Others titles
- Prescription Drug Event Reconciliation
- PDE
- Medicare Audit
- Reconciliation by Contract
Keywords
- Medicare Part D
- Medicare Part D Plans
- Medicaid Plan D
- Account Reconciliation
- Agreement Template
- Medicare
Medicare Part D Plan Reconciliation Contract
This dataset contains the results by contract of the audit of the Centers for Medicare & Medicaid Services’ Medicare Part D Prescription Drug Event (PDE) reconciliation process performed by an independent certified public accounting firm.
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Description
On November 15, 2005, Medicare Part D, the prescription drug coverage program for senior and other eligible citizens, went into effect. Under this program, private health insurance companies and organizations (Plan sponsors) offer insurance coverage for prescription drugs in which Medicare and eligible Medicaid recipients can enroll. CMS contracted with Plan sponsors nationwide to offer the Part D benefits for qualified beneficiaries on January 1, 2006.
The audit contained in this data set, by the accounting firm KPMG, was performed “in accordance with auditing standards generally accepted in the United States of America.”
The objectives were to determine whether CMS controls over payments to Plan sponsors, PDE records, and year-end reconciliation provided reasonable assurance that:
– the inputs that drive the calculation of monthly payments are accurate and complete
– the Risk Adjustment Factor calculations by the Risk Adjustment Processing System are accurate
– monthly payments are accurately calculated and are tracked
– submitted PDE records are valid, accurate, and complete
– PDE data are complete before year-end reconciliation, and
– Direct or Indirect Remuneration (DIR) reporting is accurate and complete.
CMS has designed a layered compliance framework that uses as inputs beneficiary reported complaints, internal data analysis results, audits, and other continuous oversight activities to take compliance action against Plan sponsors when needed. In addition, monthly payments are accurately being calculated and tracked. However,
(1) the bid review and audit process needs improvement to ensure that inputs to monthly payments are accurate and complete;
(2) controls need to be improved to ensure that submitted PDE records are accurate and complete and PDE data are complete before year-end reconciliation; and
(3) improved benchmarks and metrics are needed to ensure the completeness and accuracy of DIR before reconciliation.
About this Dataset
Data Info
Date Created | 2012-02-23 |
---|---|
Last Modified | 2021-10-01 |
Version | 2021-10-01 |
Update Frequency |
Semiannual |
Temporal Coverage |
2019 |
Spatial Coverage |
United States |
Source | John Snow Labs; Centers for Medicare and Medicaid Services; |
Source License URL | |
Source License Requirements |
N/A |
Source Citation |
N/A |
Keywords | Medicare Part D, Medicare Part D Plans, Medicaid Plan D, Account Reconciliation, Agreement Template, Medicare |
Other Titles | Prescription Drug Event Reconciliation, PDE, Medicare Audit, Reconciliation by Contract |
Data Fields
Name | Description | Type | Constraints |
---|---|---|---|
Contract_Code | Code of the insurance contract | string | - |
Contract_Name | Name of the insurance contract | string | - |
Number_of_Plans | Number of plans | integer | level : Ratio |
Reconciliation_Amount | Total net reconciliation amount of all plans in the contract in a coverage year | number | - |
LICS | Net reconciliation amount of the Low Income Cost Sharing Subsidy, which is calculated by subtracting the Prospective Low-income Cost-sharing Subsidy Amount for the Actual Low-income Subsidy Amount | number | - |
Reinsurance | Net reinsurance reconciliation amount, which is calculated by subtracting the Prospective Reinsurance Subsidy Amount from the Actual Reinsurance Subsidy Amount | number | - |
Risk_Sharing | Net risk-sharing reconciliation amount | number | - |
Data Preview
Contract Code | Contract Name | Number of Plans | Reconciliation Amount | LICS | Reinsurance | Risk Sharing |
E0654 | IBT VOLUNTARY EMPLOYEE BENEFITS TRUST | 1 | 4038527.55 | 590707.39 | 3447820.16 | |
E3014 | PSERS HOP PROGRAM | 2 | 24547793.21 | 1164348.07 | 23383445.14 | |
E4744 | MODOT/MSHP MEDICAL AND LIFE INSURANCE PLAN | 1 | 3135593.28 | 199337.3 | 2936255.98 | |
H0022 | BUCKEYE COMMUNITY HEALTH PLAN, INC. | 1 | 18012328.17 | 2577242.11 | 11777423.78 | 3657662.28 |
H0028 | CHA HMO, INC. | 35 | -2653895.58 | -3609561.67 | 3603117.4 | -2647451.31 |
H0062 | SUPERIOR HEALTHPLAN COMMUNITY SOLUTIONS, INC. | 7 | -241286.38 | 206051.21 | -234996.51 | -212341.08 |
H0088 | WELLCARE HEALTH INSURANCE OF NEW YORK, INC. | 1 | -35909.36 | -39874.99 | -2992.74 | 6958.37 |
H0104 | BLUE CROSS AND BLUE SHIELD OF ALABAMA | 5 | 12011902.7 | -568896.53 | 11791551.18 | 789248.05 |
H0105 | THE METHODIST OAKS | 2 | -166839.62 | -34493.58 | -88616.83 | -43729.21 |
H0107 | HEALTH CARE SERVICE CORPORATION | 3 | 2537713.74 | 197242.58 | 2459945.99 | -119474.83 |