Three Reasons Why Pre-AEP Marketing Is Critical
One of the reasons healthcare marketing is so interesting is that it’s never static for long. Once you think you have it figured out, something changes in the mix. Pre-Annual Election Period (AEP) marketing is one of those phenomena that changes the mix in AEP marketing. If a pre-AEP marketing strategy is not in your marketing plan this year, here are three reasons why you may want to reconsider:
- In working with plans across the country, many are finding the pre-AEP mailing to be the most cost-effective mailing in the AEP mix and also generates the most leads. Typically, these are inexpensive mailings or postcards that arrive in the mailbox the latter part of September – right before AEP.
- Since the Centers for Medicare & Medicaid Services (CMS) states plans/Part D sponsors cannot market for an upcoming plan year prior to October 1, you must develop advertising that is very generic in your messaging, can be informational and educational, and utilizes direct response-oriented language with a very strong call to action to generate a response. This strategy seems to be paying off.
- When a plan is new to the market or introducing a new product to the market, multi-channel, pre-AEP marketing has been found to be very productive. Advertising the brand and/or hinting of something new helps build recognition, chatter, and leads before the full barrage of marketing begins in October, especially for new plans. Although this type of marketing may not have a strong return on investment by itself, it can be measured in the overall AEP marketing analytics.
Whatever your situation, we have seen pre-AEP marketing take many different approaches – with a few that appear to have crossed the line – so make sure you “stay within the lines” of CMS’ regulations with your pre-AEP marketing. We would be happy to assist you with developing a pre-AEP strategy to help you meet your goals.
Resources:
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 >>
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Three Compliance-Minded Steps to Take for 2018 Marketing and Sales
Is it me, or is time flying by? Applications are done, bids are in, new plans are in planning stages, and existing plans are getting ready for the launch of the next benefit year.
The 2018 model materials were released late last month, and any second now, we should see the release of the 2018 Medicare Marketing Guidelines (MMG). The industry is expecting additional Summary of Benefits guidance to be incorporated in the MMG by the Centers for Medicare & Medicaid Services (CMS) as my colleague Diane Hollie noted in her article on the CMS Spring Conference. We are also interested to see if any modifications are made to CMS’ draft MMG language on Additional Marketing Fees as discussed in this article. Time will tell!
What is the compliance professional to do to help sales and marketing professionals prepare while we are in this holding pattern for the finalized guidance? Three things:
- Evaluate what worked and what didn’t work well in the material review process last year. Did you conduct a lessons learned session at the end of the season? Any top performers that contributed to the success of last year’s material creation, review, and submission activities? If you did not have a chance to do a lessons learned session, take some time to reflect this week. This way, you can set expectations with your team and colleagues.
- Identify greatest risks and rewards in sales and marketing activities, and take proactive steps to correct. We all understand the obligation to conduct a risk assessment. As Carrie Barker-Settles told an engaged audience at this year’s Gorman Health Group Forum, it is important to understand both the risks and rewards of each sales channel. Did your organization have an upswing in marketing misrepresentation complaints? What sort of turnover did the prospective member call center experience over the past year? Ongoing review of potential risks of non-compliance and fraud, waste, and abuse is necessary to help drive continued customization to monitoring and auditing plans.
- Develop training tools and checklists. If these are not in place already at your organization, these resources are integral to helping marketing and sales stay in between the lines.
Does this quick hit list warrant additional discussion within your team? If you are doing the above already, fantastic! As a good friend so alliteratively once told me, proper prior planning prevents poor performance. That said, are you inundated with the day-to-day of CMS requests, six+ hours of meetings a day, and little time to catch up on what new guidance was released? Do you need temporary help during the material review season? At anytime of the year when things go wrong, we often see it become an “us vs. them” situation between Operations and Compliance; it’s demoralizing and unproductive, and we don’t like to see anyone in that situation.
Contact me directly at rpennypacker@ghgadvisors.com for more information on how we can help.
Resources:
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 >>
New Webinar! Join us on Tuesday, June 20, from 1-2 pm ET, for a webinar on best practices for agent onboarding and oversight, compliant and efficient solutions to onboard and certify agents for the 2018 selling season and more! Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Final Benefit Submission Is Done. Top 5 Items To Focus on Now!
Benefits were submitted on June 5, 2017. Too many times we see health plans wait until the last minute to complete important information. This tends to lead to incorrect mailings and advertising getting into the marketplace with costly errata mailings occurring. Gorman Health Group recommends you start with a strong work plan in place to get the following documents completed, starting now:
Annual Notice of Changes (ANOC) and Explanation of Coverage (EOC). The 2018 model materials have been released by the Centers for Medicare & Medicaid Services (CMS). The ANOCs and EOCs are typically the most difficult documents to develop, get reviewed, and have printed. It is best to develop these documents now since they must be mailed by September 30, 2017. Also, make sure you have a reputable printer who understands these documents and the importance of meeting CMS deadlines.
Summary of Benefits (SBs). As stated during the CMS Spring Conference, CMS will no longer be issuing annual memos for the SB; instead, changes will be listed each year in the Medicare Marketing Guidelines (MMG). Although the 2018 MMG have not yet been released, CMS did highlight the following changes for 2018:
- No more hard copy changes.
- Outpatient hospital coverage will be listed right after inpatient hospital coverage.
- The extra premium for optional supplemental benefits can be included in the SB.
- The document must be labeled “Summary of Benefits,” and the plan year should be visible on the cover.
- If a benefit is not covered, such as transportation, you still need to list the benefit and state “Not covered.”
- Plans can add other benefits not listed by CMS to the SB and should label the section “Additional Benefits.”
It is important to start development of the SB early since it is typically inserted into sales kits/packages and needs to be in the hands of your sales representatives no later than October 1. Printing, fulfillment, and shipping of the SB is a timely and costly endeavor.
Sales Kits/Packages. In addition to the SB, you should begin working on the following materials:
- Enrollment Form. If you are still working with enrollment forms, start now. Although the Medicare Managed Care Manual Chapter 2, Medicare Advantage Enrollment and Disenrollment, guidance is not usually updated until August, it is important to have this document submitted and ready to go if you have to make changes if it is non-model, especially since this is part of the sales kit/packages.
- Benefit Highlights Sheet. Although CMS states they will continue to allow benefit highlights to be developed, they prefer the prospect reads the SB instead. GHG understands that benefit highlights sheets are a great resource for sales staff, as well as for prospective enrollees who wish to quickly view key benefits most important to them.
Sales Presentations. If you develop sales presentations for your sales team, start working on them now. The last thing you need is to have your sales force sitting with a prospect and not have the approved resources.
Annual Election Period (AEP) Mailing #1. There is nothing worse than the phones not ringing, idle sales reps, and websites with no traffic. We have seen this firsthand, and it is not pretty. Get your mailings started! Even though you may think it’s too early, it isn’t. There are so many interruptions during the summer months with employee vacations, release of the MMG, and review periods, it’s best to start as soon as possible.
One last important NOTE: As you know, filed benefits are not final until they have been “blessed” by CMS. Every year, we hear complaints about how benefit changes are communicated – or not communicated. Please make sure you have a communication strategy in place to update all departments’ if/when benefits change. This process – when done correctly – saves money, time, and embarrassing communications with CMS!
Our team of experts can develop or review your sales collateral and creative by product type to help ensure your high-impact messaging is both targeted and compliant. Contact me directly at dhollie@ghgadvisors.com for more information.
Resources:
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 >>
New Webinar! Join us on Tuesday, June 20, from 1-2 pm ET, for a webinar on best practices for agent onboarding and oversight, compliant and efficient solutions to onboard and certify agents for the 2018 selling season and more! Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Top Challenges in Provider Data Management
While health plan provider directory inaccuracies have been at the forefront of the news, regulatory agencies, and consumer protection agencies, the directories are only the tip of the iceberg in how difficult provider data management is for health plans. Plans continue to gather information on providers in a multitude of ways and from a variety of functional areas, continue to create conflicting repositories of provider data, and thus continue to face the painstaking and almost always manual validation of provider information.
As we have worked with clients through Medicare Advantage service area expansion applications, exception process, and the upcoming bid filing, we have repeatedly seen plans faced with spending hours having their provider teams manually tracking down providers and correcting provider information in order to prepare accurate Health Services Delivery (HSD) tables and exception request forms. A few of the top challenges found have been the following:
- The CMS Provider Supply File: Centers for Medicare & Medicaid Services (CMS) offered an olive branch in providing the list of servicing providers they use as a source when reviewing a plan’s provider network. Plans, however, had a difficult time validating the provider information they had internally against the Provider Supply File and using it to their advantage in preparing network exceptions.
- Inter-plan relationships and provider sharing between lines of business oftentimes had unclear boundaries on which providers could be used or were contracted for the various products at hand.
- When reviewing an overall coverage area, they appeared complete; when broken out into potential provider-sponsored plan (PSP) offerings, provider gaps were found.
With all three of these situations, plans were affected by a lack of time to mitigate the compliance risk facing their networks. As health plans move forward in finding ways to keep their directories in compliance, we challenge you to take a step back and look at provider data management in a holistic manner to solving directory, credentialing, and network adequacy issues, improving care management with better data management on what your network partners offer, improving relationships with your Star Ratings and risk adjustment vendors, and ensuring a strong network management program. With a spotlight on network management across all government-sponsored programs, let Gorman Health Group be your partner in designing a provider data management system that will meet your needs.
Resources:
GHG’s multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Marketing Takeaways from CMS’ Spring Conference
Although the Centers for Medicare & Medicaid Services (CMS) Spring Conference is typically thought of as a “compliance” conference, there is always important information that comes from the conference which affects Marketing. It is important to understand the information coming today instead of waiting for a CMS memo or the Medicare Marketing Guidelines (MMG). It is also a great way to hear how CMS personnel are thinking about a subject instead of just trying to infer their thoughts from the MMG. The following are some takeaways that may affect you and your plan.
Summary of Benefits (SB)
CMS reviewed 191 SBs – one from each parent company. If you haven’t heard from CMS about your SB, congratulations, CMS did not find any issues with your document. CMS gathered the SBs from each plan’s website, so make sure your documents are uploaded timely and the correct document is utilized. Here are some of our notes from the conference on SBs.
- CMS stated one of the biggest concerns they saw was plans not using the correct order of benefits. Plans are required to maintain the specified order. Monthly premium, deductible, and maximum out-of-pocket (MOOP) should be first, followed by drug benefits. Some plans were alphabetizing benefits, including other benefits, and this is not allowed. In addition, make sure you are using the correct version of the SB. CMS noticed some SBs had multiple fonts in one sentence, brackets were not removed, and track changes were in SBs. Furthermore, some plans had incorrect cost-sharing in their SBs.
- New for 2018:
- No more hard copy changes.
- No annual memo will come out this year; 2017 requirements will continue for 2018 – a copy of the memo and any 2018 changes will be listed in the 2018 MMG.
- Outpatient hospital coverage will be listed right after inpatient hospital coverage.
- Extra premium for optional supplemental benefits can be included in the SB.
- The document must be labeled “Summary of Benefits,” and the plan year should be visible on the cover.
- If a benefit is not covered, such as transportation, you still need to list the benefit and state “Not covered.”
- Plans can add other benefits not listed by CMS to the SB and should label the section “Additional Benefits.”
- Although CMS will continue to allow plans to utilize “benefit highlights,” “Benefits at a Glance,” and other types of marketing documents to highlight their benefits, CMS would prefer plans not utilize these documents and have prospects and members read the SB instead.
Supporting Access to Information for Individuals with Disabilities
CMS explained plans should be very familiar with Sections 508 and 504 of the Rehabilitation Act. Section 508 explains the media/electronic needs, and Section 504 explains accessibility, regardless of technology utilized. CMS stated access extends beyond hearing and visual impairments. Plans need to understand what the requests are for their disabled members and meet those needs in a timely manner – as though it was a member without a disability. This requirement must also be provided by your downstream contractors, so if you utilize a call center or other vendors that handle and fulfill prospect or member requests, make sure you have policies and procedures to handle these types of requests.
“The agency expectation is that individuals with disabilities are provided equal opportunity to participate in your program, and you should want that, too,” says Regan Pennypacker, Senior Vice President of Compliance Solutions. “We know this is operationally tricky, but this is an opportunity for innovation. A plan must work with beneficiaries to identify how they would like to receive information and make sure the info is provided in a timely manner.” CMS stated they are very interested in working with plans and hearing about their challenges and also best practices and successes.
Provider Directories Review Update
Provider directories will continue to be a challenge for everyone, and although CMS acknowledges this is a difficult endeavor, plans are responsible for their data. CMS also stated, since the provider is contracted by the plan, it is the plan’s responsibility to make sure they get the proper information from the provider. Although we could spend a lot of time discussing what CMS said about directories, we have provided a few things you want to be aware of from a marketing standpoint:
- Make sure what is on your website is the latest and most up to date! Understand how and when it gets updated.
- These are common errors CMS wants addressed in provider directories (both paper and online):
- Plans must include notation if provider is accepting new patients or not. Make sure meaning of notation is clear.
- Do not assume specialists are accepting new patients.
- If listing provider prior to effective date, include effective date in directory.
- Identify when provider has significant limitation to the patients they see (e.g., only treats members of a Native American tribe).
- Does provider practice all their specialties at all locations?
- List facilities as facilities and providers as providers. For example, they sometimes see surgeons listed with facility address where surgeries are conducted, but it should be address of where the member can get an appointment.
- The languages spoken at doctor offices.
This discussion will continue to be a hot topic for CMS. As a marketer, we need to understand the data we are getting to develop these documents and help ensure it is meeting the guidelines set forth by CMS.
These are just the highlights from a few of the topics. Reach out to your Compliance Department to understand what might affect you going forward!
Resources:
CMS also recently held its 2017 Audit and Enforcement Conference. Our Senior Vice President of Compliance Solutions, Regan Pennypacker, provides a recap here >>
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Highlights from 2017 CMS Audit and Enforcement Conference
The Centers for Medicare & Medicaid Services (CMS) hosted their annual Audit and Enforcement Conference on Thursday, May 11, and addressed the following topics:
- 2017 Program Audits
- Audit Protocol Updates: Compliance Program and Medicare Medicaid Plan
- Medication Therapy Management (MTM) Panel
- 2016 Program Audit and Enforcement Report
- Timeliness Monitoring
- Civil Money Penalty (CMP) Methodology
The presentations and recordings of the morning and afternoon sessions are posted here. All sessions merit a review by Compliance and operational teams at sponsors and delegated entities alike. Apart from the communicated clarifications and content provided on the slides, CMS allowed for numerous question and answer periods, both after each session as well as at the end of the day. Here I capture highlights of those Q&As.
Can an Independent Auditor (IA) follow the same CMS process of providing samples 1 hour before webinar sessions? In regards to the IA process, most sponsors do follow CMS protocol when doing validation, but it does not really matter to us how soon samples are delivered. It’s ok if you get them a little sooner. Most IAs do use the same protocol and timing, but it is not prescriptive, which is why there is not a lot of guidance around how IAs should audit.
If we had a CAR for CDAG clinical appropriateness, would the validation audit focus on that CAR, or would the validation audit need to be a full-scale CDAG audit? When it comes to that, the sponsor simply needs to validate the condition. A full CDAG audit is not required; just that particular condition.
To what extent are Invalid Data Submission (IDS) conditions a problem in 2016? They were not terribly problematic. Last year there may have been eight across seven sponsors, but CMS would like to see those at zero.
Now that you have covered 94% of enrollment with Cycle 2 audits, when do you plan to start a third cycle? CMS is not sure and is still looking at that.
Can or will CMS share overall observations in Timeliness Monitoring regarding performance? CMS believes they will be able to this summer.
How does CMS come up with the common conditions in calculating CMPs? CMS takes this from the annual audit report.
When are CMP notices posted on the CMP website? CMS posts CMPs as a result of program audits before end of February. For CMPs not related to audits, the agency posts those immediately after they are imposed.
In regards to call log universe, do we include calls placed to other vendors as a part of normal business (such as calls to transportation vendor) which do not pertain to main customer service? No, CMS wants only calls going to the main customer service line.
Is it appropriate to report date request received as AOR receipt date, or should sponsor report initial receipt date as request received? For ODAG tables with these two fields, sponsor should populate as each column specifies. CMS does consider both fields when doing timeliness calculations.
Will CMS release a revised Compliance Chapter 9/21 to reflect change in Elements from 7 to 3, or is this just a change in methodology? CMS is actively revising manual guidance. Compliance program requirements are still the same, but audit approach has changed. Do not confuse the three audit elements (Prevention Controls and Activities, Detection Controls and Activities, and Correction Controls and Activities) with the seven core elements outlined in chapter guidance.
Is there a timeline when CMS is expecting MTM audit activities to migrate from pilot to standard? At this point, it is not determined.
From a long-term perspective, considering validation is 150 days and MTM is a calendar year, how would this area be handled from a validation perspective? At this time, MTM not subject to validation. It is still to be determined if it will be subject to validation in the future.
How will appeals timeliness monitoring affect future audits? To the extent that the timeliness monitoring effort becomes annual, it would make absolutely no sense to review timeliness audit, but that change remains to be seen. However, there is a difference in that timeliness monitoring is a review of a snapshot of the year before. CMS may want to phase timeliness review out of program audits. CMS also answered the question from the perspective of the agency using results to target for audits. CMS noted they always like to compare data to audit scores and results to see if there is anything meaningful but confirmed there are no plans for that in the future.
"While CMS indicated they would not use results from the timeliness monitoring for referrals for audit, CMS did indicate they would study the results to see if there is a correlation to audit results," says a colleague on the Operational Performance team. "Knowing what is in your data and using it for process improvement should be on every plan’s radar." Since CMS staff indicated that the timeliness monitoring could one day potentially replace the timeliness review on program audits, sponsors should get ahead of that curve by using their timeliness monitoring data for their own internal review.
As always, we love to hear your thoughts and perspectives on agency activities as well as your experiences in the government programs space. Keep an eye on this blog for more updates from my colleagues on this week's conferences.
Resources:
The Gorman Health Group 2017 Forum concluded recently in New Orleans with over 200 of our closest clients and partners. John Gorman provides key takeaways from the event here. Make sure to join us next year!
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Checklist for Developing Your Marketing Plan for 2018
Developing a new marketing plan each year is a “clean slate” opportunity to look at your marketplace and develop strategies to meet your goals. Gorman Health Group has seen how baby boomers are beginning to change the landscape of Medicare marketing, and it is important not to be left behind. We have developed a checklist to help ensure your marketing plan for 2018 is very inclusive!
It is important to make sure your strategies fit your market to get the maximum result. If you are struggling with your sales, marketing and strategy plan, give us a call. Gorman Health Group is fortunate to be able to work with health plans across the country and understands how to dissect the marketplace to understand your best potential for success. Call us today!
Resources:
Tips for a Multicultural Marketing Strategy
We are all familiar with the 5% language threshold requirement by which the Centers for Medicare & Medicaid Services (CMS) mandates Medicare Advantage Organizations (MAOs) to make specific marketing materials available in any language that is the primary language of at least 5% of an MAO’s service area. This is the bare minimum. With 8% of the nationwide 65-and-older population being Hispanic or Latino, 8% being black or African-American alone, and 4% being Asian alone, it is important for MAOs to identify the various race and ethnic footprints in their service area and to distinguish multicultural marketing and advertising tactics throughout strategy development. Language is only a piece of the story – understanding variations in culture is key to building a successful and ultimately profitable relationship with potential and current members.
MAOs’ sales and marketing strategies must consider multicultural tactics. Here are four key areas to focus on when developing these tactics:
1. Start with the data. MAOs must always start by knowing their market, both prospective and current membership. To meet this necessary step, a thorough analysis of census data and current membership data should be prepared. If you utilize a marketing agency, this is an opportunity to work with them as they may have market data that goes above and beyond census data that is specific to your service area. The information gained at this step should be refreshed at least annually and serves as the base upon which you will build out the multicultural strategies – without the data, there would be no direction.
2. Represent your population within your sales and customer service teams. If you find you are servicing a multi-cultural/ethnic population, it is absolutely critical to have all ethnic groups represented in your Sales and Customer Service teams. For many ethnic groups, the sales agent/broker is considered an individual’s customer service representative, and they may look to their agent/broker as their trusted partner even before the health plan. To be successful in a multicultural environment, your Sales team must be a familiar face and have a strong presence in the community. In addition, MAOs should not hesitate to work with their Field Marketing Organizations (FMOs) to ensure ethnic agents are in the right locations and to conduct focus groups with brokers to understand how the plan benefits and the MAO overall are resonating with the various cultures represented.
3. It’s not just about the language. Materials should go above and beyond the 5% threshold rule. Important things to consider in developing multicultural materials are:
a. Colloquial versus formal language
b. Gender sensitivity across different cultures
c. Multiracial/multicultural pictures on advertisements
d. Deliver brand message with social opportunities
e. Mobile tools
Infrastructure is critical when targeting and servicing ethnic populations. It is important to have representation of the various cultures on your team. This is an opportunity to test translations internally. Gorman Health Group (GHG) also recommends performing focus groups with your current membership to test translations and things like gender sensitivity across cultures. In addition, understand what each of your ethnic populations responds to from a marketing perspective. Are there marketing tactics or channels that work better? Or do you need to find them in your grass roots campaigns?
4. Network Development. Serving multicultural populations is an opportunity for Marketing to work with Network Development to ensure staff within these areas are aware of the languages and cultures represented within the service area. This information should help guide recruitment efforts, especially for Primary Care Providers (PCPs). And once a provider is part of your network, Marketing may work with the provider to send direct mail pieces to specific current members promoting the provider in the language and culture that provider represents. In addition, the MAO should work with their providers to develop strategies that will enable them to deliver effective healthcare services that meet the social, cultural, and linguistic needs of members.
The archetypal health plan does not typically resonate with small ethnic groups. If you find you are servicing a population that is multicultural, it is important to align yourself with these groups and build unique relationships. All cultures in your service area should be considered in product development, marketing and sales strategies, network development, and customer service representation. Don’t miss out on potential members or lose current members by ignoring ethnic groups and their value in your service area. As the Medicare Advantage market becomes more homogenized and saturated, growth will need to come from other sources – don’t wait until your competition has already figured it out.
Resources:
The Medicare Advantage marketplace is evolving – are you prepared? Gorman Health Group’s marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>
Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
The Importance of Accurate Provider Data and Network Adequacy
For almost two years, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data integrity is at the forefront of the initiatives enforced by government mandates, and provider data has topped the list of areas that not only need the most improvement, but the most oversight, correction, and, potentially, sanction. As we saw with the CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. By moving the online directory guidance in the Medicare Managed Care Manual from Chapter 3 (Marketing) to Chapter 4 (Beneficiary Protections), CMS has solidified the fact it is no longer acceptable to have inaccuracies in an area key for members to evaluate their health plan choices and find access to care. CMS released its first “Online Provider Directory Review Report” in January 2017 and followed up on January 17, 2017, with a CMS Memo on Provider Directory Policy Updates.
In addition to the regulatory compliance and existing provider directory requirements, CMS noted two additional guidance steps:
- For group practices, directories must only list individual provider at locations where they routinely see patients, as opposed to every location of the group practice.
- Organizations must make a reasonable attempt to ensure provider practice names are up to date and reflect the name stated when an enrollee calls to make an appointment.
CMS also noted plans should institute other steps to ensure the information included in their directories is accurate and useful to their members. One item suggested was that plans have a hotline for members to use when they encounter a directory issue, such as a provider no longer accepting new members. The plan should then use this information to investigate and correct the issue for the member. Moreover, CMS readdressed the issue that any issues found during a directory self-audit, CMS audit, or member or provider calls should also be updated and ensure accuracy in the Health Service Delivery (HSD) tables used to submit the provider network to CMS.
Overall, plan provider networks have never had the scrutiny of CMS or other spotlight and as such have tended to take a back seat to issues unless a particular grievance was filed. At Gorman Health Group, we keep a pulse on the various health plan areas on which our organization consults as we regularly have cross-functional projects. I asked a Compliance colleague how her Compliance meetings went at a plan, and she responded that every meeting expounded upon their fear of not meeting the network and directory regulatory guidance. I discussed the directory issues with an operational colleague, and her comment from a recent project on member calls was that “approximately 40% of member calls were due to directory issues.”
For this blog, I had a chance to ask another colleague, one of our subject matter experts on Stars, to give her perspective:
Accurate provider data is a mission-critical foundation for a strong Star Rating. If provider data is inaccurate, members will likely struggle to access providers or may actually show up at the wrong location for an appointment. These issues influence all Star Ratings measures; they directly impact clinical quality measures and indirectly impact member survey and administrative measures. In addition, inaccurate provider data jeopardizes the success of numerous key health plan business functions and minimizes the return on investment of supplemental investments in Star Ratings, Risk Adjustment, and Quality Improvement (QI).
The nature and extent of inaccuracies within a health plan’s provider directory has, to date, often been a well-kept secret within health plans. Though data hygiene of names, addresses, and phone numbers is undoubtedly a very basic administrative function, competing priorities inside of a plan often redirect administrative staff away from these time-consuming, mundane activities until a crisis occurs (such as a CMS audit of the data or “ride-along” conducted for Star Ratings, Risk Adjustment, or QI purposes).
Perhaps even more troubling is when a provider listed in the directory is not accepting new patients. Although CMS recognizes this can be a “fluid item” in the directory, Medicare Advantage enrollees often select a plan specifically based on a provider’s participation in that plan’s network. When these situations arise, the health plan’s credibility and brand loyalty are placed at risk, and the member’s healthcare experience and Star Ratings status are placed in jeopardy.
Part of the anxiety is easy to diagnose: it is a new requirement, and we need to find the best approach. However, if you dig deeper, you will find directory data is the tip of the iceberg. Provider network operations in some plans can have functionalities that reside in several difference departments such as Provider Relations reporting to Operations, Credentialing reporting to Medical Management, and Contracting reporting to Finance. Like many plans, the functions were done in silos.
In retrospect, the issues identified are not new. They do, however, expose a systemic issue with provider network operations and the downstream impact they will have.
Please join us at the Gorman Health Group 2017 Forum as we further discuss the Provider Directory Accuracy and Network Adequacy regulatory requirements as well as the downstream impact they have on our internal operations and our external vendor operations. In the meantime, please contact us directly if you have questions or would like to schedule a time to meet with one of our industry experts to discuss how Gorman Health Group Forum can support your efforts to avoid risk and improve results.
Resources
GHG’s multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
The Achilles Heels of Part D in Program Audits: FA and CDAG Administration
This may seem like the movie “Groundhog Day,” but Formulary Administration (FA) and Coverage Determinations, Appeals, and Grievances (CDAG) continue to hobble plan sponsors’ Centers for Medicare & Medicaid Services (CMS) program audit results. Failure to properly administer their CMS-approved formulary continues to plague plan sponsors. As a result, enrollees experience inappropriate denials of coverage at the point of sale and were delayed access to their medications, never received their medications, or incurred increased out-of-pocket costs in order to receive their medications. Plan sponsors continue to be tripped up in the following areas of FA:
Administration of CMS-Approved Formulary
- Rejecting prescriptions for formulary medications that were written by out-of-network providers
- Improper coding of the approved drug list
- Failure to allow claims for extended day supplies on initial prescriptions
- Failure to appropriately test and/or implement coding of quantity limits (QLs) in the adjudication system, resulting in inappropriate rejections
Administration of CMS Transition Policy
- Improper look-back period of member history
- Did not register beneficiaries’ historical claims in a timely manner, which led to sponsors not properly identifying beneficiaries’ historical drug regimen and eligible transition fills
- Denied beneficiary access to transition fills as a result of errors in enrollment data; for example, beneficiaries who were new enrollees were coded as continuing enrollees
- Failed to allow claims for formulary drugs dispensed in the smallest commercially available package size when the day supply, based on the prescribed dose, exceeded the plan’s day supply benefit
- Processed transition fills for only some of the drugs that were subject to a cross-contract year formulary change
- Processed concurrent drug utilization review edits as safety edits during transition, thereby inappropriately restricting drug access during the transition period
Effectuation of Prior Authorizations
- Not dating the effectuation for approvals to the earliest request of drug purchase date resulting in enrollees’ delayed or denied access to prescription drugs, having to receive formulary alternatives, or having to pay out-of-pocket in order to receive their drugs
Application of Quantity Limits
- Utilized maximum daily dose limits that were more restrictive than the CMS-approved QLs and/or Food and Drug Administration maximum recommended daily doses
- Applying incorrect adjudication logic for the type of QL submitted on the approved formulary (Type 1 QL Qty/Time submitted but applying Type 2 daily dose logic prevents partial refills)
- Applied QLs to non-formulary medications
Application of Step Therapy
- Using improper look-back period to establish prior drug history
- Applied prior authorization edits on claims for beneficiaries with a utilization history of protected class drugs
CDAG findings remain a costly area for plans. To date in 2017, 10 plans have been hit with a civil monetary penalty (CMP) – 80% of them were cited for a violation related to Medicare Part D CDAG requirements.1 Plans should be reviewing the common conditions and evaluating their own practices to identify risk areas. A compliance and operational assessment should be completed prior to CMS audit activities to ensure adequate staffing and oversight is in place to avoid potentially costly audit findings. The most common cited conditions seen year over year remain the following:
- Denial letter rationales
- Untimely Independent Review Entity (IRE) auto-forwards
- Insufficient prescriber outreach
- Untimely decisions and/or notifications
- Not effectuating exceptions through the end of the plan yea
- Misclassification of coverage determination or redetermination requests as grievances and/or customer service inquiries
Other areas which were cited in the CMPs and represent additional case selection potential in the 2017 draft audit protocols are the following:
Misclassification of reconsiderations as organization determinations or re-openings
- Re-openings are considered a remedial action that should be used sparingly. Inappropriate use of this procedure would delay case forwarding to the IRE, thereby delaying or denying enrollees’ right to the appeal process.
Improperly dismissed coverage request
- Dismissing a coverage determination instead of making a decision (approval or denial) should be done in very limited circumstances, usually limited to cases where a review is not required (e.g., party requesting coverage is not a proper party). If dismissed inappropriately, enrollees are denied access to the appeals process, which may result in delayed or denied access to medication.
1(https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/PartCandPartDEnforcementActions-.html_
Resources:
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