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After giving plans one year to get acclimated to the Part D environment, CMS is ready to begin aggressively monitoring appeals and grievances. Now, more than ever, plans need to know exactly how to categorize complaints correctly, the various time frames in which to respond to particular complaints, and the proper procedure for denying coverage requests or they face potential civil and criminal penalties for failure to comply. CMS will audit plans' appeals and grievances procedures as part of the regularly scheduled Part D audits. This is not only a matter of compliance, but also a big factor in your ability to retain Part D plan enrollees. Plans face potential financial implications if they have unhappy enrollees who start looking at other plans to have their prescription drug needs met. Each Part D plan sponsor must establish and maintain procedures for:
Additionally, sponsors must provide all enrollees with written information about the grievance and appeal procedures available to them, as well as the complaint processes. Once a beneficiary makes a complaint, plan sponsors must respond to the complaint within specific decision-making time frames that apply to both grievances and appeals. Join Maureen Miller, an expert from Gorman Health Group and former senior policy analyst for HCFA, as she helps you differentiate between appeals and grievances, identify where your weaknesses are in your coverage determinations and complaints procedures, and develop a good work flow to handle appeals and grievances. Go beyond the audit guide and learn how to structure an effective appeals and grievances procedure so that you don't become a target of CMS enforcement. Topics covered include:
Maureen Miller, senior consultant at Gorman Health Group, was in key positions at HCFA for 20 years before joining John Gorman's company. Most recently, she was senior policy analyst for HCFA's Medicare managed care program and had an integral role in the agency's development of Medicare Advantage and provider-sponsored organization regulations. A registered nurse with a master's degree in public health, Ms. Miller's roles at HCFA included product development, legislative reform and regulatory affairs specifically pertaining to Medicare managed care. At GHG she is part of the team specializing in Part D compliance, advising clients on CMS regulations and program guidance and assisting PDPs and MA-PDs with implementation and operations in several program areas. Moderator: Barbra Golub, JD, managing editor of A Guide to the Medicare Drug Benefit and editor of Medicare Part D Compliance News.
Compliance officers, legal counsel, government-relations executives,
financial executives, program managers, provider-relations managers
and other managers with Part D responsibilities at:
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