Appeals, grievances and formulary exceptions are some of the biggest compliance minefields for Part D plans, consistently rating tops in CMS site-visit findings. It's important for plans to structure appeals and grievances procedures effectively to minimize compliance risks. Plans not only face potential civil and criminal penalties for failure to adhere to the specific appeals and grievances time frames, but also face other compliance actions by CMS and the potential immediate impact on member retention.

Part D Appeals & Grievances: Strategies for Minimizing Compliance Risks examines key issues surrounding Part D appeals and grievances. It includes an edited transcript of a well-received Jan. 25, 2007, AIS audioconference, as well as presenters’ slide presentations and AIS articles on the topic.

In this report, expert advice is given on topics such as:

• The difference between an appeal and a grievance
• Identifying your weaknesses in handling coverage determinations and complaints
• The benefits of having a good "work flow" and what it reveals
• Using your Web site to minimize your risks
• Actual case studies from the long-term care, pharmacy and other industries

Learn how to structure an effective appeals and grievances procedure so that you don't become a target of CMS enforcement. Order your copy of Part D Appeals & Grievances: Strategies for Minimizing Compliance Risks today!

Table of Contents

Introduction

Transcript of AIS Audioconference Jan. 25, 2007

• Remarks by Maureen Miller
• Questions and Answers

Materials Supplied by Maureen Miller

Selected Articles From AIS Publications

• Plans, CMS See Few Trouble Spots in Exceptions and Appeals Process
• Part D Appeals Process Called Confusing by Plans, Beneficiaries; CMS Disagrees
• Plans Must Use Proper Analysis When Denying Part D Coverage

Written By

This book was compiled by the editorial staff of AIS. The speaker at the January 25, 2007, audioconference was:

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.

Written For

Compliance officers, legal counsel, government-relations executives, financial executives, program managers, provider-relations managers and other managers with Part D responsibilities at:

• Medicare Prescription Drug Plans (PDPs)
• Medicare Advantage plans
• Pharmaceutical companies
• Pharmacy benefit management companies
• Lawyers and consultants

International orders will be fulfilled in PDF format via email.