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Plan agile projects: Stage 1

08.20.19

Editor’s note: If you are a state government CFO, CIO, project or program manager, this blog is for you. 

This is the second blog post in the blog series: “Procuring Agile vs. Non-Agile Service”. Read the first blog. This blog post demonstrates the differences in Stage 1: Plan Project in the five stages of procuring agile vs. non-agile services.

Overview of Procurement Process for Agile vs. Non-Agile IT Services

What is important to consider in agile procurement?

Here are some questions that can help focus the planning for procurement of IT services for agile vs. non-agile projects.

Plan Project Considerations for Agile vs. Non-Agile IT Services

Why are these considerations important?

When you procure agile IT services, you can define the scope of your procurement around a vision of what your organization intends to become, as opposed to being restricted to an end-date for a final delivery.

In an agile project, you get results iteratively; this allows you to constantly reassess requirements throughout the project, including the project plan, the guiding principles, and the project schedule. Your planning is not restricted to considering the effect of one big result at the end of the project schedule. Instead, your plan allows for sequencing of changes and improvements that best reflect the outcomes and priorities your organization needs

Since planning impacts the people-aspect of your strategy, it is important to consider how various teams and stakeholders will provide input, and how you will make ongoing communication updates throughout the project. With an agile procurement project, your culture will shift, and you will need a different approach to planning, scheduling, communicating, and risk management. You need to communicate daily, allowing for reviewing and adjusting priorities and plans to meet project needs. 

How do you act on these considerations?

A successful procurement plan of agile IT services should include the following steps:

  1. Develop a project charter and guiding principles for the procurement that reflect a vision of how your organization’s teams will work together in the future
  2. Create a communication plan that includes the definition of project success and communicates project approach
  3. Be transparent about the development strategy, and outline how iterations are based on user needs, that features will be re-prioritized on an ongoing basis, and that users, customers, and stakeholders are needed to help define requirements and expected outcomes
  4. Provide agile training to your management, procurement, and program operation teams to help them accept and understand the project will present deliverables in iterations, to include needed features, functionality and working products
  5. Develop requirements for the scope of work that align with services and outcomes you want, rather than documented statements that merely map to your current processes 

What’s next? 

Now that you have gained insight into the approach to planning an agile project, consider how you may put this first stage into practice in your organization. Stay tuned for guidance on how to execute the second stage of the procurement process—how to draft the RFP. Our intention is that, following this series, your organization will better understand how to successfully procure and implement agile services. If you have questions or comments, please contact our team.
 

Related Professionals

Editor’s note: If you are a state government CFO, CIO, project or program manager, this blog is for you.

What is the difference in how government organizations procure agile vs. non-agile information technology (IT) services? (Learn more about agile here).

In each case, they typically follow five stages through the process as shown in Figure A:
 

Figure A: Overview of Procurement Process for Agile vs. Non-Agile IT Services

However, there are differences in how these stages are carried out if procuring agile vs. non-agile IT services. 

Unfortunately, most government organizations are unaware of these differences, which could result in unsuccessful procurements and ultimately not meeting your project’s needs and expectations. 
This blog series will illustrate how to strategically adjust the standard stages outlined in Figure A to successfully procure agile IT services.

Stage 1: Plan project
In Stage 1, you define the scope of the project by identifying what your organization wants, needs, and can achieve within the available timeframe and budget. You then determine the project’s objectives while strategically considering their impact on your organization before developing the RFP. Figure B summarizes the key differences between the impacts of agile vs. non-agile services to consider in this stage.


Figure B: Plan Project for Agile vs. Non-Agile IT Services

The nuances of planning for agile services reflect an organization’s readiness for a culture shift to a continuous process of development and deployment of software and system updates. 

Stage 2: Draft RFP
In Stage 2, as part of RFP drafting, define the necessary enhancements and functionality needed to achieve the project objectives determined in Stage 1. You then translate these enhancements and functionalities into business requirements. Requirement types might include business needs as functionality, services, staffing, deliverables, technology, and performance standards. Figure C summarizes the key differences between drafting the RFP for a project procuring agile vs. non-agile services.


Figure C: Draft RFP for Agile vs. Non-Agile IT Services

In drafting the RFP, the scope of work emphasizes expectations for how your team and the vendor team will work together, the terms of how progress will be monitored, and the description of requirements for agile tools and methods.

Stage 3: Issue RFP
In Stage 3, issue the RFP to the vendor community, answer vendor questions, post amendments, and manage the procurement schedule. Since this stage of the process requires you to comply with your organization’s purchasing and procurement rules, Figure D illustrates very little difference between issuing an RFP for a project procuring agile or non-agile services.


Figure D: Issue RFP for Agile vs. Non-Agile IT Services 

Stage 4: Review proposals
In Stage 4, you evaluate vendor proposals against the RFP’s requirements and project objectives to determine the best proposal response. Figure E summarizes the key differences in reviewing proposals for a project that is procuring agile vs. non-agile services.


Figure E: Reviewing Proposals for Agile vs. Non-Agile IT Services 

Having appropriate evaluation priorities and scoring weights that align with how agile services are delivered should not be under-emphasized. 

Stage 5: Award and implement contract
In Stage 5, you award and implement the contract with the best vendor proposal identified during Stage 4. Figure F summarizes the key differences in awarding and implementing the contract for agile vs. non-agile services.


Figure F:  Award and Implement Contract for Agile vs. Non-Agile Services 

Due to the iterative and interactive requirements of agile, it is necessary to have robust and frequent collaboration among program teams, executives, sponsors, and the vendor to succeed in your agile project delivery.

What’s next?
The blog posts in this series will explain step-by-step how to procure agile services through the five stages, and at the series conclusion, your organization will better understand how to successfully procure and implement agile services. If you have questions or comments, please contact our team.  

Blog
Procuring agile vs. non-agile projects in five stages: An overview

Government projects conducted in challenging conditions require trust, collaboration, communication, and project management acumen to succeed. Here are five recommendations for project success.

In today’s dynamic technical, business, and political environment, government projects often come with significant challenges, including undefined scope and unclear deliverables, rapidly changing influencing factors, diverse groups of busy stakeholders, and multiple vendors with work interdependencies. Although these generally are not optimal conditions in which to conduct a project, leaders often choose to move forward anyhow since doing so seems less risky than maintaining the status quo. And when faced with federal, state, or other mandatory requirements, leaders may be forced to move forward with projects they have not prioritized or planned for.

To facilitate success in such situations, projects need to abide by traditional project management best practices. They also demand a commitment to clear, open, and honest communication by all team members – government and vendor alike.

Five important activities to guide complex government projects toward success include:

  1. Create a culture of trust and collaboration: Establish trust and collaboration with the project team from the beginning, aligning disparate stakeholders by focusing on common project goals and objectives. Doing so lays the foundation for future project communications and decision making, which is particularly important if times get tough.
  1. Establish clear roles and responsibilities: Define roles and responsibilities early in the project to create a strong sense of ownership for assigned tasks. Doing so will ensure that government and vendor project teams avoid duplication of effort, while preventing work from ‘slipping through the cracks’. This also helps people focus on the right tasks at the right time, maximizing their involvement and minimizing their effort so they may effectively continue their ‘day job’.
  1. Check in regularly: Hold regular checkpoints and work sessions to discuss the latest project information and changes in the current environment. This allows the team to make and document decisions to ‘correct course’ as needed, keeping the project headed toward its goals while minimizing time- and resource-consuming detours.
  1. Define — and redefine — outcomes: Regularly confirm that work products and targeted outcomes remain relevant as factors in the project environment change. As work progresses, it is essential to ensure that links between all vendor work products remain clear and efforts are integrated. If changes are needed, follow a formal change management process, allowing key stakeholders outside of the project team to weigh in on the requested changes and document approved changes for posterity.
  1. Communicate risks openly: Understand that risks are a normal and healthy part of any project and openly discuss them. When risks are identified early, without fear of repercussion, they are more likely to be addressed promptly, preventing them from turning into issues that negatively impact project success.

By integrating traditional project management practices with an unyielding commitment to transparency, collaboration, and communication, even the most challenging of government projects may achieve success and deliver tangible, valuable outcomes.

Blog
Guiding challenging government projects to success

Read this if you are planning for, or are in the process of implementing a new software solution.

User Acceptance Testing (UAT) is more than just another step in the implementation of a software solution. It can verify system functionality, increase the opportunity for a successful project, and create additional training opportunities for your team to adapt to the new software quickly. Independent verification through a structured user acceptance plan is essential for a smooth transition from a development environment to a production environment. 

Verification of functionality

The primary purpose of UAT is to verify that a system is ready to go live. Much of UAT is like performing a pre-flight checklist on an aircraft. Wings... check, engines... check, tires... check. A structured approach to UAT can verify that everything is working prior to rolling out a new software system for everyone to use. 

To hold vendors accountable for their contractual obligations, we recommend an agency test each functional and technical requirement identified in the statement of work portion of their contract. 

It is also recommended that the agency verify the functional and technical requirements that the vendor replied positivity to in the RFP for the system you are implementing. 

Easing the transition to a new software

Operational change management (OCM) is a term that describes a methodology for making the switch to a new software solution. Think of implementing a new software solution like learning a new language. For some employees, the legacy software solution is the only way they know how to do their job. Like learning a new language, changing the way business and learning a new software can be a challenging and scary task. The benefits outweigh the anxiety associated with learning a new language. You can communicate with a broader group of people, and maybe even travel the world! This is also true for learning a new software solution; there are new and exciting ways to perform your job.

Throughout all organizations there will be some employees resistant to change. Getting those employees involved in UAT can help. By involving them in testing the new system and providing feedback prior to implementation, they will feel ownership and be less likely to resist the change. In our experience, some of the most resistant employees, once involved in the process, become the biggest champions of the new system.  

Training and testing for better results

On top of the OCM and verification benefits a structured UAT can accomplish, UAT can be a great training opportunity. An agency needs to be able to perform actions of the tested functionality. For example, if an agency is testing a software’s ability to import a document, then a tester needs to be trained on how to do that task. By performing this task, the tester learns how to login to the software, navigate the software, and perform tasks that the end user will be accomplishing in their daily use of the new software. 

Effective UAT and change management

We have observed agencies that have installed software that was either not fully configured or the final product was not what was expected when the project started. The only way to know that software works how you want is to test it using business-driven scenarios. BerryDunn has developed a UAT process, customizable to each client, which includes a UAT tracking tool. This process and related tool helps to ensure that we inspect each item and develop steps to resolve issues when the software doesn’t function as expected. 

We also incorporate change management into all aspects of a project and find that the UAT process is the optimal time to do so. Following established and proven approaches for change management during UAT is another opportunity to optimize implementation of a new software solution. 

By building a structured approach to UAT, you can enjoy additional benefits, as additional training and OCM benefits can make the difference between forming a positive or a negative reaction to the new software. By conducting a structured and thorough UAT, you can help your users gain confidence in the process, and increase adoption of the new software. 

Please contact the team if you have specific questions relating to your specific needs, or to see how we can help your agency validate the new system’s functionality and reduce resistance to the software. We’re here to help.   
 

Blog
User Acceptance Testing: A plan for successful software implementation

The BerryDunn Recovery Advisory Team has compiled this guide to COVID-19 consulting resources for state and local government agencies and higher education institutions.

We have provided a list of our consulting services related to data analysis, CARES Act funding and procurement, and legislation and policy implementation. Many of these services can be procured via the NASPO ValuePoint Procurement Acquisition Support Services contract.

READ THE GUIDE NOW

We're here to help.
If you have any questions, please contact us at info@berrydunn.com

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COVID-19 consulting resources

Read this if you are at a state Medicaid agency or CHIP agency.

CMS has posted additional Frequently Asked Questions (FAQs) to Medicaid.gov, to aid state Medicaid and Children’s Health Insurance Program (CHIP) agencies in their response to the coronavirus disease 2019 (COVID-19) pandemic.

These new FAQs have been integrated into the previously released COVID-19 FAQ document. The new FAQs cover a variety of Medicaid and CHIP topics, including:

  • Emergency Preparedness and Response
  • Eligibility and Enrollment Flexibilities
  • Benefit Flexibilities
  • Cost-Sharing Flexibilities
  • Financing Flexibilities  
  • Managed Care Flexibilities
  • Information Technology  
  • Data Reporting

Updated CMS processes for reviewing 2021 contracts between states and Medicare Dual Eligible Special Needs Plans (D-SNPs)

CMS has issued a reminder to states of the upcoming submission deadline for the Contract Year (CY) 2021 contracts with Medicare Advantage Dual Eligible Special Needs Plans (D-SNPs). The due date for D-SNPs to submit to CMS their CY 2021 contracts with the state Medicaid agencies is July 6, 2020.

  • CMS encourages state Medicaid agencies to review the November 14, 2019 Informational Bulletin that describes new requirements for CY 2021 D-SNP contracts, which CMS finalized in rulemaking to implement new statutory provisions of the Bipartisan Budget Act (BBA) of 2018.
  • The Integrated Care Resource Center (ICRC) continues to provide technical assistance to states to help with the implementation of these new requirements. CMS and ICRC have a number of important resources for states regarding the new requirements for contracts with D-SNPs. Additional resources for states can be found here.
  • As a result of COVID-19, CMS is extending the review and approval timelines to allow D-SNPs more time to work with states on the new CY 2021 requirements. As a result, D-SNPs will have until November 2, 2020 to resubmit revised state Medicaid agency contracts or contract amendments.

CMS announces rule changes to support healthcare workforce augmentation

CMS has taken steps to limit or remove potential barriers for hiring and retaining physicians, nurses, and other healthcare professionals in order to keep staffing levels high at healthcare facilities.

  • In response to the need for in-home services during the COVID-19 crisis, nurse practitioners, clinical nurse specialists, and physician assistants can now provide home health services. These changes are effective for both Medicare and Medicaid.
  • Prior to this, Medicare and Medicaid home health member were only able to receive home health services with the certification of a physician. 
  • Physicians and other practitioners whose privileges are expiring will be able to continue taking care of patients. Consistent with a change made for hospitals, CMS is waiving a requirement for ambulatory surgery centers to periodically reappraise medical staff privileges during the COVID-19 emergency declaration. 

Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes 

CMS has issued a memo along with frequently asked questions which address the new requirement that nursing homes and long term care facilities report COVID-19 facility data to the Centers for Disease Control and Prevention (CDC).

  • CMS will be requiring nursing homes to report COVID-19 facility data to the CDC and to residents, their representatives, and families of residents in facilities. 
  • CMS has updated the COVID-19 Focused Survey for Nursing Homes, Entrance Conference Worksheet, COVID-19 Focused Survey Protocol, and Summary of the COVID-19 Focused Survey for Nursing Homes to reflect COVID-19 reporting requirements. 
  • CMS will begin posting data from the CDC National Healthcare Safety Network (NHSN) for viewing by facilities, stakeholders, or the general public. The COVID-19 public use file will be available on https://data.cms.gov/.
     

Increase hospital capacity - CMS Hospitals Without Walls

On April 30, CMS announced expansions of the Hospitals Without Walls initiative, granting flexibility for services to be provided outside of traditional venues.

  • CMS is encouraging the use of existing flexibilities that allow outpatient hospital services to be delivered outside of traditional settings, such as at expansion locations, converted hotels or parking lots, or patients’ homes.
  • Certain outpatient departments that relocate off-site can qualify to be paid under the Outpatient Prospective Payment System (OPPS), rather than the Physician Fee Schedule.
  • Hospitals may relocate outpatient departments to more than one off-campus location, or partially relocate while still furnishing care at the original site.
  • As part of the CARES Act, long-term acute-care hospitals can now accept patients from any acute-care hospital and be paid at a higher Medicare rate.

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team

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Additional Medicaid & CHIP COVID-19 FAQs

Read this if you are a leader at a state Medicaid agency.

Leveraging Medicaid to support and fund state efforts
In infectious disease control and prevention, contact tracing is the process of identifying people who may have come into contact with an infected person and tracking with whom the infected person has been in contact. The intent is to halt the chain of transmission. State Medicaid Agencies (SMAs) may be able to leverage the Medicaid program to support state efforts with systems, training, and reimbursement for contact tracing. 

What is contact tracing?
Tracing the contacts of infected individuals throughout a community, testing their contacts for infection, and treating and quarantining the disease when it is found is a long-standing practice to address infectious diseases. While contact tracing may not be a service that is reimbursable by Medicaid, it may be possible for Medicaid to cover a broader package of services designed to slow the spread of COVID-19.

Contact tracing has three major components:

  1. Contact identification—Confirmation of an individual’s infection is the first step. Once identified, it is essential to identify any additional people with whom that person came into contact, including family, co-workers, community members, etc.
  2. Contact tracing—After conducting a complete review of the individual's contacts, outreach begins to inform them of their contact status and discuss critical next steps, starting with testing.
  3. Contact follow-up—Continued follow-up with identified contacts helps prevent the spread of infection by monitoring spread and/or additional symptoms.

Public health experts maintain that contact tracing is one of the tools needed to manage the pandemic. Medicaid can play a key role in supporting systems, training, and reimbursement for contact tracing. This is enabled through Medicaid’s unique role as a significant payer in the healthcare system, along with its role as a government partnership between federal and state governments. In addition, acting to implement contact tracing may offer an opportunity to increase employment at a time when the economy has shed countless jobs. 

Systems and training: Medicaid support for health IT system
To support contact tracing, Medicaid agencies can leverage 75% or 90% federal match or Federal Financial Participation (FFP) for the systems, training, and equipment. This match is applicable for the Medicaid population, while the remainder likely needs to be cost-allocated to other state programs. Activities that can qualify include:

  • Design, development, and installation (DDI) of Medicaid solutions. The Centers for Medicare and Medicaid Services (CMS) may allow this funding to apply to data-tracking systems or changes to support new reimbursement models. 
  • Provider outreach and training related to systems operation, such as training on claims submissions, claims processing, and eligibility inquiries related to case management and care coordination.
  • Training of vendor or state personnel directly engaged in the operation of an approved system, including workers processing claims or determining eligibility.

To obtain this type of funding, states must submit an advanced planning document (APD). 

Reimbursement: Services and authority options for contact tracing
For Medicaid to support contact tracing, SMAs need to identify both state plan services and authority to provide the service. Defining a service and authority may be challenging, as contact tracing is historically a public health intervention and not a medical service that directly benefits a Medicaid member. CMS does not typically allow this type of service under Medicaid. Given the flexibility afforded under current disaster declarations, however, CMS may have more flexibility than usual. Some options for services include: 

Case management

  • How it works 
    First, an individual tests positive and contact-tracing interviews occur. Then, a healthcare provider, such as a hospital, reaches out to the individual, facilitates testing and education, delivers results, and follows up for any care needed. This process applies to any Medicaid members or other individuals who have private insurance that is identified. The provider can discharge the member from case management once the individual recovers. Case management as a Medicaid service is unique in that a diagnosis requiring medical management is the impetus for providing the service.
  • Federal approval rationale
    Hospitals may be a good partner for this service due to CMS’s Hospital Without Walls guidance. If the hospital partners with the Public Health Entity for contact tracing, then the case management piece could—in theory—be billed by the staff providing case management through the hospital. The hospital would also be able to bill for testing and lab, care, etc. Public Health could track where there is capacity through the medical community for treatment, especially hospital beds, ventilators, and alternative testing sites. The case manager providing coordination of care for COVID-19 testing and treatment would have access to the hospital medical record system, and the hospital could bill for the service.

Health home

  • How it works
    A health home under the state plan could also serve as a vehicle for services for this population. To better care for Medicaid members with chronic conditions, the Affordable Care Act created an optional Medicaid state plan benefit to coordinate care. Health homes are designed to integrate all physical and behavioral healthcare. Participation in health homes is voluntary. In order for members to participate, they must possess at least one chronic condition (e.g., high blood pressure, asthma, obesity, diabetes, or any serious chronic condition) and be at risk for a second (e.g., COVID-19).
  • Federal approval rationale
    The health home may be a good support model, as it is eligible for FFP of 90% for the first two years—likely long enough to respond to the pandemic—making it economically attractive. 

The most flexible potential authority for a Medicaid agency to use for contact tracing is the 1115 waiver. As part of the Medicaid Disaster Response Toolkit, CMS made expedited review available. In addition, State Medicaid Director Letter (SMDL) #20-002 provides guidance on a new section 1115 waiver available to assist states in addressing the COVID-19 public health emergency. 

Section 1115 demonstration waiver
The 1115 waiver is the most dynamic option available, and states can access it through the 1115 disaster waiver option under the Medicaid toolkit. The state may be able to show that providing contact tracing will result in savings for services billed under Medicaid. These savings may be able to be justified by decreasing the number of people who test positive for the virus, leading to budget neutrality. The budget neutrality model would need to show “with” and “without waiver” scenarios that demonstrate to Medicaid the cost of the spread of the virus with and without contact tracing. A challenge to this approach is the time necessary to develop the waiver and budget neutrality model and gain CMS approval. 

Recently, CMS approved one of these new section 1115 waivers for the state of Washington. While Washington did not request to cover contact tracing, the speed of approval and the fact that CMS has indicated for the pandemic 1115 requests states will not be required to submit budget neutrality calculations, is a positive indicator for states to consider in envisioning creative models for leveraging Medicaid to minimize the impacts of COVID-19. 

Next steps

  • Check in with your CMS contacts. COVID-19 is new, and America’s response continues to evolve. Check in with your CMS contact for input on the latest guidance that may be applicable to your agency. 
  • Develop an APD. Develop your state’s APD to help fund the technology needs for tracking COVID-19, along with training for your SMA team and providers. 
  • Determine services. In partnership with CMS, determine if case management, a health home, or other service makes the most sense for your state to help trace contacts, reduce the spread of COVID-19, and encourage employment in this important work. 
  • Submit your waiver for state plan amendment. After working with CMS to determine the service that makes sense for your state, develop and submit the request to provide this service through a 1115 waiver, 1135 waiver, or if necessary, emergency state plan amendment. 

We’re here to help
If you have more questions or want to have an in-depth conversation about your specific situation, please contact the Medicaid consulting team

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Contact tracing for COVID-19: What it is and how Medicaid can use it

Read this if you are a leader at a state Medicaid agency, Long-Term Care Hospital, Rural Health Clinic, Federally Qualified Health Center, or intermediate care facility.

New toolkit launches to help states navigate COVID-19 health workforce challenges 

In order to maximize workforce flexibility to help confront COVID-19, CMS and the Assistant Secretary of Preparedness and Response (ASPR) have released a new toolkit to assist state and local healthcare decision makers. The toolkits are available as a set of resource collections including:

Our team will be taking a closer look at these resource collections in the coming week and plan to have detailed information on the opportunities within.

Compliance flexibilities announced for implementation of interoperability final rules due to COVID-19

CMS and the Office of the National Coordinator for Health IT (ONC), in conjunction with the Health and Human Services (HHS) Office of Inspector General (OIG), have announced a policy of enforcement discretion to allow compliance flexibilities regarding the implementation of the interoperability final rules previously announced on March 9, 2020.

  • Announced in March, the Interoperability and Patient Access final rule (CMS-9115-F) is focused on the pursuit of interoperability and patient access to health information.
  • CMS-regulated payers, including Medicaid Fee-for-Service (FFS) programs, Medicaid managed care plans, CHIP FFS programs, and CHIP managed care entities are required to implement and maintain a secure, standards-based (HL7 FHIR Release 4.0.1) API that allows members access their claims and encounter information, as well as provider directory information available through third-party applications of their choice.
  • Due to the public health emergency posed by COVID-19, CMS is exercising the “enforcement discretion” to adopt a temporary policy of relaxed enforcement for the final rule.

CMS releases additional blanket waivers for Long-Term Care Hospitals (LTCHs), Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs) and intermediate care facilities

CMS is providing additional blanket waivers related to care for patients in LTCHs, temporary expansion locations of RHCs and FQHCs, staffing and training modifications in intermediate care facilities for individuals with intellectual disabilities, and the limit for substitute billing arrangements (locum tenens).

  • The new flexibilities do not require a waiver or any requests be sent to CMS electronically or any other notification to CMS regional offices.
  • The guidance includes flexibilities related to provider location, staffing, reporting requirements, discharge, patient rights and other areas regulated by CMS.
  • The blanket waiver authority exercised by CMS in this case applies only to federal requirements and does not apply to state requirements for licensure or conditions of participation.

State of Washington COVID-19-related section 1115(a) demonstration approval

Washington’s approval is the first section 1115(a) demonstration specifically intended to combat the effects of COVID-19 in a state.

  • CMS authorized a time-limited approval for several of the requests in Washington’s March 24, 2020 section 1115(a) demonstration with a retroactive effective date of March 1, 2020 through 60 days after the public health emergency declaration.
  • CMS approved two waiver authority requests, as well as six expenditure authority requests from Washington’s section 1115(a) demonstration. 
  • CMS did not require the state to submit budget neutrality calculations for the Washington COVID-19 section 1115(a) demonstration. 

CMS issues guidance allowing Independent Freestanding Emergency Departments (IFEDs) to provide care to Medicare and Medicaid beneficiaries during the COVID-19 Public Health Emergency

CMS issued guidance On April 21, 2020 which allows licensed IFEDs in the states of Colorado, Delaware, Rhode Island, and Texas to temporarily provide care to Medicare and Medicaid patients to address any surge.

  • IFEDs generally offer a range of services including basic imaging services, computed tomography (CT) scans, ultrasound, and basic on-site laboratory services. During this public health emergency these entities can temporarily bill Medicare and Medicaid as a certified hospital.
  • CMS is waiving certain conditions of participation for hospital operations to maximize patient care capabilities during this public health emergency. IFEDs may participate in Medicare and Medicaid in one of three ways: 
     
    • Becoming affiliated with a Medicare/Medicaid-certified hospital under the temporary expansion 1135 emergency waiver; 
    • Participating in Medicaid under the clinic benefit if permitted by the state; or
    • Enrolling temporarily as a Medicare/Medicaid-certified hospital to provide hospital services.

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team

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CMS launches toolkits, releases guidance, and loosens some restrictions to help states and others address COVID-19

Read this if your organization, business, or institution has leases and you’ve been eagerly awaiting and planning for the implementation of the new lease standards.

Ready? Set? Not yet. As we have prepared for and experienced delays related to Financial Accounting Standards Board (FASB) Accounting Standards Codification Topic 842, Leases, we thought the time had finally come for implementation. With the challenges that COVID-19 has brought to everyone, the FASB recognizes the significant impact COVID-19 has brought to commercial businesses and not-for-profits and is proposing a one-year delay in implementation, as described in this article posted to the Journal of Accountancy: FASB effective date delay proposals to include private company lease accounting.

But what about lease concessions? We all recognize many lessors are making concessions due to the pandemic. Under current guidance in Topics 840 and 842, changes to lease contracts that were not included in the original lease are generally accounted for as lease modifications and, therefore, a separate contract. This would require remeasurement of the new lease contract and related right-of-use asset. FASB recognized this issue and has published a FASB Staff Questions and Answers (Q&A) Document,  Topic 842 and Topic 840: Accounting for Lease Concessions Related to the Effects of the COVID-19 Pandemic. Under this new guidance, if lease concessions are made relating to COVID-19, entities do not need to analyze each contract to determine if a new contract has been entered into, and will have the option to apply, or not to apply, the lease modification provisions of Topics 840 and 842.

Implementation of the lease accounting standard will most likely be delayed for Governmental Accounting Standards Board (GASB) entities as well. On April 15, 2020, the GASB issued an exposure draft that would delay most GASB statements and implementation guides due to be implemented for fiscal years 2019 and later. Most notably, this includes Statement 84, Fiduciary Activities, and Statement 87, Leases. Comments on the proposal will be accepted through April 30, and the board plans to consider a final statement for issuance on May 8. More information may be found in this article from the Journal of Accountancy: GASB proposes postponing effective dates due to pandemic.

More information

Whether you are a FASB or GASB entity, you can expect a delay in the implementation of the lease standard. If you have questions, please contact a member of our financial statement audit team. For other COVID-19 related resources, please refer to BerryDunn’s COVID-19 Resources Page.

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FASB and GASB news: Postponement of the lease accounting standards

Read this if you work at a public health department and would like a brief summary of how you can maximize funding and meet new federal requirements.

Unpacking the trillions

In response to the COVID-19 pandemic, several pieces of legislation were passed by congress and signed into law. The three bills, H.R. 6074 Coronavirus Preparedness and Response Supplemental Appropriations Act, H.R. 6201 Families First Coronavirus Response Act, and H.R. 748 Coronavirus Aid, Relief, and Economic Security (CARES) Act, have provided funding for various federal agencies with different roles in responding to the crisis. Because of the urgency required, much of the guidance for use of funds and reporting requirements were released after passage of the bills or have yet to be released.

Here is a brief timeline and summary of the acts:

Implication and next steps for state public health departments

While little guidance has been provided for how state public health departments should prepare to access federal funds, BerryDunn will continue to monitor and release updates as they become available. 

While at this point HR 6074 has the greatest implications for public health departments, here are some actions that states should take now for their public health programs from the recent legislation:

  1. H.R. 6074: Provides appropriations to the CDC to be allocated to states for COVID-19 expenses.
    • To ensure maximum funding, prepare a spend plan to submit to CDC.
    • To ensure compliance, provide CDC with copies or access to COVID-19 data collected with these funds.
    • To maximize the impact of new funding, develop a COVID-19 community intervention plan.
    • To support streamlined operations, submit revised work plans to CDC.
    • To prevent missed deadlines, submit any requests for deadline extensions to the CDC.
  2. H.R. 6201: Provides guidance specific to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs.
    • To encourage social distancing and loosen administrative requirements, seek waivers through the USDA’s Food and Nutrition Service (FNS).
    • To ensure compliance, prepare to submit a report summarizing the use of waivers on population outcomes by March 2021.
  3. H.R. 748: Allocates $150 billion to a coronavirus relief fund for state, local, and tribal governments.
  • To secure funding, monitor the US Department of Health & Human Services (HHS) for guidance on using funds for:
    • Coronavirus prevention and preparation
    • Tools to build health data infrastructure
    • COVID-19 Public Health Emergency expenses
    • Developing countermeasures and vaccines for coronavirus
    • Telehealth and rural health activities
       
  • To ensure HIPAA compliance when sharing protected patient health information, monitor the US Department of Health & Human Services (HHS) for guidance.

For more information

For specific issues your agency has, or if you have other questions, please contact us. We’re here to help. 

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COVID-19 laws and their impact on state public health agencies

Read this if you are a leader at a state Medicaid agency.

CMS has delivered nearly  $34 billion, later updated to $51 billion, in the past week to the healthcare providers on the frontlines battling the 2019 novel coronavirus

  • The process in which CMS is implementing requests has reduced times of an accelerated or advance payment to four to six days. Previously the timeframe was three to four weeks. 
  • To date, CMS has received over 25,000 requests from providers and suppliers for accelerated and advance payments. Of these, CMS has approved over 17,000 requests in the past week. 
  • It should be noted that this funding is separate and distinct from the $100 billion provided in the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

CMS issues new wave of infection control guidance based on CDC guidelines to protect patients and healthcare workers 

CMS has issued a series of updated guidance documents focused on infection control to prevent the spread of COVID-19 in a variety of inpatient and outpatient care settings.

  • The updated guidance includes a number of updates, notably the option of providing home dialysis training and support services. These are designed to help some dialysis patients stay home during the pandemic.
  • In particular, the guidance includes the establishment of Special Purpose Renal Dialysis Facilities (SPRDFs), which can allow dialysis facilities to isolate vulnerable or infected patients.
  • For hospitals, psychiatric hospitals and CAHs, the updated guidance provides recommendations on screening and visitation restrictions, discharge to subsequent care locations, as well as staff screening and testing.

CMS acts to ensure US healthcare facilities can maximize frontline workforces to confront COVID-19 crisis 

CMS has temporarily suspended a number of rules in order for hospitals, clinics, and other healthcare facilities to boost their frontline medical staffs.

The CMS guidance focuses on reducing supervision and certification requirements so that practitioners can both be hired rapidly and perform work to the extent of their licensure. CMS guidance allows the following:

  • Doctors can now directly care for patients in certain settings without having to be physically present.
  • Nurse practitioners may now perform some medical exams on Medicare patients at skilled nursing.

CMS approves additional state Medicaid waivers and amendments to give states flexibility to address coronavirus pandemic

CMS continues to deliver regulatory relief to a number of new states in the form of waivers and state plan amendments.

  • In total, CMS has now approved 49 emergency 1135 waivers, 26 state amendments, seven COVID-19 related Medicaid disaster amendments and the first CHIP COVID-related disaster amendment
  • The COVID-related Children’s Health Insurance Program (CHIP) disaster amendment is for the State of Maine. 
  • CMS has now approved COVID-related Medicaid disaster state plan amendments for North Dakota, Rhode Island, and Wyoming.

HHS authorizes licensed pharmacists to order and administer COVID-19 tests

On April 8, HHS released new guidance under the Public Readiness and Emergency Preparedness Act that authorizes licensed pharmacists to order and administer FDA-approved COVID-19 tests.

  • The guidance allows pharmacists to order and administer COVID-19 tests to their patients will provide easier access to testing and will expand testing for healthcare workers and first responders. 

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team

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CMS approves over $51 billion for providers with the accelerated/advance payment program for Medicare providers

Read this if you would like a refresher of common-sense approaches to protect against fraud while working remotely.

Coronavirus (COVID-19) has imposed many challenges upon us physically, mentally, and financially. Directly or indirectly, we all are affected by the outbreak of this life-threatening disease. Anxious times like this provide perfect opportunities for fraudsters. The fraud triangle is a model commonly used to explain the three components that may cause someone to commit fraud when they occur together:

  1. Financial pressure/motivation 
    In March 2020, the unemployment rate increased by 0.9 percent to 4.4 percent, and the number of unemployed persons rose by 1.4 million to 7.1 million.
  2. Perceived opportunity to commit fraud 
    Many people are online all day, providing more opportunities for internet crime. People are also desperate for something, from masks and hand sanitizers to coronavirus immunization and cures, which do not yet exist. 
  3. Rationalization 
    People use their physical, mental, or financial hardship to justify their unethical behaviors.

To combat the increasing coronavirus-related fraud and crime, the Department of Justice (DOJ) launched a national coronavirus fraud task force on March 23, 2020. It focuses on the detection, investigation, and prosecution of fraudulent activity, hoarding, and price gouging related to medical resources needed to respond to the coronavirus. US attorney’s offices are also forming local task forces where federal, state, and local law enforcement work together to combat the coronavirus related crimes. Things are changing fast, and the DOJ has daily updates on the task force activities. 

Increased awareness for increased threats

Given the increase in fraudulent activity during the COVID-19 outbreak, it’s important for employees now working from home to be aware of ways to protect themselves and their companies and prevent the spread of fraud. Here are some of the top COVID-19-related fraud schemes to be aware of. 

  • Phishing emails regarding virus information, general financial relief, stimulus payments, and airline carrier refunds
  • Fake charities requesting donations for illegitimate or non-existent organizations 
  • Supply scams including fake shops, websites, social media accounts, and email addresses claiming to sell supplies in high demand but then never providing the supplies and keeping the money 
  • Website and app scams that share COVID-19 related information and then insert malware that could compromise the device and your personal information
  • Price gouging and hoarding of scarce products
  • Robocalls or scammers asking for personal information or selling of testing, cures, and essential equipment
  • Zoom bombing and teleconference hacking

If you have encountered suspicious activity listed above, please report it to the FBI’s Internet Crime Complaint Center.

Staying vigilant

To protect yourself from these threats, remember to use proper security measures and follow these tips provided by the Federal Bureau of Investigation (FBI) and DOJ:

  • Verify the identity of the company, charity, or individual that attempts to contact you in regards to COVID-19.
  • Do not send money to any business, charity, or individual requesting payments or donations in cash, by wire transfer, gift card, or through the mail. 
  • Understand the features of your teleconference platform and utilize private meetings with a unique code or password that is not shared publicly.
  • Do not open attachments or click links within emails from senders you do not recognize.
  • Do not provide your username, password, date of birth, social security number, insurance information, financial data, or other personal information in response to an email or robocall.
  • Always verify the web address of legitimate websites and manually type them into your browser.
  • Check for misspellings or wrong domains within a link (for example, an address that should end in a ".gov" ends in .com" instead).

Stay aware, and stay informed. If you have specific concerns or questions, or would like more information, please contact our team. We’re here to help.
 

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COVID-19 and fraud―a security measures refresher

Read this if you are a leader at a state Medicaid agency.

Here is a summary of information we have gleaned from the Center for Medicare and Medicaid Services (CMS) Administrator Verma’s recent call.

CMS is implementing new rules and waivers that increase provider flexibility and free up resources to deal with a surge in COVID-19 patients. CMS is working with the provider community to provide clarity around specific changes that impact their operations.

  • The rulemaking process has been dramatically expedited to accommodate recent and forthcoming regulatory changes
  • CMS is in the process of working out details to administer CARES Act provisions, including further regulatory flexibilities, expansion of accelerated payment program, and $100 billion appropriated to reimburse eligible health care providers
  • CMS clarifies that the 3-Day Rule Waiver for skilled nursing facilities applies throughout the country and to all patients, regardless of their COVID-19 status

Medicaid Substance Use Disorder Treatment via Telehealth, and Rural Health Care and Medicaid Telehealth Flexibilities Guidance

This informational bulletin is composed of two parts: Rural Health Care and Medicaid Telehealth Flexibilities and Medicaid Substance Use Disorder Treatment via Telehealth.

  • The informational bulletin identifies opportunities for telehealth delivery for services to increase access to Medicaid services. It is composed of two parts, Rural Health Care and Medicaid Telehealth Flexibilities and Medicaid Substance Use Disorder (SUD) Treatment Services Furnished via Telehealth
  • The bulletin provides SUD guidance around Medication Assisted Treatment (MAT), counseling, high risk populations, and other areas critical to providing SUD services.

Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit

CMS is issuing an electronic toolkit regarding telehealth and telemedicine for Long Term Care Nursing Home Facilities.

  • The toolkit includes electronic links to sources of information regarding telehealth and telemedicine, including the changes made by CMS over the last week in response to the national health emergency.
  • Much of the toolkit’s information is intended for providers who may wish to establish a permanent telemedicine program, but there is information here that will help in the temporary deployment of a telemedicine program as well.
  • There are specific documents identified that may be useful in choosing telemedicine vendors, equipment, and software, initiating a telemedicine program, monitoring patients remotely, and developing documentation tools. 


CMS makes regulatory changes to help US healthcare system address COVID-19 patient surge

CMS has issued a number of temporary regulatory waivers and new rules to assist the nation’s healthcare system with improved flexibility.

  • Increased hospital capacity. CMS will allow communities to take advantage of local ambulatory surgery centers that have canceled elective surgeries, per federal recommendations.
  • Healthcare workforce expansion. CMS’s temporary requirements allow hospitals and healthcare systems to increase their workforce capacity by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community as well as those licensed from other states without violating Medicare rules.
  • Paperwork requirements. CMS is temporarily eliminating paperwork requirements.
  • Telehealth in Medicare. CMS will now allow for more than 80 additional services to be furnished via telehealth.

Additional COVID-19 FAQs for state Medicaid and Children's Health Insurance Program (CHIP) agencies

CMS released an update to the COVID-19 FAQs posted on March 18, 2020 related to emergency preparedness and response, eligibility and enrollment flexibilities, benefit flexibilities, cost sharing flexibilities, financial flexibilities, managed care flexibilities, fair hearing flexibilities, health information exchange flexibilities, and COVID-19 T-MSIS coding guidance. Notably:

  • States that have CHIP disaster provisions in their state plans can activate these provisions. CMS considers a significant outbreak of an infectious disease to be a disaster. CMS also recommends that states that do not have disaster relief provisions in their CHIP state plans include language that a federal- or governor-declared emergency is considered an event that can trigger the disaster provisions.

States may not suspend use of their AVS, however CMS reminds states that they can rely on self-attestation of assets and verify financial assets using their AVS post-enrollment in Medicaid.

  • CMS can help provide technical assistance regarding approaches states can use to rapidly scale telehealth technologies.
  • CMS clarified and provided COVID-19 T-MSIS coding guidance.

For more information

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team

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Takeaways from CMS national stakeholder call

Read this if you are a business owner, in management, or in HR at a company with less than 500 employees.

We have received many questions regarding the FFCRA and its provisions and how it affects different employers and their employees. Here are some of the questions our clients have asked the most. Please contact us if you have questions regarding your specific situation. We’re here to help.  

Besides compensation, what other costs paid by an employer are eligible for the credit (i.e., employer paid health insurance, employer payroll taxes)?
Employers can deduct the cost of providing continuing health care coverage, and the employer’s share of Medicare taxes related to the leave wages. Any compensation paid under the FFCRA is not subject to the employer’s portion of the Social Security tax.

How do you determine the total number of employees? 
In calculating the total number of employees, all full-time or part-time employees working within the US, including all US territories or possessions, are counted, including all employees on leave and temp employees who are jointly employed with another company as determined under the Fair Labor Standards Act (FLSA). 

How does a business know if it employs less than 500 employees and is subject to the FFCRA?
Generally, a private sector employer is subject to the Family and Medical Leave Act of 1993 (FMLA) if it employs 50 or more employees for each working day during each of 20 or more calendar workweeks in the current or preceding calendar year. The FAQs issued by the Department of Labor (DOL) indicate an employer has fewer than 500 employees if, at the time an employee’s leave is to be taken, there are fewer than 500 full-time and part-time employees within the United States, which includes any state of the United States, the District of Columbia, or any territory or possession of the United States. 

In making this determination, an employer should include employees on leave; temporary employees who are jointly employed by you and another employer (regardless of whether the jointly-employed employees are maintained on only your or another employer’s payroll); and day laborers supplied by a temporary agency (regardless of whether you are the temporary agency or the client firm if there is a continuing employment relationship). Workers who are independent contractors under the FLSA, rather than employees, are not considered employees for purposes of the 500-employee threshold.

Where a corporation has an ownership interest in another corporation, the two corporations are separate employers unless they are joint employers under the FLSA with respect to certain employees. In general, two or more entities are separate employers unless they meet the integrated employer test under the FMLA.

Please check with your advisors if you believe the integrated employer test may apply to your businesses.

Which employees are entitled to the $511 payment under sick leave?
For an employee who is unable to work because of the coronavirus quarantine or self-quarantine or has COVID-19 symptoms and is seeking a medical diagnosis, the employee may receive sick leave wages equal to the employee’s regular rate of pay, up to $511 per day and $5,111 in the aggregate, for a total of 10 days. Note that only employers who employ less than 500 employer are required to provide sick leave payments. Such employees may also receive a refundable tax credit for sick leave paid to employees.

Which employees are entitled to the $200 payment under sick leave?
For an employee who is caring for someone with COVID-19, or is caring for a child because the child’s school or child care facility is closed, or the child care provider is unavailable due to the coronavirus, the employee may receive sick leave wages equal to two-thirds of the employee’s regular rate of pay, up to $200 per day and $2,000 in the aggregate, for up to 10 days. Note that only employers who employ less than 500 employer are required to provide sick leave payments. Such employees may also receive a refundable tax credit for sick leave paid to employees.

Which employees are entitled to the $200 payment under the family leave portion of FFCRA?
For an employee who is unable to work because of a need to care for a child whose school or child care facility is closed or whose child care provider is unavailable due to the coronavirus, the employee may receive family leave wages equal to two-thirds of the employee’s regular rate of pay, capped at $200 per day or $10,000 in the aggregate. Up to 10 weeks of qualifying leave can be counted towards the child care leave credit. Note that only employers who employ less than 500 employer are required to provide sick leave payments. Such employees may also receive a refundable tax credit for sick leave paid to employees.

What is “regular rate of pay” for purposes of the FFCRA?
For purposes of the FFCRA, the regular rate of pay used to calculate paid leave is the average of the employee’s regular rate over a period of up to six months prior to the date on which leave is taken. If an employee has not worked for the current employer for six months, the regular rate used to calculate paid leave is the average regular rate of pay for each week the employee has worked for the current employer.

If an employee is paid with commissions, tips, or piece rates, these amounts will be incorporated into the above calculation to the same extent they are included in the calculation of the regular rate under the FLSA.

You can also compute this amount for each employee by adding all compensation that is part of the regular rate over the above period and divide that sum by all hours actually worked in the same period.

What is the effective date of the sick leave/family leave provisions?
Employers must comply with the FFCRA from April 1, 2020, until it expires on December 31, 2020. Paid leave prior to April1, 2020 will not count. The IRS recently issued guidance indicating the tax credits for qualified sick leave wages and qualified family leave wages required to be paid by the FFRCA will apply to wages paid for the period beginning on April 1, 2020, and ending on December 31, 2020.

Who is considered a “health care provider”?
For the purposes of employees who may be exempted from paid sick leave or expanded family and medical leave by their employer under the FFCRA, a health care provider is anyone employed at any doctor’s office, hospital, health care center, clinic, post-secondary educational institution offering health care instruction, medical school, local health department or agency, nursing facility, retirement facility, nursing home, home health care provider, any facility that performs laboratory or medical testing, pharmacy, or any similar institution, employer, or entity. This includes any permanent or temporary institution, facility, location, or site where medical services are provided that are similar to such institutions. 

This definition includes any individual employed by an entity that contracts with any of the above institutions, employers, or entities institutions to provide services or to maintain the operation of the facility. This also includes anyone employed by any entity that provides medical services, produces medical products, or is otherwise involved in the making of COVID-19 related medical equipment, tests, drugs, vaccines, diagnostic vehicles, or treatments. This also includes any individual that the highest official of a state or territory, including the District of Columbia, determines is a health care provider necessary for that state’s or territory’s or the District of Columbia’s response to COVID-19.

To minimize the spread of the virus associated with COVID-19, the DOL encourages employers to be judicious when using this definition to exempt health care providers from the provisions of the FFCRA.

For more information
If you have more questions, or have a specific question about your particular situation, please call us. We’re here to help. 

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Families First Coronavirus Response Act (FFCRA): FAQs for businesses

Per CMS, all state Medicaid agencies, including territories, are eligible for the increased Federal Medical Assistance Percentage (FMAP), provided they adhere to the conditions outlined in the Families First Coronavirus Response Act (FFCRA). 

Key takeaways:

  • The increase in FMAP will be retroactive to January 1, 2020 and will be available to state Medicaid agencies through the end of the quarter in which the public health emergency for COVID-19 ends.
  • This guidance answers some of the following questions for states, including:
    • How long the funding will be available and when it begins
    • What costs are matchable under the enhanced funding 
    • The specific conditions under which states are eligible to claim the funds 
    • What documentation and processes will be needed in order to gain full access to funding

Trump administration releases COVID-19 checklists and tools to accelerate relief for state Medicaid & CHIP programs

In order to assist states as part of the COVID-19 outbreak, the Trump administration has released a number of tools and checklists that constitute a federal authority toolkit to support states in applying for and receiving federal waivers and other key flexibilities for their program. 

Key takeaways:
The tools released today include:

CMS issues FAQs on catastrophic health coverage and the coronavirus

A catastrophic health plan may not provide coverage of an essential health benefit prior to an enrollee meeting the deductible for that plan. In order to clarify treatment and coverage of COVID-19 for catastrophic health plans CMS has issued Frequently Asked Questions (FAQs).

Key takeaways:

  • Catastrophic plans currently include coverage for the diagnosis and treatment of COVID-19 as they must cover the essential health benefits (EHB) as required by the Patient Protection and Affordable Care Act (PPACA).
  • Issuers of catastrophic plans will be able to provide coverage for the diagnosis and treatment of COVID-19 for enrollees who have not yet met their deductible without CMS taking enforcing action.
  • The FAQ document encourages states to take an enforcement approach and CMS does not “consider a state to have failed to substantially enforce section 1302(e) of the PPACA if it takes such an approach.”

Relief for clinicians, providers, hospitals, and facilities participating in quality reporting programs in response to COVID-19

CMS is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs.  

Key takeaways:

  • The exceptions include pending dates for measure reporting and data submission for related programs. 
  • For data submission deadlines in April and May of 2020, submission of those data will be optional, based on the facility’s choice to report.
  • 2019 data submission
    • Deadline extended from March 31, 2020 to April 30, 2020.
    • Deadlines for October 1, 2019 - December 31, 2019 (Q4) 
    • Data submission is optional for inpatient rehabilitation and hospital-acquired conditions.

CMS releases telehealth toolkits for general practitioners and End-Stage Renal Disease (ESRD) providers

CMS has released two toolkits on telehealth which follow the broadened access to Medicare telehealth services under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

Key takeaways:

  • The toolkit consists of electronic links to sources of information pursuant to telehealth and telemedicine. 
  • Generally directed towards providers, particularly ones who may be considering a permanent telemedicine program.
  • CMS notes that most of the resources were established prior to the current COVID-19 crisis. As a result, there are likely references to rules and regulations whose requirements may have been waived for the duration of the outbreak.

Toolkits:

For more information

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team

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New guidance regarding enhanced Medicaid funding for states

Here is a summary of information we have gleaned from recent CMS updates and guidance. 

COVID-19 stakeholder call - March 16 

CMS held a National Stakeholder Call on March 16, 2020 to update the healthcare community on the rapidly evolving COVID-19 situation, which was declared a national emergency by President Trump on March 13, 2020.

Key takeaways:

  • Administrator Verma reaffirmed the goal of reducing administrative barriers in the way of healthcare workers and agencies and to support them as best CMS is able.
  • Acknowledging that there were questions on testing, Administrator Verma outlined that there will be a ramp-up in testing in conjunction with state and local governments. 
  • CMS is relaxing clinician enrollment requirements for Medicare and making the same option available to states in their Medicaid programs.
  • The administration has been clear that it wants agencies to focus on infection control efforts. CMS is designing a streamlined template to evaluate infection control.
  • CMS sends guidance to Programs of All-Inclusive Care for the Elderly (PACE) Organizations.

On March 17, 2020, CMS issued guidance to all Programs of All-Inclusive Care for the Elderly (PACE) Organizations (POs) on accepted policies and standard procedures with respect to infection control.

Key takeaways:

  • POs will need to create, apply, and sustain a documented infection control plan that involves procedures to recognize, examine, regulate, and avert infections in PACE centers
  • POs will need to work to prevent infections within each participant’s place of residence, as well as implement procedures to record and develop corrective actions related to incidents of infection.
  • CMS provides guidance that recognizes POs may need to undertake strategies that do not traditionally comply with CMS PACE program requirements in order to provide benefits while guarding from COVID-19. Some examples of this may include telehealth services.
  • President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak.

CMS is expanding Medicare’s telehealth benefits under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act.

Key takeaways:

  • Under the new 1135 waiver, Medicare can pay for office, hospital, and other visits provided via telehealth across the country and including in patient’s place of residence starting March 6, 2020. 
  • Medicare telehealth visits: These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
  • Virtual check-ins: Virtual check-in services can only be reported when the billing practice has an established relationship with the member.  
  • E-visits: Such services can only be reported when the billing practice has an established relationship with the patient.  

CMS coronavirus partner virtual toolkit

CMS has released a virtual toolkit to help stakeholders stay up-to-date on CMS materials available on COVID-19. Here is specific guidance from the toolkit designed for states and health plans:

CMS approves first state request for 1135 Medicaid waiver in Florida and Washington

The 1135 waiver allows Florida and Washington to modify certain Medicaid program requirements, policies, operational procedures, and deadlines applicable to each state’s administration of its Medicaid program during the period of the national state of emergency to prevent further transmission of COVID-19. 

Key takeaways from Florida’s waiver

  • Provider participation flexibilities for Medicaid and CHIP Waiver of Service Prior Authorization (PA) Requirements for fee-for-service delivery systems
  • Waiver for Pre-Admission Screening and Annual Resident Review (PASRR) Level II Level II Assessments for 30 Days
  • Waiver to allow evacuating facilities to provide services in alternative settings, such as a temporary shelter when a provider’s facility is inaccessible
  • Waiver to temporarily delay scheduling for state fair hearing requests and appeal deadlines (NOTE: CMS was unable to waive all of Florida’s requested authorities in this area)

If you have questions or would like more information, we are here to help. Please contact us

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CMS update for the healthcare community: Our takeaways

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification effort.

On October 24, 2019, the Centers for Medicaid and Medicare Services (CMS) published the Outcomes-Based Certification (OBC) guidance for the Electronic Visit Verification (EVV) module. Now, CMS is looking to bring the OBC process to the rest of the Medicaid Enterprise. 

The shift from a technical-focused certification to a business outcome-focused approach presents a unique opportunity for states as they begin re-procuring—and certifying—their Medicaid Enterprise Systems (MES).

Once you have defined the scope of your MES project—and know you need to undertake CMS certification—you need to ask “what’s next?” OBC can be a more efficient certification process to secure Federal Financial Participation (FFP).

What does OBC certification entail?

Rethinking certification in terms of business outcomes will require agencies to engage business and operations units at the earliest possible point of the project development process to define the program goals and define what a successful implementation is. One way to achieve this is to consider MES projects in three steps. 

Three steps to OBC evaluation

Step 1: Define outcomes

The first step in OBC planning seems easy enough: define outcomes. But what is an outcome? To answer that, it’s important to understand what an outcome isn’t. An outcome isn’t an activity. Instead, an outcome is the result of the activity. For example, the activity could be procuring an EVV solution. In this instance, an outcome could be that the state has increased the ability to detect fraud, waste, and abuse through increased visibility into the EVV solution.

Step 2: Determine measurements

The second step in the OBC process is to determine what to measure and how exactly you will measure it. Deciding what metrics will accurately capture progress toward the new outcomes may be intuitive and therefore easy to define. For example, a measure might simply be that each visit is captured within the EVV solution.

Increasing the ability to detect fraud, waste, and abuse could simply be measured by the number of cases referred to a Medicaid fraud unit or dollars recovered. However, you may not be able to easily measure that in the short-term. Instead, you may need to determine its measurement in terms of an intermediate goal, like increasing the number of claims checked against new data as a result of the new EVV solution. By increasing the number of checked claims, states can ensure that claims are not being paid for unverified visits. 

Step 3: Frequency and reporting

Finally, the state will need to determine how often to report to measure success. States will need to consider the nuances of their own Medicaid programs and how those nuances fit into CMS’ expectations, including what data is available at what intervals.

OBC represents a fundamental change to the certification process, but it’s important to highlight that OBC isn’t completely unfamiliar territory. There is likely to be some carry-over from the certification process as described in the Medicaid Enterprise Certification Toolkit (MECT) version 2.3. The current Medicaid Enterprise Certification (MEC) checklists serve as the foundation for a more abbreviated set of criteria. New evaluation criteria will look and feel like the criteria of old but are likely to be a fraction of the 741 criteria present in the MECT version 2.3.

OBC offers several benefits to states as you navigate federal certification requirements:

  1. You will experience a reduction in the amount of time, effort, and resources necessary to undertake the certification process. 
  2. OBC refocuses procurement in terms of enhancements to the program, not in new functions. Consequently, states will also be able to demonstrate the benefits that each module brings to the program which can be integral to stakeholder support of each module. 
  3. Early adoption of the OBC process can allow you to play a more proactive role in certification efforts.

Continue to check back for a series of our project case studies. Additionally, if you are considering an OBC effort and have questions, please contact our team. You can read the OBC guidance on the CMS website here
 

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Three steps to outcomes-based certification

Editor's note: read this blog if you are a state liquor administrator or at the C-level in state government. 

Surprisingly, the keynote address to this year’s annual meeting of the National Alcohol Beverage Control Association (NABCA) featured few comments on, well, alcohol. 

Why? Because cannabis is now the hot topic in state government, as consumers await its legalization. While the thought of selling cannabis may seem foreign to some state administrators, many liquor agencies are―and should be―watching. The fact is, state liquor agencies are already equipped with expertise and the technology infrastructure needed to lawfully sell a controlled substance. This puts them in a unique position to benefit from the industry’s continued growth. Common technology includes enterprise resource planning (ERP) and point-of-sale (POS) systems.

ERP

State liquor agencies typically use an ERP system to integrate core business functions, including finance, human resources, and supply chain management. Whether the system is handling bottles of wine, cases of spirits, or bags of cannabis, it is capable of achieving the same business goals. 

The existing checks and balances on controlled substances like alcohol in their current ERP system translate well to cannabis products. This leads to an important point: state governments do not need to procure a new IT system solely for regulating cannabis.

By leveraging existing ERP systems, state liquor agencies can sidestep much of the time, effort, and expense of selecting, procuring, and implementing a new system solely for cannabis sales and management. In control states, where the state has exclusively control of alcohol sales, liquor agencies are often involved in every stage of product lifecycle, from procurement to distribution to retailing.

With a few modifications, the spectrum of business functions that control states require for liquor—procuring new product, communicating with vendors and brokers, tracking inventory, and analyzing sales—can work just as well for cannabis.

POS

POS systems are necessary for most retail stores. If a state liquor agency decides to sell cannabis products in stores, they can use a POS system to integrate with the agency’s ERP system, though store personnel may require training to help ensure compliance with related regulations.

Cannabis is cash only (for now)

There is one major difference in conducting liquor versus cannabis sales at any level: currently states conduct all cannabis sales in cash. With cannabis illegal on the federal level, major banks have opted to decline any deposit of funds earned from cannabis-related sales. While some community banks are conducting cannabis-related banking, many retailers selling recreational cannabis in places like Colorado and California still deal in cash. While risky and not without challenges, these transactions are possible and less onerous to federal regulators. 

Taxes 

As markets develop, monthly tax revenue collections from cannabis continue to grow. Colorado and California have found cannabis-related tax revenue a powerful tool in hedging against uncertainty in year-over-year cash flows. Similar to beer sold wholesale, which liquor agencies tax even in control states, cannabis can be taxed at multiple levels depending on the state’s business model.

E-commerce

Even with liquor, few state agencies have adopted direct-to-consumer online sales. However, as other industries continue shifting toward e-commerce and away from brick and mortar retailing, private sector competition will likely feed increased consumer demand for online sales. Similar to ERP and POS systems, states can increase revenue by selling cannabis through e-commerce sales channels. In today’s online retail world, many prefer to buy products from their computer or smart phone instead of shopping in stores. State agencies should consider selling cannabis via the web to maximize this revenue opportunity. 

Applying expertise in the systems and processes of alcoholic beverage control can translate into the sale and regulation of cannabis, easing the transition states face to this burgeoning industry. If your agency is considering bringing in cannabis under management, you should consider strategic planning sessions and even begin a change management approach to ensure your agency adapts successfully. 

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Considering cannabis: How state liquor agencies can manage the growing industry

Phew! We did it—The Medicaid Enterprise Systems Conference (MESC) 2019 is one for the books! And, it was a great one. Here is my perspective on objectives and themes that will guide our work for the year.

Monday 

My day started in the fog—I live on an island in Maine, take a boat to get into Portland, and taxi to the airport. Luckily, I got to Portland, and, ultimately Chicago, on time and ready to go. 

Public Sector Technology Group (PSTG) meeting

At the PSTG meetings, we reviewed activities from the previous year and did some planning for the coming year. Areas for consideration included:

  • Modernization Schedule
  • Module Definitions
  • Request for Proposal (RFP) Requirements
  • National Association of State Procurement Officers

Julie Boughn, Centers for Medicare and Medicaid (CMS) Director, Data and Systems Group (DSG) introduced her new boss, Karen Shields, who is the Deputy Director for the Center for Medicaid and CHIP Services (CMCS) within CMS. Karen shared her words of wisdom and encouragement with us, while Julie reminded us that being successful in our work is about the people. CMS also underscored the goal of speeding up delivery of service to the Medicaid program and asking ourselves: “What is the problem we are trying to resolve?” 

CMS’ “You be the State” officer workshop

Kudos to CMS for creating this open environment of knowledge sharing and gathering input.  Areas for discussion and input included:

  • APD Processes
  • Outcomes-Based Certification
  • Increasing and Enhancing Accountability

Tuesday
Opening Plenary

I was very touched by the Girls Inc. video describing the mission of Girls Inc. to inspire girls to be strong, smart, and bold. With organizations like this, and our awareness and action, I am optimistic for the future. Thank you to NESCSO for including this in their opening program.

John Doerr, author of Measure What Matters: OKRs: The Simple Idea that Drives 10x Growth and famed investor, shared his thoughts on how to create focus and efficiency in what we do. Julie’s interview with him was excellent, and I appreciated how John’s Objectives and Key Results (OKR) process prompted Julie to create objectives for what we are trying to do. The objectives Julie shared with us:

  • Improve the quality of our services for users and other stakeholders 
  • Ensure high-quality data is available to manage the program and improve policy making 
  • Improve procurement and delivery of Medicaid technology projects

Sessions

The sessions were well attended and although I can't detail each specific session I attended, I will note that I did enjoy using the app to guide me through the conference. NESCSO has uploaded the presentations. 

Auxiliary meetings

Whether formal or informal, meetings are one of the big values of the conference—relationships are key to everyone’s success, and meeting with attendees in one-on-one environments was incredibly productive. 

Poster session

The poster sessions were excellent. States are really into this event, and it is a great opportunity for the MESC community to engage with the states and see what is going on in the Medicaid Enterprise space.

Wednesday

Some memorable phrases heard in the sessions:

  • Knowledge is power only if you share it
  • We are in this together and want the same outcomes, so let’s share more
  • Two challenges to partnering projects—the two “P”s—are purchasing and personnel
  • Don’t let perfection be the enemy of the good
  • Small steps matter
  • Sharing data is harder than it needs to be—keep in mind the reason for what you are doing

Our evening social event was another great opportunity to connect with the community at MESC and the view of Chicago was beautiful.

Julie Boughn challenged us to set a goal (objective) in the coming year, and, along with it, to target some key results in connection with that goal. Here are some of her conference reflections:

  • Awesome
    • Several State Program and Policy leaders participated at MESC—impressed with Medicaid Director presence and participation
    • Smaller scoped projects are delivering in meeting the desired improved speed of delivery and quality
    • Increased program-technology alignment
  • Not so awesome
    • Pending state-vendor divorces
    • Burden of checklists and State Self-Assessments (SS-As)—will have something to report next year
    • There are still some attempts at very large, multi-year replacement projects—there is going to be a lot of scrutiny on gaining outcomes. Cannot wait five years to change something.

OKRs and request for states and vendors

  • Objective: Improve the quality of services for our users and other stakeholders
    • Key Result (KR): Through test results and audits, all States and CMS can state with precision, the overall accuracy of Medicaid eligibility systems.
    • KR: 100% of State electronic visit verification (EVV) systems are certified and producing annual performance data.
    • KR: 100% of States have used CMS-required testing guidance to produce testing results and evidence for their eligibility systems.
  • Objective: Ensure high-quality data is available to manage the program and improve policy making
    • KR: Transformed Medicaid Statistical Information System (T-MSIS) data is of sufficient quality that it is used to inform at least one key national Medicaid policy decision that all states have implemented.
    • KR:  Eliminate at least two state reporting requirements because T-MSIS data can be used instead.
    • KR: At least five states have used national or regional T-MSIS data to inform their own program oversite and/or policy-making decisions.
  • Objective: Improve how Medicaid technology projects are procured and delivered
    • KR: Draft standard language for outcomes metrics for at least four Medicaid business areas.
    • KR:  Five states make use of the standard NASPO Medicaid procurement.
    • KR:  CMS reviews of RFPs and contracts using NASPO vehicle are completed within 10 business days.
    • KR:  Four states test using small incremental development phases for delivery of services.
  • Request: Within 30 days, states/vendors will identify at least one action to take to help us achieve at least one of the KRs within the next two years.

Last thoughts

There is a lot to digest, and I am energized to carry on. There are many follow-up tasks we all have on our list. Before we know it, we’ll be back at next year’s MESC and can check in on how we are doing with the action we have chosen to help meet CMS’s requirements. See you in Boston!

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MESC 2019―Reflections and Daily Recap

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer—or if you work on a State Medicaid Enterprise System (MES) certification effort.

Measuring performance of Medicaid Enterprise Systems (MES) is emerging as the next logical step in moving Medicaid programs toward modularity. As CMS continues to refine and implement outcomes-based modular certification, it is critical that states adapt to this next step in order to continue to meet CMS funding requirements.

This measurement, in terms of program outcomes, presents a unique set of challenges, many of which a state may not have considered before. A significant challenge is determining how and where to begin measuring program outcomes―to meet it, states can leverage a trusted, independent partner as they undertake an outcomes-based effort.

Outcomes-based planning can be thought of as a three-step process. First, and perhaps most fundamental, is to define outcomes. Second, you need to determine what measurements will demonstrate progress toward achieving those outcomes. And the final step is to create reporting measurements and their frequency. Your independent partner can help you answer these critical questions and meet CMS requirements efficiently by objectively guiding you toward realizing your goals.

  1. Defining Outcomes
    When defining an outcome, it is important to understand what it is and what it isn’t. An outcome is a benefit or added value to the Medicaid program. It is not an output, which is a new or enhanced function of a new MES module. An output is the product that supports the outcome. For example, the functionality of a new Program Integrity (PI) module represents an output. The outcome of the new PI module could be that the Medicaid program continuously improves based on data available because of the new PI module. Some outcomes may be intuitive or obvious. Others may not be as easy to articulate. Regardless, you need to direct the focus of your state and solution vendor teams on the outcome to uncover what the underlying goal of your Medicaid program is.
     
  2. Determining Measurements
    The second step is to measure progress. Well-defined Key Performance Indicators (KPIs) will accurately capture progress toward these newly defined outcomes. Your independent partner can play a key role by posing questions to help ensure the measurements you consider align with CMS’ goals and objectives. Additionally, they can validate the quality of the data to ensure accuracy of all measurements, again helping to meet CMS requirements.
     
  3. Reporting Measurements
    Finally, your state must decide how―and how often―to report on outcomes-based measurements. Your independent partner can collaborate with both your state and CMS by facilitating conversations to determine how you should report, based on a Medicaid program’s nuances and CMS’ goals. This can help ensure the measurements (and support information) you present to CMS are useful and reliable, giving you the best chance for attaining modular certification.

Are you considering an outcomes-based CMS modular certification, or do you have questions about how to best leverage an independent partner to succeed with your outcomes-based modular certification effort? BerryDunn’s extensive experience as an independent IV&V and Project Management Office (PMO) partner includes the first pilot outcomes-based certification effort with CMS. Please visit our IV&V and certification experts at our booth at MESC 2019 or contact our team now.

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Three steps to measure Medicaid Enterprise Systems outcomes

Read this if you are a State Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer.

As CMS moves away from the monolithic Medicaid Management Information System (MMIS) toward an outcomes-based approach that includes a modular Medicaid Enterprise System (MES), there is now more emphasis on system integration (SI). 

In the August 16, 2016 letter, State Medicaid Director (SMD) #16-010, CMS clarified the role of the system integrator (SI) by stating:

CMS envisions a discrete role for the system integrator (SI) in each state, with specific focus on ensuring the integrity and interoperability of the Medicaid IT architecture and cohesiveness of the various modules incorporated into the Medicaid enterprise. 

While the importance of the SI role is apparent, not all states have the resources to build the SI capability within their own organizations. Some state Medicaid IT teams try to solve this by delegating management roles to vendors or contractors. This approach has various risks. A state could lose:

  • Institutional knowledge, as vendors and contractors transition off the project
  • Control of governance, oversight, and leadership
  • The ability to enforce contractual requirements across each vendor, especially the SI

In addition, the ramifications of loss of state accountability can have wide-reaching implementation, operational, and financial impacts, including:

  • The loss of timely decision making, causing projects to fall behind schedule
  • State-specific policy needs not being met, impacting how the MMIS functions in production 
  • Poor integration into the state-specific Operation and Maintenance (O&M) support model, increasing the state’s portion of long-term O&M costs
  • Inefficient and ineffective contract management of each module vendor and contractor (including the SI), possibly leading to unneeded change requests and cost overruns
  • Lack of coordination with the state’s business or IT roadmap initiatives (i.e., system consolidation or cloud migration vendor/approach), possibly leading to rework and missed opportunities to reduce cost or improve interoperability 

Apply strong governance and IV&V to tackle risks

Because the SI vendor is responsible for the integration of multiple modules across multiple vendors, you may consider delegating oversight of module vendors to the SI vendor. 

The major benefit states get from using the SI vendor is efficiency. Having your vendor as the central point of contact can quickly resolve technical issues, while allowing easy coordination of project tasks across each module vendor on a continual basis. 

If you choose to use a vendor for the SI role, establish safeguards and governance to make sure your goals are being met:

  • Build a project-specific governance model (executive committee [EC]) to oversee the vendors and the project
  • Establish a regular meeting cadence for the EC to allow for status updates on milestones and discuss significant project risks and issues 
  • Allocate state resources into project leadership roles (i.e., project manager, vendor contract manager, security lead, testing/Quality Assurance lead, etc.)
  • Conduct regular (weekly) SI status meetings to track progress and address risks and issues 

You also need a strong, involved governance structure that includes teams of state senior leadership, state program managers, SI vendor engagement/contract managers, and Independent Verification and Validation (IV&V) vendors. By definition, one responsibility of IV&V is to identify and monitor project risks and issues that could arise from a lack of independence. 

Your governance teams can debate decisions and disputes, risks and issues, and federal compliance issues with their vendors to define direction and action plans. However, a state representative within these teams should always make the final management decisions, approve all SI scope items and changes, and approve all contractual deliverables from each vendor or contractor.

Your state staff (business and IT) provides project management decision, business needs, requirements (functional and non-functional), policy guidance, and continuity as the vendors and/or contractors change over time. 

The conclusion? In order to be successful, you must retain certain controls and expertise to deploy and operate a successful MMIS system. Our consultants understand the need to keep you in control of managing key portions of implementation projects/programs and operational tasks. If you have questions, please contact BerryDunn’s Medicaid team.  
 

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Risks when using vendors to manage Medicaid system implementation projects

Read this if you are a state Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, State Procurement Officer, or work in a State Medicaid Program Integrity Unit.

The Centers for Medicare & Medicaid Services (CMS) issued a Payment Error Rate Measurement (PERM) Final Rule on July 5, 2017, that made several changes to the PERM requirements. One important change was the updates to the Medicaid Eligibility Quality Control (MEQC) requirement. 

The Final Rule restructures the MEQC program into a pilot program that requires states to conduct eligibility reviews during the two years between PERM cycles. CMS has also introduced the potential for imposing disallowances or reductions in federal funding percentage (FFP) as a result of PERM eligibility error rates that do not meet the national standard. One measure states can use to lessen the chance of this happening is by successfully carrying out the requirements of the MEQC pilot. 

What states should know―important points to keep in mind regarding MEQC reviews:

  • Each state must have a team in place to conduct MEQC reviews. The individuals responsible for the MEQC reviews and associated activities must be separate from the state agencies and personnel responsible for Medicaid and Children’s Health Insurance Program (CHIP) policy and operations, including eligibility determinations.
  • States can apply for federal funding to help cover the costs of the MEQC activities. CMS encourages states to partner with a contractor in conducting the MEQC reviews.
  • The deadline to submit the state planning document to CMS is November 1 following the end of your state’s PERM cycle. If you are a Cycle 2 state, your MEQC planning document is due by November 1, 2019. 
  • If you are a Cycle 1 state, you are (or should be) currently undergoing the MEQC reviews.
  • There are minimum sample size requirements for the MEQC review period: 400 negative cases and 400 active cases (consisting of both Medicaid and CHIP cases) over a period of 12 months.
  • Upon conclusion of all MEQC reviews, states must submit a final findings report along with a corrective action plan that addresses all error findings identified during the MEQC review period.

CMS encourages states to utilize federal funding to carry out and fulfill MEQC requirements. BerryDunn has staff with experience in preparing Advanced Planning Documents (APD) and can assist your state in submitting an APD request to CMS for these MEQC activities. 

Check out the previously released blog, “PERM: Prepared or Not Prepared?” and stay tuned for upcoming blogs about specific PERM topics, including the financial impacts of PERM, and how each review phase will affect your state.   

For questions or to find out more, contact the team

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PERM: Does MEQC affect states?

Read this if you are a state Medicaid Director, State Medicaid Chief Information Officer, State Medicaid Project Manager, or State Procurement Officer.

When I was growing up, my dad would leave the Bureau of Motor Vehicles or hang up the phone after talking with the phone company and say sarcastically, “I’m from the government (or the phone company) and I’m here to help you. Yeah, right.” I could hear the frustration in his voice. As I’ve gotten older, I understand the hassle of dealing with bureaucracy, where the red tape can make things more difficult than they need to be, and where customers don’t come first. It doesn’t have to be that way.

In my role performing Independent Verification and Validation (IV&V) at BerryDunn, I hear the same skepticism in the voices of some of my clients. I can hear them thinking, “Let me get this straight… I’m spending millions of dollars to replace my old Medicaid Management Information System (MMIS), and the Centers for Medicare and Medicaid Services (CMS) says I have to hire an IV&V consultant to show me what I am doing wrong? I don’t even control the contract. You’re here to help me? Yeah, right.” Here are some things to assuage your doubt. 

Independent IV&V―what they should do for you and your organization

An independent IV&V partner that is invested in your project’s success can:

  • Enhance your system implementation to help you achieve compliance
  • Help you share best practice experience in the context of your organization’s culture to improve efficiency in other areas
  • Assist you in improving your efficiency and timeliness with project management capabilities.

Even though IV&V vendors are federally mandated from CMS, your IV&V vendor should also be a trusted partner and advisor, so you can achieve compliance, improve efficiency, and save time and effort. 

Not all IV&V vendors are equal. Important things to consider:

Independence―independent vendors are a good place to start, as they are solely focused on your project’s success. They should not be selling you software or other added services, push vendor affiliations, or rubber stamp CMS, nor the state. You need a non-biased sounding board, a partner willing to share lessons learned from experience that will help your organization improve.

Well-rounded perspective―IV&V vendors should approach your project from all perspectives. A successful implementation relies on knowledge of Medicaid policy and processes, Medicaid operations and financing, CMS certification, and project management.

“Hello, we are IV&V from BerryDunn, and we are here to help.”

BerryDunn offers teams that consist of members with complementary skills to ensure all aspects of your project receive expert attention. Have questions about IV&V? Contact our team.
 

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We're IV&V and we are here to help you improve your Medicaid organization

Federal contractors with the Centers for Medicare & Medicaid Services (CMS) have begun performing Payment Error Rate Measurement (PERM) reviews under the Final Rule issued in July 2017—a rule that many states may not realize could negatively impact their Medicaid budgets.

PERM is a complex process—states must focus on several activities over a recurring three-year period of time—and states may not have the resources needed to make PERM requirements a priority. However, with the Final Rule, this PERM eligibility review could have financial implications. 

After freezing the eligibility measurement for four years while undergoing pilot review, CMS has established new requirements for the eligibility review component and made significant changes to the data processing and medical record review components. As part of the Final Rule, CMS may implement reductions in the amount of federal funding provided to a state’s Medicaid and Children’s Health Insurance Program (CHIP) programs based on the error rates identified from the eligibility reviews. 

Since the issuance of the Final Rule in July 2017, Cycle 1 states are the first group of states to undergo a PERM cycle, including reviews of the data processing, medical record, and eligibility components. These states are wrapping up the final review activities, and Cycle 2 states are in the early stages of their PERM reviews.

How can your state prepare?

Whether your state is a Cycle 1, Cycle 2, or Cycle 3 state, there are multiple activities your Medicaid departments should engage in throughout each three-year period of time during and between PERM cycles: 

  • Analyzing prior errors cited or known issues, along with the root cause of the error
  • Identifying remedies to reduce future errors
  • Preparing and submitting required questionnaires and documents to the federal contractors for an upcoming review cycle
  • Assisting federal contractors with current reviews and findings
  • Preparing for and undergoing Medicaid Eligibility Quality Control (MEQC) planning and required reviews
  • Corrective action planning

Is your state ready?

We’ve compiled a few basic questions to gauge your state’s readiness for the PERM review cycle:

  • Do you have measures in place to ensure all eligibility factors under review are identifiable and that all federal and state regulations are being met? The eligibility review contractor (ERC) will reestablish eligibility for all beneficiaries sampled for review. This process involves confirming all verification requirements are in the case file, income requirements are met, placement in an accurate eligibility category has taken place, and the timeframe for processing all determinations meets federal and state regulations. 
  • Do you have up-to-date policy and procedures in place for determining and processing Medicaid or CHIP eligibility of an individual? Ensuring eligibility policies and procedures meet federal requirements is just as important as ensuring the processing of applications, including both system and manual actions, meet the regulations. 
  • Do you have up-to-date policy, procedures, and system requirements in place to ensure accurate processing of all Medicaid/CHIP claims? Reviewers will confirm the accuracy of all claim payments based on state and federal regulations. Errors are often cited due to the claims processing system allowing claims to pay that do not meet regulations.
  • Do you have a dedicated team in place to address all PERM requirements to ensure a successful review cycle? This includes staff to answer questions, address review findings, and respond to requests for additional information. During a review cycle, the federal contractors will cite errors based on their best understanding of policies and/or ability to locate required documentation. Responding to requests for information or reviewing and responding to findings in a timely manner should be a priority to ensure accurate findings. 
  • Have you communicated all PERM requirements and updates to policy changes to all Medicaid/CHIP providers? Providers play two integral roles in the success of a PERM review cycle. Providers must understand all claims submission requirements in order to accurately submit claims. Additionally, the medical record review component relies on providers responding to the request for the medical records on a sampled claim. Failure to respond will result in an error. Therefore, states must maintain communication with providers to stress the importance of responding to these requests.
  • Have you begun planning for the MEQC requirement? Following basic requirements identified by CMS during your state’s MEQC period, your state must submit a case planning document to CMS for approval prior to the MEQC review period. After the MEQC review, your state should be prepared to issue findings reports, including a corrective action plan as it relates to MEQC findings.

Need help piloting your state’s PERM review process?

BerryDunn has subject matter experts experienced in conducting PERM reviews, including a thorough understanding of all three PERM review components—eligibility, data processing, and medical record reviews. 

We would love to work with your state to see that measures are in place that will help ensure the lowest possible improper payment error rate. Stay tuned for upcoming blogs where we will discuss other PERM topics, including MEQC requirements, the financial impacts of PERM, and additional details related to each phase of PERM. For questions or to find out more, please email me
 

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PERM: Prepared or not prepared?

As the Project Management Body of Knowledge® (PMBOK®) explains, organizations fall along a structure and reporting spectrum. On one end of this spectrum are functional organizations, in which people report to their functional managers. (For example, Finance staff report to a Finance director.) On the other end of this spectrum are projectized organizations, in which people report to a project manager. Toward the middle of the spectrum lie hybrid—or matrix—organizations, in which reporting lines are fairly complex; e.g., people may report to both functional managers and project managers. 

Problem: Weak Matrix Medicaid System Vendors

This brings us to weak matrix organizations, in which functional managers have more authority than project managers. Many Medicaid system vendors happen to fall into the weak matrix category, for a number of different reasons. Yet the primary factor is the volume and duration of operational work—such as provider enrollment, claims processing, and member enrollment—that Medicaid system vendors perform once they exit the design, development, and implementation (DDI) phase.

This work spans functional areas, which can muddy the reporting waters. Without strong and clear reporting lines to project managers, project success can be seriously (and negatively) affected if the priorities of the functional leads are not aligned with those of the project. And when a weak matrix Medicaid system vendor enters a multi-vendor environment in which it is tasked with implementing a system that will serve multiple departments and bureaus within a state government, the reporting waters can become even muddier.


Solution: Using a Project Management Office (PMO) Vendor

Conversely, consulting firms that provide Project Management Office (PMO) services to government agencies tend to be strong matrix organizations, in which project managers have more authority over project teams and can quickly reallocate team members to address the myriad of issues that arise on complex, multi-year projects to help ensure project success. PMOs are also typically experienced at creating and running project governance structures and can add significant value in system implementation-related work across government agencies.

Additional benefits of a utilizing a PMO vendor include consistent, centralized reporting across your portfolio of projects and the ability to quickly onboard subject matter expertise to meet program and project needs. 
For more in-depth information on the benefits of using a PMO on state Medicaid projects, stay tuned for my second blog in this series. In the meantime, feel free to send your PMO- or Medicaid-related questions to me
 

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The power of the PMO: Fixing the weak matrix

As your organization works to modernize and improve your Medicaid Enterprise System (MES), are you using independent verification and validation (IV&V) to your advantage? Does your relationship with your IV&V provider help you identify high-risk project areas early, or provide you with an objective view of the progress and quality of your MES modernization initiative? Maybe your experience hasn’t shown you the benefits of IV&V. 

If so, as CMS focuses on quality outcomes, there may be opportunities for you to leverage IV&V in a way that can help advance your MES to increase the likelihood of desired outcomes for your clients. 

According to 45 Code of Federal Regulations (CFR) § 95.626, IV&V may be required for Advanced Planning Document (APD) projects that meet specific criteria. That said, what is the intended role and benefit of IV&V? 

To begin, let’s look at the meaning of “verification” and “validation.” The Institute of Electrical and Electronics Engineers, Inc. (IEEE) Standard for Software Verification and Validation (1012-1998) defines verification as, “confirmation of objective evidence that the particular requirements for a specific intended use are fulfilled.” Validation is “confirmation of objective evidence that specified requirements have been fulfilled.” 

Simply put, verification and validation ensure the right product is built, and the product is built right. 
As an independent third party, IV&V should not be influenced by any vendor or software application. This objectivity means IV&V’s perspective is focused on benefiting your organization. This support includes: 

  • Project management processes and best practices support to help increase probability of project success
  • Collaboration with you, your vendors, and stakeholders to help foster a positive and efficient environment for team members to interact 
  • Early identification of high-risk project areas to minimize impact to schedule, cost, quality, and scope 
  • Objective examination of project health in order for project sponsors, including the federal government, to address project issues
  • Impartial analysis of project health that allows state management to make informed decisions 
  • Unbiased visibility into the progress and quality of the project effort to increase customer satisfaction and reduce the risk and cost of rework
  • Reduction of errors in delivered products to help increase productivity of staff, resulting in a more efficient MES 

Based on our experience, when a trusted relationship exists between state governments and IV&V, an open, collaborative dialogue of project challenges—in a non-threatening manner—allows for early resolution of risks. This leads to improved quality of MES outcomes.    

Is your IV&V provider helping you advance the quality of your MES? Contact our team.

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Leveraging IV&V to achieve quality outcomes

Modernization means different things to different people—especially in the context of state government. For some, it is the cause of a messy chain reaction that ends (at best) in frustration and inefficiency. For others, it is the beneficial effect of a thoughtful and well-planned series of steps. The difference lies in the approach to transition - and states will soon discover this as they begin using the new Comprehensive Child Welfare Information System (CCWIS), a case management information system that helps them provide citizens with customized child welfare services.

The benefits of CCWIS are numerous and impressive, raising the bar for child welfare and providing opportunities to advance through innovative technology that promotes interoperability, flexibility, improved management, mobility, and integration. However, taking advantage of these benefits will also present challenges. Gone are the days of the cookie-cutter, “one-size-fits-all” approach. Here are five facts to consider as you transition toward an effective modernization.

  1. There are advantages and challenges to buying a system versus building a system internally. CCWIS transition may involve either purchasing a complete commercial off-the-shelf (COTS) product that suits the state, or constructing a new system internally with the implementation of a few purchased modules. To decide which option is best, first assess your current systems and staff needs. Specifically, consider executing a cost-benefit analysis of options, taking into account internal resource capabilities, feasibility, flexibility, and time. This analysis will provide valuable data that help you assess the current environment and identify functional gaps. Equipped with this information, you should be ready to decide whether to invest in a COTS product, or an internally-built system that supports the state’s vision and complies with new CCWIS regulations.
     
  2. Employ a modular approach to upgrading current systems or building new systems. The Children’s Bureau—an office of the Administration for Children & Families within the U.S. Department of Health and Human Services—defines “modularity” as the breaking down of complex functions into separate, manageable, and independent components. Using this modular approach, CCWIS will feature components that function independently, simplifying future upgrades or procurements because they can be completed on singular modules rather than the entire system. Modular systems create flexibility, and enable you to break down complex functions such as “Assessment and Intake,” “Case Management,” and “Claims and Payment” into modules during CCWIS transition. This facilitates the development of a sustainable system that is customized to the unique needs of your state, and easily allows for future augmentation.
     
  3. Use Organizational Change Management (OCM) techniques to mitigate stakeholder resistance to change. People are notoriously resistant to change. This is especially true during a disruptive project that impacts day-to-day operations—such as building a new or transitional CCWIS system. Having a comprehensive OCM plan in place before your CCWIS implementation can help ensure that you assign an effective project sponsor, develop thorough project communications, and enact strong training methods. A clear OCM strategy should help mitigate employee resistance to change and can also support your organization in reaching CCWIS goals, due to early buy-in from stakeholders who are key to the project’s success.
     
  4. Data governance policies can help ensure you standardize mandatory data sharing. For example, the Children’s Bureau notes that a Title IV-E agency with a CCWIS must support collaboration, interoperability, and data sharing by exchanging data with Child Support Systems?Title IV-D, Child Abuse/Neglect Systems, Medicaid Management Information Systems (MMIS), and many others as described by the Children’s Bureau.

    Security is a concern due to the large amount of data sharing involved with CCWIS systems. Specifically, if a Title IV-E agency with a CCWIS does not implement foundational data security measures across all jurisdictions, data could become vulnerable, rendering the system non-compliant. However, a data governance framework with standardized policies in place can protect data and surrounding processes.
     
  5. Continuously refer to federal regulations and resources. With the change of systems comes changes in federal regulations. Fortunately, the Children’s Bureau provides guidance and toolkits to assist you in the planning, development, and implementation of CCWIS. Particularly useful documents include the “Child Welfare Policy Manual,” “Data Sharing for Courts and Child Welfare Agencies Toolkit,” and the “CCWIS Final Rule”. A comprehensive list of federal regulations and resources is located on the Children’s Bureau website.

    Additionally, the Children’s Bureau will assign an analyst to each state who can provide direction and counsel during the CCWIS transition. Continual use of these resources will help you reduce confusion, avoid obstacles, and ultimately achieve an efficient modernization program.

Modernization doesn’t have to be messy. Learn more about how OCM and data governance can benefit your agency or organization.

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Five things to keep in mind during your CCWIS transition

Truly effective preventive health interventions require starting early, as evidenced by the large body of research and the growing federal focus on the role of Medicaid in addressing Social Determinants of Health (SDoH) and Adverse Childhood Experiences (ACEs).

Focusing on early identification of SDoH and ACEs, CMS recently announced its Integrated Care for Kids (InCK) model and will release the related Notice of Funding Opportunity this fall.

CMS describes InCK as a child-centered approach that uses community-based service delivery and alternative payment models (APMs) to improve and expand early identification, prevention, and treatment of priority health concerns, including behavioral health issues. The model’s goals are to improve child health, reduce avoidable inpatient stays and out-of-home placement, and create sustainable APMs. Such APMs would align payment with care quality and support provider/payer accountability for improved child health outcomes by using care coordination, case management, and mobile crisis response and stabilization services.

State Medicaid agencies have many things to consider when evaluating this funding opportunity. Building on current efforts and innovations, building or leveraging strong partnerships with community organizations, incentivizing evidence-based interventions, and creating risk stratification of the target population are critical parts of the InCK model. Here are three additional areas to consider:

1. Data. States will need information for early identification of children in the target population. State agencies?like housing, justice, child welfare, education, and public health have this information?and external organizations—such as childcare, faith-based, and recreation groups—are also good sources of early identification. It is immensely complicated to access data from these disparate sources. State Medicaid agencies will be required to support local implementation by providing population-level data for the targeted geographic service area.

  • Data collection challenges include a lack of standardized measures for SDoH and ACEs, common data field definitions, or consistent approaches to data classification; security and privacy of protected health information; and IT development costs.
  • Data-sharing agreements with internal and external sources will be critical for state Medicaid agencies to develop, while remaining mindful of protected health information regulations.
  • Once data-sharing agreements are in place, these disparate data sources, with differing file structures and nomenclature, will require integration. The integrated data must then be able to identify and risk-stratify the target population.

For any evaluative approach or any APM to be effective, clear quality and outcome measures must be developed and adopted across all relevant partner organizations.

2. Eligibility. Reliable, integrated eligibility and enrollment systems are crucial points of identification and make it easier to connect to needed services.

  • Applicants for one-benefit programs should be screened for eligibility for all programs they may need to achieve positive health outcomes.
  • Any agency at which potential beneficiaries appear should also have enrollment capability, so it is easier to access services.

3. Payment models. State Medicaid agencies may cover case management services and/or targeted case management as well as health homes; leverage Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services; and modify managed care organization contract language to encourage, incent, and in some cases, require services related to the InCK model and SDoH. Value-based payment models, already under exploration in numerous states, include four basic approaches:

  • Pay for performance—provider payments are tied directly to specific quality or efficiency indicators, including health outcomes under the provider organization’s control. 
  • Shared savings/risk—some portion of the organization’s compensation depends on the managed care entity achieving cost savings for the targeted patient population, while realizing specific health outcomes or quality improvement.
  • Pay for success—payment is dependent upon achieving desired outcomes rather than underlying services.
  • Capitated or bundled payments—managed care entities pay an upfront per member per month lump sum payment to an organization for community care coordination activities and link that with fee-for-service reimbursement for delivering value-added services.

By focusing on upstream prevention, comprehensive service delivery, and alternative payment models, the InCK model is a promising vehicle to positively impact children’s health. Though its components require significant thought, strategy, coordination, and commitment from state Medicaid agencies and partners, there are early innovators providing helpful examples and entities with vast Section 1115 waiver development and Medicaid innovation experience available to assist.

As state Medicaid agencies develop and implement primary and secondary prevention, cost savings can be achieved while meaningful improvements are made in children’s lives.

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Three factors state medicaid agencies should consider when applying for InCK funding

Over the course of its day-to-day operations, every organization acquires, stores, and transmits Protected Health Information (PHI), including names, email addresses, phone numbers, account numbers, and social security numbers.

Yet the security of each organization’s PHI varies dramatically, as does its need for compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Organizations that meet the definition of a covered entity or business associate under HIPAA must comply with requirements to protect the privacy and security of health information.

Noncompliance can have devastating consequences for an organization, including:

  • Civil violations, with fines ranging from $100 to $50,000 per violation
  • Criminal penalties, with fines ranging from around $50,000 to $250,000, plus imprisonment

All it takes is just one security or privacy breach. As breaches of all kinds continue to rise, this may be the perfect time to evaluate the health of your organization’s HIPAA compliance. To keep in compliance and minimize your risk of a breach, your organization should have:

  • An up-to-date and comprehensive HIPAA security and privacy plan
  • Comprehensive HIPAA training for employees
  • Staff who are aware of all PHI categories
  • Sufficiently encrypted devices and strong password policies

HIPAA Health Check: A Thorough Diagnosis

If your organization doesn’t have these safeguards in place, it’s time to start preparing for the worst — and undergo a HIPAA health check.

Organizations need to understand what they have in place, and where they need to bolster their practice. Here are a variety of fact-finding methods and tools we recommend, including (but not limited to):

  • Administrative, technical, and physical risk analyses
  • Policy, procedure, and business documentation reviews
  • Staff surveys and interviews
  • IT audits and testing of data security

Once you have diagnosed your organization’s “as-is” status, you need to move your organization toward the “to-be” status — that is, toward HIPAA compliance — by:

  • Prioritizing your HIPAA security and privacy risks
  • Developing tactics to mitigate those risks
  • Providing tools and tactics for security and privacy breach prevention and minimization
  • Creating or updating policies, procedures, and business documents, including a HIPAA security and privacy plan

As each organization is different, there are many factors to consider as you go through these processes, and customize your approach to the HIPAA-compliance needs of your organization.

The Road to Wellness

An ounce of prevention is worth a pound of cure. Don’t let a security or privacy breach jump-start the compliance process. Reach out to us for a HIPAA health check. Contact us if you have any questions on how to get your organization on the road to wellness.

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How healthy is your organization's HIPAA compliance?

A year ago, CMS released the Medicaid Enterprise Certification Toolkit (MECT) 2.1: a new Medicaid Management Information Systems (MMIS) Certification approach that aligns milestone reviews with the systems development life cycle (SDLC) to provide feedback at key points throughout design, development, and implementation (DDI).

The MECT (recently updated to version 2.2) incorporates lessons learned from pilot certifications in several states, including the successful West Virginia pilot that BerryDunn supported. MECT updates have a direct impact on E&E systems—an impact that may increase in the near future. Here is what you need to know:         

Then: Initial Release

In February 2017, CMS introduced six Eligibility & Enrollment (E&E) checklists. Five were leveraged from the MECT, while the sixth checklist contained unique E&E system functionality criteria and provided a new E&E SDLC that—like the MECT—depicted three milestone reviews and increased the Independent Verification and Validation (IV&V) vendor’s involvement in the checklists completion process.

Now: Getting Started

Completing the E&E checklists will help states ensure the integrity of their E&E systems and help CMS guide future funding. This exercise is no easy task, particularly when a project is already in progress. Completion of the E&E checklists involves many stakeholders, including:

  • The state (likely more than one agency)
  • CMS
  • IV&V
  • Project Management Office (PMO)
  • System vendor(s)

As with any new processes, there are challenges with E&E checklists completion. Some early challenges include:

  • Completing the E&E checklists with limited state project resources
  • Determining applicable criteria for E&E systems, especially for checklists shared with the MMIS
  • Identifying and collecting evidence for iterative projects where criteria may not fall cleanly into one milestone review phase
  • Completing the E&E checklists with limited state project resources
  • Working with the system vendor(s) to produce evidence

What’s Next?

Additionally, working with system vendors may prove tricky for projects that already have contracts with E&E vendors, as E&E systems are not currently subject to certification (unlike the MMIS). This may lead to instances where E&E vendors are not contractually obligated to provide the evidence that would best satisfy CMS criteria. To handle this and other challenges, states should communicate risks and issues to CMS and work together to resolve or mitigate them.

As CMS partners with states to implement the E&E checklists, some questions are expected to be asked. For example, how much information can be leveraged from the MECT, and how much of the checklists completion process must be E&E-specific? Might certification be required in the near future for E&E systems?

While there will be more to learn and challenges to overcome, the first states completing the E&E checklists have an opportunity to lead the way on working with CMS to successfully build and implement E&E systems that benefit all stakeholders.

On July 31, 2017, CMS released the MECT 2.2 as an update to the MECT 2.1.1. As the recent changes continue to be analyzed, what will the impact be to current and future MMIS and E&E projects?

Check back here at BerryDunn Briefings in the coming weeks and we will help you sort it out.

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Check this: CMS checklists aren't just for MMIS anymore.