Importance of Accurate Universes Move past the Universe being the “Victory” Improving Operations through the Universes

1. The Importance of Clean Universes
Not Just for a CMS Audit
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2. Not Just for a CMS Audit
•Importance of Accurate
Universes
•Move past the Universe being
the “Victory”
•Improving Operations through
the Universes
Today’s Agenda

4. Consequences for Universes Failures
• Can drastically affect your audit
score
• May lead to a referral for
possible enforcement actions
• Can adversely affect STAR
“An inability to pull a universe will adversely affect our ability to conduct the audit
and your ability to complete the audit”
- Jennifer Smith CMS , Division of Analysis, Policy, & Strategy (DAPS)

5. Example from an ODAG Universe
Timely = Yes
Interest Paid = Yes
WHY?

6. Completerequiredfollow-upactions
Operational systems /
databases
Retrieve Report
Analyze Report
• Marketing Activities
• Agent/Broker Management
Sales and
Marketing
• Enrollment/Membership Accounting
• Configuration/Claims Processing
• Appeals and Grievances
Operations
• Utilization Management
• Case Management
• Quality Management
Health Care
Services
• Provider Contracting
• Credentialing
• Delegation Oversight
Network
Management
• Agency Relations
• Contract Management
Government
Contracts
Typical Current Compliance System
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Compliance Reporting
Process
● Initiate query / pull data
components from repository
● Analyze, roll up, calculate,
aggregate data components
into defined metrics –
o KPIs, Dashboards,
Analyses, Monitoring
Results
● Manager Review / Approval
● Create Report or Input Data
into Reporting Application
Process may be manual,
automated, or both
Functional Areas Regulatory Compliance
Issues identified – initiate
appropriate follow-up:
● Request additional information
● Create compliance incident
● Conduct focused audit
● Report to committee or senior
leadership

7. Direct link to operational
systems / databases
Provides Compliance
real-time data access
Operational systems /
databases
• Marketing Activities
• Agent/Broker Management
Sales and
Marketing
• Enrollment/Membership Accounting
• Configuration/Claims Processing
• Appeals and Grievances
Operations
• Utilization Management
• Case Management
• Quality Management
Health Care
Services
• Provider Contracting
• Credentialing
• Delegation Oversight
Network
Management
• Agency Relations
• Contract Management
Government
Contracts
A New Framework – Compliance in Real Time
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Functional Areas Regulatory Compliance
Compliance has direct line of sight to operational
source data:
● Real-time access to defined metrics AND all
underlying data elements
● Eliminates intermediate reporting steps and
reliance on functional areas and/or IT
● Ensures data accuracy and validity
● Ability to set flags to track all key measures in
real time
● Ability to immediately drill down on any data
point for further analysis
Issues are identified and addressed in real time:
● Request additional information
● Create compliance incident
● Conduct focused audit
● Report to committee or leadership
Completerequiredfollow-upactions

8. Common Universe Problems
Description of the Problem Examples
Data in the wrong fields Date in time fields
Missing data Blank fields – no N/A when appropriate
Inappropriate data • Existing Members included in the
universe for new members
• Denied Claims in Paid claims Universes
Repeated errors despite CMS finding Incorrect Date (written vs. mailed)

9. The False Victory Effect

10. Challenges with Clean Universes
 Technical specifications are extremely complex
 Data must come from a variety of sources
o Internally
o Externally
 Compilation – data gathered from internal and
external sources must be accurately aggregated and
entered in the Universes
 Quality check

11. Why should CMS have all the fun?

12. The Bigger Picture

13. Paradigm Shift
Real Time Compliance:
• Not an Ask, but a Need
• Direct Line of Sight
• Avoid Surprises
On-Demand Data Visibility:
• Own your Data Not Just during Audits
• Identify and Improve
• Routinely Monitor

15. Thank You
Inquiries: info@inovaare.com
brenda.wade@Inovaare.com
gabe.viola@Inovaare.com
(405) 850-2235 www.inovaare.com
Real compliance in Real time
If you would like to obtain additional information or are interested in discussing how Inovaare can help
please feel free to contact us.