Breaking the Incompatibility Barrier — Four Keys to Merging Operational Productivity and Compliance
Can compliance and efficiency co-exist in Operations? Is there a "right" balance between the two, or could it be more of an intertwining of the two? If you have been in Operations long enough, you have been told you have to increase efficiency, reduce staff, and improve handle time or auto-adjudication rates. What you probably have not been told is to be more compliant, except maybe by the Compliance Department. Widgets in, widgets out, is the name of the game.
It's a lot of plates to keep in the air, trying to balance more with less, and now we add in compliance. What if compliance and productivity cannot only co-exist but can cause a department to thrive? Here are the four critical keys to an intertwined compliant, productive Operations team.
- Don't Ignore the Human Factor — Productivity and compliance are both reliant on employees. All the best tools, reporting, and systems can be in place, but if well-trained and engaged employees aren't on the team, we won't have well-run productive and compliant processes and teams. Employee engagement, like member engagement, is critical to success.
- Know the "Why" behind an Action — We need to change compliance from an obstacle to be circumvented to a process to be embraced. We do that by showing the relevance to the process — the "Why." Have you asked your team what the critical Centers for Medicare & Medicaid Services (CMS) requirements are for the activities they perform? Does the Claims staff know the time frames for processing a claim or the requirement for a clear and understandable denial reason? Even more important, do they know why those requirements are in place and how they impact the beneficiary?
- Have the Right Tools — Do you know how many manual work-arounds your team completes on a given day? How many member communications must be manually completed? How much manual research is needed to adjudicate a claim? Does your management know? IT changes are costly and take time, but we must get things on "the list." That's why a current prioritized list of enhancements is needed. Make sure to document the productivity and compliance loss due to the work-arounds. Include team member's input — their voice is important to understanding the true issues. Spearhead the top critical needs on the earliest IT release possible.
- Provide Measurable Results of Success and Failure — How do you and your teams know when you are successful or when you failed? Do your reports show both your production and compliance goals? Typically, Operations has lots of reports, but how are they aligned — with commercial or Medicaid metrics or the unique Medicare metrics? Is this shared with your team?
In the Medicare world, Operations can't be a balancing act — it's all about intertwined compliance and productive Operations teams. At Gorman Health Group, we know how important it is to link compliance and productivity. For actionable advice on this topic and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas.
During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
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Register your team now through February 14 for the 2016 GHG Forum, and take advantage of our standard registration rate of $1,095 before the price goes up to $1,295 on February 15. Register now >> For more details around the event and agenda, download the full conference brochure or visit our website.
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Risk Adjustment: Proposed Changes & New Regulations
At Gorman Health Group (GHG), we pride ourselves on having our fingers on the pulse of what continues to be a complex and volatile government programs environment. Whether it is fact or fiction, our clients and our peers look to us to interpret and filter through the official announcements, the breaking news, the propaganda, and the hype.
Being accountable for GHG's Risk Adjustment division keeps me and our team of consultants quite busy, and just when other departments get to breathe for the holidays, we are inevitably fielding questions and providing "home stretch" support to clients as they prepare for the final submission of risk adjustment data. (In case you missed it, CMS published this memo outlining extended deadlines for data submission.) See full memo here.
If you live in the risk adjustment world, you know this critical business function never really takes a holiday. The Centers Medicare & Medicaid Services (CMS) calendar for data collection and submissions leaves little room for vacations, especially knowing risk scores recalibrate annually and the work to ensure complete and accurate diagnostic data for Medicare Advantage (MA) beneficiaries requires a watchful eye at all times. The reality is, either your hair is on fire, or you just sent the guy in the cube next to you out to refill your propane tank.
Whether we are in the trenches with our clients, or supporting them from afar, GHG is always keeping an eye on what is coming next. So, while you were collecting charts and checking them twice, and making sure your In-Home Assessment vendors were sending information to your Case Management department, here is what has been coming across the wire…don't worry, we have been keeping tabs on all of the critical activity in the risk adjustment space:
October 28, 2015: CMS announces proposed changes to the CMS-HCC Risk Adjustment Model for Payment Year 2017 which would apply "improved predictive ratios" for full benefit and partial benefit dual-eligible beneficiaries.
November 4, 2015: CMS admits to having underpaid dual-eligible health plans and, in turn, overpays for beneficiaries with low medical costs, sparking concern not only about inequities in payment, but the potential for adverse selection.
December 2, 2015: CMS released an early preview of 2017 MA Ratebook Growth Rates, signaling a hopeful bump in MA plan payments due to a 3.1% increase in traditional Medicare spending in 2017. This is one variable in the equation. Risk adjustment calculation changes and other policy changes will complete the puzzle. More to come on February 22 when CMS releases the Advance Notice for 2017. Stay tuned.
http://www.modernhealthcare.com/article/20151202/NEWS/312029999
December 28: CMS released a Request for Information outlining the expansion of Medicare's Recovery Audit Program in an effort to identify instances where Medicare is overpaying.
http://www.modernhealthcare.com/article/20151228/NEWS/151229937
January 14, 2016: The Medicare Payment Advisory Commission (MedPAC) voted to pass recommendations which would change how MA plans are potentially paid, potentially saving CMS $5 billion and revealing its position on In-Home Assessments and Star Ratings Quality Bonus Payments.
http://www.modernhealthcare.com/article/20160114/NEWS/160119925
January 22, 2016: This one has a bit of a political spin to it, but we thought it was worth reporting. AHIP released a funded analysis conducted by Avalere Health, finding the risk adjustment model used by CMS "lowballs" the cost of treating chronic conditions such as depression, osteoarthritis, chronic pain, and rheumatoid arthritis by millions, and, in some cases, billions of dollars.
http://www.modernhealthcare.com/article/20160122/NEWS/160129948
Just like our consulting services and our analytics solutions, we assessed the current state of the Medicare risk adjustment industry, collected our findings, and delivered meaningful, actionable information which will keep our clients and readers informed and prepared for what lies ahead in 2017.
A more in-depth analysis and industry-leading commentary on the key announcements from CMS and MedPAC can be found in this recently created whitepaper.
For additional questions and inquiries about how GHG can support your organization's risk adjustment programs, please contact me directly at dweinrieb@ghgadvisors.com.
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Whether you rely on multiple vendors or a largely internal team, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>
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Sales 2017 Readiness — Are You Maximizing Your Sales Potential Today?
Here we go again, planning for the upcoming selling season. Every year it seems to approach more quickly than the year before. Are you ready? If the answer is no, or you are not sure, here are a few critical items to consider as you create your 2017 Annual Election Period (AEP) strategy:
- Market Analysis — What worked during AEP 2016? This is the time to reflect on strategies which helped and/or hindered your success from the previous year. While it's fresh in your mind, create a market analysis to review all the components of your sales process. From material distribution to product design, it's important to understand what components of your strategy worked and what needs to be adjusted.
- Channel Mix — Do you have the right mix of agents to represent your plan? It's important to evaluate the effectiveness of both your internal and external sales forces. The industry is moving toward a more diverse distribution channel. The need for internal and external field agents, coupled with telesales, helps maximize your footprint and reach all corners of your market.
- Seminar Plan Development — Did the materials you provided keep your agents compliant during their presentations? CMS secret shoppers are out in full force, and having the right tools for your agents will be imperative to high Star Ratings. In addition, baby boomers are also forcing us to rethink how we present products to Medicare beneficiaries. With the growth of internet shopping, online enrollment presentation opportunities must be included as a part of your strategy.
- Marketing — Did your direct mail make the phones ring, or did your marketing miss the mark? How you implement your marketing strategy impacts lead flow, brand awareness, and enrollment. Successful marketing programs deploy a multi-touch communication strategy which blends education, lead generation, and conversation tactics to maximize new member acquisition.
- Sales Training — Was your sales force ready to sell your plan? Sales training is a critical part of plan and agent success. Create a curriculum which encompasses sales and product training, time management, Medicare basics, and compliance. Don't forget to teach them about member retention―it's hard enough to acquire new members, so you also need to know how to retain them. Enable your agents to start the season with all the knowledge needed to make that sale and keep that new member on the books.
With the narrowed time frame for AEP, your sales strategy must continually change to adjust to the Medicare climate. What worked last year may not work this year. Don't delay, the time is now―start planning for your success today!
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
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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 >>
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To File or Not To File, That Is the Question
We've made it clear through this blog the Centers for Medicare & Medicaid Services (CMS) is throwing down the gauntlet in terms of ensuring Medicare Advantage provider networks are adequate. The biggest change to the 2017 application process supports this initiative. For Service Area Expansions, CMS is requiring current service area network data at the contract level in addition to the pending service area data. Previously, CMS requested only those providers supporting the pending counties. Applicants took to the CMS User Calls to ask clarifying questions about this requirement, including a number of "what if" questions, indicating that applicants either know they have unknowns in their networks, or they know how their network fares and they want to know the consequences. In addition to some provider network documentation changes, here are some other notable changes to the application process:
- Quality Improvement Plan and Crosswalk are no longer required at the time of submission.
- If a contract of the applicant has been terminated or non-renewed over the past two years, a Two-Year Prohibition Waiver Request is required.
- Additional required contacts have been added.
Here are some key dates to keep in mind:
- User Calls took place on January 13 and 20. Current and pending Sponsor applicants are encouraged to review the CMS Part C & D User Call recordings.
- The application deadline is February 17, 2016, at 8:00 PM Eastern time.
- Part C deficiency notices will be sent mid-March.
- Part D deficiency notices will be sent late March.
- Part C and Part D Notices of Intent to Deny or Approve will be sent late April.
- Requests to drop counties are due May 20.
- Part C and Part D Conditional Approvals or Denials will be sent late May.
Additional important dates have been communicated in the Part C and Part D application materials and in the User Call presentations. Something CMS has made clear again this year is that applicants should review all instructions provided, and reach out with questions, as there are no exceptions to the filing deadline. A well-prepared applicant will target for an early submission date so as not to risk getting caught up in a bottleneck of uploads. If you haven't done so already, get ready and start your engines!
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We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Don't let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process. Contact us today to learn how we can help >>
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New AHC Model Supports Better Care, Smarter Spending & Healthier People
The Centers for Medicare & Medicaid Services (CMS) Center for Medicare & Medicaid Innovation (CMMI) recently announced the Accountable Health Communities (AHC) Model, which will examine whether systematically identifying and attempting to address health-related social needs of Medicare and Medicaid beneficiaries through referral and community navigation services can impact healthcare costs, reduce inpatient and outpatient healthcare utilization, and improve healthcare quality and delivery.
As Accountable Care Organizations (ACOs), integrated delivery systems, and community-based organizations collaborate on how to best meet the medical and socio-economic needs of our most vulnerable populations, this new grant opportunity is a way to further solidify and strengthen provider partnerships. "The AHC Model will allow providers to leverage the clinical and technology infrastructure they have built and test solutions and interventions for the health-related but unmet social needs such as food insecurity and unstable housing," said Olga Bronnikova, Senior Legislative & Policy Advisor at Gorman Health Group (GHG).
"Since the time of Hippocrates, physicians have known their patients' physical health is highly dependent on factors in their physical, economic, and social environment," said Leslie Mullins, Senior Consultant at GHG. "The World Health Organization (WHO) has described these Social Determinants of Health (SDH) as the conditions in which people are born, grow, work, live, and age, and studies have shown SDH account for 15% to 40% of the variance in health between different groups. The AHC model will directly address how improving the SDH will affect beneficiaries' healthcare costs and improve health outcomes.
Information about the AHC Model is available at Accountable Health Communities Model web page.
Eligible Participants:
Eligible applicants are community-based organizations, healthcare provider practices, hospitals and health systems, institutions of higher education, local government entities, tribal organizations, and for-profit and non-profit local and national entities with the capacity to develop and maintain a referral network with clinical delivery sites and community service providers. All states are eligible. Medicare Advantage (MA) and Program of All-inclusive Care for the Elderly (PACE) organizations are not eligible to serve as bridge organizations.
Model Details:
The model is a five-year test which will aim to address beneficiaries' social needs in the following core areas:
• Housing instability and quality,
• Food insecurity,
• Utility needs,
• Interpersonal violence, and
• Transportation needs beyond medical transportation.
The model includes three tracks which will attempt to test the following service delivery approaches:
Track 1 — Awareness: Increasing beneficiary awareness of available community services through information dissemination and referral.
Track 2 — Assistance: Providing community service navigation to assist high-risk beneficiaries with accessing community services to address the identified social needs impacting their total healthcare costs, inpatient and outpatient healthcare utilization, and health and quality of care.
Track 3 — Alignment: Encourage partner alignment to ensure community services are available and responsive to the needs of beneficiaries.
- The bridge organization is responsible for coordinating community efforts to: Identify and partner with clinical delivery sites and community service providers.
- Conduct systematic health-related social needs screenings
- Connect beneficiaries to community resources via referrals for identified unmet health-related social needs.
- Tracks 2 and 3: Assist beneficiaries with accessing community resources through community service navigation.
- Track 3: Partner with and align community service partners to optimize community capacity to address health-related social needs.
Bridge organizations are expected to partner with:
- At least one Medicaid state agency.
- Clinical delivery sites including at least one of the following: hospital, primary care provider or practice, provider of behavioral health services.
Community service providers who can address the health-related social needs identified through a screening.
Award Information:
Up to $1 million to each bridge organization in Track 1 — Awareness
Up to $2.57 million to each bridge organization in Track 2 — Assistance
Up to $4.51 million to each bridge organization in Track 3 — Alignment
CMS anticipates awards will be made in the fall of 2016. The model period is five years, from January 1, 2017, to December 31, 2021.
CMS will support and fund:
• 12 cooperative agreements for Track 1
• 12 cooperative agreements for Track 2
• 20 cooperative agreements for Track 3
Instructions and Deadlines
Applicants must submit a letter of intent (LOI) to http://innovationgov.force.com/ahc by February 8, 2016. If an LOI is not submitted, any subsequent application will be ineligible. Applications are due by 1:00 p.m. EST on March 31, 2016. Applicants may apply for up to two tracks, but successful applicants will only be selected for one.
At Gorman Health Group (GHG), we have successfully assisted providers in forming ACOs and developing strategies to address the clinical and socio-economic needs of vulnerable populations within our communities. We are prepared to assist you in your decision-making process for which of the various tracks of the grant application to apply, completion of the grant application, and implementation of your program. As noted above, time is of the essence. Let GHG help bring your innovative care ideas to fruition.
For more information, please contact me directly at emartin@ghgadvisors.com.
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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 >>
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
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Network Adequacy Top of Mind for CMS
The Centers for Medicare & Medicaid Services (CMS) continues to reinforce its focus on health plan provider networks with several recent announcements.
The release of the new Network Management Module (NMM) within the Health Plan Management System (HPMS) is the tool CMS will utilize for monitoring network adequacy. The NMM functionality allows both CMS and organizations to evaluate health services delivery (HSD) provider and facility networks separate from the annual application process. The NMM employs the same evaluation criteria and calculations currently used by the automated network review portion of the Medicare Advantage (MA) initial and Service Area Expansion (SAE) application process. Please note organizations can access the NMM functionality to submit their network tables for an "organization-initiated" automated review. Results generated for an "organization-initiated" review will only be available to your organization and not be viewable by CMS. Our subject matter experts at GHG are able to assist plans in utilizing this new functionality as part of an overall network audit and maintenance policy plans should adopt to continually assess how their network, as its largest asset, meets the goals of the organization.
Additionally, CMS released the Draft 2017 Letter to Issuers in the Federally-facilitated Marketplace (FFM) on December 23, 2015, and is proposing new policies on network adequacy and monitoring to provide more transparency and detail to be Qualified Health Plans (QHPs) in an FFM to fulfill the requirements to provide reasonable provider access to their members. Plans have the ability to review the draft letter and provide comments back to CMS by January 17, 2016. We have provided a link to the full draft letter, and, as with MA plans, Gorman Health Group (GHG) has the ability to manage your network adequacy reports and audit for all QHPs.
Lastly, on January 13, 2016, CMS provided training on the summary of changes to the 2017 MA applications. One of the key points addressed is the SAE application will require HSD Tables for the entire Medicare Advantage Organization (MAO) network at the contract level, not just the counties the application is proposing to expand into with the SAE request. The change comes as CMS has indicated plans should have tighter control on their existing provider networks to ensure adequacy is met over the life of the contract.
At GHG, we have experts who have worked directly with managing provider networks and adequacy for over 20 years, including detailed analytics such as specialty code mapping and software which is critical in building the infrastructure needed to fully support the quality and financial goals the network brings to your health plan. Please reach out if we can provide guidance regarding the rules and regulations for all government-sponsored health plan networks.
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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 >>
Register your team now through January 31 for the 2016 GHG Forum, and take advantage of our New Year's special! Save 15% using promo code NewYear16 at checkout. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Top Tips for Star Ratings Success in 2016
Amidst our rapidly-changing industry landscape, the Star Ratings program essentially serves as a "Medicare Advantage stress test," measuring a plan's ability to master the operational complexities encountered while improving the quality of care and general health status of Medicare beneficiaries through member-pleasing experiences. At any given time, there are multiple Star Ratings cycles in play. For example: operational teams and providers have now shifted their focus to services impacting 2018 Star Ratings, Quality and Pharmacy teams are beginning to finalize Healthcare Effectiveness Data and Information Set (HEDIS®) and Prescription Drug Event (PDE) data for 2017 Star Ratings, and the Star Ratings team is feverishly working to optimize performance across both the 2017 and 2018 Star Ratings cycles.
As we've said before, there is no rest for the weary within Star Ratings, and 2016 will likely be no different. But January is a time for new beginnings and fresh starts, so we want to provide you with a few helpful tips to start off the New Year strong:
Monitor and Manage Execution Risk
As John described in his blog this week, we are watching a slew of significant industry issues this year. Some of these issues will directly impact Star Ratings workflows (such as potential new measures, potential program changes to account for dual eligibles/low-income subsidy (LIS) members, and the evolution of Medication Therapy Management (MTM), some will directly impact Star Ratings strategy (such as mergers, drug pricing, provider networks, and care delivery), while others will have an indirect impact on Star Ratings. The Star Ratings impact of these issues and risks, combined with the impact of internal and local risks and issues, will continue to evolve and may change unpredictably throughout the year. It's important for health plan leaders to understand the Star Ratings impact associated with these, and other, types of issues so risks can be routinely evaluated and mitigated where possible. Just as importantly, monitor and evaluate your internal execution risks so mitigation strategies can be deployed when staffing challenges, organizational changes, or administrative processes are not functioning as designed. Make sure your Star Ratings reporting, monitoring, and oversight processes spotlight these risks so leadership is aware of key risks and can adjust the sails as needed if the winds change during the year.
Align Your 2016 Star Ratings Work Plan with Your Strategic Plan.
Health plans are updating their strategic plans more frequently, and often more significantly, than in the past to account for the nature, extent, and speed of industry changes. It is not uncommon for staff to invest time, effort, and resources in selected areas only to later discover there were other, more critical, areas which could have yielded a higher return on investment (ROI) from Star Ratings-related investments. Star Ratings success amidst a changing industry will test a plan's flexibility, agility, and leadership. With that in mind:
- Ensure your 2016 Star Ratings work plan aligns with your organization's strategic plan and captures activities needed to mitigate the impact of strategic adjustments.
- When planning for strategic change, engage Star Ratings leaders to ensure leadership is prepared for, and can mitigate the impact of, such strategic change on Star Ratings. As changes are made, help department leaders understand the full scope of change and its impact on Star Ratings and deploy well-planned tactics to mitigate Stars Ratings risk as changes are implemented.
- Align Star Ratings strategies and tactics with population health, quality improvement, and care management workstreams, and cross-leverage member interventions to simultaneously achieve cross-functional purposes.
- Evaluate the impact of your delegates and vendors on your Star Ratings strategic goals and deploy targeted efforts where improvement is needed.
Run Star Ratings as a Strategic Program
A health plan's Star Rating ultimately reflects the effectiveness with which the entire organization (and its first-tier, downstream, and related entities) and its provider/pharmacy networks work together to improve quality of care and the health status of Medicare beneficiaries in ways which meet members' expectations. As Star Ratings expand into long-standing, multi-faceted new clinical areas, health plans may discover a need for increased collaboration among internal teams and with providers. With this in mind, it is important plans run Star Ratings as a strategic program with dedicated leadership, well-documented workflows, and carefully-crafted leadership support to best ensure the plan hits the ever-important 4-Star threshold.
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Every Star Ratings work plan is unique, and the opportunities to improve performance are similarly unique. With this in mind, it can often be helpful to conduct an objective evaluation of your program. Gorman Health Group's team of experts can help you review key infrastructure and workflows to identify opportunities to improve your Star Ratings performance.
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Issues That Will Define Government Health Programs in 2016
The new year brings a slew of issues that will define government-sponsored health programs. Here's what we're watching closely, not necessarily in this order. Opportunities have never been greater in Medicare, Medicaid, and ObamaCare, but execution risk is rising fast. If this was an easy business, we'd be out of business.
Drug Pricing: Prospects for a legal fix in Congress is questionable, and this will be a leading issue in the Presidential campaign. Expect administrative action, demonstration project solicitations from the Centers for Medicare & Medicaid Services (CMS), "comparative effectiveness research" by federal agencies on specialty drugs, and "collaborative pricing" initiatives between pharma manufacturers and payers on high-profile therapeutic classes. Health plan CEOs expect higher specialty drug cost trends to be the biggest driver of medical cost trend in 2016.
Medication Therapy Management (MTM): 2016 is the year MTM gets real. CMS will begin conducting widespread audits of Medicare Advantage (MA) and Part D plan medication reviews, and there is tremendous emphasis on MTM in the Star Ratings system. Making MTM real for your members will require extensive vendor contracting and Pharmacy Benefit Manager (PBM) coordination, so turn your plan's attention to this fast.
Antitrust/Mergers: Sometime in Q3 or Q4 of 2016, the Federal Trade Commission and the Department of Justice Antitrust Division will rule on proposed mergers for Aetna/Humana, Anthem/CIGNA, Walgreens/Rite-Aid, and Pfizer/Allergan. We expect all four deals to be approved but with strings attached; e.g., we expect Aetna/Humana will have to divest 250,000-450,000 lives to get a green light.
Star Ratings: Must be a central focus of all payers and providers in government programs. Star Ratings has transcended MA and Part D. Star Ratings data is already being collected by ObamaCare plans, and over a dozen state Medicaid programs are using CAHPS® and Star Ratings data in contracting with plans for dual-eligible and managed long-term care (LTC) initiatives. And while there aren't major changes to Star Ratings measures in 2016, scoring is the game-changer: 50% more plans will be scored for the first time this year, guaranteeing a shift right in the ratings bell curve and that many of 2015's 4-Star plans will go off the cliff. To maintain progress, plans must run Star Ratings as a program with dedicated leadership and execution spelled out at the workflow level.
Risk Adjustment: 2016 will usher in increased efforts to ensure payment accuracy through more stringent and expansive Risk Adjustment Data Validation (RADV) reviews, and so providers delegated for risk and sharing in a percent of premium will be in the spotlight. CMS is seeking to contract with third-party auditors on RADV, and risk adjustment is a top concern in the Department of Health and Human Services (HHS) Office of Inspector General (OIG) work plan.
Providers and Care Delivery: 2016 will be a transformative year with contracted providers in government programs. Narrow/preferred networks and value-based risk contracting will go mainstream this year, whether providers are ready or not. Huge penalties start this month on network adequacy and accuracy of provider directories, and NAIC's model guidance on provider networks will be a central document governing the issue. Star Ratings measures on access to care and the member experience put new heft and revenue behind network requirements. Provider-sponsored entities will provide a mini-surge of dozens of new plans into MA and Medicaid in 2016 and 2017, especially among Medicare Accountable Care Organizations (ACOs), so keep your friends close and your enemies closer. Home- and community-based services and alternatives to nursing homes will go mainstream in 2016. Retail pharmacies will become the second-most-important provider type for health plans. With crushing burdens of ICD-10 and meaningful use, small and mid-size practices will become overwhelmed and will underperform. Plans will need aggressive oversight, quality improvement, and directory management activities to stay ahead.
Exchange Payment: For the first time in two years, CMS is going to begin paying plans HIX 820s at the member level, which will shine a spotlight on enrollment reconciliation issues that have been lingering. The plans' readiness transition period is from January to March, then it gets real in April.
Medicaid and Dual Eligibles: Unexpected states like LA, SD, and IA are now considering Medicaid expansion. CMS is focusing on new Medicaid quality measures and will be depending heavily on NCQA quality measures to gauge health plans. This will impact payment and future membership for some lower-rated plans. Beneficiary opt-outs in excess of 75% are plaguing early dual-eligible demos, but many states remain in fiscal crisis and need to move ahead to balance budgets.
Compliance: 2015 was a near-record year in CMS enforcement actions, and scores always get settled with insurers in the second term of a Democratic administration. There will be a slew of rules coming from CMS this year as well as expanded audits from OIG. Both agencies' approaches indicate how critical documentation remains: CMS added a number of items to documentation requests for Compliance Program Effectiveness; Medicaid, dual-eligible, and LTC demos are still very documentation-heavy, and CMS found that approximately two-thirds of CMS-reviewed FFM issuer plan policies and procedures (P&Ps) were incomplete or had operational findings with their vendor contracts. So even though there is focus on data monitoring and passed/failed samples, P&Ps and documents are still the cornerstone.
There is no question that 2016 will be a banner year in government programs enrollment, and the long walk in the desert on payment rates in MA and Medicaid appears to be over. But execution risk and the enforcement environment have never been tougher. This year will be a "Darwinian moment:" it's not about being the biggest or even the smartest but being the most adaptable.
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New Hospice Policies Could Mean Big Changes for MA
Medicare's hospice care is garnering much attention and starting the evolution process this year. The Centers for Medicare & Medicaid Services (CMS) issued several new regulations changing hospice payments, and these regulations come with big implications for Medicare Advantage (MA) plans as well.
Last month, the Senate Committee released a policy options paper, discussing solutions for managing chronic illness. In the paper, the Committee proposed that MA plans be required to offer the hospice benefit currently provided under Medicare Part A. Such a change would mean changes to the MA payment system in order to include hospice reimbursement. It would also come with the inclusion of additional measures under the Star Ratings system.
These proposals have been floated around throughout the years, however, with the inclusion of the new end of life talks and the evaluation of the Care Choices Model, this proposal has more teeth and may become reality in the next several years.
Medicare will now also pay for Advance Care Planning talks. Most Medicare beneficiaries and their families state they would like to be involved in end of life planning, yet these talks are often avoided because of the sensitivity of the subject, prognostic uncertainty, and, most importantly, lack of training or pathways for physicians to facilitate these talks. A small number of beneficiaries currently have advanced care directives. This year is an important test for this new payment in assessing whether the talks will have an effect on the care patients choose to receive and whether this will result in more frequent and earlier hospice admission.
Although these payments are small, this is a great opportunity for plans to lead more physicians to discuss end of life care and put plans at an advantage if approached correctly. More patients electing hospice care could lead to better patient quality and experience. Hospice care is more person-centered and tends to improve outcomes such as pain and satisfaction. At the same time, although plans would lose the patient's premium from the shift to hospice, they would also shift the bad claims experience due to the highly expensive end of life palliative treatments and unnecessary hospital care. However, due to the sensitive nature of the discussions, plans should establish a careful framework in their approach in order to contain patient satisfaction and quality.
This year also marks the launch of the Medicare Care Choices Model (MCCM) from CMS. The five-year model allows some hospice-eligible patients to access hospice care without having to forego curative treatments, the way the system is currently set up, and allows for providers to receive payment for this care. The program has some significant limitations: hospice providers will only receive $400 per month or $200 per month for those enrolled for less than 15 days. This means in order to be financially appealing, patients will receive much lower benefits than normally received through hospice treatment. However, it may set up a basis for continued advanced care discussions and lead to more patients electing full hospice care. Despite the low payment, however, the model received significant provider interest and will see a high level of participation.
Resources
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Health Insurance Marketplace — What's Contributing to the 2016 Enrollment Growth?
On December 22, 2015, the Centers for Medicare & Medicaid Services (CMS) released a snapshot report of the Health Insurance Marketplace Open Enrollment, capturing Marketplace enrollment from the beginning of Open Enrollment (November 1) through December 19 (Week 7 of Open Enrollment) for consumers who signed up for health coverage through the Healthcare.gov platform. Not accounting for the millions more selecting plans through State-based Marketplaces (SBMs):
- More than 8.2 million consumers signed up for healthcare coverage — 28% more than enrollment a year prior.
- Approximately 29% (about 2.4 million) are new consumers, while 71% are consumers renewing coverage.
- New consumers are over one-third higher than the number of new consumers who signed up by the deadline for January 1 coverage last year.
- More than 4 million people made plan selections between December 13 and December 19, which represents almost 50% of the cumulative Open Enrollment plan selections through December 19, 2015.
So what is contributing to the positive enrollment growth in the 2016 Health Insurance Marketplace?
While it is normal to see higher consumer demands during the weeks leading up to the January 1 effective coverage deadline, there are some other factors which may be contributing to the enrollment trends.
- Automatic renewal process — As part of the Federally-facilitated Marketplace (FFM) auto-enrollment process, generally, if consumers do nothing, they will be auto-enrolled in the same plan with the same premium tax credit and other financial assistance, if applicable, as the prior plan year. This provides consumers with a simple, familiar process to renew their coverage.
- Broker guidance and training— CMS is providing more guidance and instructional tips to brokers on how to engage consumers and simplify the consumer enrollment experience. This can been seen in:
- the numerous broker training sessions CMS hosted going into Open Enrollment,
- CMS provided enrollment tools such as the "Marketplace Application Checklist" brokers can use to help consumers prepare to complete their applications on Healthcare.gov,
- a new "For Agents and Brokers" link has been added at Healthcare.gov, making it easier for agents and brokers to get to the Agents and Brokers Resources webpage (http://go.cms.gov/CCIIOAB),
- and consumer research shared with brokers showing what drives consumers to take action.
- Customer awareness — The first Health Insurance Marketplace Open Enrollment period was longer than in future years in order to give consumers a chance to understand their options and make a selection (in addition to allowing further opportunity to beneficiaries impacted by hiccups in FFM enrollment functionality to complete enrollment). As we enter the 2016 plan year, enrollment processes and functionality are not only tighter, renewing beneficiaries are now more familiar with how to research coverage options and avenues in which they can enroll.
With Open Enrollment coming closer to the end, extremely high traffic is anticipated on Healthcare.gov specifically on the January 15 cut-off date.
CMS will continue to release snapshot reports for the Healthcare.gov platform throughout Open Enrollment. It is anticipated more detailed reports which look at plan selections across the FFM and SBM will be released by the Department of Health and Human Services (HHS) later in the Open Enrollment period.
For more Open Enrollment Trends:
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-12-22.html
Resources
Gorman Health Group's annual training can help you prepare. As a CMS approved training vendor, we offer robust training on an easy-to-use platform at an unbelievably low price. Visit our website to learn more >>
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