Quick Hits for September Sweeps
Unfortunately, Risk Adjustment does not have the luxury of taking the summer off. As CMS continues to stress the criticality of submitting complete, timely and accurate data to support plan payments related to Risk Adjustment, health plans must have year-round processes in place to ensure compliance as well as accurate payment from the government.
As premiums continue to be reduced, health plans and capitated medical groups must have strategies in place to ensure an accurate Risk Adjustment Factor (RAF) score, meaning you must not only recapture your members' persistent conditions, but find new clinical conditions as they appear. Sounds easy? Not quite. As we've seen the processes, programs and requirements are daunting and difficult to juggle. Our advice: leverage existing analytics and data to drive efforts for Risk Adjustment and the looming September deadline.
Items to focus on:
- Specialists/Providers- What is your strategy to engage specialists? Collaborative partnerships between health plans and providers will ensure optimum performance outcomes for revenue, medical management, and quality. Assess the root cause and go right to the source. By following the initial diagnosis, you will be able to prioritize your outreach by disease prevalence.
- Pharmacy- Mine your pharmacy data. If this data reveals prescriptions for medications specifically prescribed to treat risk adjustable diagnoses and the patients are consistently filling medication — yet there hasn't been a diagnosis submitted through a claim- a new variable for prioritizing provider or member outreach has been created. Try looking at your patients that meet the criteria for Medication Therapy Management (MTM). Not only is MTM a strong tool for managing costs, improving outcomes, and positively impacting your Star Ratings, the program can support your efforts to prioritize initiatives for Risk Adjustment.
- Clinical Quality and HEDIS- Partner and coordinate with your Healthcare Effectiveness and Data Information Set (HEDIS) teams. Leverage the information and clinical data retrieved and reported for HEDIS measures to identify members with risk adjustable diagnoses. If your plan uses a HEDIS vendor, make sure that you are reviewing their most recent audited HEDIS reports. If a claim or claims do not exist, but patients have been pulled into HEDIS measures through chart reviews, create a chase list to reconcile that data and then assign the most appropriate patient and provider intervention.
- Manpower — Are you lacking the technology to aggregate and create your target and suspecting lists? If interim staffing is what you need, Gorman Health Group (GHG) can enhance your team with our own, providing knowledgeable, effective assistance and an eye for detail from processors and analysts with decades of experience.
- In- Home Assessments — Adopt a core set of components and best practices for In-Home Assessments, prioritization and timing of these assessments is key. Track subsequently provided care: In CY 2015, The Centers for Medicare & Medicaid Services (CMS) will track and analyze care provision following in-home visits. If you are mining your data and notice a beneficiary has not been to the doctor in some time, take initiative and facilitate an in-home assessment. These encounters can also be leveraged to close HEDIS gaps and close the care coordination loop, avoiding ER visits or unnecessary trips to Urgent Care facilities.
- Vendors - Convene with your vendor partners to coordinate strategies. Include the Case Management team, Utilization Management team, and Provider Network team in your strategy discussions. All departments need to be working together to understand what visits are coming up in your provider network and why — who better than the teams who are on the front lines? Whether you rely on multiple vendors or a largely internal team, we can help you streamline the execution of your risk adjustment approach, and maximize your analytic strategy to ensure you're keeping pace with CMS expectations in both compliance and healthcare outcomes.
It's all about prioritizing. Mining the data to leverage the analytics you already have is a good way to start.
Get it right the first time. Managing the operations of your risk adjustment function is no easy task. The integrity of your data impacts virtually every other department in your organization - especially Finance, Quality, and Care Management. It's important to examine the data and submit it correctly the first time to guard against data inaccuracies, errors as well as to allow for appropriate reimbursement.
GHG supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure the procedures for capturing, processing, and submitting risk adjustment data to CMS are accurate, timely, and complete.
Whatever your organization decides to do, your strategy should be targeted, prioritized, and have a clear call to action. You have time and options. Contact us today to discuss them.
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Gorman Health Group (GHG) announced its new vision for maximizing healthcare analytics and optimizing risk adjustment programs. Read the full press release >>
CMS to Monitor Access to Care, Defines Provider Network Adequacy Pilot Program
During the Centers for Medicare & Medicaid Services (CMS) Audit & Enforcement Conference & Webinar held on June 16, 2015, CMS provided a glimpse as to how the Provider Network Adequacy (PNA) Pilot Program would begin to monitor beneficiary access to care.
The two-pronged approach will evaluate both provider network adequacy and the plan's provider directory. As we have seen over the past several months, from the Call Letter to the proposed Medicaid rule, there is a renewed focus on provider network access across all government-sponsored health plans. The focus is on not only the beneficiary's ability to access care in a timely manner but to ensure the member and referring providers have up-to-date demographic information on providers, including open/closed panel status.
Historically speaking, Medicare Advantage (MA) plans have submitted their provider and facility networks via Health Service Delivery (HSD) tables during their initial application or during a service area expansion (SAE). The HSD tables have been the source of truth for the MA plan to validate 90% of their enrollees had access to the full spectrum of providers and facilities within a given time and distance metric. Unless requested during the bid submission process, plans may not have validated their network against CMS standards from the original date of inception. We have found from year to year, even with no changes to the provider network, it is possible for adequacy to change due to the beneficiary population files updated by CMS. Additionally, we may have kept the same providers in the network but may not have captured changes, such as closing their panel to new patients, in our directories. Fueled by increasing beneficiary complaints, plans will now be required to diligently monitor their providers and the provider office information.
As a result, CMS is supplementing the current guidance on provider directories and network access and availability reporting. CMS expects plans to establish and maintain a proactive, structured process to assess the availability of contracted providers on a monthly basis and monitor more closely member access to their provider network. CMS will monitor compliance via direct monitoring and the new PNA Pilot Program.
The new PNA Pilot Program will evaluate the two functional areas, network adequacy and provider directory, by requiring submission of HSD tables and by CMS calling a sub-set of providers from the HSD tables to monitor accuracy of information. The process, while still under development by CMS, is designed to promote continual self-evaluation by health plans. During the Audit & Enforcement Conference & Webcast, CMS outlined the process for the PNA requests.
- CMS will issue a Pre-Audit Issue Summary (PAIS)
- Plans will have the ability to disclose network adequacy issues in two ways: sponsor-disclosed, meaning the issue was discovered by the plan and disclosed to CMS prior to the audit, or self-identified, meaning the issue was discovered by the plan after the start of the audit and self-reported to CMS.
- In response to the network adequacy findings, plans will be asked to provide a Beneficiary Impact Analysis to disclose areas where beneficiaries will be affected by network issues. The impact analysis should be a three-month look-back at all beneficiaries who received care by the identified provider(s).
- Plan will also be asked to provide their provider directory to CMS.
A Sample PNA Audit Timeline:
- Within 5 business days of the engagement letter:
- PAIS will be issued
- Impact Analysis for PAIS
- Provider Directory
- Within 10 business days of the engagement letter:
- HSD tables uploaded to Network Management Module (NMM)
- NMM will provide plan with a report identifying all network deficiencies
- Within 14 days of receipt of the deficiency notice:
- Submit exception requests
The aggressive audit timeline will require plans to incorporate a robust network adequacy monitoring policy into its workflow processes. When we look at the types of exception requests that will potentially be included in the final CMS policy, plans will not only need to be well-versed on their network but also the total number of providers/facilities available in their service area. Plans must be able to identify patterns of care for their network and non-network providers, alternative providers that could provide the services, such as ENTs providing allergy clinics, and be able to pull the information together in a relatively short time.
The second portion of the audit process will be to ensure the provider directory is current for provider demographic information and open/closed panel status. Per CMS, they will review a select representative sample of providers from the HSD tables and verify the directory information, by calling each provider office, to ensure the information available to the beneficiary is correct. The Call Letter indicated plans should incorporate a robust policy to outreach to providers on a monthly basis to validate the provider's network status and ensure any changes, both provider or plan initiated, are updated on a real-time basis. CMS intends to further define the new policies and procedures governing the PNA Pilot Program and issue the guidance late summer/early fall via the Health Plan Management System (HPMS).
As CMS increases the scrutiny on provider network access and availability, we can only wait to see the impact it will have on a plan's ability to move towards building a network based upon quality indicators and the value-based contracting and reimbursement models needed to shift providers into a population health and outcomes-oriented mindset.
Gorman Health Group can assist your organization navigate the network adequacy pilot and provide the infrastructure support solutions needed to build a smarter provider network. Contact me directly at emartin@ghgadvisors.com for more information.
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Game Changer: Key Reforms Proposed in CMS Medicaid Rule
You've got your nose to the grind stone working to meet all the waves of operational changes and requirements related to Medicare, Medicaid, Obamacare, and Health Care Reform - you literally don't even have time to glance upward to the skies. Understandable. But it can cost you.
July 27th is the CMS deadline for all to submit their comments about the recent Medicaid Rule, which according to Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS) is intended to "…better align regulations and best practices to other health insurance programs, …to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage." What does this have to do with me TODAY?
Now is the time to strategize, innovate and transform your plan and benefit design so that your operational platforms can grow as the rule will require you to. Here are two examples from Gorman Health Group's (GHG's) Medicaid webinar that took place on Wednesday, June 24, hosted by my colleague, Sunmi Janicek, Vice President of Medicaid and myself.
According to John Gorman's blog, "You're Doing it Wrong in Care Management" issued May 18, 2015, you are going to need to modernize your approach in care management into data-driven care coordination "pods" providing a holistic model of care focused on high utilizers and those about to become them. This means you need to recommit to data analytics identifying and directing the work of care managers toward those beneficiaries with long-term needs that can be impacted. Further, you need to place a greater emphasis on preventable episodes of care, and on end-of-life care preferences, advance directives and care plans. If you take the top 5% of the membership that is incurring the most cost and provide complex care management, including a higher level of home care, hospital diversion, medication therapy management, nutrition counseling, and wound care, plans and their provider organizations will see a reduction in avoidable medical expenses. Those reductions in avoidable medical expenses translate to better managed Medical Loss Ratios (MLRs), which directly impact your bottom line. How so?
The proposed implementation of the new rate setting will require managed care organizations to meet a MLR minimum of an 85% threshold. This is to ensure adequate funds are being spent on coverage for Medicaid members appropriately as states seek to move more and more Medicaid beneficiaries into managed care on a mandatory basis. CMS has charged states to develop new rates that will promote program goals that include benchmarks for quality of care, community integration of enrollees, and cost containment. Further, CMS wants to ensure enrollees are receiving quality of care and access in a timely manner, so they have asked the states to propose set standards for time/distance for specific provider types.
MLR thresholds are currently being used by the private health insurance plans, as well as, Medicare Advantage plans for projections of future medical costs and covered services. By including Medicaid in this imitative, it's evident CMS is trying to find a way to align standards among the different offerings across the board, but how will it affect your MCO?
While Medicaid MCOs don't have the high sales and marketing costs of individual commercial plans, since sales are handled by the states, compliance costs could be high, making the 85% figure a cause for concern. Medicaid MCOs will have to be diligent in identifying and documenting costs incurred to improve quality; essentially determining spend that could be considered medical versus administrative; to drive up their MLRs. Plans need to be able to fine-tune care coordination and quality, which are the hallmarks of managed care, and a federal MLR regulation could inhibit this. Do you have the right processes in place to ensure this happens?
With all these new changes, we can't stress enough that there will be a huge impact on implementation initiatives and sustainability that affect not only the finance department, but all departments. Once sustainability is achieved, it needs to be maintained as it will be addressed in future compliance reviews.
We are currently working with organizations in your area to identify gaps in operations while improving the ways they respond to clients, and developing care management models for the Long-Term Services and Supports (LTSS) population that make sense and will impact MLR. We share the same goal as you: to implement high quality, accessible, and cost-effective health care to our nation's most vulnerable population.
As soaring enrollment issues with varying populations of people persist, and new programs continue to be introduced, tough challenges are ahead. We can help make the transition smooth. Contact us today to get started >>
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To download the recording of the June 24, 2015 webinar mentioned above, please click here >>
GHG understands the complexities of the Medicaid population, and the numerous shifting variables that affect plan financial performance, such as state specific requirements for risk adjustment. GHG can assist with identifying the current and future costs of doing business, while building in anticipated adjustments that make sense for each population served. Visit our website to learn more >>
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Financial Impacts of Unscrubbed Data
We have written many articles on the importance of maintaining accurate, reliable data. Data is everywhere and in many versions. Health plans need to be very careful to input only that information coming from a reliable source of truth. In government programs, that reliable source of truth is prescribed to be information contained within the government's systems. "Scrubbing" data means reconciling against that reliable source of truth. For health plans, this means reconciling with information within the government's systems, regardless of whether that information is right or wrong. Correcting the government's erroneous information requires adherence to prescribed processes.
The most effective way to process transactions with government programs is using the government's own data. This is most effective because it greatly lends itself to automation. A clear example of how this works is in Enrollment processing using what we call an "Intelligent Front-End." The objective of an Intelligent Front-End is to import the government's data and then utilize that same data in transactions back to the government. This Intelligent Front-End also receives data files from the government and then utilizes that same data to trigger required actions within the health plans' systems. This tactic ensures reconciliation, compliance, efficiency, and manageability.
Another example of utilizing "scrubbed" data is in validating health care providers' information. This is critical for provider credentialing, contracting, medical claims processing, pharmacy claims processing, risk adjustment, and encounter data submissions. The monthly National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) downloadable files and weekly incremental NPI files provide an abundance of information. Combining the Medicare Exclusion Database (MED) and Office of Inspector General List of Excluded Individuals and Entities (LEIE) helps to build a national universe of health care providers' information. Automating reconciliation with this comprehensive database can tremendously expedite provider set-up for processing claims from non-contracted providers. This helps to avoid interest payments for untimely processed claims.
It is imperative for health plans to keep current on updates to payment codes. This includes:
- International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM);
- International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM);
- International Classification of Diseases, Tenth Edition, Procedure Coding System (ICD-10-PCS);
- Current Procedural Terminology (CPT);
- Healthcare Common Procedure Coding System (HCPCS);
- Modifiers;
- Revenue Codes;
- Place of Service;
- Bill Types;
- Condition Codes;
- Occurrence Codes;
- National Drug Codes (NDCs).
Finally, it is absolutely necessary for health plans to keep current on updates to fee schedules and prospective payment pricers. Provider payment disputes are on the rise. Ironically, so are overpayments to providers. Ensure payment accuracy by utilizing up-to-date fee schedules and pricers.
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Gorman Health Group (GHG) includes some of our industries most experienced and proficient health plan subject matter experts. Our consultants can help your organization with developing or improving your Intelligent Front-End, scrubbed health care provider information and national provider database, and assess whether your claims adjudication codes and payment systems are current and used appropriately. Contact us today to get started. >>
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Don't miss Gorman Health Group's Chief Consulting Officer, with colleagues Jane Scott, Senior Vice President of Clinical Innovations and Regan Pennypacker, Vice President of Compliance Solutions, as they discuss your member experience and the factors that influence success and failure, as well as prominent compliance and service issues plaguing the industry. Register today >>
CMS 2015 Oversight and Enforcement Conference - Compliance Edition
The pessimist complains about the wind. The optimist expects it to change. The realist adjusts the sail. -William A. Ward
Those who had the opportunity to view or attend the Centers for Medicare & Medicaid Services (CMS) annual Audit & Enforcement Conference & Webcast better start thinking about which group of folks you will be a part of: pessimists, optimists, or realists. In order to maximize your success, you best classify yourself in the realist bucket — quick.
One thing that did not change over last year is CMS' overall assessment of improvement. Mr. Mulcahy confirmed CMS has still not seen the improvement they had hoped to see after years of issuing best practices and common conditions information to the industry. Go back to last year's video archives, and you will find he said the same thing last year. According to CMS, sponsors are still surprised by audit activities and findings and unaware of their level of compliance.
Many best practices to combat this type of situation in your organization were discussed during the conference. For example, one organization pulls universes using CMS' data layouts on a monthly basis. Another organization stressed the need to not only focus on the short term in corrective action plans (CAPs) but also consider the long-term solutions required for long-term success—that includes a deep-dive into processes and continuous training. Once-a-year specialized training will no longer cut it, especially in the areas of Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) where CMS notes sponsors, at times, seem unaware of their compliance.
Some things that are changing are the audit protocol instructions and data layouts currently on the Program Audits site. CMS confirmed there are a number of issues requiring clarification or correction in the protocol — we anticipated this. They hope to release updated protocols by the end of this month, but if a plan is subject to audit in the meantime, they will receive the updates. In terms of audit support, CMS' Jennifer Smith confirmed there is still a plan for CMS to release a chapter on audit activities. Once released, this should be a great help to plan sponsors. CMS also provided detail pertaining to the Medication Therapy Management (MTM) and Provider Network Adequacy audit pilots, scheduled to be released in late summer or early fall.
We are continuously making adjustments to processes to ensure alignment with CMS activity, and we hope our clients and all plan sponsors are doing the same. The Medicare Parts C and D Oversight and Enforcement Group (MOEG) confirmed that, if any sponsor receives a civil money penalty (CMP) or sanction, they will be expected to engage an independent auditor to validate corrections. CMS confirmed 93% of plans audited in 2013 received some sort of CMP, and at the recent GHG Forum in April, I shared the majority of enforcement actions since 2014 have indeed been related to CDAG and ODAG. Talk about a risk! It really is time to look inward, be a realist, captain your ship, and adjust those sails.
If you have questions pertaining to the audit protocol, CMS advises you to forward any questions to part_c_part_d_audit@cms.hhs.gov. If you have questions regarding the conference, or have questions on how we can assist, please feel free to contact me directly at rpennypacker@ghgadvisors.com.
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Register now for a new webinar on improving quality ratings and member retention efforts, as well as prominent compliance and service issues plaguing the industry on Friday, June 26 from 1-2 pm ET.
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AEP Begins in 120 Days. Are your agents ready?
It's so much more than training. GHG's fully-automated Sales Sentinel™ can take your agents from zero to ready-to-sell in as little as one week, ensuring agents are not only trained, but contracted, licensed, and appointed per CMS requirements. Sentinel can also assist the organization with administrative onboarding functions such as form collection and writing code assignment.
See full capabilities below:
No matter what you need — we can help. Contact us for more information.
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Gorman Health Group's Sales Sentinel™ is specifically designed to make agent onboarding easier for health plans. The web-based, modular solution manages every step of getting your agents ready to sell: contracting, license verification, background check, training, and appointment. Let's get started.
Takeaways from Accountable Physician Groups' Annual Summit
Twice a year I get the honor of speaking to the California Association of Physician Groups' (CAPG) annual summit and DC policy meeting. CAPG represents accountable, capitated physician groups, and now has members in 39 states. They're always among my favorite speeches given how sophisticated the audiences are. Here's a few takeaways from my talk last week on "The Future of Government Programs":
- Forevermore, physician group revenues and earnings will be dominated by Medicare Advantage, Medicaid and dual eligible health plans, and the ObamaCare plans, most likely in that order.
- Everything that Medicare Advantage (MA) does, the Medicaid, ObamaCare, and commercial markets follow 3-5 years later. Nobody knows this better than the CAPG members from CA, which the rest of the nation lags. Want to still be attending CAPG meetings in 2020? Master Star Ratings and risk adjustment. They'll apply to all lines of business if they don't already, and they are the keys to survival already in MA.
- Value-based contracting is in its infancy but will soon define all health plan contracts with physician groups. Fee-for-service is dead. Performance-based capitation is the only future. To master it a physician group needs a range of capabilities, including eligibility verification, interoperability, actionable clinical intelligence in real time, standardized care processes, and chronic care management, across all business lines.
- Most Accountable Care Organizations (ACOs), especially the 424 in Medicare, will not see a return on their investment. They will have spent millions to participate in these experiments and around 80% won't see a payoff. 2016 and 2017, when Medicare Advantage benchmark rates turn into a tailwind, present the perfect opportunity for ACOs to "move up the food chain" to become health plans.
- Dual eligibles are the biggest opportunity of our lifetimes, and there is no question that Special Needs Plans designed to serve them can be profitable. SNPs are a principal mechanism for states to shift long-term care risk into the private sector, and will be a central product for ACOs converting into Medicare Advantage. But they require a range of capabilities most physician groups lack today, such as enabling and social services that duals must have from their insurer.
- In all government programs, the "5/60 Rule" governs. 5% of members often account for 60% of costs. Any physician group that aspires to bear risk must be able to identify and intervene with their 5 percenters or they won't be risk-bearing for long.
- The biggest vulnerabilities for MA plans are consumer protections like appeals and grievances and complaint management, and who they have selected as their pharmacy benefit manager (PBM). Most PBMs are frankly terrible at Medicare Part D administration, and Star Ratings now count far more in Part D than in Medicare Advantage to a health plan's overall score. Physician groups typically have little or no experience with either PBMs or consumer protections.
- Retail pharmacies and the home are the most underutilized sources of care to government programs beneficiaries. Any successful physician group evolution will involve better integration of both sites for the chronically ill.
- Most at-risk physician groups are directly involved in coding and reporting for risk adjustment. Federal agencies are paying unprecedented attention to upcoding in Medicare Advantage with an eye to hundreds of millions of dollars in clawbacks and recoveries. The emphasis at physician groups involved in risk adjustment must move from chart reviews and claims extracts to more holistic member evaluations, and from a culture of "what can we get?" to "how do we stay out of trouble?"
Evolution is a messy business. Nowhere is that more the case than in physician groups evolving from fee-for-service to value-based contracting and becoming insurance companies. If it was an easy business, we'd be out of business.
Resources
Don't miss Gorman Health Group's Chief Consulting Officer, with colleagues Jane Scott, Senior Vice President of Clinical Innovations and Regan Pennypacker, Vice President of Compliance Solutions, as they discuss your member experience and the factors that influence success and failure, as well as prominent compliance and service issues plaguing the industry. Register now >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Let's get started. Contact us today.
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CVS Health is Serious About Growing its Clinic Business
CVS Health is serious about growing its clinic business. On Monday, USA TODAY reported that CVS Health plans to acquire Target's pharmacy and clinic business for $1.9 billion.
Healthcare reform is producing a surge in newly insured people seeking care, and hospitals are under severe pressure to keep pace.
"This long-term strategic relationship will certainly benefit the patients, the employees and the shareholders of both companies," CVS Health CEO Larry Merlo said in a conference call.
In addition, a primary care provider shortage is predicted to limit access to care. This is where CVS Health's new acquisition will come into play with more than 1,660 Target pharmacies offering accessible care in 47 states.
Demographic change exacerbates the challenge, with a steep rise in the ratio of elderly to young, adding yet more demand. Retail health clinics may be the "release valve" to the strained healthcare system and the future of care.
CVS Health has been the leader in the retail clinic industry to date, but other retailers like Walmart and Walgreens are poised for growth. The move to acquire Target's pharmacy and clinic business allows CVS Health to solidify its lead in the clinic business.
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Gorman Health Group continues to provide strategic, operational, financial, and clinical services to the healthcare industry, across a full spectrum of business needs. Our software solutions place efficient and compliant operations within reach. Learn more: https://www.ghgadvisors.com/about/.
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Implementing a new PBM? What you need to know.
Now that the smoke has cleared and the ink is dry on the formulary/transition and bid submissions, it's okay for plans to breathe for a couple of weeks. Then—if you're implementing a new Pharmacy Benefit Manager (PBM)—it's time to roll up your sleeves and get started with conceptualizing and developing a road map for the next six months. It's important to start early and work steadily to make decisions, create processes, and complete training. During this time, you must continue to partner with your current PBM to process claims, make coverage determinations, and oversee and monitor all the delegated functions according to the plan you have in place. With the new PBM, you have the opportunity to tweak some processes that perhaps weren't working exactly as you had envisioned originally.
The new PBM should have a detailed work plan they utilize for implementations, and their team can be invaluable in assisting with timing needed for decisions and keeping the project on track. Don't cancel meetings or get behind on decisions that need to be made. You will need every bit of the time in November and December to get testing done on the new formulary and to reach out to members who will be disrupted by formulary changes. And, if you're implementing a new PBM because of dissatisfaction with your current PBM, begin as you mean to go on. In other words, think about the nature of the relationship that best serves your organization and staff and start developing it from the beginning. It IS just business, but you will be working with the PBM team members on a daily basis for the next few years. So start off on the right foot and build the foundation of a relationship that will benefit your members and your organization.
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The GHG Pharmacy team can assist you with your PBM implementation by providing subject matter expertise on all the decisions that need to be made and the processes that need to be developed. And we have a state-of-the-art benefit administration testing plan to help you before go-live.
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HRADV: What you don't know could cost you millions
Now that the 2014 EDGE server submission is complete, it will soon be time to audit a large sample of the data. Are you ready?
HRADV is the Commercial Risk Adjustment Data Validation that will be conducted annually on the data submitted to the EDGE server. This audit is similar in nature to the Medicare Risk Adjustment Data Validation (RADV) with a few exceptions. You do not get selected for the HRADV; rather, it is an annual requirement that the auditing process is conducted on at least 200 members. An error percentage will be assigned for health status and demographic information that does not have appropriate supporting documentation. This error percentage amount will be deducted from the prospective years' risk adjustment payment, or a payable will be due to The Department of Health and Human Services (HHS).
I have heard many health plans say, "There are no financial implications to the 2014 and 2015 HRADV errors" and "These are the learning curve years." While both statements are true, the fact of the matter is, these years DO count. You could be leaving millions of dollars behind for these years, not only for risk adjustment but for reinsurance as well. You are also at risk of being fined a significant error penalty after the "learning curve" years. Now is the time to ensure you have all of the necessary processes in place. Here are a few questions to ask yourself about the risk adjustment operations at your company:
- Are your providers familiar with the tremendous impact the transition from ICD-9 to ICD-10 has on risk adjustment, reinsurance, Stars, and the Healthcare Effectiveness Data and Information Set (HEDIS®)?
- Do you have the right staffing in place to support end-to-end risk adjustment successfully?
- Did you successfully submit complete and accurate 2014 data to the EDGE server?
There are many areas inside and outside of the company where membership and claims data may be compromised. This information is being sent through many different systems which increases the probability for information to unknowingly be altered. Here are some tips to prevent submitting incorrect or incomplete data to the EDGE server:
- Ensure you have a solid provider contract and education program in place.
- Align a risk adjustment staffing model appropriate for your organization.
- Develop ongoing data review and reconciliations with various departments throughout the company to create data integrity.
- Be prepared for the HRADV and appeals process.
HRADV and appeals is the final step in the risk adjustment process. More information will be released from HHS regarding the specifics around the audit for 2014. Be prepared and ensure you have selected your Initial Validation Auditor (IVA).
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