CMS-10836 Audits and Letters - Intermediaries

Medicare Plan Performance Warning Information: Guide 1 (i)
Audits and Letters
Intermediary IDI Discussion Guide (90-minute online interviews)

Interviewer: _________________________
Participant:

_________________________

Date/Time:

_________________________

Objectives
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●
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Gauge reactions to and interest in information on Medicare plan audits.
Understand how intermediaries may use audit information when discussing plan
decisions with beneficiaries.
Gain insights on best ways to share plan audit information with intermediaries.
Understand experience with appeals letters.

Introduction (3 min)
Thank you for agreeing to speak with me today. My name is ______ and I’ll be leading our
conversation. This is opinion research, which means there are no wrong answers. I am
interested in everything you have to say. Since we are talking about your opinions, you are
the expert.
Before we get started, there are a few things I want to mention. First, I am an independent
researcher. You will not offend me or get me in any trouble. My only goal is to hear your
honest opinions. So please be as open and candid as possible.
We have a number of questions to get through and a few things to look at and read. So, if
at some point I ask that we move on, it’s because I want to make sure that we finish on
time. It’s not because I am not interested in what you have to say.
I am recording our conversation so I don’t miss anything. The recording is confidential and
is not shared outside the research team. There are also other people watching this
interview to help me take notes and to understand what was said. Ultimately, the findings
from this interview will be combined with other interviews we’re conducting, and we’ll write a
report with some recommendations. Your name won’t be used in the report.
The sponsor of this study is the Centers for Medicare and Medicaid Services, specifically,
the Medicare program, or CMS. I do not work for the Medicare program.

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Do you have any questions before we get started?
Warm-up (7 min)
I like to start by getting to know more about you.
1. How long have you been working as/with a [SHIP counselor / broker / advocacy
group]?
a. [IF A YEAR OR LESS]: Previous to this role, have ever you done similar work
in some other capacity?
b. What does that work look like on a day-to-day basis [PROBE TO
UNDERSTAND THEIR ENGAGEMENT WITH BENEFICIARIES]
2. What do you find most challenging about this work? [KEEP BRIEF]
3. What are some of the most common things you get asked about by
beneficiaries/beneficiaries care about? [LISTEN FOR QUALITY OR
PERFORMANCE ISSUES]
a. What are some of the most common concerns that beneficiaries have about
Medicare plans? [PROBE TO UNDERSTAND ISSUES RELATED TO
QUALITY OR PERFORMANCE]
4. In general, how could you determine if a Medicare Advantage or prescription drug
plan is “good” or not? By “good,” I don’t mean affordable or if a beneficiary’s doctor
participates, I mean if the quality of the plan itself is good, or how well it operates or
serves beneficiaries? I’ll refer to this as “plan performance.” [IF RESPONDENT
REFERS TO HEALTHCARE QUALITY, CLARIFY THIS IS REFERRING TO PLAN
OPERATIONS AND HOW WELL THE PLAN CONDUCTS THOSE.]
Audit Information: Introduction (20 min)
Today we are going to talk about how Medicare monitors plans and collects information on
the performance of plans.
5. To begin, what do you know about how Medicare monitors plan performance? What
kind of activities would you expect it to conduct?
a. What would you expect or hope Medicare would share with intermediaries
who help beneficiaries, like yourself?
b. What would you expect or hope Medicare would share with beneficiaries?
c. Do you think sharing any information on this topic would help beneficiaries to
have more trust in Medicare? IF YES: What would be most helpful to share?
6. I want to share some information with you about how Medicare monitors plan
performance. [SHARE OVERVIEW TO INCLUDE AUDITS, ENFORCEMENT
ACTIONS, AND OTHER PLAN PERFORMANCE INDICATORS]

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a. What is your reaction to this information? How much of it was familiar to you
already?
b. How have you learned about this in the past?
7. Now I want to share some information with you specifically about plan audits.
[SHARE MORE DETAILED INFORMATION ON AUDITS, INCLUDING THAT NOT
ALL ARE AUDITED, THE FREQUENCY OF AUDITS, COMPONENTS OF AN
AUDIT, AND THAT AUDITS ARE DONE AT THE PARENT ORGANIZATION
LEVEL (AND WHAT THAT MEANS)]
a. What is your reaction to this information? How much of it was familiar to you
already?
b. How have you learned about this in the past?
8. In general, how interested are you in audit information about the parent
organizations of Medicare plans? Please rate your interest on a scale from 1, not at
all interested, to 10, very interested. Please explain your answer.
a. What most interests you about audit information? Why?
b. How, if at all, would you use this information (e.g., general interest, informing
discussions with beneficiaries, etc.)?
c. When might you use it?
Audit Information: Examples and Details (40 min)
Now we are going to look at some of the information Medicare currently shares about
audits.
9. I want to get your reaction to some high-level information across all audits. I will
share several parts of a national report with you and get your reactions. This is a
real report from [YEAR]. [SHOW MORE RECENT VERSION IF AVAILABLE

https://www.cms.gov/files/document/2021-program-audit-enforcementreport.pdf READ ACCOMPANYING INFORMATION TO DESCRIBE EACH
FIGURE]
a. Figure 1: What is your reaction to this information?
b. Figure 2: What is your reaction to this information?
c. Figure 6: What is your reaction to this information?

10. What questions do you have about this information?
11. Overall, how helpful is this kind of information as you think about your work and/or
educating and assisting beneficiaries? Please rate how helpful it is on a scale from
1, not at all helpful, to 10, very helpful. Please explain your answer.
a. What’s most helpful? What’s least helpful?
b. Would having this kind of information be useful in any way to your work?
c. Would having this kind of information change how you (or someone else)
assists beneficiaries when they are making decisions on a plan? Why or why
not?

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i. Would having this kind of information impact how you viewed a plan’s
performance?
d. How, if at all, would you use this information (e.g., general interest, informing
discussions with beneficiaries, advocacy work, etc.)?
e. When would you use this information?
f. Is this kind of information official/impartial enough such that you could/would
share this information with a beneficiary to advise them about a plan if you
had concerns?
12. Now I want to share some audit information in a different format. [SHOW
REFORMATTED INFORMATION INCLUDING NAME OF PLAN, YEAR FORMED,
ENROLLMENT, NAME OF PARENT ORG, DATE OF LAST AUDIT (IF ANY), AND
WHETHER ANY ENFORCEMENT ACTIONS RESULTED FROM MOST RECENT
AUDIT]
a. Example with no recent audit: What is your reaction to this information?
b. Example with recent audit, no findings: What is your reaction?
c. Example with recent audit, with findings: What is your reaction?
13. What questions do you have about this information?
14. Overall, how helpful is this kind of information as you think about your work and/or
educating and assisting beneficiaries? Please rate how helpful it is on a scale from
1, not at all helpful, to 10, very helpful. Please explain your answer.
a. What’s most helpful? What’s least helpful?
b. Would having this kind of information be useful in any way to your work?
c. Would having this kind of information change how you (or someone else)
assisted beneficiaries when they are making decisions on a plan? Why or
why not?
i. Would having this kind of information impact how you viewed a plan’s
performance?
d. How, if at all, would you use this information (e.g., general interest, informing
discussions with beneficiaries, etc.)?
e. When would you use this information?
f. Is this kind of information official/impartial enough such that you could/would
share this information with a beneficiary to advise them about a plan if you
had concerns?
15. Where would you expect to learn about this kind of audit information? Why?
a. IF NOT DISCUSSED: How might you expect to find it?
b. Where do you think beneficiaries would expect to learn about this kind of
audit information? Why?
16. Now I want to share some examples of how the type of information we’ve been
talking about might be shared. [SHOW EXAMPLES OF WAYS TO SHARE
INFORMATION, INCLUDING AN OVERVIEW OF PLAN FINDER WEBSITE FOR
THOSE NOT FAMILIAR; KEEP IN MIND PURPOSE OF PLAN FINDER VS.
OTHER SOURCES LIKE MEDICARE & YOU TO EXPLORE WHAT THE BEST
PLACE IS FOR THIS TYPE OF INFORMATION]
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What is your reaction to:
a. Language on the Plan Finder website
b. Indicators or icons on the Plan Finder website
c. Links from Plan Finder to a separate website with more information
d. Information hosted on a separate website not directly linked from Plan Finder
e. Others?
17. Which of these options to share information is most helpful? Why? Who do you think
the target audience of this information should be?
a. Does it depend on the type of information being shared? How so?
b. Does it depend on the engagement level of the beneficiary? [PROBE TO
UNDERSTAND IF WHERE OR HOW INFORMATION IS DISPLAYED
WOULD DIFFER BASED ON WHETHER A BENEFICIARY IS MORE OR
LESS ENGAGED]
c. Is there some other way Medicare could communicate information related to
audits that would be helpful to your work or for assisting beneficiaries?
d. Thinking of your own work and all the information you (or your organization)
share, when, if ever, would you share audit information with beneficiaries?
Why?
Appeals Letters (15 min)
Thank you. Now I want to briefly get your feedback on appeals letters.
18. [SHOW SAMPLE LETTER FOR PART C, BASED OFF MODEL NOTICES AT
https://www.cms.gov/Medicare/Appeals-andGrievances/MedPrescriptDrugApplGriev/PlanNoticesAndDocuments]
a. Has a beneficiary ever brought you an appeals letter like this/raised concerns
about appeals with your organization?
i. IF YES: What questions or comments did they have about this
letter/appeals?
ii. Overall, how might a letter like this be improved so it was more
helpful for beneficiaries?
iii. What about the communications process around appeals could be
improved, e.g. speed, follow-up, the links and guidance the letter
includes for beneficiaries to educate themselves, how the letter
references the SHIP program or other assistance, etc.?
b. What questions, if any, have you gotten from beneficiaries on the appeals
process?
c. [IF APPLICABLE] Have you ever worked with a beneficiary to file an appeal?
i. IF YES: How often does this happen? What kind of information would
be helpful for you?
Wrap-up (5 min)

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TIME ALLOWING: Before we wrap up, I’m going to check to see if there are any additional
questions for you from anyone else on the team. [CHECK FOR QUESTIONS]
19. This has been really helpful. Thanks so much for participating in this project. Do you
have any other thoughts or comments you’d like to share?
We really appreciate your assistance. Have a great day.
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