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PE

Establish Compliance Incident

Compliance Management

Description

The Establish Compliance Incident business process is responsible registration of a case for incident tracking of utilization anomalies. It establishes an incident file, generates incident identification, assigns an incident manager, links to related cases, and collects related documentation.

Business Process Template

Trigger events
Environment-based
  • Request to initiate incident tracking for business partner, member, provider, contractor or other entity.
  • Request to initiate incident from communication (e.g., mail, telephone, facsimile or web).
  • Receive requests for suppression of information or corrective action from federal and state law enforcement.
  • Receive compliance investigation information from Centers for Medicare & Medicaid Services (CMS).
  • Receive compliance investigation information from Medicaid Fraud Control Unit (MFCU).
  • Receive compliance investigation information from Office of Inspector General (OIG).
  • Receive self-disclosure of actual or potential violations from provider.
Interaction-based

None published

Results
  • Initiation of a compliance incident.
  • Alert sent to Manage Compliance Incident Information business process for incident monitoring.
  • If applicable, notification sent to state or federal law enforcement agencies of possible criminal investigation.
  • If applicable, notification sent to CMS of compliance investigation.
  • If applicable, notification sent to MFCU of compliance investigation.
  • If applicable, notification sent to OIG of compliance investigation.
  • Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
  • 1. START: Request to establish incident tracking.
  • 2. Establish incident case with required information.
  • 3. Generate incident identification.
  • 4. Assign and authorize an incident manager to manage an incident and request additional information.
  • 5. Identify and link related incidents to this one.
  • 6. Collect relevant documentation.
  • 7. If applicable, send notification to state or federal law enforcement agencies of possible criminal investigation.
  • 8. If applicable, send notification to CMS of compliance investigation.
  • 9. If applicable, send notification to MFCU of compliance investigation.
  • 10. If applicable, send notification to OIG of compliance investigation.
  • 11. END: Send alert to Manage Compliance Incident Information business process for incident monitoring.
Predecessor processes
Successor processes
Shared data
  • Member data store including demographics, eligibility, enrollment, and grievance information
  • Provider data store including provider network, contract, and grievance information
  • Contractor data store including provider network, and contract grievance information
  • Claims data store including payment information
  • Financial data store including accounts receivable and accounts payable information
  • Business Activity data store including performance information
  • Compliance Management data store including compliance incident information
Constraints

States and programs within States establish different criteria for their investigations. Rules change along with the experience of the state, health care best practices, modifications in benefits, and with the addition of new provider and member types.

Failures
  • No incident tracking requests made.
  • Lack of required information to establish an incident.
Performance measures
  • Time to complete the process = e.g., ___ days, ___ hours or ___ minutes
  • Accuracy with which rules are applied = __%
  • Consistency with which rules are applied = __%
  • Error rate = __% or less

Source: CMS MITA 3.0 Business Process Template, Performance Management BPT.pdf, pages 3-5.

Business Capability Model (11 questions)

Each capability question defines five maturity levels, from Level 1 through Level 5.

Business Capability Descriptions

How integrated or central is the process?
  1. LEVEL 1SMA has duplicate processes multiple parts of the organization. There is little coordination among SMA programs or between SMA and other stakeholders (e.g., other state agencies, CMS, intermediaries, other payers) in relation to the process.
  2. LEVEL 2SMA integrates the process within SMA. There is improved coordination between SMA and other stakeholders in relation to the process.
  3. LEVEL 3SMA integrates the process with state and federal law enforcement agencies, CMS, and providers to the extent possible within the intrastate.
  4. LEVEL 4SMA receives requests for suppression of information or corrective action from federal and state law enforcement; compliance investigation information from CMS; and self-disclosure of actual or potential violations from providers.
  5. LEVEL 5SMA fully integrates the process with state, regional and federal law enforcement, CMS, providers, and other federal agencies across the nation.
Is the process primarily manual or automatic?
  1. LEVEL 1The process consists primarily of manual paper-based activity to accomplish tasks.
  2. LEVEL 2SMA uses a mix of manual and automatic processes to accomplish tasks.
  3. LEVEL 3SMA automates process with state and federal law enforcement agencies, CMS, and providers to the extent possible within the intrastate. SMA produces audit trail of compliance decision 100% of the time.
  4. LEVEL 4SMA automates process with state and federal law enforcement agencies, CMS, and providers to the full extent possible across the interstate.
  5. LEVEL 5SMA automates process with state and federal law enforcement agencies, CMS, and providers to the full extent possible across the nation.
Does the State Medicaid Agency use standards in the process?
  1. LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
  2. LEVEL 2SMA applies a mix of HIPAA and state-specific standards. Increases availability of information improves data usefulness for performance monitoring, management reporting and analysis over Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, state and federal law enforcement agencies, and CMS standards, and other nationally recognized standards for intrastate exchange of information.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, state and federal law enforcement agencies, and CMS standards, and other nationally recognized standards for compliance and interstate information exchange.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, state and federal law enforcement agencies, and CMS standards, and other nationally recognized standards for national exchange of information.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
  1. LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
  2. LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and Electronic Data Interchange (EDI) transactions.
  3. LEVEL 3SMA collaborates with other intrastate agencies and entities, e.g., state law enforcement, federal law enforcement agencies, and CMS to adopt national standards, and to develop and share reusable business services.
  4. LEVEL 4SMA collaborates with other interstate agencies and entities, state and federal law enforcement agencies, and CMS to adopt national standards, and to develop and share reusable processes including clinical information.
  5. LEVEL 5SMA collaborates with agencies and entities, state and federal law enforcement agencies, CMS, and other federal agencies and entities for national (and international) interoperability improvements that maximize automation of routine operations.

Business Capability Quality: Timeliness of Process

How timely is the end-to-end process?
  1. LEVEL 1Process meets threshold or mandated requirements for timeliness (i.e., the process achieves results within the time specified by law or regulation).
  2. LEVEL 2Process timeliness improves through use of automation. Timeliness exceeds legal requirements.
  3. LEVEL 3Timeliness improves via state and federal collaboration, use of information sharing, standards, and regional information exchange hubs. Timeliness exceeds Level 2. SMA distributes Notice of appeal rights within 15 minutes or less 100% of the time.
  4. LEVEL 4Information is available in near real time. Processes that use compliance incident information result in immediate action, response, and results. SMA has interstate interoperability, which further improves timeliness over Level 3.
  5. LEVEL 5Information is available in real time. Processes improve further through connectivity with other States and with federal agencies. Most processes execute at the point of service. Results are almost immediate.

Business Capability Quality: Data Access and Accuracy

How accurate is the information in the process?
  1. LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
  2. LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
  3. LEVEL 3Automation of information collection increases the reliability of SMA’s internal information. External sources of information use MITA Framework and industry standards for information exchange. Decision-making is automatic using standardized business rules definitions. Accuracy rating is at 99% or higher.
  4. LEVEL 4Automation of information collection increases the reliability of SMA’s internal and external sources of information. SMA adopts MITA Framework and industry standards for information exchange with interstate agencies. Decision-making is automatic using regional standardized business rules definitions. Accuracy rating is at 99% or higher.
  5. LEVEL 5SMA adopts MITA Framework and industry standards for information exchange with national agencies. Decision-making is automatic using national standardized business rules definitions. Accuracy rating is at 99% or higher.
How accessible is the information in the process?
  1. LEVEL 1SMA stores information in disparate systems including paper storage and obtains information manually.
  2. LEVEL 2SMA stores information in disparate systems, but automation and HIPAA standards increase accessibility over Level 1.
  3. LEVEL 3SMA obtains information easily and exchanges with state and federal law enforcement, CMS, providers, and other intrastate agencies and entities based on MITA Framework and industry standards. Accessibility is greater than Level 2.
  4. LEVEL 4SMA obtains information easily and exchanges with state, district, and federal law enforcement, CMS, providers, interstate agencies and entities. Accessibility is greater than Level 3.
  5. LEVEL 5SMA obtains information easily and exchanges with state and federal law enforcement, CMS, providers, federal agencies and entities. Accessibility is greater than Level 4.

Business Capability Quality: Cost Effectiveness

What is the cost of the process compared to the benefits of its results?
  1. LEVEL 1High relative cost due to low number of automatic, standardized tasks.
  2. LEVEL 2Automation improves process and allows focus on exception resolution, improving cost effectiveness ratio over Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards, state and federal law enforcement, CMS, and other nationally recognized standards further improving cost effectiveness ratio over Level 2.
  4. LEVEL 4SMA adopts MITA Framework, industry standards, state and federal law enforcement, CMS and other nationally recognized standards for interstate information exchange. SMA increases cost effectiveness ratio over Level 3.
  5. LEVEL 5SMA adopts MITA Framework, industry standards, state and federal law enforcement, CMS, and other nationally recognized standards for national (and international) information exchange. SMA increases cost effectiveness ratio over level 4.

Business Capability Quality: Effort to Perform; Efficiency

How efficient is the process?
  1. LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and SMA performance standards. Efficiency is low.
  2. LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with state and federal law enforcement, CMS, and intrastate agencies and entities improving efficiency to 95% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with state, district and federal law enforcement, CMS, and interstate agencies and entities improving efficiency to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with state and federal law enforcement, CMS, and federal agencies and entities improving efficiency to 98% or higher.

Business Capability Quality: Accuracy of Process Results

How accurate are the results of the process?
  1. LEVEL 1Manual processes result in greater opportunity for human error. Accuracy is low.
  2. LEVEL 2Automation and standardized business rules definitions reduce error and improve accuracy above Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with intrastate agencies and entities improving accuracy to 90% or higher.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with interstate agencies and entities improving accuracy to 98% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with national agencies and entities improving accuracy to 98% or higher.

Business Capability Quality: Utility or Value to Stakeholders

Does the business process satisfy stakeholders?
  1. LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
  2. LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
  3. LEVEL 3SMA adopts MITA Framework, industry standards and information exchange with state and federal law enforcement, CMS, and intrastate agencies and entities improving stakeholder satisfaction to 90% or higher. SMA uses survey or questionnaire for information collection.
  4. LEVEL 4SMA adopts MITA Framework, industry standards and information exchange with state, district, and federal law enforcement, CMS, and interstate agencies and entities improving stakeholder satisfaction to 95% or higher.
  5. LEVEL 5SMA adopts MITA Framework, industry standards and information exchange with state and federal law enforcement, CMS, and federal agencies and entities improving stakeholder satisfaction to 98% or higher.

Source: CMS MITA 3.0 Business Capability Model, Performance Management BCM.pdf, pages 7-14.

Other Performance Management processes

Determine Adverse Action IncidentIdentify Utilization AnomaliesManage Compliance Incident InformationPrepare REOMB