Five Critical Steps to Enhance Revenue & Maximize Growth Potential
Everybody's talking about revenue management and maximizing growth opportunities for health plans, but no one has laid out the steps for successful outcomes…until now. Gorman Health Group (GHG) is giving you our recipe for enhancing your premium revenue and maximizing your growth potential in the following five-step plan:
Step 1. Targeted Population/Demographics
Different populations have different needs. Understand the makeup of your membership and their healthcare needs, their provider preferences, and understand what they want to experience when interacting with your health plan. Is your health plan designed to meet the needs of your targeted population?
Step 2. Optimizing Revenue and Performance-Based Payments
Revenue management is best performed at the member level. Each member should be viewed as an investment needing optimizing. Revenues for members are based upon bids or other established "base" amounts. These base payments need to be optimized for each member. Optimizing member-level revenue begins with an effective member onboarding and retention program, whereby the following factors can be assigned to each member:
- Health Risk Assessment (HRA) to identify potential Hierarchical Condition Categories (HCCs)
- Medical management needs
- Member-level attributes included in Star Ratings measures denominator (e.g., diabetes, rheumatoid arthritis, high-risk medications, etc.)
- Special payment status for Medicaid, end-stage renal disease (ESRD), hospice, long-term institutional, and other health insurance (OHI)
- Continuous vigilance for status changes that could impact payments (e.g., actively monitoring claims for indications of circumstances warranting special payment statuses)
Focus on keeping members by enhancing the member experience through the entire organization. Member retention is the new "selling."
Step 3. Delivery System and Care Management Approach towards 85% Medical Loss Ratio (MLR)
It is imperative that health plans aggressively manage their medical costs as the most expensive component of healthcare operations. Employing the following programs can significantly impact MLR:
- Effective medical management
- Effective provider and network management
- Effective pharmacy management
- Effective Pharmacy Benefit Manager (PBM) contracting/re-contracting
- Effective claims processing and claims payment rules (Medicare vs. Commercial vs. Medicaid)
- Effective durable medical equipment (DME) management
- Effective hospice and end-of-life care
- Effective fraud, waste, and abuse (FWA) detection and prevention programs
- Effective payment responsibility/Coordination of Benefits (COB) processing
- Effective capitation leakage/correction processes
Health plans must spend at least 85% of premium dollars on healthcare. Effectively managing MLR to below 85% of premium revenue enables a health plan to offer more attractive benefits, lower cost-sharing, offer best-in-class providers, and reward top delivery system performers.
Step 4. Optimized Cost of Operations, Selling, and Administration
A well-run health plan should target cost of operations, selling, and administrative costs to a level at or below 10% of premium revenue. This involves knowing your operational strengths and weaknesses and outsourcing the appropriate functions to experts. This involves making brutally honest assessments of internal capabilities and a willingness to make tough decisions. It is often best to have these "no sacred cows" assessments performed by external experts having an independent viewpoint. In addition to the health plan core operational areas of Membership Accounting, Member Services, Claims Processing, and Appeals and Grievances, health plans must perform critical assessments to ensure:
- Effective financial management
- Effective benefit and premium design
- Effective sales and marketing
- Effective information technology
- Effective project management
The goal is to operate as efficiently and effectively as possible at a performance level that earns maximum quality bonus payments.
Step 5. Profit Margins for Reinvestment in Growth
That leaves a profit margin of 5% of premium revenue. This provides opportunity for strategic investments in:
- More staff and training
- Best practice processes (member onboarding, healthcare concierge, member/patient experience)
- Updated systems and analytics
These investments are key to serving your existing membership with best-in-class performance — all intended to place your organization heads and shoulders above your competitors. In the current competitive environment, growth means attracting members from other health plans. There will be winners and losers.
Winning!
GHG is comprised of some of our industries most experienced and proficient health plan subject matter experts. Our consultants can help your organization with a "whole house" assessment or targeted assessments, and we can help you fix the problems we identify. Contact us today to get started.
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GHG Operational Performance Group includes some of our industries most experienced and proficient claims subject matter experts. Our consultants can help your organization implement best practices in claims cost containment. Contact us today to get started >>
When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. Visit our website to learn more >>
19 Lessons from 19 Years
Nineteen years ago this week, I left the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS) and the Office of Managed Care, to launch what would become Gorman Health Group. Time has flown, the company has grown, and my backside sewn with hard lessons about our industry and government health programs. Here are 19 lessons I've learned in those 19 years.
- What Medicare Advantage and Part D do, Medicaid and the commercial market, including the ObamaCare Exchanges, follow 3-5 years later.
- Every CMS staffer I've ever known is well-intentioned, many are downright brilliant, and all want to be good business partners to health plans. Their shortcoming is lack of business experience and how stuff works in the real world. There is a huge difference between policy/guidance and operations. That's where we come in.
- If government health programs were an easy business, we'd be out of business.
- Inspect what you expect. Or, as Reagan said, "Trust but verify."
- Star Ratings, like risk adjustment before it, is the biggest and most consistent experiment in performance-based payment on the planet, a total game-changer and the new fulcrum of competition. You don't excel at Stars by working on them off the side of your desk.
- Fish where the fishes is.
- Pick your vendors and partners like you pick your fruit.
- Capitation with performance-based payment is the only real hope for long-term viability of entitlement programs.
- Being a doctor is the worst job ever. Right after community hospital CEO and President of the United States.
- High-performing health plans are good at everything, especially those functions that are member- and/or provider-facing. It's about culture and execution.
- Health plans' days are numbered if they can't consistently provide value to CMS, their customer, and to providers, their partners. That value is about two things: making data actionable and moving money to contributors when quality and results improve.
- It's easier to increase revenue than it is to cut costs.
- Pharmacy benefit managers are a health plan's most important partner. They are also the ultimate B2B companies and most are struggling in the transition to B2C and true government accountability for results.
- Big data and high-tech is all the rage -- and all noise, unless it's actionable. What works is low-tech: clogs on the street; a house call; a medication consult.
- Doctors of the future are in multispecialty practice and leaders of a team of nurses, aides, social workers, and pharmacists. They are quarterbacks, not gods. They diagnose, and everybody else treats.
- So much of the future is about retail pharmacy. In short time, they will make more providing services than filling bottles.
- Ninety percent of the evil and waste in the system occurs at the tip of a doctor's pen.
- We are all going to retire thanks to government programs. Demographics is destiny.
- Five percent of members account for 60 percent of your spend. Put the love and focus on them, and you can pretty much leave everyone else alone.
It's been an incredible ride these last two decades, and especially the last five as health reform blossoms. We look forward to continuing the journey, older, wiser, and bigger. Stay tuned.
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Next Generation Accountable Care Organization
With the NextGen model, the Centers for Medicare & Medicaid Services (CMS) is attempting to respond to some of the criticisms of the first two Medicare ACO models: the Pioneer demonstration program and the Medicare Shared Savings Program (MSSP) authorized under the Affordable Care Act (ACA). CMS says that the NextGen model represents:
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A new opportunity in accountable care:
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More predictable financial targets;
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Greater opportunities to coordinate care;
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High-quality standards consistent with other Medicare programs and models
The Model seeks to test how strong financial incentives for ACOs can improve health outcomes and reduce growth in expenditures for Original Medicare fee-for-service (FFS) beneficiaries.
There will be two rounds of applications. Deadlines are listed below:
The NextGen model is a demonstration program that will run from 2016 through 2020.
Interested in this opportunity, but unsure if its right for your organization?GHG can support your organization with a variety of services from an initial ACO operational readiness assessment, including financial modeling, benchmark & trends, assistance with preparing your application, to implementation and on-going support. Contact us today >>
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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 >>
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Claims Leakage and the Path to Avoidance
All managed care organizations must operate a high-performing Claims Management. With strict medical loss ratios (MLR) as required by healthcare reform, timeliness provisions, payment accuracy, and constant regulatory requirement changes, covering operating costs pose significant challenges. Cost containment whereby eliminating excess, leakage and waste must be top priority.
The environment is rapidly changing. It doesn't mean that healthcare will be less complex—indeed, probably the opposite. These changes must be properly evaluated, managed and monitored with a focus on cost control. Claims spend is the main expense for many organizations. As customer expectations, competition and regulatory burdens crunch margins, eradicating claims leakage is critical. Throughput and efficiency are key performance data measurements. Organizations need processes and systems that minimize costs while delivering a high-quality claims experience. Rather, operational silos, as well as ineffective and disparate systems across multiple products lines cause many issues.
What is Claims Leakage?
Claims Leakage is defined as the difference between the actual claim payment made and the amount that would have been paid if more practical claim payment controls had been in place.
Claims is a key driver to a couple of very critical components of your revenue. Everyone is aware of claims as it relates to MLR, but equally important is how the claims data impacts revenue in the forms of HEDIS measures and Star Ratings (year to year composite score). As a component of MLR on the costs side — this drives benefit design; if your medical costs are lower than 85% you need additional benefits. HCC (hierarchal conditions categories) are assigned risk adjustment factors — missing claims information (leaking) could result in diminished Risk adjustment scores — same thing as with HEDIS and Stars — missing claims information means less performance in Stars measure and HEDIS.
Leakage equals wrong payment that went out the door. Bottom line, it can cause you money and rework.
Examples of leakage include:
- Inappropriate benefit design, including member cost sharing
- Inaccurate provider pricing and reimbursement methodologies design and updates
- Missing claims and encounter data
- General configuration issues: Edit rules, duplicate check, NCCI (national correct coding initiatives) and auto-denial/pay rules
- Minimal data scrubbing: The number 1 and 2 causes of claims leakage is inaccurate membership information and inaccurate provider information.
- Lack or poorly designed MUEs (medical unlikely edits), coding and mapping issues, including CPT, modifier guidelines, HCPCS, ICD-9/ICD-10, and all UB04 institutional coding
- Upcoding — billing for higher level of services while lower level services were
- Claims submitted by bogus providers
- Pharmacy claims: Appropriate payment allocation of Medicare drug coverage: Part D versus Part A or Part B payments
How does it stop?
The path to avoidance and some best practices are as follows:
- Develop a strategy in enhancing claims quality control and oversight activities.
- Implement quality control auditing through pre-payment auditing reviews.
- Develop and generate focused exception reports of where the leakage dollars are
- Invest in strong post-pay detection technology to achieve cost avoidance savings.
- Develop and implement automated and sophisticated algorithms:
- Scale
- Claims Check and Edits
- Focus on the 5% of the financial leakage
Execution of these best practices and automating each procedural step of the claims cycle results in accurate claims resolution. Monitoring operational performance helps continuously track and trend claims inputs and outputs.
Proven Strategies to Plug the Leaks
Optimize your organization's operational performance, requiring coordination across people, processes and systems. Align and take a holistic integrated view, end-to-end, when monitoring operations.
Leaks don't occur because we plan them. They happen because we fail to plan to address them.
Resources
GHG Operational Performance Group includes some of our industries most experienced and proficient claims subject matter experts. Our consultants can help your organization implement best practices in claims cost containment. Contact us today to get started >>
When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. Visit our website to learn more >>
You've Got Mail: National Sample RADV Audit Scores are In
By now you may have received your score from the Centers for Medicare & Medicaid Services (CMS) regarding the national sample for Risk Adjustment Data Validation (RADV) audits.
Wondering how you compare to your peers or competitors and what the implications of your score are?
Factors that should be taken into account regarding your score compared to the national average:
- If you were to extend your score across your entire membership, would you be satisfied with the results?
- What is the impact on your revenue and bid/benefit design?
- Are inaccuracies going to have an impact on HEDIS measures and Medical Trend Management?
- Do you have a long-term strategy to positively affect your results through concurrent reviews and targeted provider education/engagement strategies?
Regardless of what your results are, you need to have a solid action plan in place for improvement and maintenance. Due to the size of the sample, it is not statistically significant enough for your organization to receive the large scale impact this number potentially poses on revenue, medical costs related to beneficiaries, and your organization as a whole.
Mock RADV's and concurrent chart reviews should be a part of your risk adjustment program, and should be coupled with targeted provider education and engagement strategies.
Critical next steps:
- Implement standard operating procedures for internal Mock RADV audit programs
- Leverage analytics to target and profile your provider network for education and engagement
- Implement year-round concurrent reviews to ensure optimal results for revenue capture and avoidance of RADV exposure and potential overpayment recovery requests from CMS.
Gorman Health Group supports our clients in evaluating the efficiency, compliance, and strategic value of risk adjustment programs from start to finish. We have a unique opportunity to collaborate with our clients and design, implement and operationalize year-round processes to ensure risk score accuracy and alignment. Together, we can develop enterprise-wide strategies to manage medical costs and improve clinical quality outcomes.
If you have any questions or would like to hear more about how we can help, please contact me directly at dweinrieb@ghgadvisors.com.
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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 >>
Spring Fever Focus: Grievances and Appeals
Spring is here, showing us all different signs of renewal. It motivates us to clean out clutter, open those windows, and start the year fresh. Audit season is also upon us, and people are taking a close, hard look at internal processes that surround grievances and appeals processing. Findings in this area keep showing up, like that college grad that keeps popping in to visit his friends back on campus. Just leave already, you've had your time!
What is causing the frequent failures that the Centers for Medicare & Medicaid Services (CMS) describes? I spoke recently at the 2015 GHG Forum regarding this issue. We believe it is one of the following factors: people, processes, or technology. It's time to perform an assessment on this area. Ask yourself these questions:
- How much specialized training has this team received this year? How do I know our team leaders are up on the regulations and best practices? Is the Grievances and Appeals (G&A) Department a dumping ground for service issues that could have been handled in Member Services? With constant call center turnover, is G&A working closely with Member Services management to educate new staff?
- Are procedures for case processing overly complicated? Is staff empowered to effectuate change, or are they hampered by rigid workflows? Are the procedures even referenced anymore, or are they just a placeholder document for the intranet policy and procedure (P&P) library?
- Can I customize our case database to meet my changing reporting needs? Are the reports I am getting out of the system providing me with the information leadership needs to make decisions? Are there steps in place to ensure all aspects of the case were completed? Can it produce universes according to CMS audit specifications, or do I need to prep them manually?
These are tip-of-the-iceberg questions that we consider during an operational assessment of Complaints Tracking Module (CTM), grievances, and appeals processes. As one of the highest risk, beneficiary-facing areas of your plan, this is a great place to kick off spring cleaning. Create a checklist of your own to conduct an assessment of these processes. Chances are, you already know your pain points, and you just haven't documented and escalated as of yet. Don't wait until a CMS audit notice, as illustrated by a very truthful sentiment (thanks someecards!)
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Gorman Health Group's Complaints Tracking Module (CTM), grievances, and appeals processes, provides a new way to ensure your cases come to a timely and compliant resolution. Created with CMS in mind, as it captures key information related to intake, processing, categorization, determinations and higher appeals or re-openings to process cases according to CMS' complex and detailed requirements. Contact us >>
How Do You Cross a Threshold to Success When There Isn't One?
Many plans are reacting to the changes affecting the Star Ratings as described by the most recent release of the 2016 Advanced Notice. One of the most impactful changes is that of the removal of the thresholds for plan year 2016 measures. CMS gave early warning of the removal of the thresholds for many of the measures and restates their position as per page 86 of the Call Letter:
"Our primary goal in eliminating the thresholds is to improve the accuracy of the assignment of overall and Part C and D summary Star Ratings and to make certain the system creates incentives for quality improvement. While there is general support for this change, some sponsors and stakeholders remain concerned that it is difficult to improve without published targets for achieving 4 or more stars on a measure. We also understand that some sponsors are concerned that eliminating pre-determined 4-star thresholds will make it more difficult to set targets for performance or value-based contracting."
It will be difficult for many plans to manage the removal of the thresholds when that has been the reliance for the benchmark of improvement in many instances — from improvement in the quality work plan (which, by the way, don't forget, will have to be modified) to the provider incentive plan to the overall strategy for value-based contracting many plans are now trying to implement.
Because CMS stated that having pre-determined thresholds may restrict continued quality improvement, plans now must begin to become stronger in the quality improvement/assurance arena. What does this mean for you? This means rethinking your quality work plan, the benchmarks or baselines used, and asking yourself as a plan: What other data sources can we now use to make sure we are on the road to continuous quality improvement? This also means re-evaluating your Stars work plan/strategy and the tools used to support it. How can you create a better dashboard for 2016? Think about using industry standards already out there for the new "thresholds" and incorporate those into the dashboard. In fact, why not try that exercise now — start running "new" thresholds" alongside the ones in place today for 2015 and see where your plan will land. CMS believes this change of threshold removal will not impact the industry greatly. In fact, they cited that their research shows close to 7% of plans would possibly have their ratings raised one-half a percentage point, and approximately 10% would go down by the same rate. If plans want to be certain this really is the outcome, it is time to start preparing now, especially if your plan will experience a reduction to a greater percentage.
So what are good baseline or benchmark replacements, you ask? Well, let's start with the easy one — HEDIS. NCQA publishes a memo which reports the national benchmarks and national and regional thresholds for HEDIS/CAHPS. Plans could start comparing themselves in this fashion now and preparing for the removal of thresholds, strategizing on the results they see.
Another thought: plans certainly have the capability to trend historically on their own performance — examine those 19 measures that have no threshold today and think about the interventions or methods used in the management of these. Don't be afraid to use the document published by CMS, "Trends in Part C & D Star Rating Measure Cut Points," and conduct the same exercise within your organization if you have not already. That document can be found here.
Also, have the discussion within your plan's provider networking/contracting area and ask the question, "What does the threshold removal do to our contracting strategy and the use or identification of high performing providers?" Will we, as a plan, need to redefine what high performance means so we can measure it correctly? Will we, as a plan, need to change what measures/benchmarks on which we are paying bonuses? I think you will.
Plan to start tying providers to measures they can influence and then talk with those providers about changing outcomes for measured improvement. Remember, you will have to help them prioritize now.
Plan and be prepared for the changes by reviewing your quality program, the QIPs you have in place, and how will they need to be modified to account for the changes coming down the road.
With a few simple steps, you can still cross over to success, even without a threshold!
Don't know where to start? Contact me today at jscott@ghgadvisors.com.
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Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.
GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. Visit our website to learn more >>
Gorman Health Group Client Forum Takeaways: Government Programs are Booming, Bar is Rising
We just wrapped our best-ever Gorman Health Group 2015 Client Forum at National Harbor with over 200 of our closest clients and partners. There was both great and tough news, so here's a few takeaways, including a couple stunners:
- For the first time, a prominent Wall Street analyst said he could see a path to 100% Medicare Advantage penetration. Barclay's eminent health care observer, Josh Raskin, stunned our audience with projections of over 29 million Medicare Advantage enrollees by 2023, a penetration rate of over 42%, with the potential to go all the way with Ryan Plan-like legislation now feasible this decade.
- 47 states now hold Section 1915(c) home and community-based services waivers for Medicaid, which will unleash a new flood of dual eligibles into health plans. Special Needs Plans (SNPs) for duals are now on a path to permanent reauthorization, and over 30 states now use D-SNPs to enroll over 1.6 million beneficiaries. That number will more than double in the next 2 years.
- While year 2 of open enrollment for ObamaCare was dramatically improved from its messy launch, problems persist, especially with membership reconciliation and issues related to the interim process to auto-enroll most members staying in their plans. Cleanup of membership discrepancies will likely take another year or even longer.
- Risk Adjustment Data Validation (RADV) audits will become the new normal in Medicare Advantage. 2015 will be the first time we see plans prosecuted under the False Claims Act and hundreds of millions clawed back by the Centers for Medicare and Medicaid Services for unsubstantiated codes submitted for higher payments.
- Maximizing data, strong provider partnerships, documentation and ICD-10 preparedness are keys to audit proofing your Risk Adjustment program.
- The Star Ratings system of performance-based payment is the new cornerstone of competition among health plans. Stars has expanded into more than a dozen state Medicaid programs, and to ObamaCare's issuers as well, and the bar is rising. Technical changes to several measures mandate much higher performance to stay ahead of the curve and avoid falling below 4 Stars, where bonus payments and bid rebates vanish. 2015 will be the first year where plans below 3 Stars are terminated.
- Medicare Advantage plans won several lobbying victories in this year's "Call Letter", the rate and policy announcement for 2016, including an average 1.25% benchmark increase from a cut in the February draft. This signals a new era of influence muscle for the industry, where CMS will increasingly fight out policy changes "below the waterline" in subregulatory guidance and enforcement, where politicians are less likely to intervene.
- Appeals and grievances and pharmacy benefit management vendor performance remain the #1, 2 and 3 regulatory infractions in Medicare Advantage, and integration of long-term care and supports and services the leading challenge facing Medicaid health plans.
- CMS is on pace for its most aggressive enforcement year ever, with over a dozen actions taken against plans this year already.
As we've said since the passage of the Affordable Care Act, we are now in the Golden Age of government-sponsored health programs, and the opportunities and challenges that come with this shift have never been greater. Our clients went home with a clear grasp of both, and we are thrilled so many joined us this year.
Resources:
Join John Gorman, GHG's Founder & Executive Chairman, as well as Bill MacBain, GHG's Senior Vice President of Strategy on April 14 as they provide a hard-hitting analysis of critical areas addressed and finalized in the document from 1-2pm ET. Register now >>
GHG's Senior Vice President, Healthcare Analytics & Risk Adjustment Solutions, Dan Weinrieb, recaps the Risk Adjustment rulings in the Final Call Letter and provides keys to success in an article on the GHG blog. Read more here >>
Risk Adjustment Recap & Keys to Success
The 2016 Final Call Letter released on Monday, April 6, confirmed proposed rulings highlighting the following categories:
- End the Blend; For payment year 2016, CMS will only use the 2014 HCC Risk Adjustment Model.
- Coding Pattern Adjustment; CMS has increased the adjustment factor for MA coding pattern differences by 0.25 percent, the lowest amount possible under the statute. As such, the updated adjustment factor for 2016 is 5.41 percent.
- Encounter Data as a Source for 2014; CMS will apply the 90/10 rule until they implement "risk adjustment using Medicare Advantage diagnostic, cost, and use data," meaning until they have recalibrated the model using MA encounter data.
- ICD-10; CMS will not accept or process ICD-9 codes for risk adjustment for services with dates of service beginning October 1, 2015.
- RXHCC Model; The model has been updated to reflect the 2016 benefit structure, updates to the data years used to calibrate the model, and clinical updates to the diagnoses included in some prescription drug hierarchical condition categories.
- In-Home Assessment; Adopt a core set of components and best practices for In-Home Assessments, Track subsequently provided care: In CY 2015, CMS will track and analyze care provision following in-home visits.
These are the facts. Gorman Health Group is focused on providing you the tools in order to succeed and implement an enterprise-wide risk adjustment model. Based on The Centers for Medicare & Medicaid Services (CMS), collaborative partnerships between health plans and providers will ensure optimum performance outcomes for revenue, medical management and quality. Is your organization currently assessing, enhancing and managing the following critical success factors.
Leverage and integrate data and processes
- Is MRA included in your Medical Management and Quality Improvement Strategies? AND Pharmacy!
- Do your systems talk to each other: Interoperability and Integration
- Show me your spreadsheet!
Partner with your partners: Quality over Quantity
- Convene with your vendors and coordinate efforts
- Ensure compliance, patient-centered care and reduce provider abrasion
- Use Provider Incentives wisely
Targeted, Meaningful, Valuable, Actionable Provider Engagement and Education
- Deliver results: Good and Bad
- What is your strategy to engage specialists?
- Support Practice Transformation Models through incentives
Evaluate your current infrastructure to support Clinical Documentation
- More than just Coding- Population Health Management
For health plans: Make sure you are prepared for ICD-10, studies show that your providers don't think you are
- Have you modeled the impact to your Risk Score?
- Are you prepared for DENIALS?
In-Home Assessments: Bring the PCP's back into the fold
- Target based on complexity and patient care needs, not a money grab
- Care Coordination and medical management is key- align with quality
Shift your chart review and storage strategy
- Retrospective chart reviews…transition to concurrent chart reviews, not a last stich effort
- Do you have a Clinical Documentation Improvement (CDI) strategy?
- Use targeting strategies for patient and provider engagement, not just code collection
Benefit Design and New Member Onboarding
- Pilot new strategies to gather comprehensive patient data from the beginning
- Engage providers for preventive services off the bat
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You Got Them . . . Now How Do You Keep Them?
Your plan's marketing and sales efforts have proven fruitful, and the Annual Election Period (AEP) was a success! The question is . . . do you have a member for life?
New members are bombarded with information they need to digest and questions they need to answer. And everyone speaks in acronyms, e.g., OOA, OEV, LEP, LIS, BAE, OHI, MSP, HRA, and POA. How many hand-offs will it take before your new members' questions are answered? Are your members aware of all the great services your plan can provide? Does their healthcare experience generate a feeling that you are all in it together? Do you have a complete and accurate dashboard of your members' needs?
At Gorman Health Group (GHG), we believe every member interaction — every member touch-point — creates an opportunity to leave your member with a positive impression. Developing a process where members have a positive experience with your plan should be the goal of every high-performing plan. Reaching out to members to ensure they are benefiting from all their health plan has to offer will translate to member satisfaction, loyalty, and the best marketing outcome money can't buy . . . a positive referral for your plan.
Developing a comprehensive member onboarding program not only requires data analytics at the member level but, most importantly, the ability to quickly solve those pesky problems that pop up with new enrollees.
GHG will work with your plan to develop a member onboarding process and dashboards to ensure you are capturing the data that is critical to providing 5-Star services and engineering a positive experience for your members.
When it comes to developing positive outcomes from member interactions, developing a robust onboarding process should be job number ONE!
Visit our website to learn more.
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Even as you are enrolling beneficiaries for the new plan year, your team should be working on your strategic positioning for the following year — reviewing the past year's performance, conducting feasibility analyses, testing assumptions — all to ensure future success. Contact us for more information >>
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