CMS Releases New Guidance on Coverage Determinations & Redeterminations
On October 18, 2016, the Centers for Medicare & Medicaid Services (CMS) issued enhanced guidance on outreach attempts to support coverage decisions in its memo titled “Guidance on Outreach for Information to Support Coverage Decisions.” In recent years, CMS Program Audits have consistently identified the failure of plans to have documented sufficient outreach attempts when more information is needed to make a coverage decision. Guidance hasn’t been clear on what CMS expected, but it was obvious based on audit results most plans were not meeting the level of outreach CMS considered to be sufficient. The memo has many critical points every plan should be reviewing and implementing.
Here are four items your plan should look at today to determine system and process capabilities to support the new clarifications:
- Ability to Begin Outreach Quickly – How quickly does your plan open a coverage request or redetermination? Most plans process expedited cases quickly, but standard requests are often in a queue that may take days to open and review for completeness. The new guidance requires the initial request for additional information for a standard Part C organization determination to be sent within two calendar days of receipt and a redetermination request to be sent within four calendar days. This means plans must not only be able to triage weekend requests for expedited versus standard requests but determine if standard requests need more information.
- Multiple Outreach Methods – CMS outlined several methods for requesting information. Those include telephone, fax, email, and standard or overnight certified mail. Many plans use one or maybe two methods. CMS indicated, upon review of cases, consideration will be given to the plan’s use of multiple means of communication.
- Documentation of Outreach Attempts – It is critical systems be able to both store and report on the methods and date/time of the communication. CMS noted for emails and faxes, the timestamp is the evidence. For mail, it is the date/time of the postmark, which is a change from the mail date often used in internal systems. For telephonic outreach, it is the date and time of the call. In addition to the date and time documentation, plans should document two other critical pieces of information for the outreach attempt: 1) the specific description of the required information being requested and 2) the name, phone number, fax number, email, or mailing address of the point of contact. In the case of a phone call, the plan should document with whom they spoke, what was discussed or requested, and what information was obtained.
- Ability to Enforce Response with Contracted Providers – CMS has often indicated there is a concern plans are unable to get timely responses from their contracted providers. In the new guidance clarification, CMS reinforces this requirement. CMS expects plans to set up contractual requirements to support contracted provider responses to requests for information. Additionally, CMS is looking to health plan physicians to outreach to contracted providers when more information is needed to make a determination and the provider did not respond to requests.
While the new requirements may be aggressive, they do provide additional clarity on what CMS is expecting health plans to complete in order to be compliant. The question is, what types of systems and process changes will be needed to store and report on these changes?
Gorman Health Group (GHG) subject matter experts have been a part of numerous CMS audits and have observed similar feedback from the auditors. We have worked on remediation projects to implement this type of enhancement as well as recommend this to our clients on operational assessment projects. We know the struggles these changes present and can assist you in working through them. Implementing these changes may be challenging, but the end results of higher compliance and consistent, fully reviewed decisions for members will be worth it.
If you have questions about implementing the changes outlined in this memo or whether your current processes are compliant, we can help. You can reach us through our website or by emailing me directly at jbillman@ghgadvisors.com
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CMS conducts their audit and provides a list of risks and a short timeframe (ninety days) to correct the deficiencies. We can help. Visit our website to learn more about how we can help ensure the right actions have been taken to remediate the issues found >>
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New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
MACRA Final Rule: CMS Announces Flexible Approach
No doubt sighs of relief could be heard from across the industry when the Centers for Medicare & Medicaid Services (CMS) announced its flexible approach to next year’s reporting requirements under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS took these flexibilities even further in its final rule released last Friday. Below I dive into some of the changes CMS made for the 2017 “transition year” and beyond.
- Relief for Small Providers – The final rule steps back even further from its requirements that providers billing more than $10,000 under Medicare are required to comply with reporting requirements. CMS finalized that Merit-Based Incentive Payment System (MIPS)-eligible clinicians who do not exceed $30,000 of billed Part B allowed charges or 100 Part B enrolled beneficiaries are excluded from MIPS. According to CMS, this is about one-third of Medicare clinicians but only represents about 5% of Part B spending.
- CMS also previously announced it will allow for virtual groups where up to ten clinicians could combine into one group, however, virtual groups will not be implemented during 2017
- “Pick Your Pace” – CMS also codifies its prior announcement that it will allow for a “pick your pace” approach for the first reporting year, 2017. The first year essentially now contains five options:
- Report a full 90-day or one-year period to maximize chances to qualify for a positive payment adjustment.
- Report for less than one year but more than 90 days: more than one quality measure, more than one improvement activity, or more than the required advancing care information performance category in order to avoid a negative adjustment and possibly receive a positive adjustment.
- Report one measure in the quality performance category, one activity in the improvement categories, or the required measures of the advancing care information performance category and avoid a negative adjustment.
- Participate through an Advanced Alternative Payment Model (APM) and qualify for a 5% bonus incentive payment in 2019.
- Don’t report anything for a hefty 4% negative adjustment.
- Basics of MIPS and Changes for 2017 – Eligible clinicians will see either a negative, neutral, or positive payment adjustment of up to 4% under the MIPS program. CMS will also pay out bonus payments for exceptional performers between 2019 and 2024 (beginning with the 2017 reporting year). The payments are based on four categories, and CMS made some significant changes from its proposal:
- Quality – Full participation requires reporting on six quality measures or one specialty-specific or sub-specialty-specific measure set, five required advancing care information measures, and engage in up to four improvement activities for the highest score. For 2017, full participation is met by submitting at least one out of the six quality measures. However, higher points may be awarded for higher performance in the measure.
- Improvement Activity – CMS reduced the number of activities from six to up to four medium-weighted or two high-weighted improvement activities. Attesting to at least one improvement activity will be sufficient in 2017.
- Advancing Care – CMS reduced the number of total required measures from 11 to five. Reporting on all five would earn 50%, and reporting on the optional measures would allow for a possible higher score. CMS will also award a bonus score for improvement activities that utilize Certified Electronic Health Record Technology (CEHRT) and for reporting to public health or clinical data registries.
- Performance Category – Although CMS will raise the weight of this category, it will be weighted at 0% for the 2017 reporting year.
- Advanced APMs – Clinicians who are eligible to participate through an Advanced APM are exempt from the above MIPS requirements. Additionally, the Advanced APM track is eligible for a 5% bonus payment. In order to qualify as an Advanced APM, CMS finalized that a provider must bear a risk of a potential downside of 8% of all Medicare reimbursements or 3% of the expected expenditures for which the provider is responsible under the APM. Notably, CMS retracted its proposals relating to marginal risk and medical loss ratio (MLR) for now.
- “MIPS APMs” – CMS noted the significant criticism that many APMs will not meet the requirements to participate in Advanced APMs in 2017. For example, participants of Track 1 Medicare Shared Savings Program (MSSP) are not eligible as an Advanced APM. CMS moved forward with their proposal that these “MIPS APMs” are subject to MIPS reporting requirements, however, they will be scored using an APM scoring standard in 2017. CMS did announce it is developing an MSSP Track 1+ Model under which Accountable Care Organizations (ACOs) participating in Track 1 and new ACO participants could take more limited downside risk than Tracks 2 and 3 and still be eligible as an Advanced APM. CMS also announced it plans to reopen applications for some current APMs, such as the Medicare All-Payer Model and the Comprehensive Care for Joint Replacement (CJR) Model.
While CMS took the job of responding to industry feedback and “simplifying” the jump into the Quality Payment Program (QPP) for 2017 while moving forward with the move to QPP to an art form, the gargantuan 2,400-page final regulation is a hint of what’s to come. Reinventing the Medicare payment wheel is no simple task and will undoubtedly come with a slew of interim proposed rules as well as fixes to encountered problems during the first transitional years. This payment overhaul is only going to get more complicated, and the time to roll up those sleeves and get to work is now.
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The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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Directory & Provider Data: How Small Inaccuracies Could Lead to Big Risks
For the past year, 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 last year 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. Now is the time to set new ongoing network monitoring processes in place that ensure your CMS network submissions and Health Service Delivery (HSD) tables mirror your online provider directories, guaranteeing you are prepared to address provider and member complaints stemming from directory inaccuracies.
A recent investigation by the Government Accountability Office (GAO)[1] identified serious deficiencies in CMS’ oversight and enforcement of Medicare Advantage (MA) network requirements and recommended greater scrutiny of the plans’ networks. The GAO found CMS reviews less than 1% of all networks and does little to assess the accuracy of the network data submitted by plans. It was found CMS relies primarily upon complaints from beneficiaries to identify problems with networks and does not assess whether plans are renewing their current contracts to continue to meet network requirements.
For MA plans who currently have the least stringent directory requirements of all government-sponsored health plans, this means plans are only required to outreach to the providers on a quarterly basis to validate the following information is correct:
- Provider’s ability to accept new patients,
- Provider’s street address,
- Provider phone number, and
- Any other changes that affect availability to patients.
Although seemingly straightforward, when coupled with several other nuances, the task becomes daunting and, in some cases, an operational impossibility. Real-time updates to provider demographics, grievance resolution, reconciliation of provider location, and notation of individual providers accepting new patients are a few examples of where a simple requirement can reveal so many gaps and pose so much risk. Inefficiencies capturing, storing, and governing provider data at the onset of the contracting and credentialing processes is a place to start, but what about the historic legacy information that needs to be sanitized? Add the individual specifications and data requested by and delivered from industry vendors and delegated entities, risk adjustment, the Healthcare Effectiveness Data and Information Set (HEDIS®), behavioral health, and the large, delegated provider and academic groups that should be providing the plan with a current roster each month – this is no small task.
At this point, you might be asking yourself:
- How do we bridge the gap between understanding our compliance risk and deploying a successful change in operations to ensure the loop is closed and successfully maintained at every point in the contract life cycle?
- How do we ensure vendor partners are supporting us and aligning their business practices with both the regulatory requirements and our key performance indicators for Star Ratings, risk adjustment, care management, and member experience?
- Is it possible to fix my content management system as it exists today, or do I need to rip and replace?
Gorman Health Group (GHG) can answer these questions, and we encourage you to follow along with us as we explore these questions and how they relate to the results from the first CMS pilot audit. Next week, we will provide in-depth detail on the operational and cross-functional elements of how this regulatory change will impact the entire industry. We’ll have commentary from several leading vendors in the industry and dig deeper into the downstream implications provider data inefficiencies can have on your plan as a whole. 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 GHG can support your efforts to avoid risk and improve results.
[1] http://www.gao.gov/products/GAO-15-710
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GHG can assess the alignment of your products, your current network, your market, and your network requirements. We’ll help you track results – both positive and negative – back to related network components. From there, we assist in developing and executing a networking strategy, from contracting targets to model contract terms, to payment terms that match your budgets and the capabilities of your claim payment systems. Visit our website to learn more about how we can help you address your needs >>
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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AEP Marketing: It's Not Too Late
It’s Not Too Late…
To Make Your Marketing Lead and Sales Goals.
During Presidential election years, it can be difficult to book media time, especially with direct response television. If you live in an area with hotly-contested political races, you may be finding it hard to break through the clutter to get the number of marketing leads needed to make your sales goals.
There is still time to make it work, but to do it correctly requires a considerable amount of teamwork and cooperation, especially with your vendors, during this very busy time of year. Although we know every situation is very different, here are some tips to consider:
- Increase online media. If you have not tried remarketing, now might be the time to try it.
- Direct mail – but don’t use oversized postcards that may get confused with political propaganda until after the election. Having a direct mailing with a very colorful envelope may help break through the clutter. Make sure you mail your best prospects first class.
- Move more money into co-op dollars with your most productive agents or Field Marketing Organization.
These are just a few tips to jumpstart the thought process. This is a great time for the Marketing and Sales teams to come together and develop a “unified action plan” to recoup the leads and sales needed to make your goals. Carrie Barker-Settles, Director of Sales & Marketing Services at Gorman Health Group, stated, “It’s not too late to evaluate lead distribution by ensuring marketing leads go to the ‘closers.’ No need to try out new agents/brokers if leads are limited – put company leads in the hands of those agents/brokers who have proven results.”
If you need help brainstorming ideas or assistance with an action plan, don’t hesitate to contact Gorman Health Group ― it’s not too late to make a difference.
Resources
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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MedPAC Meeting Highlights
The Medicare Payment Advisory Commission (MedPAC) held a public meeting last week and had a full plate of a variety of topics from Accountable Care Organizations (ACOs) to Medicare Part B drug payment issues.
Some takeaways:
- The Woes with ACOs: MedPAC found that in 2015, the Centers for Medicare & Medicaid Services (CMS) paid Medicare Shared Savings Program (MSSP) providers $625 million. This means that after paying out $429 to providers who generated enough for savings, the agency lost money. One commissioner recommended MedPAC look into organizations that generated savings for CMS in order to better gauge which factors make an ACO succeed. Though true that ACOs are slow to show the progress everyone is hoping for, it is important to note organizations that have been in the program longer are showing more success.
- Quality Measurement: MedPAC once again discussed the possibility of a premium support system to be implemented for Medicare. The conversation focused heavily on the commission’s alternative concept for measuring quality in Medicare as well as finding quality measures that can be used across Medicare Advantage (MA), ACOs, and Fee-for-Service (FFS). MedPAC is becoming increasingly concerned the current quality program relies on too many clinical process measures that do not strongly correlate with health outcomes. Under MedPAC’s proposal, Medicare would use a small set of population-based outcome measures and patient experience to compare quality of care under each of the three payment models in a local area. This was the first of many conversations MedPAC will have on this topic over the next year.
- Imminent Move toward Biosimilars: MedPAC seemed to offer much support in moving forward with the greater use of biosimilars under Part D. The use of biosimilars in Medicare would likely lead to drastic drug program savings, especially for chronic conditions such as diabetes. Solutions thrown around included extending the coverage gap discount to include biosimilars, something that is currently only applied to brand name drugs.
- Part B Drug Payment Policies: Given that Part B drug spending has grown at an average rate of more than 8 percent per year over the lastfive years, the commissioners ran through several proposals on how to address this growth and tackle Part B payments. Options considered included increasing price competition, consolidating billing codes, limiting average sales price (ASP) inflation, modifying the payment formula, improving data, and restructuring the competitive acquisition program (CAP). The discussion did not end with any recommendations other than to continue to work on this matter. Of course, we are all anxiously awaiting CMS’ response to the flood of comments to its Part B Drug Payment Proposal.
- Behavioral Health: It was also suggested MedPAC explore policy solutions to the weaknesses in behavioral health services under Medicare. The commission discussed exploring both weaknesses in inpatient facilities for serious mental health issues as well as care in ambulatory settings. Solutions thrown around included integrating primary care with behavioral health specialists and examining readmissions and emergency room data to determine what kind of readmission measures and penalties could be used to drive better inpatient performance.
Resources:
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
The 2017 Star Ratings: A Contrast Between Macro Versus Micro
The more things change, the more they stay the same. Despite the many, often significant, changes amidst plan-specific 2017 Star Ratings, there is a surprising amount of stability in the 2017 Star Ratings. Stable performance is evident at the macro level:
- The 2017 average Star Rating is 4.00 (down only slightly from 4.03 in 2016).
- Approximately 49% of Medicare Advantage Prescription Drug plans (MA-PDs) earned ≥4 stars in both 2016 and 2017.
- Weighted by enrollment, approximately 68% of MA-PD enrollees are in contracts with ≥4 stars in 2017, down from 71% in 2016.
- The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) cut points for 7 measures again stagnated in 2017, and national average performance rates (not ratings) for 13 additional measures remain unchanged.
This stable performance seemingly contradicts the generally accepted notion that “quality is improving.” Indeed, a closer analysis of the many micro-level performance changes reveals many changes and fluctuations:
- United delivered perhaps the strongest performance in the 2017 Star Ratings among the largest industry players, showing strong performance improvement across all plans.
- Pending industry mega-mergers eroded Star Ratings performance of the plans being acquired while the acquiring organizations’ Star Ratings survived relatively unscathed.
- Thirty-four plans that earned ≥4 stars in 2016 dropped below 4 stars in 2016 and will lose their Quality Bonus Payment (QBP) revenues. Eighteen of these 34 plans earned only 1 star on both the Part D Appeals Upheld and Appeals Autoforward measures, mostly, if not entirely, due to audit results. Because many plans rely exclusively on their Pharmacy Benefit Manager (PBM) for these measures, this is an opportune time to reevaluate the Centers for Medicare & Medicaid Services’ (CMS’) somewhat utopic expectation an MA plan has enough contractual and practical leverage to influence its PBM’s operations and performance in a way that prevents audit findings and delivers consistently high Star ratings within the plan’s MA population. Particularly given CMS’ ongoing, transparent acknowledgement that audited plans are disproportionately affected by audit findings, these plans face strong headwinds as they prepare to lose QBPs, even if only temporarily. With long-term PBM contracts already in place, most of the financial impact resulting from these pharmacy audit-related penalties will be felt by beneficiaries and the provider network if CMS does not reconsider its approach to capturing audit results within Star Ratings.
- The uncertainties associated with bell-curved Star Ratings continue to present serious challenges for health plans as they attempt to build sustainable benefits that meet member needs and expectations over the long term.
- Five of the 6 plans receiving the Low Performance Indicator (LPI) in 2016 were not rated in 2017, and 4 of these 5 remain active at present. The long-term future of these plans appears to remain at the mercy of Congress. Despite being slated for termination by CMS due to consistently low Star Ratings performance, a “hospital improvement” bill, which has passed the House and is currently in the Senate, includes a provision to delay CMS’ authority to terminate MA contracts based on poor Star Ratings. It is unclear when Congress will take up this issue, though the bill does have noteworthy bipartisan support. As with many of the important program changes on the horizon for next year, we’ll be watching this issue closely to determine the bill’s ultimate fate and to determine its impact within the parameters of Star Ratings.
So where do we go from here? At a macro level, significant evolution and effort lies ahead to accomplish the Triple Aim foundation of the Star Ratings program. But in order to do so, the micro-view is where we must focus our energy and effort. Successfully improving health, and thus Star Ratings, requires us to carefully decide when, where, how, who, and why to work with micro-targeted groups of members in micro-targeted, person-centered ways.
For questions or inquiries about how Gorman Health Group can support your organization’s Star Ratings efforts, please contact me directly at msmith@ghgadvisors.com.
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New Webinar! The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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2017 Readiness Checklist – Valuable Tool or an Exercise in Redundancy?
Some people are list makers and wholeheartedly embrace the value of checklists. They utilize lists to manage tasks, stay focused, and ensure high-quality results. A publication by the Institute of Health’s Committee on Quality of Health Care in America, titled “To Err is Human: Building a Safer Health System,” lays out the value of checklists in improving patient safety. We should view the Centers for Medicare & Medicaid Services (CMS) Readiness Checklist in that same view: it is a tool to allow health plans to improve the quality and compliance of their health plan and safety of their members.
As with all checklists, the process can be a “check the box” experience or a valuable tool to make sure everything is in place and nothing was forgotten. We all know to expect a CMS Readiness Checklist on an annual basis, but do we use this amazing tool to its fullest? Be sure you make this a serious exercise to evaluate your program and readiness for 2017. Some sections may be redundant year after year, but health plans find broken processes year after year, sometimes through negative member experience―don’t let that be your plan.
Every item on the Readiness Checklist should be reviewed and validated. Some items are new and may take more time and effort to validate. Here are four new items on the 2017 Readiness Checklist where you may want to invest additional time:
- Medicare-Medicaid Dual Eligibles Non-Discrimination and Cost Share Protection – The 2017 Readiness Checklist has a new emphasis on protecting the rights of lower income members, particularly Medicare and Medicaid dual eligibles and others eligible for the Low Income Subsidy (LIS). CMS also highlighted this topic in their conference in September. Plans are required to ensure dual eligible beneficiaries are not balance billed for deductibles, coinsurance, or copayments for which they are not responsible. CMS is requiring plans to verify they have procedures in place to ensure their providers do not discriminate against beneficiaries due to their dual eligible status or balance bill those members who receive assistance with Medicare cost-sharing from a state Medicaid program. It is a health plan’s responsibility to manage their provider network to prevent this type of abuse of Medicare and Medicaid full dual eligible individuals.
- Best Available Evidence (BAE) – CMS included additional guidance for plans to review their BAE process. CMS expects plans to have processes in place to allow BAE to be accepted at the point of sale. If health plans do not have scripts in place to assist their member services and pharmacy help desk staff, then they must be developed and put in place to support members requesting assistance with BAE-type issues.
- Online Enrollment Center (OEC) Application Receipt Date – One policy change this year is the way the receipt date is calculated for OEC applications. Plans need to calculate the receipt date to 11 hours earlier than the time and date stamp provided on the CMS file.
- Non-Discrimination and Alternate Language Tagline Language – CMS also raises the new requirement for Non-Discrimination and Alternate Language Tagline translation language plans are now required to distribute to their members. CMS is requiring plans to verify they have processes in place to satisfy these new requirements.
This year’s release is earlier than previous years, allowing plans more time to validate and implement all actions. Similar to last year, CMS has changed the attestation process for the 2017 Readiness Checklist to a strategic conversation between plans and their CMS Account Managers. Without that formal attestation process, don’t devalue the Readiness Checklist and required actions – utilize the tool as the valuable resource it is which will ultimately make your health plan better and your members safer. To err is human, and for that reason, redundant validation is a critical step to make sure your program is ready for 2017.
Our consultants have implemented items from the 2017 Readiness Checklist for health plans just like yours. If you need assistance verifying you are ready for 2017 or have questions on your processes, we can help. You can reach us through our website or by emailing me directly at jbillman@ghgadvisors.com.
Resources
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Plan Now for Performance
As 2016 comes to a close, planning for next year should be well underway. Bids are in, and budgets for the current year are being evaluated against reality before next year's strategies are finalized. As the ACA continues to evolve, CMS has been busy with new programs and more oversight. A plan or provider has to be vigilant about identifying any weaknesses that could mean high costs or low expectations relative to budget. Parent companies have to be aware of line of business similarities and differences as Exchange and Medicaid business become more like Medicare Advantage in terms of programs and benchmarks. A recent article from Kaiser on retention makes great points about the line of business impact on retention and how it is a simple metric that encompasses many operational issues.
GHG is constantly improving its tools to identify outliers as well as relationships between different metrics that cross department lines. Finding root causes and quantifying them for the organization are more impactful than just handling them on an ad hoc basis. Just like compliance is everyone's responsibility, so is financial performance. Identifying weaknesses AND leveraging strengths combine to form a more complete business model for sustained growth.
GHG can prepare a tailored snapshot of your market and your company's performance. Contact us here.
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New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Helping Your Providers Assess Their Ability to Take Risk
We have often noted when a team works well together, it can collectively accomplish more than its members alone. This adage has never been truer than the looming Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) legislation and the steps providers will need to take to make a successful transition.
Your network providers, especially the individual and small groups, have been inundated with and trying to digest huge amounts of information from all directions on how to prepare for the changes that are coming. A significant portion of the information providers have received on where they rank compared to their peers on quality metrics has come from benchmarks established by the health plans with whom they are contracted. It also is understood providers have been wary of the data they have received. Real-time, transparent data has been at the top of the list for providers when building trust and long-term partnerships.
As health plans, 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, not only in their ability to take on risk and make the shift from fee-for-service 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 wrong office addresses, the lack of staffing makes it difficult for the office to have time to digest the information we are sending, or it is not getting into the hands of the correct person. The lack of correct provider demographics affects the ability of your risk adjustment team to gather the information they need in a timely manner.
Another observation to note is while your representative is there with the best of intentions to review provider data and offer suggestions on how to improve and capture bonus dollars left on the table, they are one of many reps sitting in the office vying for a minute to talk with the office staff. It is a juggling act for the provider to be able to provide top-notch clinical care for his or her patients and meet the demands of a new value-based world. In order to ensure your largest asset is prepared, why not empower your network with a checklist on how to evaluate their practices? We have provided a comprehensive checklist providers can utilize to examine the skills, knowledge, systems, and questions they should ask themselves when evaluating their ability to navigate the new reimbursement landscape.
Gorman Health Group is poised to assist your plan in developing a fully engaged provider architecture to ensure the cross-functional needs of all your department "asks" come to the provider at the right time for shared success.
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We have provided a comprehensive checklist providers can utilize to examine the skills, knowledge, systems, and questions they should ask themselves when evaluating their ability to navigate the new reimbursement landscape.
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
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CMS Releases Long-Awaited Civil Money Penalty Calculation Methodology
On September 13, 2016, the Centers for Medicare & Medicaid Services (CMS) quietly released its long-awaited proposed methodology on the calculation of Civil Money Penalties (CMPs). The memo describes the calculation method of CMPs for Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), Cost Plans, and Programs of All-Inclusive Care for the Elderly (PACE) plans in 2017. While CMS is not mandated to release this methodology, it did so in response to industry concern over transparency of CMP calculation and to provide more clarity to compliance operations. Comments on the proposed methodology are due to CMS by 5:00 p.m. ET on October 13, 2016.
Given that 60% of the referrals for potential enforcement actions stemmed from MA and Part D program audits, this memo focused on CMP calculations for deficiencies detected during such audits. For each deficiency identified, CMS determines whether the sponsor:
- Failed to substantially carry out the contract;
- Is carrying out the contract in a manner inconsistent with the efficient and effective administration of this part; or
- Is no longer substantially meeting the applicable conditions of 42 C.F.R Parts 422 or 423.
CMS then calculates CMPs on a per enrollee or per determination basis, as developed during its pilot, to standardize CMP calculations in 2014. The main difference CMS made between the pilot and its proposed calculation is the slight increase in penalty amounts over time to "encourage" compliance with CMS' rules. CMS also introduced an enrollment-based limit on the maximum CMP amount a sponsor can receive for each deficiency.
CMS calculates the standard penalty amount by taking the CMP amount and multiplying it by the number of enrollees or determinations. CMS then applies the aggravating and/or mitigating factors, multiplied by the number of enrollees, to the CMP which either increases or lowers the amount. Finally, CMS applies the enrollment-based or per determination limit, which caps the overall penalty CMS can issue.
The specific amounts CMS applies for the above can be found in the memo.
"In my daily conversations with Compliance professionals, the challenge to compile clean universes on the first pass is still that — a challenge — regardless of plan size," says Regan Pennypacker, Senior Vice President of Compliance Solutions. "This memo clarifies the agency will also consider Invalid Data Submission (IDS) as a condition that could result in beneficiary harm. This is cited when a Sponsor fails to produce an accurate universe within three attempts. CMS has noted this would be cited for each element which cannot be tested, and counts as one point in the scoring. CMS will calculate a CMP for this deficiency on a per determination basis."
This proposed methodology comes during the same time frame federal agencies are increasing CMP maximums across the board to comply with the Federal Civil Penalties Inflation Adjustment Act of 2015. The Department of Health and Human Services (HHS) released its interim final rule on September 6 across all its agencies. Some MA maximum penalties will see a maximum increase more than double its current amount. However, as the CMP methodology memo points out, CMS rarely utilizes the maximum amounts currently, instead using amounts that are likely to "better encourage the remaining non-compliant sponsors to improve performance." Currently these amounts are significantly lower than the maximum possible CMPs, however, this memo clearly puts plans on notice continued non-compliance will lead to increased penalty amounts that will cause a greater sting. Given this notice penalties among health plans for common infractions will increase, health plans should make sure to focus on highest risk areas like delegation oversight and appeals and grievances.
Now is the time to confirm those responsible for pulling and compiling CMS universes are equipped with the tools and skills to complete the task. Failure to produce accurate universes after a third attempt during an audit will significantly impact a CMP. Contact us for ways we can help.
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The Centers for Medicare & Medicaid Services (CMS) audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. Visit our website to learn how we can help you >>
New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 — 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>