Miss Our Star Ratings Webinar? Here Are the Top 5 Takeaways
With just a few more weeks remaining before the 2018 Star Ratings cycle begins, we are on the cusp of yet another exciting iteration of program changes and updates within the Star Ratings program. In case you missed our Star Ratings webinar, here are our top five takeaways from the session:
Silo-busting will be more important than ever to earning a 4 Star Rating.
Despite the absence of any new Star Ratings measures in 2017, the areas to be measured by the new 2018 Star Ratings measures proposed by the Centers for Medicare & Medicaid Services (CMS) cut right to the heart of some silos still remaining within health plans. For example, many, if not all, health plans have developed their Medication Therapy Management (MTM) programs within their pharmacy department, and many MTM programs are outsourced entirely through the Pharmacy Benefit Manager (PBM). However, CMS is proposing addition of the Medication Reconciliation Post Discharge measure as a Part C Healthcare Effectiveness Data and Information Set (HEDIS®) measure. Simultaneous success on this new HEDIS® measure and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) measures will require a well-coordinated, cross-functional evolution of medication reconciliation workflows into time-sensitive, clinically-appropriate patient engagement workstreams. CMS' proposal to introduce the new statin therapy measures without classifying both as either Part C measures or as Part D measures will be a true test of internal silo-busting within health plans. From provider reporting and outreach to member engagement and outreach, simultaneous success on these measures and CAHPS® measures will require strategic, innovative use of data and analytics to drive a seamless experience for all. CMS' proposal to introduce the new asthma-related medication measures (which contain significant adherence components) as HEDIS® measures will reinforce this need.
Star Ratings must be approached strategically and managed as a program.
Approximately 35% of the 2016 Star Rating is driven by patient experience, complaints, and measures capturing access. An additional 11% is driven from the remaining CAHPS® survey measures and the Health Outcomes Survey (HOS) measures, and yet another 12% is based on the contract's overall improvement or decline from one year to the next. Mathematically, that means less than 50% of the Star Rating is now driven by traditional measures of clinical quality. This, combined with the breadth, depth, and scope of the individual measures which comprise each of these categories and the expertise necessary to improve performance on individual measures, necessitates use of a highly-strategic approach to designing a Star Ratings program in order to ensure time and resources are invested where most needed in a way that is seamless and well-coordinated to members and providers.
Your members' perceptions matter. A lot.
The combination of patient experience and complaints, measures capturing access, and the other survey measures comprise 46% of the Star Rating. This, combined with the fact the range between a 2 Star Rating and a 5 Star Rating was less than 10% for 8 of the 1.5-weighted CAHPS® measures in the 2016 ratings, requires us to be strategic and purposeful in all of our operational decision-making. Every program, phone script, and member mailer should be evaluated from the member's perspective. It is no longer enough for us to do the right thing — now we have to both do the right thing and manage the member's perception of what we are doing. With this in mind, it's important for us to ask:
- Will the member understand why we're calling/mailing?
- Will our request resonate with the member's current health status?
- Will the member perceive our outreach to be well coordinated?
- Will our outreach align with his/her doctor's recommendations?
Each of these questions is important to consider as part of every decision made by every team in the new era of Star Ratings.
Change is the only constant in Star Ratings.
From the changes introduced in the 2016 Star Ratings program to the future changes proposed in CMS' recent Request for Comments on potential future changes to the Star Ratings program, it is clear change will continue to abound within Star Ratings. We must prepare for growth in the number of Star-rated Medicare Advantage plans, an interim and permanent solution to address the impact of socio-economic and disability status on Star Ratings, and the new measures proposed by CMS as potential 2018 Star Ratings. Educating providers, staff, and the executive team, adjusting reports and analytics, and enhancing strategies and tactics to account for these changes will require increased investment of resources and expertise during the coming months.
Measure, manage, then act.
Success will depend on purposeful activity during the coming months. With the extent of changes on the horizon, it will be important to stay focused on identifying the actions needed for success and executing such tactics swiftly. We can enhance the member's experience (and our Star Ratings) by conducting the right action, at the right time, using the right channel.
The first quarter is a great time for strategic planning and reflection. Not only is there still opportunity to influence your 2017 Star Ratings, but there is also time to refine and enhance your 2016 tactical roadmap to help you earn ≥4 Stars next year.
Evolution of Validation: Selecting an Independent Auditor
The Centers for Medicare & Medicaid Services (CMS) audit validation process has evolved over the past few years. Here is what you should know about the changes and how to best prepare to contract with an Independent Auditor, or IA.
Let's go back to 2012. CMS was conducting the validation of audited Sponsors' corrective action plans (CAPs) by retesting areas found to be problematic. While the terminology has changed, the charge was led at that time by the Regional Office. In 2013, validation became an activity conducted by the Medicare Parts C & D Oversight and Enforcement Group (MOEG) at Central Office and Regional Office staff. Any items that resulted in a Corrective Action Required (CAR) or an Immediate Corrective Action Required (ICAR) were subject to validation.
As part of the 2013 validation timeline, the Sponsor had seven days from the issuance of the final audit report to submit a CAP for each condition. If we reference the 2014 Part C and Part D Program Audit and Enforcement Report, CMS outlined the average number of days which elapsed after an audit notice was issued.
If we take a look at the average days elapsed from the Exit Conference to the Final Report Issued date, the number of days elapsed has decreased, from 241 days in 2011 to 99 days in 2014. Based on the last year of reported data, plans still had a healthy three months from the verbal acknowledgement of CARs and ICARs (that is, the Exit Conference) to the issuance of the final report in order to implement corrections. In theory, by the time the final report was issued, some issues could have been corrected and, therefore, could have been ready for validation. However, time had to elapse for CMS to approve the CAPs, and after that point, CMS allowed Sponsors another 90 calendar days from that approval to implement and test the results of those CAPs. That's a lot of time when you look at it from the beneficiary perspective.
Fast forward to today — CMS is exercising their authority to require a Sponsor to hire an IA in order to validate if deficiencies found during a CMS program audit have been corrected. In a memo released on November 12, 2015, CMS confirms they will not provide recommendations on IA firms. Instead, they require the Sponsor to attest to both the independence of the IA as well as an absence of conflicts of interest. They point to the 2010 guidance for the selection of a Data Validation auditor for examples of relationships not meeting the standard for organization independence.
We are united with CMS' recommendation that Sponsors solicit proposals to select an IA early in the post-audit phase. Speaking from the auditor standpoint, it is much better for all parties involved to plan early, so exceed CMS' expectations and seek proposals as soon as possible. It's better to have that agreement in place ahead of time, rather than waiting until CMS sends you their instruction to hire an IA. This will give you the time to evaluate your options, so you can best determine their experience and subject matter expertise. When you are accountable to CMS to validate corrections, it is particularly important to partner with someone you can trust to apply a skilled eye to the validation activities. Otherwise, you may be subject to further scrutiny by CMS, which is the last thing any Sponsor needs when coming to the close of their audit process.
Resources
Determining conflict of interest is the responsibility of the Plan Sponsor and can be subject to interpretation. Not every auditor that a Plan Sponsor has used in the past is necessarily a conflict of interest. Contact us for further questions >>
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and February 14 and pay $1,095, the price increases to $1,295.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Update on CMS Spotlight on Provider Directories and Network Adequacy
As we learned from the 2016 Call Letter, the Centers for Medicare & Medicaid Services (CMS) is placing a renewed focus on Medicare Advantage plans' provider network with emphasis on both online provider directories and network adequacy. CMS plans to monitor compliance of plans' adherence through direct monitoring with additional contract funds and through the development of a new network adequacy audit protocol to be tested in 2016 which will determine whether the provider network meets published CMS adequacy standards. The compliance and enforcement of the new protocols will include civil money penalties and enrollment closures.
Recent beneficiary complaints have brought into focus the accuracy, or lack thereof, with Medicare Advantage Organizations' online provider directories. Beneficiaries, and sometimes-referring providers, have shown frustration in attempting to make an appointment only to find the provider is no longer accepting new patients, has moved, or is no longer participating with the plan. CMS has supplemented their current guidance on provider directories with additional updates on August 13 and November 13, 2015, and expects plans to:
Establish and maintain a proactive and structured process in which to verify the availability of its contracted providers.
In their August 13, 2015, update, CMS clarified the requirement does not apply to entities such as hospitals, and plans should use a method likely to achieve the highest response rate. This process was further updated on November 13, 2015, and effective immediately will now include outreach on a quarterly basis to verify:
- There has been no change in a provider's address or phone number and determine if the provider's panel is open or closed to new patients. CMS provided additional guidance that plans should include a notation in the online directory identifying providers who are accepting new patients or a notation identifying providers who are not accepting new patients;
- Establish a policy to review and address beneficiary complaints when they are denied access to a provider(s); and
- Include a provision for real-time updates to the online directory. In a memo released on November 13, 2015, CMS further defined "real-time" to mean within 30 days to be consistent with other Marketplace regulations.
It is important to note CMS' core focus remains ensuring provider directories are accurate for Medicare beneficiaries and their caregivers who rely on them to make informed decisions regarding their healthcare choices.
As you prepare to meet the new challenges for maintaining an up-to-date provider directory, changes to network submissions for service area expansions, or preparations in anticipation of the network adequacy (pilot) audit, please feel free to reach out and let us know how Gorman Health Group can assist you!
Contact me directly at emartin@ghgadvisors.com to learn more.
Resources
At Gorman Health Group, we can help you decide what payment models are appropriate to your unique circumstance and support your implementation efforts. Learn more >>
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
2016 Readiness Review Smaller Size, Bigger Punch.
The Centers for Medicare & Medicaid Services (CMS) released the 2016 Readiness Checklist on Monday, November 9, 2015. The 20-page checklist is full of items CMS is expecting plan sponsors to review and validate it will be compliant for the 2016 calendar year. While CMS won't have an official website for plan sponsors to attest to the readiness this year, they will use other methods to validate compliance. No matter the validation method, CMS' expectations are clear: Part C and Part D plan sponsors should review and validate compliance for each item.
In reviewing the 2016 Readiness Checklist, there are some new and modified requirements as well as other areas of CMS concern. Regardless of whether or not the items are new to the readiness checklist party, they should all be known to you. If they aren't familiar, you may want to check your Health Plan Management System (HPMS) and regulatory guidance distribution process. CMS indicates at the end of almost every requirement where the guidance for that item came from―what Medicare manual or HPMS memo provides the supporting information for that item. CMS makes it convenient to validate what you are asked to validate and attest.
If you have waited until now to implement or validate new guidance from 2015, it will be a stressful few weeks in what is already a very busy time of year. Several items are heavy-hitters and get into the nitty gritty of processes. As in past years, any items which won't be in compliance are to be reported to your CMS Account Manager. No one likes to be on that list.
Many sections of the Readiness Checklist are smaller but have more potential process changes. "By no means should plans see an abbreviated Compliance and Fraud, Waste, and Abuse (FWA) section and start resting on laurels," said Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). Regan went on to say, "In this year's checklist, CMS issues another reminder about the May 24, 2014, regulation change which requires mandates on Medicare Advantage (MA) organizations to require all of their first tier, downstream, and related entities (FDRs) to take the CMS training and accept the certificate of completion of the CMS training as satisfaction of this requirement."
Another change highlighted in the readiness assessment is plan sponsor's appropriate use of extensions for organization and coverage determinations and appeals. In audits, we often see plan sponsors who have failed samples due to extensions granted for contracted providers or when extensions are used early in the process and on a routine basis rather than as an exception. CMS is expecting plan sponsors to review their process for exceptions and ensure they are in compliance.
One change Regan called out is CMS included a recommendation that plan sponsors making pharmacy network changes provide both those pharmacies whose network status is changing and enrollees using those pharmacies with notices of changes specific to their situation. "This is almost certainly a result of CMS' close work with one plan sponsor on effective notification strategies as part of pharmacy network changes. While the plan sponsor had indeed sent letters to supplement the Annual Notice of Changes' (ANOC's) notification of changes, the recommendation is to move to a more personalized notification approach," indicated Regan. "This will allow beneficiaries to make a more informed decision and will also aid pharmacies in understanding their network status."
A senior consultant of Pharmacy & Clinical Solutions at GHG, stated, "The Readiness Checklist is always an excellent method of making sure you have the bases covered for new guidance which takes effect in the new plan year (2016)." Deb went on to indicate there are three items plan sponsors must pay particular attention to in the 2016 Readiness Checklist for Part D. They are as follows:
- The long-delayed requirement "physicians and other eligible professionals who write prescriptions for Part D drugs are required to be enrolled in Medicare in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, unless the prescriber is an ‘Other Authorized Prescriber'." This takes effect on June 1, 2016, and, therefore, plans must confirm their contracted providers, including dentists, are eligible to furnish Part D prescriptions.
- Also, providers must have a valid prescriber National Provider Identifier (NPI) number for Part D claims to be valid. Specifically, "for plan year 2016 and thereafter, claims for covered Part D drugs must include a valid prescriber NPI. Part D sponsors must submit to CMS only prescription drug event (PDE) records containing an active and valid individual prescriber NPI."
- Starting on January 1, 2016, it is CMS' expectation Medicare Advantage Prescription Drug (MA-PD) plan members will not leave a network pharmacy without their prescription for a medication(s) where coverage may available under either Part D, Part A, or Part B. Plan sponsors and/or their PBMs must have processes in place so the network pharmacist can exchange information with the plan sponsor or PBM about the member to make the determination about which arm of Medicare will pay.
Parting words from Regan, "CMS makes it clear these are key requirements, and the checklist is not an exhaustive list. Consider these items to be hot topics CMS will hang their hat on in the coming year." The key to successful MA and Part D programs is to know your business better than anyone, including CMS. The Readiness Checklist is one additional tool to do just that.
Resources
If you need assistance in assessing your organization against the Readiness Checklist or in strengthening your MA or Part D program, GHG's knowledgeable team is here to help you. We've been in your shoes and know the pain points and how to move through them. We can help you prevent that punch from being a knock out. Contact me directly at jbillman@ghgadvisors.com.
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Influencing Your 2017 Star Ratings: It's Not Too Late
We are officially in the throes of the unavoidable, and much dreaded, 4th quarter Star Ratings "fire drill." While health plan leaders (again) promise their staff and providers this year will be the last a Star Ratings fire drill will be needed, the day-by-day countdown to year-end has officially begun. As even more evidence year-end is almost upon us, Star Ratings leaders throughout the nation are putting the finishing touches on their 2016 Star Ratings work plans and counting down the days until Star Ratings measure rates and denominators are reset and the annual cycle begins again.
Because providers and pharmacies can only provide Star Ratings-impactful services to members through the end of December, many health plans may mistakenly think their ability to impact the 2017 Star Ratings is also on the countdown clock. Luckily, this couldn't be farther from reality. Not only is this a great time to evaluate the adequacy of your 2016 Star Ratings work plans and budgets, but there are also plenty of opportunities for health plans to continue impacting their 2017 Star Ratings. Health Plans must continue to focus significant effort to ensure administrative processes capture all of the services provided to your members this year. Organizations still have several more months to influence members' responses to next spring's Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey and Health Outcomes Survey (HOS), and don't forget the Call Center — Foreign Language Interpreter and TTY Availability measurement period occurs entirely during the spring of 2016.
While it is certainly true Health Plans won't be able to provide additional clinical services after December 31st to impact 2017 Star Ratings, there is plenty of opportunity to influence the 2017 Star Ratings over the next few months. The following are a few ways you can continue to impact your 2017 Star Ratings even after December draws to a close:
- Review your Healthcare Effectiveness Data and Information Set (HEDIS®) medical record review workflows, encounter data workflows, and claims/prescription drug event (PDE) reconciliation workflows to identify any gaps or opportunities for improvement.
- Objectively review the effectiveness of your 2015 Star Ratings activities to determine what worked well, what didn't work as well as planned, and what areas can be improved or enhanced in support your Star Ratings vision.
- Objectively evaluate the cohesiveness and coordination occurring among your internal teams and external partners and vendors to improve your members' experience.
- Evaluate how effectively your teams are working with your high-volume providers and under-performing providers to improve Star Ratings and effectively administer risk adjustment programs.
Gorman Health Group's (GHG's) team of experts can help you leverage your infrastructure and workflows to improve your Star Ratings performance. Contact us today >>
Resources
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>
GHG understands the complexities and nuances of the Star Ratings program and measures. We know how to design programs, initiatives, and tactics to improve Star Ratings performance. From evaluating organizational strategy to developing and optimizing tactical Star Ratings work plans, our team of experts has a long history of success helping health plans achieve Star Ratings success.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Is This Payment Real? CMS Launches Policy-based FFM payments Through the HIX 820 in 2016
If you think your organization has been working from a fire hose these past few years since the launch of the Health Insurance Marketplace, wait until the Centers for Medicare & Medicaid Services (CMS) rolls out policy-based payments to Federally-facilitated Marketplace (FFM) Issuers beginning in 2016. It's not as if the accuracy of member data wasn't significant before, but now with a direct payment from CMS to the Issuer, your enrollment discrepancy rate will be transparent in real dollars.
For the first time, Issuers will be able to quantify the financial impact of enrollment discrepancies simply because CMS will be making payments directly to Plans through Advanced Premium Tax Credits (APTCs), Cost Sharing Reductions (CSRs), and User Fee (UF) charges based on effectuated subscribers within the federal system, not the Issuer system. This ups the ante for synchronization of data between the Issuer and the Marketplace.
In January 2016, CMS will begin paying Issuers at a policy-based level through a transaction called the HIX 820 complimented by the Preliminary Payment Report, or PPR. Aside from the typical challenges and workarounds Issuers are confronted with during open enrollment season, the timing of policy-based payments creates somewhat of a twist or a renewed focus on the financial impact of enrollment data being out of synch with the government.
Issuers are anticipating more work ahead in 2016 with a long list of inherited issues and newfound challenges such as 2016 renewals, ongoing Health Insurance Case System (HICS) activity, continued FFM lags with system updates, and continued interim processes. Yet, one can view the implementation of the HIX 820 as a new opportunity to review and build upon your operations and reconciliation practices simply based on your Chief Financial Officer's (CFO's) perspective.
If your CFO hasn't asked you before, he/she will.
- If we have an expected payment of $100 million based on effectuated members on our books, why is our payment $120 million this month?
- Is this a real payment or an overpayment based on lags with the FFM applying member updates such as cancels and terminations?
- Aside from timing and adjustment activity, what should the prospective payment for next month be? Let's review and find out why your estimate differs once the HIX 820 arrives.
- What does this high volume of adjustment activity in May 2016 applied to January and February 2016 coverage months represent? How do we build an expected adjustment each payment cycle so there are no surprises?
- How many monthly cycles will it take to be paid accurately for January 2016?
With the goal of measuring the overall financial impact of your enrollment and payment discrepancies, you will be able to build a strategy around successful reconciliation. Some key drivers are fundamental and important to highlight. Your organization can simply calculate your expected payment to your actual payment by comparing your PPR/820 monthly payment files to your plan data (RCNI) as a first step. At the end of the day, your CFO will not be interested in a partial picture — he/she will want to understand if the payment is real and whether it will change retroactively. Understanding the complete financial impact of all discrepancies should be your first step. The operations surrounding the resolution of discrepancies should be secondary, albeit a huge undertaking. So, how do you get there?
Recommendations for Issuer's HIX 820 Strategy:
- Be audit ready.
- Understanding CMS will pay you based on the FFM system signifies your daily enrollment processing oversight and the audit of those processes in the form of reconciliation practices go hand in hand. In an audit, you never want CMS to identify you are being paid for non-members or not paid for members consuming the benefit and everything in between.
- See the big picture.
- On a weekly or monthly basis, your organization needs to understand its discrepancy rate and the formula the rate represents. Is it 2%, 8%, 12%? Measure it, and work that rate downward.
- If you have a 5% FFM orphan discrepancy rate in January 2016, what is your January discrepancy rate in April 2016? Monitoring by coverage month each report month is critical to being paid accurately and other downstream issues impacting revenue.
- Put your CFO hat on.
- Institute a monthly review of your organization's discrepancy rate with your CFO.
- Be able to tell a story on the difference between expected and actual payment along with your retroactivity predictions. Now that the 820 will be paying prospectively and retroactively back to 1/2016, Issuers will be able to measure the swings in payment activity.
- Track discrepancy drivers within your organization and look for process improvement opportunities you can operationalize along with aligning resources more effectively.
- Track CMS-defined payment issues and submit timely through the Payment Dispute template. Remember, these are discrepancies sourced to an FFM system issue since your Issuer data matches the FFM data (Pre-Audit File).
- Summarize, work, and measure success of the FFM Recon Outbound File (RCNO).
- Update your enrollment system or dispute Issuer action flags.
- Track and monitor the FFM action flags as well as ensure CMS is applying corrections to the FFM database in conjunction with Issuer corrections. This is a two-pronged approach.
- Track orphan discrepancies (both Issuer and FFM) by coverage month through the FFM Pre-Audit file and resolve each subscriber case.
- Categorize the causal such as FFM BAR error, missing 834, Issuer processing error.
- When you know your data, you are able to answer every audit question that arises.
- At a maximum, when monthly orphan identification is working well, move to weekly discrepancy tracking by comparing the authoritative Pre-Audit file to your Issuer data. This allows you to detect internal issues more timely before interfacing with the government.
While none of this is new for government programs as history always repeats itself, it is clear you can apply the same guiding principles. Positioning your organization to succeed in this new environment is directly tied to an optimal reconciliation approach so you can answer the question, "Is this payment real?"
To learn more about Gorman Health Group's reconciliation solution, Valencia™, and how it supports enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com or Diane Fischer at dfischer@ghgadvisors.com.
Resources
Gorman Health Grouop's Valencia™ creates the workflows organizations like yours need for critical operational functions. With Valencia™, you'll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments. Contact us today to set up a demo >>
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Proposed Changes to the CMS-HCC Risk Adjustment Model
Policy changes governing risk adjustment in plans for Medicare-Medicaid dual eligibles may soon be coming.
In response to concerns about the accuracy of the Centers for Medicare & Medicaid Services (CMS)-Hierarchical Condition Category (HCC) risk adjustment model for predicting costs of dual eligible beneficiaries, CMS recently released a Health Plan Management System (HPMS) memo stating it will evaluate how well the model performs for these beneficiaries based from concerns raised that "the model may disproportionately affect specific populations, particularly dual eligibles."
These proposed changes will not affect the clinical relevance CMS has already included in the existing model or on non-dual eligibles. However, this new approach is a clear "win" for plans having significant numbers of full dual eligibles, both Dual Eligible Special Needs Plans (D-SNPs) and otherwise. The under-payment in the current system is pretty severe, based on the statistics in the CMS memo, and this new approach will fix that.
"This is an interesting change and will definitely have downstream impacts," said a member of the Operational Performance team at Gorman Health Group (GHG). "There isn't a lot of reconciliation on the Medicaid status. Health plans have to go by the designation by the state of what type of dual eligible someone is as there is no independent way to validate that level of coverage. So there isn't any additional reconciliation which will occur. Health plans can no longer submit updates to Medicaid eligibility through the retro processer. That data is much cleaner now than in past years and is fixed quickly due to Low-Income Subsidy (LIS) status cost share implications for dual eligibles."
Further, SNPs determine the type of dual eligible they will cover during the application process. They validate the member is eligible, based on that status at time of enrollment, but there is no submission or correction of that status. They have to use the state's data to validate whether they are a full dual-eligible, Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Medicare Beneficiary (QMB), etc.
What may be a challenge is identifying more clearly who is in what status to allow for projections and reconciliation of risk adjustment status.
I cannot stress the dire need for your Risk Adjustment team to be in constant collaboration with the core operations leaders within your organization to be sure the necessary reconciliation is occurring and that you have a solid data management and analytics strategy in place.
Initial Highlights:
a. The Impact on Partial Dual Eligibles
Some SNPs have most likely been generating some of their profits by enrolling partial duals for which the current HCC model generates some over-payment. The new model will eliminate this, and SNPs with significant partial dual populations need to start planning now.
b. Member Eligibility and Reconciliation
Beneficiaries could have months in one or more of the six sub-populations. Tracking a member's status and the hierarchy of the status in the base year will be important as plans forecast and reconcile their risk adjusted payments. If CMS moves forward with reviewing predictive ratios for six segments as it states in the HPMS memo, it will be very important for plans to ensure they are updating a member's Medicaid eligibility (QMBs/SLMBs, etc.) in a timely manner, which is currently a requirement, and the accuracy will be even more critical for projections and reconciliation of risk adjustment status.
Takeaways:
a. New Opportunities to Manage Trend and Control Utilization Costs
With improved accuracy for predicting cost, comes an opportunity for plans to be more targeted and efficient with their efforts to manage trend and control the utilization of those beneficiaries that are seemingly very costly (or at least are predicted to be very costly).
Processes around moving patients to and from the community and back to institutional settings will need to be seamless, clinically appropriate, and efficient. Politics and system loopholes allow facilities and health systems to game the system, keeping people in beds or reserving space in order to receive the reimbursement associated with the patient's status. Controls will need to be put in place: Utilization Management and Compliance need to be involved to keep a close eye on patterns for both beneficiaries and providers.
Data has had a staggering increase of importance and remains an integral part of the healthcare industry. The need to have refined data management processes to ensure data integrity and quality analytics is at an all-time high. Achieving this should be at the forefront of health plans' minds, especially with impending policy changes.
This proposed model will improve payments a little for the least expensive non-dual members, while reducing payments a little for the most expensive. But the most expensive probably have the most unreported and under-reported diagnoses, so a good risk adjustment program could compensate for the small predicted impact of this new approach.
CMS is soliciting feedback on their approach to revising the CMS-HCC risk adjustment model to better predict costs for beneficiaries based on their dual status and aged/disabled status for Payment Year 2017. If you wish to submit comments, please submit them to RiskAdjustment@cms.hhs.gov , with the subject heading "Proposed Updates to the CMS-HCC Risk Adjustment Model," by November 25, 2015.
If you are unsure how this will affect your organization, or how to accurately communicate your ideas to CMS in two weeks, our integrated team of experts specializing in risk adjustment, analytics, compliance, pharmacy, and operations can work with your organization to ensure you have the right processes in place to ensure a timely submission to CMS. Contact us today >>
Resources
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Mergers Pave Way for Good Opportunity to Enter Medicare Advantage Market
While the largest insurance companies await their fate at the hands of federal regulators, other plans and investors should pay close attention to the opportunity to acquire divested plans from the two deals.
With the shareholders overwhelmingly approving the merger between Aetna and Humana, all eyes are on what the Department of Justice (DOJ) and the Federal Trade Commission (FTC) will make of the proposal for the two largest health insurers to consolidate. Anthem and CIGNA also await federal scrutiny. The mild grilling of the healthcare executives on the hill has led many to believe these deals will receive federal approval. And while hospital associations warn of lack of competition in programs such as Medicare Advantage (MA), it is widely recognized these companies will face significant divestitures in markets which will become highly concentrated due to the mergers. Aetna already announced it took a conservative look at the amount of business it would need to divest in order to make this deal go through.
Humana and Aetna would need to divest their plans anywhere the two plans have too much of the market combined — financial analysts estimate this to be any county where the market share is over 40% to 50%. One example of such state is Kansas, where Humana and Aetna combined hold 90% of the MA business. Other major states include West Virginia, Iowa and Missouri, and Ohio, where the two insurers would control an overwhelming amount of MA business. While, according to the Kaiser Family Foundation, Aetna currently only controls 7% of the MA business nationwide, Humana has the largest enrollment in 11 states.
These divestures present a great opportunity for investors and existing plans to enter or increase their presence in the MA market. MA enrollment currently sees no end to the growth spurt it is experiencing. In fact, the National Committee for Quality Assurance (NCQA) recently praised MA plans for their success in increasing quality for seniors, for the first time ever outpacing commercial plans on some quality measures. These existing MA plans are also attractive because of their existing infrastructure already in place, as the investment in creating a new MA plan is very burdensome and can take a long time to reap the benefits.
With both deals expected to close mid to late 2016, investors should really consider looking at states and counties where divestitures will be particularly significant and entering the ever-growing MA market.
Interested in entering or increasing your presence in the MA market?
Gorman Health Group's integrated team of experts can provide strategic analysis in evaluating market conditions across the country to identify MA opportunities and high potential target areas for expansion. Contact us today >>
Resources
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Is Your Customer Service Ready? Top 5 Lessons Learned in 2015 Rolling into 2016
It's only a few months until we ring in a new year. Time flies, but there is still enough time to ensure we put our best foot forward as we begin 2016. Here are the top 5 lessons learned in 2015 as we roll into 2016 to ensure Customer Service is ready for the New Year:
- What were your member's pain points in 2015? Reviewing grievances and appeals and Complaints Tracking Module cases (CTMs) has many purposes. High on that list is to improve the impacted process, but of course it goes beyond that. Sometimes we forget to close the loop and review and educate Customer Service staff on managing the pain points and how to work through difficult topics with our members. Better prepared Customer Service means better educated and knowledgeable members.
- Are all tools and support materials updated for 2016? There is a close-out for issues and claims from 2015, so for a period of time, Customer Service will heavily rely on two sets of information. A clear understanding of what is in place for 2016 and how to find the correct information is critical to preventing confusion for Customer Service and members.
- Have you tested your compliance with the various required timeliness standards? Can all Customer Service staff secure a translator within 7 minutes? Do they all know to stay on the line with the member and the translator once the translator is secured? Have you tested your TTY lines to ensure they reach a live agent during all hours of operation, 8 am — 8 pm? We are all monitoring average speed to answer and disconnect rates, but translator and TTY availability is harder to monitor, and every year the Centers for Medicare & Medicaid Services (CMS) finds plans failing to adequately manage non-English language and TTY calls.
- Can your Customer Service staff recognize complaints about coverage for drugs as coverage determinations? In a recent CMS enforcement notification, the first item called out in the health plan sanction letter was the plan improperly classified coverage requests as grievances or customer service inquiries. The coverage determination request process should begin at the time of the original call. It is critical Customer Service staff can recognize and correctly process these calls. Have you pulled your Customer Service call logs to see if these are being correctly identified and routed appropriately? That's what CMS will do in an audit―don't let them discover it first.
- Have you set up a process to ensure all letters and communications sent to members are also available to Customer Service? Everyone hates being blindsided by an issue or new information. At most plans, this is an everyday occurrence in Customer Service. Have you set up a common repository for all member material to be stored, and copies of the member materials placed there, before the information is mailed? An informed Customer Service Department shows cohesiveness and gives members confidence in your program.
Customer Service is the heart of a health plan. Ensuring your Customer Service staff is top-notch and has the tools to perform at the highest level for every call is critical to your plan's success. Gorman Health Group's experienced Operations team can work with you to set up knowledgeable, well-trained Customer Service and Operations departments. We've been in your shoes and know your struggles and how to solve them.
Before we ring in the New Year, let's double check that our members will have everything they need from your Customer Service Department to start the year right!
Resources
Our team assists dozens of health plans every year in scrubbing their member data and can 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 >>
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Star Ratings: Preparing for 2016
With the Centers for Medicare & Medicaid Services (CMS) release last week of its annual Request for Comments on Enhancements to the Star Ratings program, we now have our first official glimpse into the potential changes which could be introduced in the 2018 Star Ratings.
Consistent with CMS' recent about-face on the impact of socio-economic characteristics on a plan's Star Ratings, CMS laid out two potential interim analytical methodologies which may be used to help account for the Star Ratings differences of low income subsidy (LIS)/dual eligible (DE)/disabled members. CMS indicated these interim analytical adjustments will be interim solutions only and could be used while CMS completes its broader work on a more effective quality structure and payment model which more effectively supports the unique needs of LIS/DE/disabled members. CMS has requested health plan feedback regarding both potential options as well as recommendations for any additional permutations and/or hybrid approaches based on the two options presented.
CMS is not planning to add any new 2017 measures, which is welcome news to health plans, to be certain. However, CMS announced a number of potential new 2018 measures, some of which will bring transparency to clinical areas new to the Medicare Advantage Star Ratings program. Some of the new areas which could be Star rated include asthma medication management (including dispensation of, and adherence to, asthma medications), statin therapy prescribing patterns, and hospitalizations for preventable conditions (which will assess the quality and coordination of ambulatory care). In sharp contrast to recent history, in which we have seen very few new clinical measures added as Star Ratings, the nature and scope of these new measures will put plans squarely back in the driver's seat to initiate new types of clinical quality improvement work with their providers.
The proposed retirement of the High Risk Medication (HRM) measure (which had an average national 2016 rating of 4.1) to the Display page and the continued retention of the Improving Bladder Control measure on the Display page should be considered temporary by plans. These measures continue to receive attention from CMS and measure developers and could easily be returned as Star Ratings Measures in the future — the Improving Bladder Control measure potentially as early as the 2018 Star Ratings and the HRM measure potentially as early as the 2020 Star Ratings.
As is always the case with CMS' announcements regarding potential changes to the Star Ratings program, we know final decisions will not be made until after the measurement periods are complete. To successfully cope with this reality, health plans must continue monitoring CMS' updates and announcements in the upcoming Advance Notice and Final Call Letters while simultaneously enhancing current workflows to incorporate strategic elements of the proposed changes. As we learned last spring, CMS gives strong consideration to health plan feedback regarding any proposed changes to the Star Ratings program.
With the potential Star Ratings changes on the horizon, this is a great opportunity to revisit your 2016 Star Ratings work plan to ensure you are ready for success. It's a great time to evaluate reports, analytics, member/provider workflows and targeting, and budgets to make sure you're prepared to earn your 4-Star Rating next year.
Resources
Gorman Health Group's team of experts can help your organization adapt to the new clinical areas emphasized in the Request for Comments, develop or enhance care coordination within your programs, or evaluate the effectiveness of your current Star Ratings program. We can also help you educate your staff and providers on the nuances and clinical implications of these new measures. Visit our website to learn more >>
Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>