Medicare Choice: What does the future hold HCCAs 2000 Compliance Institute

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MedicareChoiceWhat does the future
hold?HCCAs 2000 Compliance Institute

• Wendy L. KrasnerSeptember 26, 2000McDermott
  Will EmeryWashington, DC
• wkrasner_at_mwe.com

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MedicareChoice

• Overview
• Key regulatory developments
• Key compliance issues
• What next?

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Regulatory Developments

• Final MC rules (Fed. Reg. 6/29/00)
• Revised marketing guidelines
• Revised contract for 2001
• Revised OPL 77 regarding provider contracts
  (updated 7/14/00)
• New QISMC (Quality Improvement System for Managed
  Care) expected shortly

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MC Final RulesImportant Dates

• Publication date June 29
• Effective date July 29
• Comment due date August 28
• Comments authorized on
• BBRA of 1999 provisions

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Rules to Implement BBRA 1999

• Phase-in of risk adjustment methodology
• Incentives to offer MC plans in areas without
  plans
• Reduction of 5-year ban upon non-renewal to
  2-years
• New exception if during six months after
  non-renewal notice, legislative or regulatory
  change results in increased reimbursement

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Significant Issues for Plans

• Burdens reduced
• Mandatory reporting deleted
• Certification language improved
• NODMAR (Notice of discharge and Medicare appeal
  rights)
• Encounter data added to definition of clean claim
  (applies to non-participating as well)
• Value Added Items and Services allowed

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Significant Issues for Plans

• Burdens increased
• Post-stabilization and emergency coverage
• Scope of appeal rights
• No relief on pre-emption
• Applicability to 2001?

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Significant Issues for Providers

• Revised provider contract requirements
• Ability of MCOs to use providers out of area
• In-network providers can participate in POS
• Provider marketing restrictions eased
• Heads up that NODMAR obligation to be placed on
  providers

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MC Compliance Update

• Compliance plans mandatory under MC
• OIG active in area
• OIG Voluntary Compliance Guidance (11/15/99)
• Recent Humana settlement on institutionalized
  beneficiaries
• Fundamental tension is OIG views MC as if it
  were cost-based

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MC Compliance Update

• Recent OIG Corporate Integrity Agreements on MC
• Distribution of policies
• Review procedures
• Performance engagement
• Compliance engagement

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MC Compliance Update

• Performance engagement
• Enrollment data
• Encounter data
• ACR data
• Claims processing
• Selective marketing
• Disenrollment

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MC Compliance Update

• Factors influencing findings of knowledge
• Is compliance plan in place and adhered to?
• Actual or constructive notice to MCO
• Clarity of rule
• Magnitude of false claim
• Past remedial efforts of MCO
• Did MCO contact agency about rule at issue?

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MC Compliance Update

• Recent MC issues
• OIG report on high administrative overhead
• OIG report regarding findings on non-compliance
  with National Marketing Guide
• Payment for deceased beneficiaries
• Medicare appeals overturn rates
• Hospice care payment reconciliations
• ACR audit issue

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MC Compliance Update

• Ongoing MC issues
• Encounter data
• Part B certifications
• Dual eligibles
• PIP rules
• Privacy
• PBM arrangements

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Future of MC

• Significant non-renewals at end of 2000
• For-profits facing investor doubts about
  reliability of government as business partner
• Concerns with overwhelming regulatory burdens
• Compliance considerations
• Provider non-cooperation

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Future of MC

• Remaining relief basically financial
• More funding
• Repeal or modify risk adjustors
• Congress needs to act
• Prospects of Medicare pharmacy benefit complicate
  picture
• Alternatives may be revisited
• Medicare Select
• Cost contracts
• Skeptical of major renaissance in near term