Agenda

• Identify changes needed to your current operations to adapt to the CMS Program Audit process updates
• Discuss best practices to implement streamline changes throughout your department with minimal disruption
• Describe education needed to inform your team of the impending changes
• Discuss the impact of the data/items no longer required to submit to CMS for audits and the importance of still monitoring the data

• Strategies to correct re-openings within the appropriate time frame
• Identify which team members role oversees re-openings and re-determinations
• Best practices in dealing with claim corrections that have surpass the timely filing limit
• Install education practices to reduce the amount of re-openings
• Create accurate written notice to members within the appropriate time frame

Sponsored by: kiriworks

• Strategies to ensure that timeliness measures are met on appeals decisions  
• Best practices for documenting the review of an appeal decision made by the plan 
• Tools to educate staff members on the impact appeals can have on a plan’s Stars rating 
• Evaluate the reliability and accuracy of appeals Independent Review data 
• Best practices for dealing with Complaints Tracking Module (CTM) 

Caroline Spencer, STARS Program Manager/A&G Manager 

Memorial Hermann Health Plan 

Mariah Emerich, Supervisor 

Moda Health 

• Learn effective strategies to gain buy in from senior administrators and delegated entities
• Identify which personnel and skillsets are needed to build effective teams within administrative budgets
• Evaluate and leverage technology to enhance audit effectiveness 
• Leverage mock audit programs to improve compliance program effectiveness
• Discuss best practices for creating standard procedures, meaningful reporting, issue tracking, and work flow in preparation to build your team
• Identify compliant clinical documentation and decision making 
• Discuss the elements required for a compliant denial rationale 

Sponsored by: Bluepeak Advisors

• Examine what CMS is looking for when accessing call logs
• Best practices in providing education for your team and FDR’s
• Strategies to implement a monthly oversight monitoring program running ODAG and CDAG samples   through all audit measures
• Identify which members of your team are involved
• Best practices in creating reports of your findings
• Create a plan of action to find the root cause and correct issues
• Angela Lloyd, Director Medicare Audit & Corrective Action
• Health Partners Plans

• Identify a process for finding the root cause of a grievance
• Best practices in documentation of the root cause process to CMS standards
• Explore actions to reduce or eliminate grievances identified through root cause analysis
• Examine which vendors can help your plan manage member grievances
• Enhance collaboration with internal business partners for RCA and remediation of identified trends
• Identify a process for finding the root cause of appeals
• Explore actions to reduce or eliminate appeals identified through root cause analysis

Sponsored by: Ankura Consulting Group

• Analyze the impact of the changes made to the Medicare Program Integrity Manual (PIM)
• Identify what changes will influence the Local Coverage Determinations (LCD) Process 
• Evaluate immediate adaptations that need to be made in your current operational procedures

• Panel members included have experienced a CMS Audit in the past 12 months
• Evaluate the position they were in prior to the audit and what they would change
• Identify which areas CMS focused on specifically in the audit
• Examine the steps that were taken post audit, including corrective action plans and independent validation audits

• Identify educational tools to improve customer service representatives experience with members
• Best practices to create consistency with classification of request
• Tools to create a compliant culture within your customer service team
• Training strategies to generate a team with a strong culture and leadership 

Sponsored by: MedHok

• Identifying appropriate resources for communicating issues / problem solving
• Strategies to improve communication flow between all departments impacted by A & G
• Develop an understanding of the impact of one departments role on the other departments
• Best practices in building a team-oriented work place between departments
• Identify universal communication strategies that coincide with and promote the corporate culture
• Develop effective strategies for successful communication among remote workers and teams

• Describe the background and importance of the Office of the Inspector General (OIG) report on Medicare Advantage Appeals
• Discuss CMS annual audit report and key findings regarding Medicare Appeals
• Discuss top trends and common issues with Medicare Appeals in five key areas: 
• Organizational and departmental structure
• Transparency
• Effective controls and operations
• Data analytics
• Systems
• Discuss and summarize solutions for common issues

• Examine the CMS requirements for ODAG and CDAG universes that must be pulled  
• Identify issues in pulled universes and creating a plan of action to correct them 
• Strategies to recreate the experience of a CMS Audit in real life 
• Utilize recent audit experiences from other plans to recreate a mock audit 
• Examine technological solutions that can assist your team in the audit process 

Jon Swisher, Director of Solution Development
Kiriworks 

Melissa Rusk, Director Claims and BPO Operations
SummaCare

• Analyze the CMS requirements for accurate ODAG and CDAG universes and tables
• Strategies to implement regular universe and data accuracy checks
• Identify problematic areas that can cause universe disparities and solutions to correct the issues 

Sponsored by: Beacon Healthcare Systems 

• Evaluate the resources, the FDR’s need to prepare documents needed for an audit
• Understand the perspective of the FDR
• Learn strategies to improve communication and expectations with FDRs
• Understand the work load balance of FDRs managing multiple audits

• Identify personnel within your organization with leadership abilities
• Implement educational practices to develop their skills
• Maximize your current leadership to foster growth and development
• Transfer knowledge and experience between the ranks
• Identify which skills will be needed for leaders of future generations