Three Important Tips to Make Sure Your Bid Process Is Successful This Year
Now that applications are completed, it’s time to get started on developing bids for 2018. In our experience working with many health plans, we have seen a wide range of strategies for developing bids over the years. Some of the strategies have worked very well, but many times we are working to improve or develop a more robust system because something went wrong the year before. Whatever your scenario might be, here are three important tips to help your bid process run smoother this year:
1. This Is Not a One-Person Job – Gorman Health Group (GHG) believes the bid process needs to be a team approach, with one clear leader, and include representatives from the following areas to ensure the best product is brought to market, and, when it is offered, the implementation of the product is seamlessly implemented. Some of the members who should be included are the following:
• Vice President, Medicare
• Product/Sales/Marketing Representatives
• Finance/Actuary/Healthcare Economics
• Network
• Pharmacy
• Medical and Health Management
• Compliance
• Operations
It is important this team succeeds as a group. Everybody needs to be accountable for his or her part in the process. Several times we have seen the process fall apart when team members didn’t show up for meetings and waited until the last minute to complete their assignment which was critical to completing the bid. Accountability is key! And that is why we recommend a senior management executive be a part of the process. There is nothing worse than making changes the day before the bid is due!
2. Have a Plan in Place – Having a bid document in place to level-set the team of the goals of the bid development process is critical to getting everyone on the same page upfront. When you have such a disparate group of departments working together with different goals, it is important to level-set in the beginning. Some items that should be included are the following:
• Understanding of the current financials profitability and what the return on investment should be in the next year
• Enrollment goals and forecasts
• Product goals and target market
• Competitive product and premium analysis
• Market, Annual Election Period, and member analysis
• Network analysis
• Formulary overview
• Medical Management programs and their effectiveness
This type of document, where each member provides guidance to the process from the outset, helps to form a project plan and clear objectives.
3. Strong Communication Process – GHG has never participated in a bid process where there is only one iteration of benefits. There are typically many iterations and changes along the way. In addition, if new benefits are added, there may be the need for new vendors and contracts to be developed. Changes to benefits or new benefits can cause real implications to claim systems and other operations. There are also very critical mandated marketing and advertising materials being developed that must be 100% accurate. We have seen issues occur in each of these areas because of a lack of a strong communication process. There must be a consistent methodology to provide individuals responsible for implementing benefits the opportunity to get it done right. There is no one way to do this. Your job is to make sure it is done the right way.
Having a strong bid process is an important step in making sure health plans are developing the most meaningful products and benefits to meet the needs of your target audience. If you need help in putting your bid process together, call us today!
P.S. Take advantage of our Spring SALE! Sign up now for GHG's Sales, Marketing & Strategy consulting services and receive 10-15% off*. Project terms must be agreed upon by March 30, 2017, so don’t wait! Contact us today >> *Discount is based on client-specific defined scope of work.
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 >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. 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 >>
CMS Puts Plans on Notice with Recent Enforcement Actions
The Centers for Medicare & Medicaid Services (CMS) Program Audit reviews a subset of contractual requirements every year, and each year, leadership wants to know how they fared compared to others, when they are due for an audit notice, and what some of the most pervasive conditions were identified. How many of you, dear compliance-minded readers, have been asked, "What will it cost us if we stay non-compliant?" By the numbers:
- Just under $7.3 million in penalties were levied between October 2016 and February 24, 2017.
- 37 sponsors were audited, with a combined total of 115 contracts.
- The active contract with the smallest enrollment has 93 members (as of February 2017).
- The largest audited contract has almost 2.9 million members (as of February 2017).
- The 2016 average audit score was 1.22, a decrease from the 2015 average of 1.76.
- There are over 11.5 million members currently enrolled in a plan levied a Civil Money Penalty (CMP) for Contract Administration. That’s the population of Ohio, or 11 Rhode Islands¹.
CMP data points tell us not to focus on the score, the plan’s enrollment size, or number of contracts – none of this will alone tell the outcome of CMPs. There were a number of sponsors audited in 2016 with similar violations yet not issued CMPs, including violations which appear on CMS’ ever-referenced common conditions.
Do you delegate most key member-facing functions? Is there a palpable culture of a focus on other lines of business? Has your enrollment grown too quickly for operations to adjust? Are you in the midst of organizational changes? What have you done to prepare for your audit, or better yet, timeliness reviews? What do you plan on doing with this knowledge?
¹Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2016, US Census Bureau
Resources
Join John Gorman, our Founder and Executive Chairman, and Novitex Enterprise Solutions on Tuesday, March 21st to review policy analysis and forecasting in regards to government-sponsored health programs under the new Trump administration. Register now >>
Gorman Health Group’s Summary and Analysis of the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter is now available. Download now >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
Adjusting Star Ratings for Audits and Enforcement Actions
Within the Draft Calendar Year 2018 Call Letter, the Centers for Medicare & Medicaid Services (CMS) acknowledged the valuable comments received from the industry related to the use of audit findings and enforcement actions in the Star Ratings Program. As a result of those comments, CMS proposes a revision of the Beneficiary Access and Performance Problems (BAPP) measure.
First, what is the BAPP measure? You can find information on this Part C measure in the 2017 Star Ratings Technical Notes. As described, the agency checks each plan to see if there are problems with the plan, for example, whether members are having problems getting services and if plans are following all of Medicare’s rules. The current BAPP measure is based on CMS’ sanctions, civil monetary penalties (CMPs), and Compliance Activity Module (CAM) data. CAM data includes notices of non-compliance, warning letters, and ad hoc corrective action plans.
In the Draft Call Letter, CMS is proposing a number of revisions to the BAPP measure for the 2018 Star Ratings.
- CMS is proposing to change the data time frame to the period from July of the measurement year to June of the following year. For example, the time frame for the 2018 Star Ratings would be July 2016 through June 2017. (Current data time frame for 2017 Star Ratings is January 1, 2015, to December 31, 2015.) This change would address feedback to use more recent data for the CMP portion of the measure.
- In addition, CMS proposes to employ the first option outlined in the November 10, 2016, Request for Comments, that is, the agency would apply the same scaled CMP deduction to all contracts cited in the CMP notice based on a ratio of the unadjusted CMP amount to enrollment at the time of the enforcement action. So, let’s say a parent organization has five contracts cited in a CMP notice. CMS will calculate the BAPP deduction by dividing the CMP by the total enrollment of those five contracts. The resulting BAPP measure deduction would apply to all five contracts.
- CMS also proposes the total deduction for a contract for CMPs be capped at 40 points instead of 40 points per CMP, which is what is in place today. Furthermore, CMS proposes retaining both the current BAPP measure score reduction for contracts under sanction and the current CAM deductions.
After all this work, CMS is also considering whether to implement proposed BAPP measure changes for 2018 or 2019. For more information on proposed changes to Star Ratings, refer to our expert commentary on this key aspect of the program.
It is recommended Compliance, Operations and Star Ratings professionals consider scenarios and how this would affect their Star Ratings. Ideally, a plan will keep CMPs and CAM data to a minimum, but the reality is with program audits, timeliness monitoring, an annual release of CMPs for Annual Notice of Changes/Evidence of Coverage issues, provider network accuracy reviews, and CMS’ revitalized focus on nondiscrimination and accessibility, it is expected there will be plenty of data for CMS to inform this measure.
Resources
Gorman Health Group’s Summary and Analysis of the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter is now available. Download now >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
Our Star Ratings subject matter expert discusses several key changes for Star Ratings in the 2018 MA Draft Call Letter. Read now >>
Perhaps a Visit to the Physical Therapist Is in Order – Make Sure Your CDAG Process Is Not a Weak Spot
Coverage Determinations, Appeals, and Grievances (CDAG) remain a compliance Achilles heel for many Part D sponsors. The Centers for Medicare & Medicaid Services (CMS) has noticed! Challenges with interpreting CMS regulations and guidance and operational restrictions have the potential to create a very costly gap. CMS is increasing scrutiny of this area in 2017.
CMS identified this weak spot and has provided additional communications via the Common Conditions, Improvement Strategies, and Best Practice memos, Job Aids, and proposed clarifications in the 2018 Draft Call Letter. The 2017 Draft Audit Protocol proposes expanded case selection in the Clinical Decision-Making (CDM) 2017 Program Audits and increasing enforcement actions related to Part D Auto-Forwards.
GHG’s experience in assisting plans with Part D operational assessments and participation in CMS Program Audits has identified the following areas for greatest risk of non-compliance:
Timeliness – Despite overall improvements in recognizing the importance of adhering to the processing and notification regulatory time frames, many plans still struggle. On December 16, 2016, CMS released a memo describing their intent to increase the compliance to enforcement escalation process and intent to issue Civil Monetary Penalties (CMP) on a quarterly basis to sponsors that fail to meet an established threshold. The expected CMP outlier threshold is 15 or more auto-forwards per 10,000 beneficiaries per quarter. For smaller plans whose enrollment is less than 800, fewer than 10 IRE cases/appeals per quarter, and fewer than 10 auto-forward cases per quarter will be excluded from the analysis.
Classification and Processing of Re-Openings – GHG has observed sponsors that liberally utilize the reopening of coverage determinations and decisions. Sponsors may reopen a case, as a remedial action, under certain conditions; however, CMS expects plan sponsors to limit their use of the reopening procedure, so don’t get carried away! The reopening procedure must be used to process clerical errors but not the failure to execute the determination process itself to ensure enrollees have been afforded appropriate appeal rights. This scenario is on CMS’ radar for the 2017 Program Audits. Based on the draft protocol, an additional five cases may be selected for review to assess appropriate classification and processing of dismissals, withdrawals, and/or reopenings.
Tiering Exceptions – If your benefit is set up with a mix of brand and generic drugs on a formulary tier, you may need to loosen the purse strings. If a formulary tier contains both brand and generic drugs as determined by New Drug Application (NDA) and Abbreviated New Drug Application (ANDA) status, some sponsors have been incorrectly denying tiering exception requests. Many Immediate Corrective Actions Required (ICARs) were issued for this reason during the 2016 Program Audits. In the 2018 Advance Notice and Draft Call Letter, CMS provides clarification about their expectations for tiering exceptions. If a plan sponsor has a mixed tier, the lowest tier would be the tier containing alternatives to the requested drug. Make sure to review your formulary and understand the CMS definitions of “brand” and “generic” to appropriately assess your tiering exceptions procedures!
For a hands-on workshop on CDAG, plan to attend the GHG Forum April 26-27, 2017, in New Orleans. Our Conference Brochure and Preliminary Agenda Is Now Available! Download it to see the additional topics we have in store for you at this year’s event.
Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.
Resources
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Teaming with Providers: Collaboration to Achieve Results
When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs).
As health plans continue adapting to the growing influence of quality metrics on their provider network operations, building an effective team with your providers has never been more important or more challenging.
However, factor in the necessities of compensating members of the team for their role, of each side meeting its profit targets, and the competing priorities faced by often short-staffed offices, it should come as no surprise many health plan staff members and providers are left wondering how to make it happen.
We have focused on designing incentive plans to promote compliance with regulatory requirements but to also meet our clinical and financial goals. To remain provider centric, it is imperative we as plans understand where providers are in the spectrum, not only in their ability to take on risk and make the shift from fee-for-service (FFS) to value-based reimbursement, but also in their overall infrastructure. During various projects, we have shadowed highly-skilled provider relations representatives as they travel in the field to meet with office managers and providers. Often we have found plans have incorrect office addresses. If internally we are not able to easily find our providers, it is doubtful our members or the vendors we hire, for example, Star Ratings and risk adjustment vendors, will have an easy time finding our providers either. This lack of correct provider demographics affects your sales and marketing team, enrollment, member services, and clinical teams. It prevents your internal team members and vendors from gathering the information they need in a timely manner.
How do we as a health plan balance the range of providers in our network? How can we ensure the employed doctor with a large integrated delivery system has his/her needs met while at the same time engaging the single-office practitioner and ensuring his/her goals are met?
Meeting the needs for each of these scenarios and others starts with how well defined our provider incentive programs are. Do they adequately support the clinical and financial goals of the plan and the provider? Have we built an incentive program that has achievable and actionable benchmarks for each type of provider in our network?
Whether your providers are still FFS or at full percentage of premium risk, a few building blocks will ensure success:
- Healthcare Is Local: Have we done our benchmarking for incentive programs at the local/regional level to ensure we are measuring apples to apples and taken into account the local practice of medicine?
- Prioritization: Ensure Clinical, Risk Adjustment, Star Ratings, Claims, and Network Operations are all collaborating and prioritizing their “asks” of the providers and working together to ensure the needs of the providers are met.
- Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
- Data Validation Reviews: Data integrity starts with collecting and configuring the provider data at the start of the contracting and credentialing process and becomes critical for downstream health plan operations.
- Focus on Actionability: Health plans often provide catalogs of reports each month showing providers numerous views of their panels and sometimes forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let providers be providers.
- Continuous Measurement, Re-Evaluation, and Reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a “thank you” are often simple but overlooked motivators.
There is no one straight line to navigate the path from FFS to pay for performance to risk for the plan or the provider, but there is one way to ensure success on that path ‒ collaboration between the plan and the providers. At Gorman Health Group, we are experienced in breaking down the silos and barriers and helping health plans be transparent in their actions and reporting. We can support your health plan to build the trust needed to ensure it is more than just “checking the boxes” on the incentive plan but rather seeing the success in better patient outcomes and lower expenditures.
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 >>
How to Maximize Your Medicare Advantage Website Strategy
How was your Annual Election Period (AEP)? Have you evaluated your performance? Do you need to enhance your sales and marketing strategies? Now is the time to recognize and appreciate your 2017 successes as well as confront your shortcomings.
There are several moving parts to a successful sales and marketing strategy, one being your Medicare Advantage (MA) website. The internet shopping trend is ever rising and this now applies to MA. Baby Boomers are aging into Medicare and with them come a new trend in internet shopping, enrolling and communicating with not only family and friends but with organizations they receive goods and services. In the 2016 Age-In Study by Deft Research, we learn, “Internet shopping rates have surpassed the rates of all other shopping activities.” The days of only direct mail are in the rear view. In fact, we also learn that your direct mail is actually motivating your website visits. Take advantage of these trends and take control of your website strategy.[1]
Here are the top 3 items to keep in mind when evaluating, developing and implementing your MA website strategy.
- Think Easy: Your website mantra shall be: “clear and easy to navigate.” Not only is this the top requirement given to us from the Centers for Medicare & Medicaid Services (CMS) – in fact, this is the first requirement listed in section 100 of the 2018 draft Medicare Marketing Guidelines (MMG) – but this approach will ensure your website is user friendly and an effective marketing tool. Shoppers want the facts about your plan offerings and most importantly, they want them now. And if they are ready to enroll – the online enrollment process should just as easy as the shopping.Helpful tip: Organize your website around 3 general focus areas:
- Prospective member information – Here are your sales and marketing web pages, including the online enrollment tool.
- Current member information – These web pages focus on required content that is mostly geared towards your current members.
- Member Experience –Enhance your website with tools and a member portal that help drive your retention efforts.
- Follow the Rules: Make your list and check it twice. Compliance is key and whether you are developing, revising or monitoring your website, it is critical that you and your team have an understanding of all the CMS requirements as they apply to your MA website.Helpful tip: GHG recommends creating a website checklist that includes all CMS requirements. Are you developing a new website? List these requirements out as they would impact each of your proposed web pages or section of the website (prospective, current, retention). This is your content development driver. Are you revising or monitoring your website? This checklist is your tool to ensure compliance and it documents where each requirement is met by URL tracking.
- Member Perspective: It’s all about that member portal. As the Deft study highlights, web is worth it. Ensure an easy transition from prospect to member by providing your membership with an online, password protected member portal. Here the possibilities are endless – think newsletters, healthcare/health service reminders, provider/pharmacy look-up, drug search, claims check.Helpful hint: Collaborate with Stars! The experience of your members directly impacts your Star Rating. Collaborate with your Stars and care management teams to develop a member portal that truly supports member needs while simultaneously moving the numerator of your Stars measures.
Finally – don’t forget about your third-party websites. You may not have much control over the look and feel of your third-party websites but you must ensure they are compliant. Take note that one of the major changes proposed by CMS in the 2018 draft MMG is the addition of section 100.7 on third-party websites. CMS expects plans to be monitoring these sites in addition to their own.
All in all, enhancing our sales and marketing strategies is found in understanding our successes and failures. Take advantage of the rise in internet shopping and develop or revise your MA websites to go beyond the compliance requirements but to sell your products and retain your members. We are here to help!
[1] Deft Research, LLC. (n.d.) Marketing to Medicare Age-Ins: Internet and Direct Mail Trends. Retrieved from deftresearch.com
Resources
On Thursday, February 9, from 2-3 pm ET, join John Gorman and colleagues Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document, including CMS’ changes to risk adjustment and encounter data, Star Ratings, Benefit Parameters and Bid Requirements, Part D Utilization Review, and more. Register now >>
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 >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. 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 >>
Current Trends in Retiree Health Coverage Expected to Continue Under a Trump Administration
The landscape for retiree healthcare is not expected to change significantly under a first Trump term. However, several Republican proposals, if enacted, could incent group members to shift to the individual market over time.
Background - According to the September 2016 Kaiser Health Foundation (KFF) – Health Research & Educational Trust (HRET) Health Benefits Survey, 24% of large employers (200 employees or more) that offer health benefits to their employees still offer retiree coverage http://files.kff.org/attachment/Report-Employer-Health-Benefits-2016-Annual-Survey. Of the firms offering retiree coverage, 92% offer retiree coverage to early retirees and 72% to Medicare-eligible retirees. Over the past several decades, there has been a slow decline in employer coverage of retiree health benefits – down from 34% in 2006 and 40% in 1999. The 2016 level of 24% is similar to levels in recent years. Consistent with recent trends, employers are expected to continue to gradually reduce retiree coverage, but most employers that offer retiree coverage are expected to continue to offer this coverage in the next several years.
Impact of the Affordable Care Act (ACA) on Employer and Retiree Coverage – Use of the ACA Marketplace by employers has been low. The 2016 KFF-HRET Survey found only 17% of large firms offering retiree health coverage are considering shifting to Marketplaces that offer subsidies, which was lower than the percentage in 2015 (26%). So if the Marketplaces are repealed or substantially modified, the impact on employers should be small.
If the employer mandate is repealed, the penalties and much administrative burden on employers will be eliminated. This change would provide more flexibility on how retiree benefits are offered and could result in delaying any reduction in retiree offerings.
If the 40% employer Cadillac plan excise tax is repealed, more employers may retain their current retiree coverage and not follow in the footsteps of employers that have already acted to mitigate the Cadillac plan provision, e.g., switching to a lower cost plan, increasing cost sharing, selecting plans with a smaller network, or moving benefit options to account based plans. However, if an alternative price proposal to enact a cap on the annual tax exclusion for employer-sponsored benefits is enacted (e.g., $8,000 individual and $20,000 family), then employers may modify their plan designs and offerings.
Impact on Medicare Advantage (MA) Plans – MA Employer Group Waiver Plans (EGWPs) should continue to grow in markets that have not been fully penetrated over the next several years.
Defined Contribution Plans – In recent years, some employers have moved towards defined contribution plans, sending retirees to the individual market to choose a plan rather than remain in the group market. This trend has been smaller than predicted. In 2016, only 6% of large firms (200 or more workers) offering retiree health benefits report offering benefits through a private exchange, similar to the percentages in 2015. According to the KFF survey, an additional 21% of firms were considering a defined contribution approach. Assuming the individual market remains sound, some employers may move to a defined contribution in the future, thus eroding the employer group market over time. Some Republican proposals could spur this trend. For example, Tom Price’s 2015 repeal and replace bill (H.R. 2300) included a proposal that would cap the tax exclusion for employer provided benefits and permit employers to contribute to an employee or retiree plan in the individual market. If enacted, the proposal could make shopping in private exchanges more attractive and/or cause employees to leave the employer group plan because there would be more plan choices available.
Account Based Plans (Health Savings Accounts) – Many employers offer an account based plan, such as a Health Savings Account (HSA) or a Health Reimbursement Account, as part of their group coverage. A Trump administration is expected to pass legislation and regulations to allow more flexibility in these plans, and they can be expected to grow. For example, Tom Price’s 2015 legislation included a provision that would provide a one-time $1,000 tax credit for HSA contributions, increase HSA contribution limits to the maximum individual retirement account limit, broaden coverage of drugs before the deductible, and provide credit for over-the-counter (OTC) medications and fitness/nutrition services. Under the Price proposal, Part A Medicare beneficiaries would be allowed to contribute to HSAs while Medicare beneficiaries with Parts A and B could contribute to an Medicare Medical Savings Account (MSA) plan. While this change could make the MSA more successful than in the past, it would not address the small percentage of beneficiaries who understand the product and would be willing to move from a product that provides first-dollar coverage.
Resources
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. 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 >>
A Vendor's Oversight is Never Done
There are many industry voices adding their perspectives about the new administration and changes to come. However, the Compliance Officers I know do not have the luxury of stopping and truly considering the potential impact as they are managing the continuous pressures of their daily directives. Today I address a group of very industrious Compliance professionals not often addressed, and those are the staff responsible for Compliance Programs at first tier, downstream and related entities, or “FDRs.” Under Medicare regulations, plan sponsors may enter into contracts with FDRs to provide administrative or healthcare service functions on their behalf.
Building the relationship between the sponsor and FDR, just like any marriage, is very important for the partnership to be fruitful. In order to ensure a successful relationship, it is important for delegated entity Compliance staff to have a firm grasp on what the health plans face and to build a strong foundation to support those needs. So often we talk about the Centers for Medicare & Medicaid Services (CMS) Program Audit, so delegates supporting those services should already be in lock-step with their plan sponsor partners. However, that review methodology is a small subset of Medicare Advantage Prescription Drug (MA-PD) plan requirements.
One question we are often asked is: How are sponsors looking at FDRs? FDRs can be collaborative, cost-saving partners that bring significant value to an organization. However, we have also heard dozens of anecdotes of buyer’s remorse, some of which are in credit to the following:
- The sponsor’s Compliance Officer was informed months later that a business area contracted with an FDR.
- A key business owner did not ask the right probing questions during the sales presentation.
- No pre-delegation site visit was conducted to validate processes, or the right attendees were not included in the visit.
- The procurement process was not followed, and appropriate monetary penalties were not imposed for failure to perform.
As a Compliance professional at an FDR, what could you be doing to improve current relationships?
As a vendor, the sponsor is entrusting you to perform an activity on their behalf. If you are looking to partner for success, we recommend you take a look at current processes and evaluate if you are making the right impression from the beginning. You can be a proactive partner in supporting your sponsor, or you can be reactive, thereby weakening your product/service and increasing your and your sponsor's oversight. Whether you are thinking of contracting with a plan sponsor for the first time or you are already in the thick of it, ask yourself these questions:
- Do you “speak” CMS? Can you and your business leaders hold a fruitful conversation about current industry issues, recent CMS releases, and agency focus?
- What is the state of your Compliance Program? Is it in good shape? Have you tested mechanisms and safeguards lately? Do you have an independent audit of your Compliance Program Effectiveness on an annual basis?
- Are your record-keeping tools equipped to handle the many sponsor requests received, such as attestation data, training information, and exclusion list checks documentation?
- How does your organization demonstrate knowledge of CMS requirements, and, more critically, how do you demonstrate meeting or exceeding those requirements?
- Are you restrictive in how often you allow plan sponsors to audit each year?
To be successful in fulfilling the daily rituals of a delegated entity Compliance Officer, it requires a very particular set of skills (thanks, Liam Neeson), as they are often communicating with multiple sponsor contacts at a time. They are not off the hook just because they are not CMS-facing. And as history has shown, when a potentially large-scale, pervasive problem occurs, CMS can and will contact a vendor directly. Think about the above questions and evaluate your current resources to ensure CMS never feels the need to do so.
Resources
Join Nilsa Lennig Rudisill, Gorman Health Group’s Vice President of Sales & Marketing Services, and colleague Diane Hollie, Senior Director of Sales & Marketing Services, on January 31, 2017, from 1:00 - 2:00 PM ET, as they outline how to analyze your market and the necessary steps to develop a successful growth strategy. Register Now >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. 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 >>
January Release of the Draft MMG - Perfect Timing
It’s still January, and, yes, the Centers for Medicare & Medicaid Services (CMS) has released the draft 2018 Medicare Marketing Guidelines (MMG). Perfect timing! The Annual Election Period (AEP) has come and gone, and here we are once again, having post-mortem discussions on what went right, what went wrong, and where to go from here. Once you have gathered all the necessary data, the next logical step is to begin planning for 2018 and revising your sponsor and organization strategies for Sales and Marketing. Don’t forget to review and provide feedback to CMS on the draft MMG changes. Although there weren’t many major updates (CMS provides mostly clarifications this year), there are a few key items that we highlight below:
- 30.5.1 – Multi-Language Insert
CMS essentially removed the standard Multi-Language Insert (MLI) section we have all become familiar with and defers to the requirements under Section 1557 and all questions to the Office for Civil Rights (OCR). Given the many interpretations of Section 1557 compliance and the confusion we saw around implementation of these requirements, it should be interesting to follow industry updates now that CMS is deferring sponsors to consult with OCR. Now more than ever, make sure your organization understands the requirements, documents the implemented process adopted within your organization, and consistently and compliantly operationalizes this process.
- 50.4 – Disclaimer on Availability of Non-English Translations
Previously, sponsors which met the five percent threshold for language translation were required to include the applicable disclaimer on all marketing materials. In the MMG draft, CMS updates the disclaimer and simplifies the requirement to a set list of documents only: Annual Notice of Changes/Evidence of Coverage (ANOC/EOC) or EOC, Low-Income Subsidy (LIS) Rider, Formularies, Star Ratings, Summary of Benefits (SB), and the Part D Transition letter. In addition, CMS proposes requiring the non-English translation of the disclaimer only – the English version is no longer required. Consider this draft change as you prepare marketing materials for 2018.
- 70.11.2 – Provider Affiliation Announcements
Here, CMS clarifies sponsors and/or contracted providers may not announce new or continuing affiliations until the contractual agreement has been approved. If implemented in the final MMG, organizations will need to ensure contractual agreements are complete and approved before any announcements of the relationship are published. CMS removed some announcement parameters from the section as well. For example, CMS previously stated announcements could be made once within the first 30 days of new contract agreement. Since this implied the contracts needed to be in place, clarification was needed to the section since they removed the sentence which limited the number of announcements. Also, CMS reminds sponsors affiliation announcement materials that contain benefits, premiums, or cost sharing are considered marketing materials. It is up to the sponsor to ensure providers adhere to distribution and mailing guidance.
- 100.7 – Third-Party Websites
Brand new section to the MMG! Sponsors are now required to submit third-party marketing websites that contain plan names or logos, even if there is no benefit information included, to CMS’ Health Plan Management System (HPMS). This includes any online forms that need to be filled out to receive more information about Medicare Advantage (MA) or Part D plans, including generic forms used to obtain information about non-MA or Part D plans. CMS includes that third-party websites may not:- Request health status information, such as pre-existing conditions, weight, and whether a beneficiary smokes;
- Provide misleading information, such as identifying a Medicare Supplement plan as an MA plan;
- Use prohibited terminology, including unsubstantiated absolute superlatives.
This list looks like it is made up of no-brainers and is consistent with requirements, but chances are, CMS has included this in the draft MMG because it is occurring in the industry. When preparing your website development, review, and submission schedule for 2017, don’t forget to include your third-party marketing websites. This will be on CMS’ radar, and it is up to the plan sponsors to ensure compliance of their third-party marketing website vendors.
- 120.4.1 – General Rules Regarding Compensation
CMS adds new language to this section indicating that plans may not pay agents/brokers who have not been trained and tested. If implemented in the final MMG, organizations will need to update payment processes to ensure agents who have not passed the training and testing are not paid.
The above is not an exhaustive list of the draft 2018 MMG updates. CMS is specifically requesting comments and questions from plan sponsors on proposed updates on provider affiliation announcements and third-party websites. Consider how this will impact your organization, and be sure to take advantage of CMS’ request for comments!
In addition to the release of the draft MMG, another hot topic we must also consider for our 2018 planning is provider directory accuracy. Last week, 21 Medicare health plans were warned to fix their provider directories – 18 warning letters and 3 warning letters with a request for a business plan to outline efforts to correct errors. In addition, 31 notices of non-compliance were delivered. Plan sponsors must have compliant directories. As recently as January 17, CMS released a memo titled “Provider Directory Policy Updates,” reiterating existing policy but also providing additional guidance. Don’t fall short on this – it’s no easy task and cannot be taken lightly. Spend time on this topic and develop robust data gathering techniques to keep your directories accurate.
Not sure how best to plan for 2018 or decide which strategies are best for you? This is not a one-size-fits-all industry, and we are here to help. Let us partner with you in developing appropriate, compliant, and effective sales and marketing strategies.
Resources
Don’t miss our webinar on Tuesday, January 31, at 1:00 PM EST, where we will provide an informative session on how to conduct a feasibility study to develop a successful growth strategy for your organization. Register now >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. 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 >>
It’s Product, Benefit, and Premium Time for 2018
Whether you are just updating your current product benefits, are offering a new plan benefit package (PBP), new product, or service area, or are new to Medicare Advantage altogether, now is the time to start planning for the 2018 bid submission.
It is best practice in the bid process to utilize a working team approach, with one clear leader. The team should include representatives from the following areas to ensure the best product is brought to market, and, when it is offered, that the implementation of the product is seamlessly implemented. Some of the members who should be included are:
- Sales/Marketing
- Finance/Actuary
- Network
- Pharmacy
- Medical and Health Management
- Operations
- Compliance
GHG believes, at the beginning of the bid process, it is important to level-set the team on the marketplace. Some of the analyses we typically like to present include:
- Service area demographics
- Medicare penetration
- Current membership analysis
- Enrollment trend analysis
- Results of the Annual Election Period (AEP): Who are the winners and losers this AEP, and why?
- Product analysis
- Benefit analysis
- Competitive analysis
Strong planning is key in the bid process. You want to understand the goals upfront and make sure your product and benefits can deliver. We have found weekly meetings, a detailed project plan with strong leadership, and project management skills are critical if you want to limit the number of iterations and last-minute back and forth that brings along the increased risk of errors.
Having a strong operations component incorporated in the process helps identify the planning needed to seamlessly implement benefit changes and pinpoint impacts on customer service. The Sales and Marketing team are key in characterizing product differentials and how the benefits will be sold, and not only how the sales team will sell, but if the Sales team can sell the benefits.
We could go on, but you get the importance of every department working together and pulling their weight. GHG has seen the success of plans who get the need for a deliberate process, as well as those plans in nail biting situations – hoping it all comes together at the end. Let me tell you, the first way is always preferable! So get your analysis started, put your project plan together, and start putting together your team if you haven’t already!
Resources
Don’t miss our webinar on Tuesday, January 31, at 1:00 PM EST, where we will provide an informative session on how to conduct a feasibility study to develop a successful growth strategy for your organization. Register now >>
The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year's event. 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 >>