) – Several webinar participants reported
difficulty tracking performance on this requirement. As a result, compliance issues were not
discovered timely.
• Care Coordination Benchmarks: HRA, Care Plan, Care Team, Member Goals, etc. –
Several webinar participants reported difficulty tracking compliance with various Medicaid and
D-SNP care coordination requirements, which impeded early issue detection.
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The key question is, why is early detection and response so difficult??

17. Does Your Reality Match Expectations?
Typical Compliance Reporting System – The Proverbial “Fly in the Ointment”
Completerequiredfollow-upactions
Operational systems /
databases
Retrieve Report
Analyze Report
• Marketing Activities
• Agent/Broker Management
Sales and
Marketing
• Enrollment/Membership Accounting
• Configuration/Claims Processing
• Appeals and Grievances
Operations
• Utilization Management
• Case Management
• Quality Management
Health Care
Services
• Provider Contracting
• Credentialing
• Delegation Oversight
Network
Management
• Agency Relations
• Contract Management
Government
Contracts
Compliance Reporting
Process
● Initiate query / pull data
components from repository
● Analyze, roll up, calculate,
aggregate data components
into defined metrics –
o KPIs, Dashboards,
Analyses, Monitoring
Results
● Manager Review / Approval
● Create Report or Input Data
into Reporting Application
Process may be manual,
automated, or both
Functional Areas Regulatory Compliance
Issues identified – initiate
appropriate follow-up:
● Request additional information
● Create compliance incident
● Conduct focused audit
● Report to committee or senior
leadership
Copyright @ Inovaare Corporation | Confidential
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18. Does Your Reality Match Expectations?
Consequences of the Typical Compliance Reporting System:
• Lack of Transparency
• No Assurance of Accuracy
• Significant Data Lag
• Limited Data = Limited Insight
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19. • Resource-Intensive, Cost-Intensive
• Leadership Must Manage Risk Reactively
Does Your Reality Match Expectations?
Consequences of the Typical Compliance Reporting System:
• Promotes a “Culture of Friction”
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20. A Vision for a New Reality:
Compliance in Real Time
Evaluating the Effectiveness of Your Compliance Program –
Closing the Gap between Expectations and Reality
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21. Direct link to operational
systems / databases
Provides Compliance
real-time data access
Operational systems /
databases
• Marketing Activities
• Agent/Broker Management
Sales and
Marketing
• Enrollment/Membership Accounting
• Configuration/Claims Processing
• Appeals and Grievances
Operations
• Utilization Management
• Case Management
• Quality Management
Health Care
Services
• Provider Contracting
• Credentialing
• Delegation Oversight
Network
Management
• Agency Relations
• Contract Management
Government
Contracts
Copyright @ Inovaare Corporation | Confidential
Functional Areas Regulatory Compliance
Compliance has direct line of sight to operational
source data:
● Real-time access to defined metrics AND all
underlying data elements
● Eliminates intermediate reporting steps and
reliance on functional areas and/or IT
● Ensures data accuracy and validity
● Ability to set flags to track all key measures in
real time
● Ability to immediately drill down on any data
point for further analysis
Issues are identified and addressed in real time:
● Request additional information
● Create compliance incident
● Conduct focused audit
● Report to committee or leadership
Completerequiredfollow-upactions
A Framework for Real-Time Compliance Oversight
A New Reality – Compliance in Real Time
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22. Direct link to operational
systems / databases
Provides Compliance
real-time data access
Copyright @ Inovaare Corporation | Confidential
Regulatory Compliance
Compliance has direct line of sight to
operational source data:
● Real-time access to defined metrics AND all
underlying data elements
● Eliminates intermediate reporting steps and
reliance on functional areas and/or IT
● Ensures data accuracy and validity
● Ability to set flags to track all key measures
in real time
● Ability to immediately drill down on any data
point for further analysis
Issues are identified and addressed in real time:
● Request additional information
● Create compliance incident
● Conduct focused audit
● Report to committee or leadership
Old Model Versus New Model
A New Reality – Compliance in Real Time
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Retrieve Report
Analyze Report
Compliance Reporting
Process
● Initiate query / pull data
components from repository
● Analyze, roll up, calculate,
aggregate data components
into defined metrics –
o KPIs, Dashboards, Analyses,
Monitoring Results
● Manager Review / Approval
● Create Report or Input Data
into Reporting Application
Process may be manual,
automated, or both
Regulatory Compliance
Issues identified – initiate
appropriate follow-up:
● Request additional information
● Create compliance incident
● Conduct focused audit
● Report to committee or senior
leadership
Input Needed from
Functional Areas or IT
NO Input Needed from
Functional Areas or IT

23. A New Reality – Compliance in Real Time
Benefits of a Real-Time Compliance System:
• Transparent Process
• Assures Accuracy
• Eliminates Data Lag
• Allows Immediate, In-Depth
Analysis on All Data Points
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24. • Reduces Resource Burden, Reduces Costs
• Leadership Can Manage Potential Risks Proactively
• Promotes Harmony between
Compliance and Operations
Benefits of a Real-Time Compliance System:
A New Reality – Compliance in Real Time
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25. How Do You Get There
From Here?
Evaluating the Effectiveness of Your Compliance Program –
Closing the Gap between Expectations and Reality
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26. How Do You Get There From Here?
Some Basic Stepping Stones for the Do-It-Yourselfer:
• Create Compliance Data Repository
• Mapping to Operational Systems
• Create Reports
• Create Flags / Algorithms
• Processes and Staffing for Updating / Data Management
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27. How Do You Get There From Here?
Is the Shift to a Real-Time Compliance Model Financially Viable?
• A Simple Business Case for Senior Management:
 Reduction in Staff Time = $$
 Reduction in Accrued Monetary Penalties = $$
 Improvement in Measures like STAR Ratings = $$
 Potential Reduction in Waste/Increase in Efficiency = $$
Net/Net – The shift to Real-Time Compliance, if done effectively, will have a
significant, positive impact to the company’s bottom line.
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28. How Do You Get There From Here?
The Lift is Heavy… Will It Be Worth It?
• Major Paradigm Shift for Compliance Oversight and
Risk Management
• Organization Stays Ahead of Regulator and Senior
Management Expectations
• Compliance Function Becomes a Competitive
Advantage
• Significant, Positive Bottom Line Impact
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29. How Do You Get There From Here?
Final Thoughts: Do You Really Have a Choice?
• The regulatory environment in the Health Care industry becomes
more complex all the time, with the volume of laws and
requirements governing Health Plans increasing every year. As
Regulators become more and more sophisticated in their oversight
capabilities, the benefits of compliance success become greater,
while the penalties for compliance failure become more severe.
With so much at stake, implementing a Real-Time Compliance Model
is not really optional – it’s imperative!
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30. • Brenda Wade
(562) 225-2881
Brenda.Wade@inovaare.com
Questions or Comments?
If you have questions, comments or feedback, please let us know!
• Kevin Lillywhite
(916) 337-1144
Kevin.Lillywhite@gmail.com
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