HCRA Compliance Reviews

Payor Milestones and Timelines for Review of Three Years

Timeline Phase Description Reviewee Responsibilities
Day 1 Reviewee Notification, Review Kick-off KPMG LLP (KPMG) sends letter, questionnaire, and data requests to Reviewee. The Reviewee will have 44 business days to compile data requests, ask questions, and prepare documentation. KPMG will schedule on site time for the entrance conference.
  • Assign liaison
  • Assemble electronic data files per "blue prints" provided as part of the questionnaire process
  • Provide supporting documentation on how patients, members, and/or claims are flagged
  • Assemble reconciliations requested as explained in the questionnaire
  • Assemble supporting documentation for prior period adjustments
  • Coordinate interviews with applicable process owners
Day 11
Day 22
Day 33
Pre-fieldwork Planning KPMG will schedule a series of status calls and/or on-site visits with the Reviewee to discuss:
  • HCRA Compliance Review Notification Package
  • Milestones
  • Data Blue Print
  • Status of data request
  • Any other relevant issues
  • Reviewee questions
  • Prepare relevant questions to discuss with KPMG
  • Present any potential obstacles the Reviewee anticipates in regards to providing the required supporting documentation and data
  • Provide status updates to KPMG
  • Provide a sample data extract to KPMG
Day 40 Questionnaire Submission Reviewee´s completed questionnaire is due to KPMG
  • The reviewee submits a completed electronic version of the questionnaire
Day 45 - Day 55 Entrance Conference/ Data Receipt/ Fieldwork Begins On Day 45, an entrance conference will be held, and at least one years´ worth of data is due. The additional years will be due incrementally in each of the following weeks. The last day to submit requested data and documentation to KPMG is Day 55. Fieldwork begins on Day 45, and KPMG will be on site at this time conducting interviews and reviewing documentation.
  • Provide KPMG with data/documentation requested
  • Review supporting documentation, electronic data files as well as the responses to the questionnaire
  • Participate in interview process
  • Provide timely responses to interview questions
  • Review meeting minutes and/or weekly status tracker
Day 45 Data and Information Request Representation Letter Due Letter indicating that all documentation and data provided to this point is complete, accurate, and in accordance with the instructions in KPMG´s questionnaire
  • Using the KPMG provided letter, please sign and provide to KPMG at the entrance conference.
Day 65 Fieldwork - Resolution of Data Issues KPMG will resolve data follow up questions and confirm if alternative procedures are required. Testing commences at this point.
  • To the extent alternative procedures are required, the review liaison will provide timely response to the additional data request(s).
  • Respond timely to follow-up questions
Day 95 Testing Results Sent to Reviewee KPMG will send the Preliminary Results Packet to the Reviewee for their review and response. KPMG and the Reviewee will have a meeting to briefly discuss the preliminary findings and next steps. The Reviewee will have 24 business days to formulate and document their response to KPMG´s results.
  • Review KPMG test results
  • Prepare supporting evidence for exceptions noted
  • Review weekly status tracker
Day 98 Preliminary Results Meeting DOH, KPMG, and Reviewee will have a meeting to discuss preliminary findings and next steps.
  • Review KPMG test results
  • Prepare supporting evidence for exceptions noted
Day 101 Preliminary Review of Responses to Test Results On Day 101, a meeting will be held with KPMG, DOH, and the Reviewee to discuss sample(s) of supporting evidence prepared by the Reviewee to clear KPMG´s preliminary results.
  • Provide and explain sample(s) of supporting evidence for exceptions noted
Day 104 Preliminary Determination of Acceptable Supporting Evidence KPMG, DOH, and the Reviewee will have a meeting to communicate DOH´s preliminary determination of whether sample(s) of supporting evidence provided on Day 101 is acceptable.
  • Continue to prepare supporting evidence for exceptions noted
Day 107 Communicate Preliminary Determination to Reviewee KPMG, DOH, and the reviewee will have a meeting to communicate DOH´s preliminary determination of whether sample(s) of supporting evidence provided on Day 101 is acceptable.
  • Using the KPMG provided letter, please sign and provide to KPMG at the entrance conference.
Day 110 Preliminary Review of Responses to Test Results On Day 110, a second meeting will be held with KPMG, DOH, and the Reviewee to discuss sample(s) of supporting evidence prepared by the Reviewee to clear KPMG´s preliminary results.
  • Continue to provide and explain sample(s) of supporting evidence for exceptions noted
Day 113 Preliminary Determination of Acceptable Supporting Evidence KPMG and DOH will meet to discuss the sample(s) of supporting evidence. DOH will determine whether the supporting evidence is acceptable.
  • Continue to prepare supporting evidence for exceptions noted
Day 116 Communicate Preliminary Determination to Reviewee KPMG, DOH, and the Reviewee will engage in a conference call to communicate DOH´s preliminary determination of whether sample(s) of supporting evidence provided on Day 110 is acceptable.
  • Continue to prepare supporting evidence for exceptions noted
Day 119 Responses to Test Results are due to KPMG Reviewee responses and supporting documentation are due to KPMG.
  • Submit responses to test results to KPMG project manager
  • Respond to any additional requests or questions regarding the Reviewee responses
Day 122 Review of Preliminary Results Response with DOH KPMG will review responses and supporting documentation with DOH during the Review of Preliminary Results Response Meeting. N/A
Day 149 Data Exceptions Conference KPMG, the Reviewee, and DOH will engage in a conference call to discuss final results of testing. The Reviewee will be notified of the outcome of the response review, and will be given next steps. It should be noted the results of testing are final.
  • Participate on the Data Exceptions Conference.
Day 154 Extrapolation Process To the extent a statistical sample is used, KPMG will send the results of testing to its statistician for extrapolation. N/A
Day 179 DOH Reviews Draft Report KPMG to submit the draft report to DOH. DOH to have 10 business days for report review. N/A
Day 189 KPMG Draft Report Revisions DOH comments on report due to KPMG. N/A
Day 193 DOH Approves Draft Report KPMG to provide revised draft report to DOH for final approval prior to delivery to the Reviewee. N/A
Day 194 Formal Response to Report KPMG to send draft report to Reviewee for their formal response. The Reviewee to have 15 business days to formally respond to KPMG´s report, which will be included as part of the final report.
  • Prepare formal response to the report to be included in the final report.
Day 199 Exit Conference KPMG, the Reviewee, and DOH will engage in a conference call to discuss the report.
  • Review the draft report. Prepare any questions related to the report or the review close-out process.
Day 209 KPMG Response to Report Reviewee´s formal response due to KPMG
  • Submit final responses to the report to KPMG
Day 219 Final Report KPMG to submit final report with Reviewee responses attached. N/A