Integrated OTC Benefits: A Prescription for Customer Satisfaction
Most over-the-counter products and medications like pain relievers, allergy medications, heartburn drugs and topical antimicrobials were once available only by prescription. In OTC form, these drugs are FDA approved and often equally effective as prescription drugs at a fraction of the cost. Yet their OTC status has long meant these drugs are not covered under prescription drug plans for Medicare Advantage, Medicaid or commercial health plans. As a result, consumers with limited incomes may simply forgo needed medications while others may opt for more expensive prescription drugs that are covered by their health plans.
Adding an OTC benefit component to a health or drug plan may seem like one more administrative burden. After all, why add products and medicines to a formulary that subscribers are already buying anyway? Because an integrated OTC benefit can be a real cost-saver for health plans and subscribers alike, and OTC benefits boost customer satisfaction and retention.
The Consumer Healthcare Products Association Clinical/Medical Committee found that OTC medicines bridge treatment gaps, are convenient and reduce unnecessary use of health care services. The Center for Medicare and Medicaid Services allows OTC coverage in Medicare Part D drug plans in acknowledgement of OTCs’ utility as part of step-therapy algorithms and to improve cost-effective utilization management.
Each dollar spent on OTC medicines saves the US health care system $6 to $7, according to a 2012 study commissioned by the CHPA. The savings come not only from lower drug costs but also from fewer patient visits to health care providers and emergency departments.
The key to an effective OTC benefit is seamless integration of robust formulary management, benefit management and customer service. Various vendors offer an OTC benefit add-on in the form of prepaid cards, but the cards must be set up to cover only approved drugs. The result is frustrated customers who find out at the pharmacy cash register that their card doesn’t cover the medicines and health supplies in their shopping carts. That’s not good for customer retention.
What Carriers Should Look for in an OTC Benefit Partner
An effective OTC benefit partner relieves administrative burdens on the carrier by managing formularies, handling member interactions, processing eligibility files frequently and generating required reports accurately and promptly. Added features like developing and distributing online and print catalogs to subscribers and mail-service delivery of approved OTC medications and supplies further enhance customer satisfaction. Mail service also enables the inclusion of educational, program and informational inserts in OTC product shipments.
An OTC plan partner should also be experienced and well-versed in compliance with regulatory requirements and oversight for OTC benefits, and the partner must be able to assist with development of a formulary that meets the carrier’s goals. In addition, all technology used for OTC benefit administration must be able to demonstrate adherence to the latest security standards for robust cybersecurity and privacy protections.
A Turnkey Solution
A fully functional OTC program delivered with minimal effort from the carrier, full CMS compliance and quality assurance, and robust cybersecurity and privacy protections relieves the administrative burden on carriers. Packaged with exceptional member service and convenience, such a program constitutes a turnkey solution that contributes to plan STAR, HEDIS and NPS ratings, while delivering customer satisfaction, retention and market share.
Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans. Convey provides member management solutions for the rapidly changing health care world.
Learn more about Convey’s OTC Benefit solution here.
For information on the other solutions Convey has to offer, please follow this link.
Resources:
"Plans that offered an OTC benefit in 2018 won big during AEP," explained GHG leaders during a recent webinar. Download the recording now.
Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe
CMS June Network Submission Deadline Fast Approaching
In early February, there was a bit of a scramble when several plans received notices they had approximately a week to submit their Health Service Delivery (HSD) tables for a network adequacy review. Fortunately, for some, the communication should have indicated the gates were open for plans wanting to test adequacy and receive technical feedback. While it was a stressful 24 hours pending the Centers for Medicare & Medicaid Services (CMS) response on the notice, we hope the false alarm sparked the much needed jump-start to ensure a compliant network adequacy monitoring program is in place.
Unfortunately, we know fire drills do not often produce the continued preparedness needed. Ask kids who grew up in the northeast how many times they shivered in the cold when a fire alarm went off and they did not grab their jackets! Oftentimes, we get busy with pressing contract negotiations or deadlines and push preparing or incorporating a new process off to the side. However, with the shift in network adequacy from an application function to a plan operational requirement, plans that fail to meet network adequacy requirements will be subject to compliance/enforcement actions such as being suppressed from Medicare Plan Finder for the upcoming Annual Election Period until deficiencies are cured or ensuring access to care by allowing members to see an out-of-network provider at in-network cost-sharing. Additionally, the short time frame in which a plan will have to submit their compliant HSD tables to CMS leaves little to no time to mitigate network deficiencies by contracting with new providers and/or doing the detailed research required to validate filing an exception. CMS as well as many states have put sanctions and monetary and enrollment penalties in place for deficiencies in network adequacy and directory accuracy. Plans no longer have a grace period to put off ensuring a compliant network monitoring program is in place.
CMS indicated they will provide plans selected for the network review 60 days’ notice prior to the June submission date. By my calendar, April is just a few days away, and June will be approaching fast. Do not let April Fool’s Day prank you with network gaps. Be prepared, and let’s start spring with a bounce in our step and a plan of action!
At Gorman Health Group, we have provided expertise to government-sponsored plans in effective network management and ensuring compliance with state and federal regulations. Feel free to reach out and discuss how we can assist you in developing the network monitoring program needed to ensure your organization not only meets initial reviews and audits but also develops a comprehensive program that truly utilizes your plan’s largest asset – your provider relationships.
Resources:
Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now
Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe
Latest Audit Enforcement Actions Issued by CMS
Like clockwork, the Centers for Medicare & Medicaid Services published the enforcement action notices issued to sponsors related to 2017 program audits. Additional detail regarding conditions, audit scores, and enforcement is expected to be included in the 2017 Program Audit Enforcement Report, which the agency hopes to release before their conferences taking place May 9-10. In the meantime, we break down the published data, which includes not only program audit actions but others as well:
- Eighteen sponsors were issued almost $2.6 million in Civil Money Penalties (CMP) between September 2017 and February 2018 based on their 2017 program audit findings.
- 72% of sponsors cited for Coverage Determinations, Appeals, and Grievances violations
- 61% of sponsors cited for Formulary and Benefit Administration violations
- 39% of sponsors cited for Organization Determinations, Appeals, and Grievances violations
- 22% of sponsors cited for Part C Beneficiary Protections/cost sharing violations
- A Program of All-inclusive Care for the Elderly (PACE) sponsor was issued a CMP in November of 2017, and two PACE sponsors had enrollment suspended in the fourth quarter of 2017.
- PACE plans: You are small but have a mighty sense of responsibility. If you have not done so already, review the posted enforcement notices, distribute within your organization, and create an action plan if you identify any similar findings.
- One Prescription Drug Plan sponsor had enrollment suspended due to medical loss ratio.
- Two sponsors were issued CMPs in 2017 based on outlier status of auto-forwards to the Independent Review Entity.
CMS noted in their draft call letter the agency is considering adding a CMP icon in Medicare Plan Finder (MPF) starting in 2019. If the agency proceeds that way, sponsors undergoing audits this year and incurring CMPs will be impacted by this new indicator. We support efforts such as this which promote beneficiary transparency. As I outlined in our analysis, sponsors should take note. Low Performing Icon information has not been limited to the MPF. Marketing organizations and other industry publications have taken that information and run with it, which may give an advantage to competitors of affected plans. In a recent Bloomberg Law article, I further discuss enforcement actions and the implications of this Low Performing Icon.
Remember that enforcement actions can be levied not just for program audit performance but also for a host of other violations. While I have provided some recent statistics, an analysis of actions taken year over year show patterns in some regards, and no rhyme or reason in other regards. Don’t spend too much time slicing and dicing these figures for your management; let us do that here in these articles. Focus on plan performance and continuous improvement. The goal should be to ensure your organization does not end up with enforcement actions in the first place.
Resources:
Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now
Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe
Audit Engagement Letters Will Start in March
If you did not have the pleasure of being part of a Centers for Medicare & Medicaid Services (CMS) Program Audit in 2017, don’t be caught off guard if you receive your invitation this year.
Audit engagement letters will start going out this month.
CMS has made few changes to the 2018 CMS program audit protocol from 2017. However, one change was for the Call Log submission for Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG). With the exception of Medicare-Medicaid Plans (MMPs), the number of call days required to be submitted varies based on the plans sponsors’ enrollment.
While helping plans survive the CMS program audits last year, Gorman Health Group observed one standout area of struggle: call logs. The addition of call logs to the audit protocol relates back to ensuring plan sponsors are appropriately classifying and handling grievances, coverage determinations (Medicare Part C and Medicare Part D), and member notifications. It really boils down to customer service and proving your representatives are handling the cases appropriately. The importance of customer service cannot be stressed enough. At the heart of every business is good customer service. Within the Medicare space, any opportunity to make the member experience a positive one is important from both a quality of care and Star Ratings perspective. Call logs are a means to assess current service levels and to identify training and improvement opportunities. There are now vendors who utilize artificial intelligence to detect the emotions of the caller and how to handle the call appropriately—if the caller is frustrated, they may need to be handled as a grievance.
If you have not established an oversight program or performed a universe pull for call logs, don’t wait any longer! Identifying any issues with data integrity and the service/information provided by your customer service representatives is crucial. Pay particular attention to how the calls are being documented and the reliance on vendor or inter-departmental communications. You want to ensure call transcripts are entered into your system and notes would easily walk an auditor through the case from the time the call was answered through to resolution and that it has been sufficiently documented. If there is a gap in your current process, it is time to put a plan in place.
Gorman Health Group can assist your plan with mock audit services ranging from a complete program audit to a specific, targeted audit of your call logs. The time to act is now to avoid getting caught with your pants down.
Resources:
Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now
Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe
CMS Focus: Compliant Independent Review Entity Data
The focus on compliant Independent Review Entity (IRE) data should come as no surprise to Part D sponsors. In December 2016, the Centers for Medicare & Medicaid Services (CMS) released the Health Plan Management System (HPMS) memo, Compliance and Enforcement Actions Related to Part D Auto-Forwards, indicating sponsors with inordinately high auto-forward rates were subject to compliance actions that could be escalated to enforcement actions. The memo established a threshold rate, and in spring of 2017, CMS began imposing civil monetary penalties (CMPs) on Part D sponsors with demonstrated non-compliance with coverage determination and redetermination auto-forwards to the IRE. And with that, the die was cast.
The Timeliness Monitoring Project (TMP) is an opportunity to demonstrate compliant processes and data integrity in support of CMS’ Star Ratings. With this data collection effort, the playing field is leveled in the evaluation of sponsors’ IRE data. The TMP effort by CMS – while offering a fair and balanced methodology as it seeks to assess all plans instead of those identified in a targeted review – also provides CMS a separate and distinct window beyond program audits in identifying sponsors with problematic organization and coverage determination processes.
Plans that are unable to provide complete and accurate universes will be at risk with both their Part C and Part D Star Ratings as described in the December 12, 2017, HPMS memo, Timeliness Monitoring Project (TMP). “CMS considers data integrity issues, if identified, as an indicator that a contract’s measure data are invalid for the Star Ratings. CMS may also independently evaluate the data to gain insight into sponsors’ performance in these two program areas.”
The unfortunate reality is that an inability to accurately capture data within organization systems is likely symptomatic of any number of inefficiencies, for example:
- Lack of systems/analytics to compile data needed to assess compliance with CMS expectations
- Insufficient monitoring efforts
- Potential for processing inefficiencies such as inadequate resources, training, or expertise
CMS proposes a scaled reduction in a sponsor’s Star Ratings data that is found to be incomplete or “lack integrity.” The consequences of a lowered Star Rating can be a devastating blow to sponsors. Yet often, performance issues remain inadequately addressed. Plans sometimes need help knowing where to begin.
Sponsors can readily utilize the Audit Process and Data Request guidance for Organization Determinations, Appeals, and Grievances (ODAG) and Coverage Determinations, Appeals, and Grievances (CDAG) as the playbook on IRE auto-forward compliance.
Start with a great outreach process
- Is plan staff aware of what clinical information is required to make a well-informed decision?
- Is there a consistent, timely, and well-documented process in place for provider outreach?
- Can this be evidenced in your systems, and more importantly, is this being tracked and monitored by plan staff?
Follow up with timely and sound decision-making
- Do the decision-makers have all the information they need to make the decision?
- Are decisions primarily made based on sponsor formulary/Evidence of Coverage (EOC), clinical criteria, federal regulations, CMS guidance, compendia, or peer-reviewed literature (where allowed)?
- Are there any trends in plan denials for lack of clinical information? What efforts are being made to address those trends?
Ensure adequate notification processes exist
- Plans should have well-established processes for enrollee and provider notification that includes consistent methods of outreach, clear and unambiguous documentation in systems, with well-written and understandable denial rationale.
- Notifications must be timely, with documentation of both oral and written outreach detailed in plan systems. Plans must be able to evidence when the notification(s) entered the mail stream.
Sponsors have the ability to ready themselves by:
- Regular monitoring through sample mock auditing
- Developing dashboard reporting to assess the veracity of the data
- Evaluating universe creation and testing it: can all steps be evidenced in plan systems?
- Ensure internal processes for organization determinations and reconsiderations/coverage determinations and redeterminations are working effectively
Gorman Health Group’s Clinical Solutions practice area has a talented team of registered nurse professionals with experience in operations and implementations in various healthcare lines of businesses. Add to that Gorman Health Group’s Compliance consulting expertise and data analysts, and you have the winning combination in driving better member outcomes and ensuring member satisfaction. One call can lead to the answers your plan is seeking!
Resources:
Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now
Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe
Data Universes - Friend not Foe
Data universes are not new in the Medicare Advantage and Part D space. The Centers for Medicare & Medicaid Services (CMS) requires data universes for a variety of purposes, including program audits and timeliness monitoring. Gorman Health Group has communicated time and time again the importance of pulling accurate universes as well as continuous review of that data. Universes tell a story often not heard via other monitoring efforts.
Whether you are from a health plan or a first tier, downstream, and related entity (FDR), universes are critical to your organization’s success. During a CMS program audit or timeliness monitoring effort is not the time to realize your organization cannot pull the data or the data is inaccurate. CMS imposes strict penalties and fines when health plans cannot produce data – $25,000 for an invalid data submission (IDS) per violation/contract. IDS issues, if identified, can also have a negative impact to a health plan’s Star Ratings. Conversely, health plans can impose corrective action plans and monetary penalties on their FDRs for the same problem.
Ask yourself the following:
- Can our organization produce all applicable data universes?
- Is the data pulling from the correct source?
- Has the data been tested for accuracy?
- If a health plan, can our FDRs produce accurate universes? Have they been validated?
These activities can be time consuming for any organization and compete with other monitoring and auditing activities. Gorman Health Group offers customizable universe review services for both health plans and FDRs, including:
- Automated review utilizing Gorman Health Group’s proprietary analytics/algorithms
- Subject matter expert review in order to identify any risks and/or compliance concerns
- Timeliness testing of CDAG and ODAG universes
- Validation testing of the data conducted via webinar
Clients can tailor these services to fit their specific needs, e.g., monthly, quarterly, annually. Contact us today to learn more!
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
CMS Reports Medicare Advantage Provider Directories Continue to be Plagued with Inaccuracies
The Centers for Medicare & Medicaid Services (CMS) issued its Round Two online provider directory review, and the results were dismal. Plans reviewed showed an overall inaccuracy average higher than Year One plans. We can try to marginalize the results and say the average inaccuracy found by location was 48%. Nevertheless, the fact remains that nearly half of all directory locations reviewed were inaccurate. Breaking it down further, the inaccuracies ranged from 11% to 97.82%. We are living in an age of tech-savvy consumerism. If our GPS or Google results proved incorrect half of the time, we would not be satisfied. If results proved correct less than 3% of the time, we would be outraged.
"The report is a black eye for our industry," said John Gorman, Gorman Health Group's Executive Chairman in a recent Modern Healthcare article. "It's easy to fix. We have to do better."
Group practices continue to be a driver of non-compliance with plans listing information at the group level rather than the provider level. In addition to access to care concerns for beneficiaries, often the same database used for provider directories is also used when plans submit their Health Service Delivery (HSD) tables to CMS. By listing every group provider at all office locations, a plan is also inflating their network adequacy results. CMS has intimated any gaps between a plan’s online directory and their network adequacy need to be mitigated in short order and an internal process in place to ensure their continued alignment.
CMS noted the lack of internal auditing and testing remains a compliance gap. Plans have not built the necessary monitoring and oversight needed to be compliant. While there are pilot programs and a few vendors have emerged, technology at large to assist with the administrative burden is lacking. However, until technology or a central database is available, the onus is on the health plan and its providers to work together to ensure data accuracy. Health plans cannot assume a provider will be prompt and forthcoming with changes; a proactive, methodical outreach program coupled with diligent monitoring and oversight must be put into place.
Data inaccuracy tentacles are far reaching and jeopardize the success of numerous key health plan business functions and minimize the return on investment of supplemental investments such as Star Ratings or risk adjustment programs. CMS notes during their outreach in Year Two, information had been out of date for long periods. Providers were found to be retired or deceased for years. As one example of the financial impact, during recent network development projects to support service area expansions, the Provider Strategy team found the data inaccuracies in plan-provided contact information, currently in use for other lines of business, resulted in a significant number of additional hours expended to research and locate or determine the status of providers. The number of inconsistencies found were on par with the overall CMS average for Round Two; additionally, as CMS notes, we found a number of providers who had been retired, deceased, or relocated for a number of years, corroborating the need for plans to proactively reach out to providers on a routine basis
For Year Two, 23 plans were issued a notice of non-compliance, 19 plans were issued warning letters, and 12 were issued warning letters with a request for a business plan. This isn't just a compliance concern -- few things can tank your Star Rating and member experience scores faster than a shoddy provider directory or unexpected medical bills. Before your plan becomes a statistic, reach out to us at Gorman Health Group for assistance. We can provide a wide range of services – from performing a mock review to having a plan self-assessment available through our Online Monitoring Tool™ (OMT™).
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
HEDIS Deadlines Approaching
It’s HEDIS® time again! Health plans should have data collection and audit activities in full swing for Healthcare Effectiveness Data Information Set (HEDIS®) 2018. High-performing plans will have started the hybrid chart collection and medical record review.
January 31 is the National Committee for Quality Assurance (NCQA) deadline for the HEDIS® 2018 Roadmap. This document is used by HEDIS® auditors as the backbone for evaluating a plan’s systems and processes to ensure the plan’s HEDIS® results comply with NCQA standards for reporting.
February 16 is the due date for submitting the Healthcare Organization Questionnaire (HOQ) to NCQA. Populating the HOQ can be confusing for some plans, but it is important to get it right to prevent surprises when it is time to upload final data submissions in June.
HEDIS® results are a significant portion of CMS Star Ratings and NCQA accreditation scores, so it is critical for plans to understand all the moving parts and multiple deadlines of the HEDIS® process. Gorman Health Group has the expertise to help your plan implement a robust strategy and targeted actions for delivering measurable HEDIS® improvements.
(related link below)
http://www.ncqa.org/hedis-quality-measurement/hedis-data-submission/hedis-data-submission-timeline
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
CMS Announces Changes to the Network Review Process for Medicare Advantage Organizations
As anticipated, the Office of Management and Budget (OMB) approved the Centers for Medicare & Medicaid Services’ (CMS’) move to network adequacy reviews on a three-year cycle, unless there is a triggering event that would reset the timing of a Medicare Advantage Organization’s triennial review.
What does that mean for Medicare Advantage plans?
Initially, CMS will pull a sample of active contracts, including those that have not had a full network review since contract initiation, and provided the plans at least 60 days’ notice before the June deadline to submit their networks. If you are a plan that may fall into this category, you have a few short months to ensure your network meets current Health Service Delivery (HSD) table requirements. When considering all the factors that can affect your adequacy, such as changes in required number of providers or simply a change in the location of members in the CMS beneficiary file, it is imperative to begin analyzing the adequacy of your network as soon as possible. Should you fail to meet current standards, there will be limited time in which to mitigate any gaps and be prepared to present to CMS.
For those Medicare Advantage plans that are not in the initial or service area expansion (SAE) application process, CMS will provide the opportunity in February 2018 for plans to upload in the Health Plan Management System Network Management Module and participate in an informal review. However, because of the shift from an application process to an operational function, initial and SAE applicants will have until June to formally submit their networks to CMS. Another key change for SAE applicants: CMS will only review your expansion counties and not your entire network.
CMS has been moving in the direction of ensuring beneficiary protections by establishing new and stringent changes in network adequacy and directory guidance. They have been clear that organizations failing to meet network adequacy standards as well as directory standards will be subject to compliance and enforcement actions. The time to invest in your provider network management program is now.
At Gorman Health Group, we have provided expertise to government-sponsored plans in effective network management and ensuring compliance with state and federal regulations. Feel free to reach out and discuss how we can assist you in developing the network monitoring program needed to ensure your organization not only meets initial reviews and audits but develops an comprehensive program that truly utilizes your plan’s largest asset – your provider relationships.
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
CMS Timeliness Monitoring Underway
The Centers for Medicare & Medicaid Services (CMS) timeliness monitoring is currently underway at organizations with active contracts in 2017 and 2018, with a few exclusions, such as Medicare-Medicaid Plans and organizations that underwent a program audit in 2017 and did not have any invalid data submissions in key audit areas. Is your organization excluded? See the Health Plan Management System memo dated December 12, 2017. If I had a nickel for every time someone referred to this activity as a timeliness audit, I’d have quite a pile of nickels. While it is not an audit, it sure feels like one as the validation activity is the same.
The first of three waves of letters is being issued this month. After upload, a data review will be conducted and a validation webinar scheduled. Once complete, timeliness rates will be calculated. To make sure this is an efficient process, here are some ways we have recently assisted clients:
- Coach and guide delegates in the timeliness monitoring requirements
- Evaluate universes for adherence to instructions
- Review both timely and untimely case samples for data accuracy
- Review systems to validate accurate population of fields
Data integrity continues to be a priority not only for informing Star Ratings and Independent Review Entity data accuracy but also for required Part C and Part D reporting and for the compliant operations of plan administration. Universe preparation steps are not one size fits all, as the methodologies for a small plan delegating very few activities and the steps a larger, more delegated model plan takes will vary. Not surprisingly, during the course of our review, our team often finds potential issues or concerns unrelated to timeliness. This gives our client partners the opportunity to conduct a deeper review to address and mitigate.
We currently provide guidance, suggestions, and best practices for universe development to address quality and identify potential risks. If your organization is not getting these data universes correct, you should ask yourself, what other reports might be flawed? Dashboard metrics? Board reporting? Identify and correct these issues before CMS and their contractors find them for you.
Resources:
Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.
Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>