Medicare Parts
C and D Data
Validation Trends
and Challenges
October 29, 2013
Presented by:
Jim Casurella
Rob Shelley
Sadie Zarnoth
Today’s Agenda
Introductions
2013
Experience
To the
Future!
•Data Validation Overview
•Why do we do this?
•Who are PSRx and MetaStar?
•2013 Results, What happened last year?
•Common Challenges
•2014 Summary and Changes
•DV Standards
•Automation possibilities
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.
2013 Data Validation
The
Team
• 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
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
3
2013 Data Validation
Overview
• 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
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2013 Data Validation
2013
Results
Part C
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%
Disclaimer: 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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2013 Data Validation
2013
Results
Part D
Data
Validation
• 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
Disclaimer: 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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2013 Data Validation
Challenging
Standards
•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
For current DV specifications and documentation, go to cms.gov
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2014 Data Validation
Contract Year 2013 Measures
2013
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.
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2014 Data Validation
2014
Changes
Part C
•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
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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
Standards
Validation
•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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In Closing…
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Providing Informed Pharmacy Decisions
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