Health Care Communiqué: Q2 – 2009

Is it Time to Raise the Red Flag?

The Federal Trade Commission (FTC) has developed a set of rules known as "Red Flag Rules" as part of the regulatory framework implementing the Fair and Accurate Credit Transactions Act of 2003 (FACT Law.)   While the law and regulations were directed to "financial institutions", they also apply to a broader definition of "creditors", which could include a health plan.  As to whether the rules apply to your health plan depend on whether you meet the definition of a "creditor" and whether you have "covered accounts."

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What are the Issues with Grievances?

When CMS performs an MA audit of a Medicare Health Plan it is not unusual for a health plan to be found non-compliant in some aspect of the review of grievances.  In fact over the past two years, 1 of every 11 findings in a CMS audits are related to grievances. 

The CMS audit review guides that are available in HPMS outline the 7 elements related to grievances that are reviewed.  The elements vary depending on whether your plan is an MA-only or an MAPD but basically CMS reviews grievances to ensure that:

  • Grievances are classified correctly (GV01)
  • Results of grievance reviews are communicated timely to the member (GV03, GV04, GV07)
  • Grievance decision notice to the member is appropriate (GV04, GV05, GV06)

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