Preparing for Compliance
Monitoring Reviews
Understanding CMS Protocols Used by
Review Organizations
January 14, 2009
Presented by:
Margaret deHesse, RN, BSN
Executive Director, State & Corporate Services
Health Services Advisory Group, Inc.
Overview of CMS Protocols
• Two main sources of information
– Document review

Assess compliance with regulatory provisions

Identify issues that will be pursued during interviews
– Interviews

Interview participants provide clarification and
confirm that documented practices are being followed

Data gathered from interviews should supplement and
verify what is learned during document review
Overview of CMS Protocols
Protocol activities
1.
2.
3.
4.
5.
6.
7.
Planning for compliance monitoring activities
Obtaining background information from the State
Medicaid agency (review organization’s responsibility)
Document review
Conducting interviews
Collecting any other accessory information (e.g., from
site visits)
Analyzing and compiling findings (review
organization’s responsibility)
Reporting results to the State Medicaid agency (review
organization’s responsibility)
Activity 1: Planning for Compliance
Monitoring Activities
• Establishing an agenda for the visit
− In conjunction with the review organization.
− An agenda will help the review organization to
perform an efficient and effective on-site evaluation.
− An agenda will help the MCO/PIHP to:
 Plan for staff participation.
 Gather documentation.
 Address logistical issues, such as arranging locations
for reviewers to conduct document review, system
demonstrations, observations, and interviews.
Activity 1: Planning for Compliance
Monitoring Activities (cont.)
• Establishing an agenda for the visit (cont.)
− An agenda sets the tone, as well as the expectations,
for the on-site visit so that both the MCO/PIHP and
the reviewers understand the objectives and time
frames for the review.
− Review the agenda at the end of each review day to
verify follow-up items and the next day’s events.
Activity 1: Planning for Compliance
Monitoring Activities (cont.)
• Preparation instructions and guidance are
provided to the MCO/PIHP by the review
organization
– An on-site evaluation process requires the
cooperation of the MCO/PIHP being evaluated.
– If the MCO/PIHP is prepared for the on-site visit,
reviewers can remain focused on conducting and
completing the evaluation in the allotted time
frame.
Activity 1: Planning for Compliance
Monitoring Activities (cont.)
• Preparation instructions and guidance are
provided to the MCO/PIHP by the review
organization (cont.)
– Review organization instructions may include the
following:

Providing the health plan with the on-site review tool,
which describes the scope of the evaluation to be
performed

Describing how the evaluation will be conducted,
including instructions

Providing a list of documents that should be available
Activity 1: Planning for Compliance
Monitoring Activities (cont.)
• Preparation instructions and guidance are
provided to the MCO/PIHP by the review
organization (cont.)
– Health plan responsibilities may include the following:

Preparing a roadmap (description of how documents,
systems, and processes meet the standard).
 Organizing the files to be reviewed.
 Verifying that the correct files are prepared (compare to
sample list, check names, documents in files, mock file
review).
Activity 1: Planning for Compliance
Monitoring Activities (cont.)
• Preparation instructions and guidance are
provided to the MCO/PIHP by the review
organization (cont.)
– Health plan responsibilities may include the following:

Completing any forms or other data-gathering instruments
(e.g., an Information Systems Capability Assessment).
 Arranging expected participant interviews.
 Making administrative arrangements.
 Confirming other expectations or responsibilities.
Examples of Successful Preparation
Activities
• Create a work team with significant involvement of
operational areas being reviewed
– Member services, information services, quality,
compliance, utilization management, case management,
provider relations, etc.
• Create a formal work plan based on the review
schedule established in conjunction with the State
• Conduct a mock review using the review tool to
identify gaps prior to the on-site review
• Prepare information files or binders coinciding with
each area under review
Activity 2: Document Review
• Consider all sources of compliance
requirements
– Assessment of compliance with regulatory
provisions

Medicaid regulatory provisions (BBA)

State contract requirements

Internal policies and procedures
Activity 2: Document Review (cont.)
• Consider all sources of compliance
requirements (cont.)
– Identified issues that will be pursued during
interviews

Disagreement between internal policies and
procedures and State and federal requirements
Activity 3: Interviews
• Consider the topic and policy/procedure when
scheduling participants
– Data gathered from interviews should supplement and
verify what is learned during document review.
– Interview participants provide clarification and confirm
that documented practices are being followed.

Interviews should be conducted with groups. Rarely is one
individual solely responsible for a particular function.
 Cross-functional/service/department interviews are
beneficial.
 What one area does not know, another may, and the
interview then becomes a learning opportunity for the
MCO’s/PIHP’s staff as well.
Example: Grievance Process Review
Activity 1: Planning
• Review organization instructions may include the following:
– The scope of the evaluation to be performed

All grievances in a time frame (between 1/1/2008 and 12/31/2008)
– How the evaluation may be conducted


Review of documentation and reports (pre-on-site and on-site)
System demonstration
o Databases—including codes/types of grievances
o Manual—paper-based system

Interviews
o Staff members who are interviewed should be prepared to describe their
role in the grievance process, including intake, routing, and oversight.

Observations
 File review of selected sample of grievances
Example: Grievance Process Review
Activity 2: Document review
• Review organization instructions may include the
following:
− Documents that may be requested for review prior to onsite review or while on-site
 Grievance and appeals policies and procedures
 Internal monitoring reports
o Reports used to monitor timeliness
o Reports used to trend types and subtypes of grievances
 External regulatory reports
 Sample acknowledgement letters
 Sample resolution letters
Example: Grievance Process Review
Activity 2: Document review (cont.)
• Review organization instructions may include the
following:
– Grievance file review by review organization
 Random sample of grievance files to review
 Size of sample determined by review organization
 The health plan will then compile documentation with each
grievance in a separate labeled file folder
– Completion of any forms or other data-gathering
instruments
 Health plan description of the system used to handle grievances
 Systems may include database and manual/paper process.
 How information is provided to other departments or committees
Example: Grievance Process Review
Activity 3: Interviews
• Review organization instructions may include the
following:
− Administrative arrangements

Need for review team meeting room including interviews
− Expected interview participants

Supervisory staff members responsible for oversight of
staff handling incoming grievances
 Member services observation
 Quality or compliance staff members responsible for
oversight of process
Example: Grievance Process Review (cont.)
Activity 3: Interviews (cont.)
• Sample interview questions
– Which staff members are responsible for helping Medicaid
members use the organization’s complaint or grievance
system, including completing forms, or taking other steps to
resolve an appeal or grievance?
– What kind of assistance is made available to Medicaid
members?
– Describe your role in the process, including documentation
you prepare.
– Who is responsible for routing grievances to the appropriate
department or staff member for resolution?
Example: Grievance Process Review
Activity 3: Interviews (cont.)
• Sample interview questions
– Do you get feedback regarding ways you could improve
your process?
– Is there a process in place to monitor either the appeal and
grievance process or the areas of concern identified by
member appeals and grievances?
– Describe reports used for monitoring.
Example: Grievance Process Review
Activity 4: Collecting any other accessory
information (e.g., from site visits)
• Other expectations or responsibilities
– Additional information may need to be copied to
validate health plan activities
– Observations and walk-through for key operations
areas such as member services call center
Wrap Up
• Questions?