Corrective Action Plan (CAP) Guidelines

The Department of Human Services (Department) Bureau of Program Integrity (BPI) requests a CAP from providers and MCOs as part of the retrospective review process. A CAP is a step-by-step plan of action developed to achieve targeted outcomes for resolution of identified problems in an effort to:

  • Ensure that quality, accessible, and timely services are provided.
  • Comply with the Medicaid State and Federal regulations.
  • Improve processes/methods so that outcomes are more effective or efficient.
  • Achieve measurable improvement in the highest priority areas.
  • Eliminate repeated deficient practices.

Providers and MCOs are responsible to correct identified areas of noncompliance. An effective CAP will identify program deficiencies, specify an efficient path toward overall improvement, monitor imposed changes (making adjustments as necessary), and improve accurate and expedient program delivery.

The CAP Process - Fee-for-Service Provider Reviews

  1. A CAP should be submitted within 30 days following notification of the Department’s final findings.
  2. If you have any questions relating to the development of a CAP, please call the Case Coordinator identified in your final findings letter.
  3. Please submit your CAP to the following address and include your 13 digit PROMISe provider number and service location: 
                         Department of Human Services
                         Bureau of Program Integrity - DPPC/DPR
                         P.O. Box 2675
                         Harrisburg, Pennsylvania  17105-2675
  4. The Department reviews the CAP and:
    1. Approves the CAP and informs the provider that the corrective action(s) implemented are deemed sufficient to bring into full compliance with the regulatory requirement(s) and MA policies; or
    2. Denies the CAP and informs the provider that some or all elements require revision and resubmission.
  5. Upon receipt of the Department’s acceptance of the CAP, the provider may be asked to submit evidence of compliance with the CAP. The Department may request progress reports relating to CAP compliance as appropriate.

The CAP Process – Managed Care Organizations’ Network Provider Reviews

  1. The Department's final findings letter issued to the MCO, includes the request for the MCO to submit a CAP to the Department to correct provider noncompliance. The provider also receives an informational copy of this final findings letter.
  2. The network provider should submit their CAP through the MCO. The provider should contact their respective MCO for instructions on submitting the CAP.
  3. The Department may request a CAP from the MCO to resolve any violations of the HealthChoices agreement or regulatory violations related to program integrity.
  4. The MCO must submit the CAP to the Department at the following address, within 30 days of receipt of the final findings letter. Please include the 13-digit PROMISe provider number and service location.
                         Department of Human Services
                         Bureau of Program Integrity - DPPC/DPR
                         P.O. Box 2675
                         Harrisburg, Pennsylvania  17105-2675
  5. The Department reviews the CAP and:
    1. Approves the CAP and informs the MCO that the corrective action(s) is deemed sufficient to bring the provider and/or MCO into compliance with the regulatory requirement(s) and MA policies; or
    2. Denies the CAP and informs the MCO that some or all elements of the CAP require revision and resubmission.
  6. Following receipt of the Department’s acceptance of the CAP, the MCO may be asked to submit evidence of the provider’s or MCO’s compliance with the CAP. The Department may request progress reports relating to CAP compliance as appropriate.

Best Practices in CAP Development

An effective CAP will identify program deficiencies, specify an efficient path toward overall improvement, monitor imposed changes (making adjustments as necessary) and advance accurate and expedient program delivery. Items to consider when developing a CAP include:

  • How should this requirement be met?
  • Who will be responsible for the elements of the CAP?
  • What other processes or people are affected by implementing the CAP?
  • What policies/procedures, manuals, provider handbooks, contract templates, etc. need to be revised to reflect the change?
  • How will we know that we are achieving our goal?
  • How can we tell if our performance is what it should be?
  • What monitoring or management reports will let us know how we are doing and that the change was implemented correctly?

To develop an acceptable CAP, the provider should:

  1. Determine who has the knowledge and authority to make the decisions, to develop the plan, to require the changes, and to coordinate across functional areas of responsibility.
  2. Assign individual responsibility and an overall CAP coordinator role.
  3. Focus on error concentrations that have the most significant impact on the error rate.
  4. Identify the root cause of the error: when did it occur, and who or what caused it?
  5. Identify operational policies and procedures that caused the error.
  6. Develop a correction strategy that wholly addresses each deficiency.
  7. Identify major tasks required to implement the corrective action, sequential timelines addressing the most critical areas first, target implementation dates, and key personnel/components responsible for each action.
  8. Address practice/process, structure, training, communication needs, monitoring and follow-up activities.
  9. Assess proposed CAP for potential unintended consequences of system changes on other areas of the business; adjust as needed.
  10. Assess whether the corrective actions in place are effective at reducing or eliminating error causes.

When developing a corrective action plan, providers should carefully review MA regulations, MA Bulletins and interpretations of those regulations.

Regulations may be viewed at:
http://www.dhs.pa.gov/publications/forproviders/regulationshandbooksguidesandmanuals/

MA Bulletins may be viewed at:
http://dhs.pa.gov/provider/more/index.htm