Corrective Action Plan (CAP) Process - CMS

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Corrective Action Plan (CAP) ProcessPresented by:Division of Error RateMeasurementCenters for Medicare &Medicaid Services

What is a Corrective Action Plan? A corrective action plan (CAP) is a step by step plan of actionthat is developed to achieve targeted outcomes for resolutionof identified errors in an effort to:- Identify the most cost-effective actions that can beimplemented to correct error causes- Develop and implement a plan of action to improveprocesses or methods so that outcomes are moreeffective and efficient- Achieve measureable improvement in the highestpriority areas- Eliminate repeated deficient practices

The Purpose of Developing a CAPA CAP is important because:-Corrective actions are developed-Corrective actions are implemented-Corrective actions are managed andmonitored-Promotes program improvement-Program continues to evolve3

Steps to a Effective/SuccessfulCorrective Action Plan Step 1- Select the right corrective action team members Step 2 - Identify all errors and deficiencies Step 3- Determine the underlying cause of the error, not justthe surface cause and don’t take any short cuts Step 4- Brainstorm corrective actions for each error or errortrend identified. Collect all ideas even though all may not befeasible or implemented Step 5- States should perform a cost benefit analysis todetermine which corrective actions are most cost effective. Step 6- Set achievable deadlines, targets and milestones Step 7- Evaluate and Monitor the corrective action progress4

PERM Medicaid/CHIP CAPRegulatory Requirements Formulate a Corrective Action Panel States must develop a separate corrective action plan forMedicaid and CHIP States must address all errors from the fee-for-service,managed care, and eligibility components as well as alldeficiencies, technical errors, and negative case errors. TheStates cycle summary reports can be used as a guide whendeveloping your plan States must submit CAPs to CMS no later than 90 calendardays after state error rate notifications have been released5

PERM Medicaid/CHIP CAPRegulatory Requirements Data analysis – an analysis of the findings to identify where and why errorsare occurring Program analysis – an analysis of the findings to determine the causes oferrors in program operations Corrective action planning – steps taken to determine actions that can beimplemented to correct error causes Implementation and monitoring – plans to implement the CAPs, includingmilestones, target dates, and how the corrective action will be monitored Evaluation – to assess whether the CAPs are in place and are effective atreducing or eliminating the targeted error causes States must submit to CMS an update on the status of any previous CAPfrom prior PERM measurement periods.6

PERM Medicaid/CHIP CAPRegulatory Requirements Cont State Medicaid and CHIP CAPs must include:Medicaid/CHIP CAP Summary Cover Page-State name, Statecontact information (email address & phone number)Medicaid/CHIP Error Rates, summary of error causes, and corrective actionsfor those errors.A. Fee-for-Services (FFS)1. Data analysis2. Program analysis3. Corrective action planning4. Implementation and monitoring5. Evaluation6. Evaluation of previous cycle submitted corrective actions7

PERM Medicaid/CHIP CAPRegulatory Requirements ContB. Managed Care (MC)1.2.3.4.5.6.Data analysisProgram analysisCorrective action planningImplementation and MonitoringEvaluationEvaluation of previous cycle submitted corrective actionsC. Eligibility1.2.3.4.5.6.Data analysisProgram analysisCorrective action planningImplementation and MonitoringEvaluationEvaluation of previous cycle submitted corrective actions8

PERM Medicaid/CHIP CAPRegulatory Requirements ContD. Evaluation of Previous Medicaid/CHIP CAPImplemented Corrective Actions– States must evaluate previous year corrective actions and provide anevaluation or analysis of those actions per Federal regulations– Address when the corrective action was implemented– Identify the status of the corrective action (complete, in progress or ongoing)– Address whether the corrective action achieved the desired resultsNon-Implemented Corrective Actions- Explain why the corrective action was not implemented (discontinued,modified, or replaced with another corrective action If FFS, Managed Care, or Eligibility programs were not measured in your cycleyear, annotate that within your CAP. States should identify if they are now meeting their PERM error-rate target asidentified by CMS9

CMS CAP Review Process State CAPs are initially reviewed by the CMS PERM CAPState Liaison to ensure that all CAP requirements are met After the initial review is complete, states will receiveone of two letters:– an acknowledgement letter stating that the CAP meets allrequirements– a letter advising what areas do not meet requirements and needto be addressed. States will be asked to submit a revised CAP bythe due date on the letter Once the state CAP meets all requirements, it willundergo a more substantive review by the CMS PERMStaff, CMS Regional Offices, and the Medicaid IntegrityGroup10

Post CAP Webinars Webinars are held to discuss the State’s CAP,provide the State with updates on PERMinitiatives, eligibility, and proposedimprovements to the next PERM cycle. States are asked to provide a presentation andhigh level review of their CAPs11

State/CMS Follow Up CMS expects the State to report theirprogress on each corrective actionimplemented. CMS will also periodicallyfollow up with States via email betweentheir PERM cycles checking on the processof corrective actions and provide anytechnical assistance if needed12

Best Practice Calls The purpose of the call is for States to sharetheir best practices related to theircorrective action plans (CAPs) submitted sothat other States can possibly benefit fromtheir experience. The call is held for allPERM cycles covering a variety of topicsrelated to PERM.13

State Cycle RotationCycleMedicaid and CHIP States Measured by CycleCycle 1Arkansas, Connecticut, Delaware, Idaho, Illinois, Kansas, Michigan,Minnesota, Missouri, New Mexico, North Dakota, Ohio, Oklahoma,Pennsylvania, Virginia, Wisconsin, WyomingCycle 2Alabama, California, Colorado, Georgia, Kentucky, Maryland,Massachusetts, Nebraska, New Hampshire, New Jersey, NorthCarolina, Rhode Island, South Carolina, Tennessee, Utah, Vermont,West VirginiaCycle 3Alaska, Arizona, District of Columbia, Florida, Hawaii, Indiana, Iowa,Louisiana, Maine, Mississippi, Montana, Nevada, New York, Oregon,South Dakota, Texas, Washington14

State CAP Liaison ContactInformation15

5. Evaluation 6. Evaluation of previous cycle submitted corrective actions C. Eligibility 1. Data analysis 2. Program analysis 3. Corrective action planning 4. Implementation and Monitoring 5. Evaluation 6. Evaluation of previous cycle submitted corrective actions PERM Medicaid/CHIP CAP Regulatory Requirements Cont 8

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