Case study: Implementing the ACA with program integrity

Case study: Implementing the ACA with program integrity

The Centers for Medicare & Medicaid Services (CMS) is tasked with developing and overseeing Affordable Care Act (ACA) programs. Developing and implementing these mission-critical ACA programs in a way that adheres to specific legislative provisions of the ACA is a significant initiative. On top of that challenge, the programs must be financially sound and adhere to government-wide regulations aimed at program integrity. This use case details how KPMG supported CMS in the development of ACA program operations needed to help achieve financial oversight and program integrity.

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The challenge

CMS is tasked with developing and overseeing ACA programs. These programs include Advance Payment of Premium Tax Credit (APTC), Cost Sharing Reduction (CSR), CSR Reconciliation, Risk Corridors, Risk Adjustment, Reinsurance, and User Fees. Developing and implementing these mission-critical ACA programs in a way that adheres to specific legislative provisions of the ACA is a significant initiative. On top of that challenge, the programs must be financially sound and adhere to government-wide regulations aimed at program integrity. This is critical to helping to ensure the strength and success of these programs.

KPMG’s response

CMS engaged KPMG to provide support in the development of ACA program operations needed to ensure financial oversight and program integrity.

  • Risk adjustment data validation: Implement an audit approach to confirm the accuracy of risk adjustment data submitted by the issuers for the calculation of payments and charges under the Federally Operated Risk Adjustment program established under the ACA.
  • Improper payments: Will develop and implement an improper payments error rate measurement methodology for the ACA programs overseen by the Center for Consumer Information and Insurance Oversight, in order to identify those programs that are susceptible to improper payments and produce programmatic error rates as required by the Improper Payment Elimination and Recovery Improvement Act (IPERIA).
  • Internal controls and financial reporting: Develop and maintain program-specific internal control plans, program-specific risk and process documents, standard operating procedures (SOPs), corrective action plans, in accordance with the requirements of OMB Circular A-123, Appendix A, and other Federal and CMS requirements.
  • Project management: Manage and track program progress against CMS’s stated goals and objectives, including project planning support to CMS and the development and maintenance of the project management plan (PMP).

The result

  • To date, KPMG has identified risks within the Payment Policy and Financial Management Group (PPFMG) program processes and has assisted program management in the development of procedures and tools to mitigate the identified risks and the development of documentation to support the procedures performed in implementing the ACA programs.
  • KPMG assisted PPFMG with the interim payment process. Despite challenges with PPFMG’s technology systems, KPMG was able to help PPFMG administer the functional ACA programs without interruption by developing contingency operation planning tools and procedures, while simultaneously helping to establish internal controls to support the normal payment process.

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