Key Components in Shared-Risk Pool Reporting

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 well as providers teaming up with other providers on initiatives such as the bundled payment program. As health plans continue adapting to the growing influence of clinical/quality and value-based care and reimbursement, building an effective patient management workflow along with financial reporting systems between plans and providers engaged in risk arrangements has never been more important.

In order to effectively manage risk dollars we have to first manage our patients in real time. We need to continue to strive towards effectively managing where our patients are at a particular point in care, what services they are currently receiving and by whom, and what their next step is in the care continuum. It is a balancing act in juggling disparate electronic health records (EHRs), an outcropping of new vendors, and community-based services providers who are new to managed care. While we continue to put patient care first, against a backdrop that still has not found the perfect solution, we need to design and implement metrics that can be meaningful and measurable to ensure the care solutions we are implementing are working clinically while reducing the total cost of care over our population.

The key components to any successful risk-based or percentage of premium contract are transparency and timeliness in reporting. Without transparency, there can be no trust in the relationship, and without timely reporting, we are unable to elicit change in a meaningful time frame. Effective management reports prepared on a periodic basis should address provider budgets versus actual performance under risk-based agreements. Baseline items to review are:

  1. Allocation (Revenue)
  2. In-Network Claims
  3. Out-of-Network (OON) Claims
  4. Incurred But Not Reported (IBNR)
  5. Reinsurance and Stop Loss
  6. Per Member Per Month (PMPM) Budget
  7. Administrative Charges/Fees

In addition to the above, plans and providers should have a clear delineation of financial responsibility, contract terms, operational items such as authorization process, and all state and federal compliance requirements. As relationships develop and expand over various populations and lines of business, your reporting models should be consistent, scalable, and reduce the administrative burden on the providers. At the same time, with the continued issue of data integrity, shared risk is also a perfect time for providers to step up and support their health plan partners by providing current provider and practice information. The improved member satisfaction that comes with correct information will be a win-win for both sides.

At Gorman Health Group, we can provide the cross-functional expertise you need to help your health plan team and providers be exceptional.



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CMS MA Proposed Rule: Star Ratings Updates

Last week, the Centers for Medicare & Medicaid Services (CMS) released a Proposed Rule allowing expanded access to telehealth services for Medicare beneficiaries, streamlining appeals processes for beneficiaries in Dual Eligible Special Needs Plans, helping CMS recover improper payments to plans based on Risk Adjustment Data Validation audits, and continuing to increase the stability and predictability for plans relative to Star Ratings.

CMS’ Star Ratings proposals demonstrate their willingness to evolve the Star Ratings program to eliminate at least some of the longstanding (and frustrating!) volatility and unpredictability within Star Ratings, which should be a welcome change for Medicare Advantage (MA) plans. Key Star Ratings proposals include:

  • Implementing cut point guard rails for non-Consumer Assessment of Healthcare Providers and Systems (CAHPS®) measures to prevent cut points from increasing or decreasing excessively from one year to the next,
  • Enhancing the cut point calculation methodology for non-CAHPS® measures to better eliminate the effect of outliers, and
  • Enhancing adjustments for extreme and uncontrollable circumstances.

CMS also presented proposed measure changes for future Star Ratings calculations:

  • Controlling Blood Pressure will be retired to display for the 2020 and 2021 Star Ratings, with a planned return as a 1x-weighted measure using the new Healthcare Effectiveness Data and Information Set (HEDIS®) 2019 measure specifications beginning with the 2022 ratings. The HEDIS® 2019 changes to this measure are substantive, including updates to reflect new hypertension treatment guidelines from the American College of Cardiology and American Heart Association and significant structural changes (including allowing two outpatient encounters to identify the denominator, allowing the use of telehealth for at least one of the denominator instances, adding an administrative approach to allow Current Procedural Terminology (CPT) Category II code collection, and allowing remote monitoring device readings for the numerator).
  • Plan All-Cause Readmissions will be substantially modified by the National Committee for Quality Assurance (NCQA) for HEDIS® 2020. As a result, this measure will be moved to display for the 2021 and 2022 ratings. HEDIS® 2020 measure changes are expected to include addition of observation stays in the measure, removal of individuals with high frequency admissions from calculations, and expansion of the calculation to include all members older than 18. Small plans may benefit from the proposed changes, as NCQA is also recommending a minimum denominator of 150 in the enhanced calculations.
    • The current MPF Price Accuracy measure will remain the 2020 and 2021 ratings using the current methodology, and the enhanced methodology will be used beginning in the 2022 ratings.  The proposed measure updates capture both the magnitude and frequency of differences between a contract’s Medicare Plan Finder (MPF) advertised prices and the actual pricing at the point of sale.

CMS seeks feedback and input from plans regarding these proposals and will accept comments through December 31, 2018. As we always do, we strongly encourage our clients and other MA plans to provide feedback and alternative proposals to CMS. We’ll provide an update as soon as these proposals are finalized. In the meantime, if you need help with your Star Ratings program or performance, we can help. Please contact us with questions or for more information.


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Medicare Advantage 2020 Proposed Rule

It’s been a long wait since the passage of the Bipartisan Budget Act in February, but the 2020 Medicare Advantage (MA) proposed rule is finally here. Perhaps the biggest opportunity for plans is the shift that makes telehealth a basic benefit, which means the digital revolution that brought us things like ATMs on every corner, iPhones, and Teslas is finally seeping into Medicare. Plans can decide which benefits to provide via telemedicine in any geography. What is really exciting is the service can be delivered to the patient in the home. This is a tremendous opportunity to bring continuity to episodes of care that will really impact outcomes. It will also be possible for plans to offer telehealth services as a supplemental benefit. Additionally, it’s an opportunity for MA to offer new advantages over Original Medicare where telemedicine is still restricted to rural areas and the patient must be in a health facility to partake in the services.

Star Ratings are in for some changes, too. Measures with proposed changes will include Medicare Plan Finder price accuracy, all-cause readmission, and controlling high blood pressure.  Additional enhancements will be made to CMS’ methodology to adjustments will be made to handle unusual situations beyond a plan’s control like the fires and hurricanes that seem to be less unusual as of late.

The Centers for Medicare & Medicaid Services (CMS) gives, but, unfortunately, it also takes. On the program integrity side, the agency proposes using extrapolation in the Risk Adjustment Data Validation audits. That is a definite cloud on the horizon for plans as the regulation predicts a return to the program of $4.5 billion for the government over 10 years. Since 2012, CMS has held extrapolation from a valid sample of records was coming, and now there is an opportunity to comment on the specific methodology that might be used. Comments on the proposed rule are due 12/31. Happy New Year.



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Inside MA-PD Premium Trends

With the release of the 2019 landscape files, benefit information and Star Ratings data, now is the time to update your market analyses to understand trends in your current and potential markets. Nationwide, 2019 monthly premiums for Medicare Advantage Prescription Drug Plans (MA-PDs), excluding Special Needs Plans (SNPs) and Medicare-Medicaid Plans (MMPs), range from $0 per month to $388 per month, with the average monthly premium being $51.21. The average monthly premium of MA-PDs decreased from 2018 by 23%. While a decrease aligns with the overall premium trends since 2016, this level of decrease is unprecedented. The overall decrease in the 2019 average monthly premium is nearly four times the average premium decrease seen in 2018 (8% decrease) and seven times the average premium decrease seen in 2017 (3% decrease). Since 2016, MA-PDs have seen an overall decrease in monthly premium amounts by 31%, from $74.25 to $51.21 – a $23 decrease. How have premiums changed in your market(s)?

As discussed often in recent years, $0 monthly premium plans are on the rise. Notably, nearly half (44%) of MA-PDs have a $0 monthly premium. This segment saw the most growth in the distinct number of plan benefit packages (PBPs) offered with an increase in nearly 300 new $0 MA-PDs. The premium segment that saw the second most growth in the distinct count of PBPs from 2018 to 2019 is MA-PDs, with a monthly premium between $1 and $50; 28% of MA-PDs fall in this premium range, with an increase of nearly 121 PBPs. Additionally, the number of PBPs available with a monthly premium over $150 has decreased since 2016. Gorman Health Group (GHG) expects to see these trends continue.

While 44% of all PBPs are $0 monthly premium plans, over half (56%) of all Health Maintenance Organizations (HMOs) are $0 premium plans, and 75% of $0 premium plans are HMOs. We expect to see the number of $0 PBPs to continue to increase, especially in the HMO product. Remarkably, nearly 30% of Preferred Provider Organization (PPO) products are $0 premium plans. For 2019, there are an additional 124 $0 premium plan PPOs available. This is nearly three times the overall $0 PPO growth in 2018. With the growth in availability of $0 PBPs, Medicare Advantage Organizations (MAOs) will need to continue to push for innovative product design benefits to remain competitive. Even $0 premium plans need to explore creative ways to make their plans stand out in the $0 crowd.

The average monthly premium by state (excluding Puerto Rico and territories) ranges from $129 in North Dakota ($129.13) to $17 in Florida ($17.01). As in years prior, the states with the highest average premium are found in the plains states region – North Dakota ($129.13), South Dakota ($104.40), and Minnesota ($104.36). This is not surprising as these states continue to have large enrollment in Cost plans, which are traditionally structured to have high premiums. For example, in 2019, the average monthly premium of Cost plans is $130.43.



So what does this all mean for you? Now is the time to replicate a similar analysis to understand your current and/or potential markets. Additionally, assess the key benefits offered, including ALL supplemental benefits. Some of these benefits include the maximum out-of-pocket, inpatient hospital cost sharing, primary care physician and specialist cost sharing, and supplemental benefits like routine dental, vision, and hearing – and don’t forget to assess plans offering targeted supplemental benefits. How do your plans stack up to the competition? Are you growth goals for this coming Annual Election Period (AEP) realistic? Are your AEP marketing and sales strategies ready to face the competition and meet growth goals – what can you adjust? What must you consider for 2020? No, it’s not too early to start planning – product and benefit development is a year-long process.




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The 2019 Star Ratings Are Out!

The 2019 Star Ratings are out! While our experts crunch the numbers and analyze the data, here are a few “fast facts:”

Of the 360 contracts rated in both 2018 and 2019,

  • 80 earned higher overall ratings in 2019 compared to 2018
  • 90 earned lower overall ratings in 2019 than in 2018
  • 190 maintained the same rating in 2018 and 2019

The more things change, the more they stay the same.

  • 45% of Medicare Advantage Prescription Drug Plans (MA-PDs) (170 contracts) earned 4+ stars in 2019, compared to 44% (170 contracts) in 2018
  • Approximately 74% of MA-PD enrollees are currently in contracts that will have 4+ stars in 2019, compared to 73% in 2018
  • The 2019 average Star Rating (weighted by enrollment) is 4.05 in 2019, compared to 4.07 in 2018
  • 376 contracts met the criteria to receive an overall rating in 2019, compared to 385 in 2018
  • Humana (with 84% of its 3.5 million members in 4+ star contracts), United (with 70% of its 5.4 million members in 4+ star contracts), and Kaiser (with 100% of its members in 4+ star contracts) continue to dominate the competitive Medicare Advantage (MA) Star Ratings arena

Sponsors with the most members impacted by year-over-year changes in the overall ratings are among industry giants:

  • Some of the big winners in 2019 include Cigna, Highmark, MCS, Wellcare, and Centene
  • Among those with the most members in contracts earning lower ratings in 2019 are United, Anthem, and Blue Cross and Blue Shield of Minnesota

Although the Star Ratings headwinds are strong for new plans, sponsors continue flocking to MA:

  • 22% of contracts operating less than 5 years earned 4+ Star Ratings in 2019, compared to 41% of contracts operating between 5 and 10 years, and 54% of contracts operating more than 10 years
  • 210 contracts were not rated in 2019 because they were too new to receive a rating or did not have enough data to be rated, compared to 168 in 2018

See a trend in the Star Ratings you’d like us to comment on in our upcoming Star Ratings webinar? Get in touch with one of our experts, and we’ll address it in our webinar!


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Bundled Payments Report Issued

Bundled payments capitate medical care at the episode level. It is one of the few “value-based” approaches the Centers for Medicare & Medicaid Services (CMS) and the Innovation Center have fielded that works. But it doesn’t work for the taxpayers, at least not yet. If you stop and think about it, the whole Prospective Payment System (PPS) is basically a bundle approach. It tied together a lot of individual hospital services that used to be separately billed and gave hospitals an incentive to be efficient. And were they ever: the average length of stay dropped 17%! The newer approach expands the bundle, in some cases to every part of the episode, including physicians, hospital, post-acute, and home health. Before the Affordable Care Act (ACA), CMS ran some demonstrations that proved the concept, yielding savings a bonus for doctors, and savings for the government and the patient, too, with reduced copayments. A further expansion under the ACA was promising, so the Obama Administration jumped ahead with a mandatory program for hip and knee replacement in 66 localities. The hospitals cried foul, but many had success and enjoyed bonuses. After the 2016 election when Tom Price became Health and Human Services (HHS) Secretary, he pared back that program just as results showed it was successful.


Keep in mind Medicare spends between $16,500 and $33,000 on knee or hip cases. Average charges in total approach $50,000 in the U.S. If you are mobile, you can get it done for less than $10,000 in India!


The Lewin Group delivered a report to CMS this week on the fifth year of the voluntary bundled payment initiative that was started under the ACA's Innovation Center in 2012. As in earlier years, the great majority of activity was in joint replacement episodes, and while there was little impact on quality for better or for worse, there were savings in spending on the services. Those savings were generated by reductions in post-acute care, both inpatient and home health. Unfortunately, the government didn't get any benefit, and the providers did because it was an upside-only risk approach. The newer “advanced” Bundled Payments for Care Improvement (BPCI) initiative, which is getting started now, will put providers at risk. Sophisticated providers are ready to play in this new space. This is where health reform is happening – initiatives that align providers’ incentives with the goals of public programs. Health plans and provider groups that stay focused on CMS’ strategy will be the winners going forward.



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Why Investing in Your Staff Will Benefit Your Members

I started my career working in social services. I wanted to change the world, as many of us do in our youth. When my family needed health insurance, I applied for a job with a health insurance company. It was an unexpected career change, but I was fortunate as I had an amazing mentor who taught me a different view point of my job. She expanded my view and taught me to see the big picture of making our members’ lives better. Was I in case management? Maybe a social worker interacting with members? No, I was a customer service representative and then an enrollment supervisor. But she gave me vision of how my job touched our members and made a difference.

Mentoring is a fine art. As the talented poet Robert Frost said, “I’m not a teacher but an awakener.” Ask yourself this, no matter your position or role, can you say that? Are you a teacher or an awakener?

It is that vision and passion that makes the difference. I learned from a few key people in my career what that looks like, and it changed my world. Today, in many ways, that skill is lacking, and it is time to bring it back. As you consider your role, and that of those on your team, what can you do to awaken those on your team to be part of the bigger change to your culture and member experience?

Some suggestions that guide me are:

Always Remember: “It’s All About the Member.” I remember very early in my career a call that impacts me still today. A member called in distraught. His wife, also a member, was dying. She was in a nursing home and didn’t have long to live. Her family had made a blanket for her, and it had disappeared. Aside from it being a participating facility, it had nothing to do with our insurance. But it had a world of impact to them. I worked for a company that valued that and allowed me to follow up to make sure the blanket was found and returned to the member. I also had the freedom to take this man’s calls as much as needed.

Systems Are Tools. Automation is great. It allows us to be efficient and focus on the things that need our attention. Auto-adjudication for claims or enrollment gives us the ability to focus on the fallout that can’t auto process. What happens often is that systems replace training and knowledge. Staff no longer know “why” the system is doing something. It makes problem resolution and oversight far more challenging as often issues are not identified quickly. Process improvement and automation are amazing tools, but don’t let them replace a knowledge and training about the behind-the-scenes requirements.

Our Staff Need Us. Management is in meetings and often behind closed doors. That leaves a gap. Where does your staff go when they need help? Is it counted against them to ask for help? Does your staff feel like you understand their barriers and are working to eliminate them? Do you give them the opportunity to grow and be challenged in a supportive environment, or is it more “sink or swim”? If we really want member-focused staff, we need to be staff-focused managers.

First Call Resolution Is Only Valuable When It Is the Right Resolution. Is first call resolution more important than the right resolution? More and more I am hearing plans say they are not giving their members homework. What a refreshing philosophy. You may not be able to fully resolve an issue on the first call because more research or activity is needed to prevent that “homework.” Sometimes that is what excellent service requires.

My team includes some of the most talented, engaged people in the industry. They understand mentoring and strive to bring that to each project. A recent example is a colleague of mine. She recently worked with a client and had a location called “Katie’s Learning Lab.” Operations staff could stop in and ask questions and get clarifications when they didn’t know what to do. It gave a sense of security; there was a place to get help without judgement. Katie invested time with the staff. She gets it. She knows that until staff have a mentor to show them their place in our members’ world, it’s just a job when, in reality, it’s people’s lives. And we have the amazing ability to positively impact them.

We understand enrollment and customer service representatives as well as analysts well-versed in MA (and engagement with seniors) are in short supply in most markets.

If interim staffing to support your front line staff is what you need to ensure a successful enrollment season, GHG can enhance your team with our own mentors, providing knowledgeable, effective assistance and an eye for detail from staff with decades of experience.

Here are suggestions to ensure your team is effectively trained to make every member touch count.


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Streamline Your Medicare Enrollment

Large Medicare Advantage carriers invested a median of $11.25 per member per month in marketing in 2015, and spent a median of $17.44 on account and membership administration, according to a Sherlock Company analysis. With that kind of spending, the last thing a carrier needs is for seniors to become confused and frustrated by the enrollment process, but that is exactly what happens when carriers rely on technology that is not up to the task.

Pain points in the enrollment process include intake, eligibility verification, enrollment acceptance and validation, and benefit activation and notification. Each is subject to federal regulations with which compliance is paramount, and at each step, consumers can run into problems, become frustrated and abandon the process.

Many MA enrollment platforms were initially designed for use by commercial health plans and retrofitted to Medicare, and these patchwork systems make for a disjointed, unfriendly consumer experience. Applicants are dropped or told they are ineligible, benefits are never activated, or the applicant is never notified of acceptance and activation. In the age of Amazon and Apple, this is unacceptable. The MA space is extremely competitive, and seniors who encounter enrollment problems with one carrier are likely to look elsewhere.

A single platform designed specifically for Medicare Advantage with capabilities to support the full enrollment lifecycle offers a better way to deliver return on your plan’s marketing investment.

A purpose-built system should guide the user with smart wizards that make it easy for customer service and sales teams. It should minimize the possibility that eligible applicants will be rejected and handle reinstatements with ease. It must accept enrollment applications in paper, electronic and telephonic formats, all of which remain important in this market. And it must capture all CMS-mandated information, regardless of the enrollment source.

Once an enrollment application is accepted into the carrier’s system, it must be transmitted to CMS for verification. An enrollment module that identifies eligibility verification errors and flags them for repair cuts down on the percentage of applications rejected by CMS – a serious problem with patchwork systems. Ideally, avoidable rejections should be reduced to a fraction of a percent, well below the CMS 1% threshold.

After an application is validated and accepted, beneficiaries must be notified within a CMS-mandated period. The right platform should be able to handle this task, too. It must reduce compliance and quality risk and keep track of ever-evolving Medicare regulations.

A purpose-built system offers the additional advantage of bridging integration and interoperability gaps between multiple systems and processes, improving efficiency and the member experience. Systems that include a module for tracking enrollment to the marketing or broker source allow plans to identify problems and further optimize marketing for future growth.

MA plans that rely on a patchwork of modules that have been tweaked and cobbled together shortchange the enrollment process, and they risk losing customers to competitors who understand the importance of a smooth, smart and efficient process. An intuitive, compliant, end-to-end system is the solution for a better consumer experience, improved market share and far fewer administrative headaches.

Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans.  Convey provides member management solutions for the rapidly changing health care world. Learn more.


First seen on SmartBrief.

For information on the other solutions Convey has to offer, please follow this link.




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Network Development in the Era of Relaxed Supplemental Benefit Regulations

As we saw in this year’s Centers for Medicare & Medicaid Services (CMS) regulations, Medicare Advantage (MA) plans are gaining greater flexibility to design and offer new types of benefits to service their members. While the information was provided after many plans had already put significant time into their Contract Year (CY) 2019 bids, we anticipate in CY 2020 to see MA plans branching out and offering more variation and specialized benefits geared towards their population.

When MA plans begin to formulate their sales and marketing strategy and determine the impact a variety of benefits could have based on addressing the particular social determinates of health that most impact their geographic area and member population, we begin to see a vast gap in the playing field from plans staying close to the basics with meals and non-emergent transport to plans willing to take more risk, having unexpected cost and the willingness to invest in innovative benefit options without knowing the exact return on investment the benefit will have on patient outcomes or financial upside/downside cost. We may see an upswing in partnerships with transitional assisted living to skilled nursing facilities, vendors offering adaptive aids to keep patients in their homes longer, meal or grocery delivery services, as well as an expansion on transportation services.

From a Provider Network perspective, the move forward with new partnerships will likely present a few stumbling blocks along the way and offer a ramp-up period we do not see with traditional MA providers. We encourage you to start early and break down the silos by having group discussions to include Sales & Marketing, Medical Management, Star Ratings, Operations, and Provider Network. The new providers are likely going to be dipping their toes in the same deep end of the pool, and extra lead time and planning will serve you well.

We would encourage all MA plans to have:

  • Planned education sessions/town hall meetings to educate and get to know the new vendors/providers and hear what their needs are
  • Plan for a more lengthy contracting process
  • Plan for additional onboarding and training with the new vendors
  • Allow for additional member education time



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How to Avoid Network Development & Expansion Pitfalls

Network management, directory accuracy, service area expansions (SAEs), and the new triennial review process have placed many Medicare Advantage (MA) plans in flux and exposed serious issues – from policy to process to staffing and technology. As we move into the countdown for network development and expansion for 2020, a review of lessons learned will be helpful in planning and avoiding some of the pitfalls from 2019.

  • In previous years, plans submitted their Health Service Delivery (HSD) tables with their applications, and, by the end of April, there was clear insight into which counties the Centers for Medicare & Medicaid Services (CMS) deemed to have an adequate network. This year provided a new challenge with bids being submitted prior to HSD tables being uploaded and reviewed by CMS.

As multiple new regulations on network adequacy and directory accuracy have been implemented, a lesson learned by many is there can never be too much communication and oversight in managing provider network contracting and credentialing data.

  • Overall project management and poor communication between outside vendors during an expansion can lead to stressful situations and put the plan at risk for compliance actions. Planning ahead and including oversight and transition plans at the start of any project can lessen the risks down the road.

Here at Gorman Health Group, we have been brought in and have identified situations described and have outlined extensive work plans to include policy and procedure (P&P) changes, technology updates, network development plans, compliance solutions, and assisted plans in working through the corrective action needed.

We can’t stress enough how the cost of prevention and planning on the front end becomes even more cost effective when faced with correcting on the back end.

Summer is the best time to be proactive and start planning your next SAE or even your first step into the MA world. Alternatively, perhaps, summer offers just the right amount of downtime to start planning for updated oversight policies.

As you start your initial or expansion planning process and set new network monitoring processes in place to ensure preparedness, consider this: Gorman Health Group has a long history of providing the following:

  • Leveraging long-standing relationships and nationwide experience coupled with a cost-effective team of Senior Consultants and Network Analysts to effectively stand up a contracted provider network
  • Designing and developing a network strategy and product strategy that take into account the quality, financial, risk adjustment, and Star Ratings goals for success within the competitive landscape of your market(s)
  • Developing the oversight and monitoring P&Ps needed to address the new network and directory requirements
  • Preparing plans’ HSD tables for a CMS filing or bid submission as well as preparing network exceptions to include all the required elements.

Let us know how we can work together now to support your plan’s goals for the future. We’ve been there, fixed that, and will ensure your success. Contact me directly at




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