Medicaid Reimbursement Rates and the Future of the Program
A recent monumental decision by the Supreme Court was just passed, and it will define the way Medicaid providers will be reimbursed now and in the future. Many Medicaid providers, including doctors, hospitals, and healthcare organizations, are already concerned with the low reimbursement rates, but now, due to the 5-4 vote by the Supreme Court, many will not have the right to push the states into increasing their payments.
In 2009, there was a ruling passed by the lower courts in Idaho to increase the state's reimbursement rates. The ruling came about due to the fact that the centers that provided care for about 6,000 mentally disabled adults and children were being reimbursed at the 2006 Medicaid reimbursement rates. The centers stated in their filings that the cost to maintain the treatment of these patients was substantially higher than what they were being reimbursed by the state. But then the Supreme Court stepped in and overturned this decision, citing that the Medicaid providers have no right to sue under the current laws pertaining to the federal funding for Medicaid programs.
The positive result of the 2009 ruling of the case, Armstrong v. Exceptional Child Center Inc., was that it set a precedence on enforcing federal payment requirements. Many of the other Medicaid states were using this as a foundation for their pursuit of fairer reimbursement. The basis of the argument was that federal requirements for rates must be "sufficient to enlist enough providers so that care and services are available under the plan. . . to the general population in the geographic area (42 U. S. C. §1396a(a)(30)(A) ("§30(a)"). Now, with the overturn of the decision, this could mean that fewer providers of service will participate in the Medicaid program, which will mean that Medicaid members will have fewer choices and restricted access to care.
Supreme Court Justice Beyer stated his decision was made based upon the rationale on "several characteristics of federal statute," in particular the Administrative Procedure Act. The debate that ensued during the session, and the final determination made, was mainly focused on alternative remedies, one of which was to engage the Department of Health and Human Services ("HHS") and cite §30(a) to withhold Medicaid funding, if the rates were inadequate.
The ruling has caused multiple groups, including 28 states, to voice their concerns with the decision. While this will be a long-term debate on both sides of the spectrum, conservatives and liberals, one thing is for sure: in the current environment, there needs to be risk strategies set into place so that the current, and future, players in Medicaid can keep sustaining the care provided with the ever-changing financial atmosphere. Gorman Health Group (GHG) understands the complexities of the numerous shifting of variables and has a team with the expertise and knowledge to perform risk adjustment models and make recommendations based on revenue vs. medical spend. Most states have rates that vary and are often moving targets; many organizations need to operate on projections or estimates.
GHG can provide assistance with identifying current and future costs of doing business while building in anticipated adjustments that make sense for the population served. We will position you for success by building a strategy that takes into account the service area, market environment, core competencies, and vision for the future. Contact us today to get started >>
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Over the last several years, GHG has committed our time to understanding the needs of the dual population, which has allowed us to build systems and processes that yield quality outcomes. As states begin to increase oversight activities and implement more robust compliance and fraud waste and abuse practices, our expertise in compliance program development will be an asset to any organization. Visit out website to learn more >>
The Risk in DIY: CMS Mandated Material
"Do It Yourself", or DIY, has been the rave for years now. From social media sites like Pinterest to television networks like HGTV, Americans have become fond of this philosophy. Now, I am a big believer in being self-sufficient and must say that I have been sucked into marathon viewings of DIY shows often (Nicole Curtis of Rehab Addict is no joke!). And, while I have seen my share of success stories, more often than not, I see DIY projects result in complete frustration from those attempting to DIY and very costly mistakes.
A prime example of this within the MA industry is the DIY approach to creating CMS mandated material. Year after year, I see organizations attempt to produce upcoming plan year material in-house with the intention of saving budget dollars, but ending up with a costly mess due to lack of subject matter expertise and lack of adequate resources. When you think about the overall importance that is placed on CMS mandated material and the level at which these materials are scrutinized by CMS, it begs the question, "Is the risk in DIY really worth it?"
Picture this: your organization decides to use existing staff to prepare mandated material for the upcoming plan year. Initially, the approach seems feasible and the cost savings looks attractive. Although the process is very time intensive, your organization completes the undertaking, or so you think. It turns out that the amount of time it took to review materials before HPMS submission could not be supported by your Medicare Compliance Department due to lack of resources. That results in functional areas being made accountable for not only the development of respective mandated material, but also the compliance review. With business-as-usual responsibilities not changing, the Enrollment department, which was tasked with creating ANOC/EOCs did not factor in a review for accuracy of information and compliance. Although your organization met the CMS distribution deadline, it is discovered that many of ANOC/EOCs contain cost-sharing errors and do not follow the CMS model templates and allowances. This discovery impacts about half of your membership and must be reported to CMS. CMS initially requires your organization to create errata for these documents, but when it is identified that the errors are so significant and high in volume, CMS requires your organization to recreate the affected ANOC/EOCs in their entirety and slaps on a civil monetary penalty. With a clear understanding of what led to inaccuracies in the first place, your organization seeks outside help from subject matter experts to limit the risk of non-compliance errors. It is later identified that an original version of an ANOC/EOC is still being sent to members upon request for a particular plan benefit package because a process for document version control was non-existent. In the end, this is a DIY project gone horribly wrong. The intention to save money by DIY resulted in something exponentially more expensive between CMPs and the exorbitant cost to reproduce materials. Most important of all, your beneficiaries were impacted by these inaccuracies.
I know we would all like to think that DIY is always a contending option, which it is, when you have the necessary resources and expertise to do so. But just as I will never claim to be an expert in building houses just because I've performed some wall patchwork here and there, organizations need to face the reality of the risks in DIY. Take the time to seriously consider how well-equipped your organization is to handle the development of CMS mandated materials as the season rapidly approaches. Is it time to bring in the experts?
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For questions regarding consulting services for CMS mandated materials, contact me directly at rpennypacker@ghgadvisors.com
The Gorman Health Group 2015 Forum is April-7-9! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for the Gorman Health Group 2015 Forum today!
Reenergized After RISE…Now What?
It's the Wednesday after a jam-packed RISE conference, focused on "Best Practices and Actionable Tools for Improving Risk Adjustment and Achieving Exceptional Quality Performance."
I am sure I speak for most of my colleagues that attended the Summit when I say, "I'm reenergized, but what should I do first?" The large group sessions and the breakout meetings delivered valuable insights into why the Centers for Medicare & Medicaid Services (CMS) keeps moving the target for both health plans and providers. As usual, the presentations were top notch.
This year, a sea of risk adjustment vendors lined the conference room, each with a solution that touted superior performance in maximizing revenue by applying innovative technology, provider/member engagement strategies, and robust analytics. Bright lights, big graphics, dashboards that actually closed the Healthcare Effectiveness Data and Information Set (HEDIS®) gap for the colonoscopy measure??? So many options, all impressive in their own right, but where do you go from here?
When I attended these events on behalf of my health plan, I would bring a box of pens and a few notebooks, head back home, and try and piece it all together. Without fail, something would get lost in translation, or my presentation back to the executive team on my takeaways left us all wondering how we're going to prioritize these initiatives, generate buy-in from across the company, and put these strategies to work.
Hearing and sharing best practices with clinicians, analysts, and other thought leaders in the risk adjustment space always proves to be informative, practical, and actionable. There always just seems to be one thing missing - your co-workers and executives weren't there to hear how important ALL of this is, and decisions continue to be made in a silo, and programs are perpetually designed with a one-dimensional approach to risk, quality, and medical trend management.
Being the only consultant at the conference who wasn't aligned with a vendor, I was able to take a very agnostic approach to the entire event. I couldn't help but notice that more providers were in attendance, voicing their concerns about managing data, navigating the complexities for Hierarchical Condition Category (HCC) coding, and still trying to deliver quality care to their patients. I listened to the health plan representatives discuss the challenges of selecting the right vendor partners, making the decision to bring these risk adjustment business functions back in-house, and integrating people, processes, and data across their entire enterprise.
Now that I am back home, and before I head back out to work with clients on their risk adjustment strategies, I wanted to take this time to stress the importance of being thoughtful about which vendors you select, which strategies you choose to pilot, and which operational processes you decide to uproot.
Just remember a few things:
- Trust that what you are doing now is most likely on the right track - it just might need a little face-lift, especially when the final Call Letter is announced.
- Technology enables an organization to launch and manage interventions that support corporate priorities. Making these investments without a solid plan to leverage the tools and analytics will only set you up for disappointment. More often than not, creating the playbook falls on your "To Do List.
- Be confident that you know the basics, and taking your programs to the next level shouldn't rest on your shoulders alone - we heard loud and clear that this needs to be a cross-departmental, integrated approach in order to really move the needle.
If you can read the above takeaways and feel confident that you and your organization are on the right path, GREAT- please continue to share your best practices with your industry colleagues.
On the other hand, if you are on information overload and not quite sure how or where to begin, know that Gorman Health Group and our team of healthcare analytics and risk adjustment experts have a proven track record of helping our health plan and provider clients assess, prioritize, and design initiatives that make sense for you and the communities in which you serve.
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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Whether you rely on multiple vendors or a largely internal team, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>
Don't miss Dan's presentation next week at the Gorman Health Group 2015 titled "Risk Adjustment: Cracking the Code" where he will provide key takeaways from the final Call Letter and future implications, discuss vendor selection, management and oversight, as well as Provider Network strategies and the value of collaboration. Not yet registered for the event? No problem, register here today!
The Medicare "Doc Fix"
The "doc fix," as just passed by the House of Representatives, would fix the annual sustainable growth rate (SGR) calculation by eliminating it. The SRG was enacted nearly 18 years ago as a way to tie physician compensation under Medicare to the growth in the national economy. It has never worked well, and Congress has had to override it 17 times to prevent sizeable cuts to Medicare's physician payment rates. The current SGR cut is about 21% and will take effect March 31 of this year.
The House bill eliminates the SGR. The estimated 10-year cost of eliminating these cuts to physician fees is in the neighborhood of $175 billion. After adding the cost of extending the Children's Health Insurance Program (CHIP) and funding for community health centers, the total price tag over 10 years is $210 billion.
The doc fix has no direct impact on payments to Medicare Advantage (MA) plans. For many years, CMS would calculate the Medicare Fee-for-Service (FFS) per capita cost trends it used to set MA benchmarks by assuming that the SGR cuts would happen. Year after year, the cuts were rescinded, requiring CMS to add a sizeable correction to the next year's trend to compensate. But that was offset by the following year's SGR impact, leaving the trends chronically depressed. CMS finally fixed this with the 2014 benchmarks, which were calculated using trends that assumed that Congress would again rescind the SGR cuts. This policy was repeated in calculating the 2015 benchmarks. For both years, CMS assumed a 0% trend for physician fees.
However, the "doc fix" may still have a small indirect impact on MA. If the final bill looks like the House bill, physicians will receive 0.5% annual increases in fees through 2019. This 0.5% trend will be incorporated into the trend used to set the benchmarks. Since CMS has been using a 0% trend for physician fees, the doc fix will elevate the trends for 2016 and following years, at least through 2019. The impact will probably be in the range of positive 0.2%, or 20 basis points, more or less. The House's doc fix would also tie physician compensation to pay-for-performance scores after 2019. We will need to wait and see whether CMS interprets this as generating an increase or decrease in physician fees when they calculate the 2020 benchmarks.
The House bill would also reduce the trend applied to payments to post-acute providers, relative to prior year trends, and make a small reduction in hospital payments relative to current law. This may have a very small negative impact on the benchmark trend since it is based on projected trends in total FFS per capita costs. But the overall impact for MA benchmarks will still be slightly positive because of the positive physician trend.
A greater impact in future years may be the impact on physician claims payment. In the near term, physician contracts that are tied to Medicare-allowable fees will experience a 0.5% increase as the fees rise. Since prior years' annual SGR corrections have included similar nominal increases, it is probable that most MA plans have already incorporated a rise of similar magnitude into their bids and budgets, meaning that the pending doc fix may have no noticeable impact. Looking at the longer term, the performance-based payment program that CMS devises to calculate payments after 2019 may have a greater impact. MA plans should be watching this closely, since any physician contracts that are tied to Medicare allowable fees will automatically incorporate this same performance-based calculation. This may also be an opportunity for plans to develop new and better value-based payment models of their own.
For now, it's time to watch what happens in the Senate, to see if this thing passes. It won't come up for a vote until the Senate gets back from Spring Break in mid-April. By then, the SGR cut of 21% will have officially taken effect. In the past when Congress dawdled on the SGR, CMS has found temporary ways to avoid cutting doctor payments, and we expect they will be able to engage in the same sleight of hand this year.
Update as of 4/1/15. Note that the 21% cut went into effect April 1, since the Senate didn't pass the bill before it went on a two-week recess. CMS can hold claim payment a couple of weeks to allow the Senate to get its act together and pass the bill. However, the Senate will need to act quickly when it returns from recess. The current estimate is that the bill will be introduced on April 13. While leadership of both parties say everyone is on board in the Senate, that clearly was not the case in the hours leading up to the spring recess, since the bill never came up for a vote. This indicates that there may be some unresolved issues. Stay tuned! There may be some interesting maneuvering in the next few weeks.
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Gorman Health Group's Summary and Analysis of the 2016 Draft Call Letter and the Medicare Advantage (MA) Advance Notice is now available. Download it today >>
The Gorman Health Group 2015 Forum is April-7-9! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Partners Needed
I calculated the total amount of civil monetary penalties (CMPs) levied by the Centers for Medicare & Medicaid Services (CMS) last year on Medicare Advantage and Part D plans, and it's a big number: $4,925,150. There were also five suspensions in 2014.
Now more than ever, plan sponsors need to assess their Pharmacy Benefit Manager (PBM) relationship to ensure that both parties are working in partnership to not only be successful as a business but to be CMS compliant. What is your PBM's priority? Is your account management team responsive? Is your issues log so long that you've given up even trying to get resolution on the old items? Are you utilizing all of their existing reporting to consistently oversee and monitor the delegated functions they perform on your behalf?
There is no perfect PBM just as there is no perfect health plan. In our experience, it is a much less onerous process to make your current PBM relationship work than to go through a Request for Proposal (RFP) and implementation project which sucks up about six months of plan resources. Finding a new PBM should be your course of action only if you have exhausted all efforts to work with your current PBM partner.
Assess this list of successful PBM partnership tenets:
- Detailed and specific PBM contract with clear definitions of the services to be provided.
- Service level agreements (SLAs) for delegated function compliance.
- Detailed and exhaustive oversight and monitoring plan for all delegated functions.
- Frequent and productive account management interactions.
- Transparent and full disclosure of all PBM-identified deficiencies which affect the plan sponsor.
- Quick resolution of identified issues or agreed-upon timelines for issue resolution.
- No CMS outlier communications due to PBM operational deficiencies.
Now is the time of year when health plans are planning for formulary submissions and working on their bids. Make sure you have the right PBM partner for a successful 2016. We can help! Contact us for more information.
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The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult — to say nothing of actually managing to them. Our Part D services are designed with your staff in mind, ensuring that with a mix of counsel and DIY tools your staff will have access to actionable information — faster. Contact us today to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
The Model of Care: More than Just a Technical Requirement
The Model of Care (MOC) represents the backbone of a health plan's operational infrastructure and offers powerful potential through which to drive quality improvement, service excellence and improved health outcomes.
Though only required for plans operating a Special Needs Plan (SNP), the MOC is not just a legal or regulatory requirement. The MOC captures and documents deep insights regarding plan leaders' strategic vision by which to provide services to members, to work with providers, to manage and coordinate care, and to conduct operations. It also includes a thorough analysis of a plan's staffing model, provider network and the local demographics of its members.
Perhaps because the MOC is such a lengthy and technical document, or perhaps because it addresses the entire spectrum of a health plan's clinical and operational processes and systems, MOC's are often developed and updated by a small team of highly experienced subject matter experts within a health plan. Despite CMS' requirement that all health plan staff and providers receive annual training on the MOC, plans often miss the opportunity to leverage their MOC's not only to comply with CMS regulations, but also to more deeply entrench their Quality Improvement (QI) and operational service models throughout the organization.
Developing and/or updating a MOC requires health plans to make important strategic and tactical decisions about the way in which their team, in conjunction with their provider network, will work together to coordinate care for their members. As a result, the MOC serves as the strategic plan for your care management, member services, provider relations, risk adjustment, Stars/quality and marketing teams.
By leveraging the strategic and tactical discussions necessary to develop a successful MOC, plans can use the MOC development process as a vehicle through which to develop, review, and enhance Star Ratings, Risk Adjustment and Provider Engagement strategies.
Gorman Health Group's team of experienced clinicians has a deep understanding of how to leverage Models of Care to refine, document and hardwire your strategic vision for collaborations with your provider network to improve Star Ratings and optimize risk adjustment performance.
If your plan is preparing to develop or update your Model of Care, contact us today and let's work together to help your plan achieve your strategic vision.
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Gorman Health Group is ready and available to execute a complete MOC evaluation that will provide the data and information needed to make smart decisions in refining your plan's strategy of managing your SNP population. Contact us today >>
Registration for the Gorman Health Group 2015 Forum is underway! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Room Rate expires on March 23. Register your team for The Gorman Health Group 2015 Forum today!
Marry Data to Build Accurate Customer Profiles
Have you ever played "Pin the Tail on the Donkey" as a kid and found yourself laughing when you got completely turned around and totally missed the donkey? That's what it's like when blindly developing benefits, products, marketing, and sales strategies without understanding what your current and prospective customers look and think like — except there's not a lot of laughing going on.
Utilizing enrollment and benefit data to gain an understanding of your marketplace is a great beginning to understanding your market. Taking the deep dive into the data gives you a greater understanding of your competitors, their benefits, and how different benefit, product, and possible provider strategies have affected the enrollment trend. It also gives you the ability to look at your own benefits/products and enrollment trends to try and build hypotheses of what is driving enrollment/disenrollment trends and develop premium, benefit, and product strategies to either reinforce the direction you are heading or to get back on track.
When you have the ability to add additional dimensions such as demographics, geographic, and psychographic elements to your current members and prospects to develop member and prospect profiles, it helps to gain clarity about your benefits and possible product development strategies to get a full picture of your market. This sets you up for changes that may need to be made or products to be developed in the future.
Analyzing these dimensions will also allow you to build a better pathway to smarter marketing and sales strategies to succeed. In June, when marketing and sales strategies are finalized, you don't know what your competitive advantage/disadvantage will be in the marketplace. Understanding how your 2016 products/benefits match your current membership and the prospective market and how your marketing and sales strategies will attack the market during the Annual Election Period (AEP) and subsequent year will give you a solid game plan to help crystallize your strategic vision.
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GHG's Sales, Marketing, and Strategy division has developed a detailed analysis of the 2015 Annual Election Period (AEP). This allows health plans to understand existing opportunities in their market as well as the potential for new market opportunities.
The Medicare Advantage marketplace is evolving — are you prepared? Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. Visit our website to learn how we can help you >>
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 >>
Time is running out to register for the Gorman Health Group 2015 Forum, April 7-9, at the Gaylord National Resort & Convention Center. Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team today >>
Is the “NUNCMO" Nightmare Keeping You Up at Night?
The recent MAPD Help Desk Memo, dated 3/3/15, advises that on March 8, 2015, "The Centers for Medicare & Medicaid Services (CMS) will be performing a clean-up to process "73" transactions that contain NUNCMO (Number of Uncovered Months) value from the extraneous NUNCMO row that was removed in Phase 1 multi-phase NUNCMO data clean-up which occurred on March 23, 2014. The effective start date of this transaction will be the preceding Part D enrollment start date."
The memo goes on to say that Part D organizations should review the NUNCMO data for these beneficiaries for ALL time frames, even if the change is prior to 2012. Organizations should submit any changes that may be necessary if the data is inaccurate or incorrect!
Looks like this could be trouble…
If your organization has an automated processes in place to update "73" transactions in your system, and the information on the data file is incorrect, these files could end up being a "nightmare." Loading incorrect data in your systems can result in significant consequences, such as generation of bills, correspondence, and increased customer service call volume.
Best-case scenario?
Increased customer service call volume.
Worst-case scenario?
Complaint Tracking Module complaints (CTMs) or increased Independent Review Entity (IRE) reconsideration requests if late enrollment penalties are inaccurately retroactively imposed.
How should you respond to this data file once you receive it?
Gorman Health Group (GHG) has developed a roadmap solution to guide you through validating and processing this file.
Contact us today to get started!
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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 >>
Registration for the Gorman Health Group 2015 Forum is underway! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Room Rate expires on March 23. Register your team for The Gorman Health Group 2015 Forum today!
Network Adequacy Test Submissions for Medicare-Medicaid Plans
In follow up to the October 2014 Health Plan Management System (HPMS) memo titled "MMP Network Adequacy Standards," the Centers for Medicare & Medicaid Services (CMS) announced dates in which Medicare-Medicaid Plans (MMPs) and Minnesota Senior Health Options Dual Eligible Special Needs Plans (D-SNPs) can check their network against the MMP standards in the HPMS Network Management Module (NMM). These standards were developed using the same methodology that is used to develop the network standards for Medicare Advantage but were adapted to reflect the population served under the demonstrations. Specifically:
- Utilization Patterns and Minimum Number of Providers — Medicare Advantage network standards are based on analysis of service utilization patterns in fee-for-service Medicare. The new standards use the same analysis but based exclusively on utilization rates for dual eligible individuals.
- Total Beneficiaries — In Medicare Advantage, network standards are set based on current market penetration in MA. In the new standards, we will use actual or projected enrollment based on the enrollment policies for each demonstration. This affects the minimum number of providers and acute inpatient hospital beds criteria.
- Time and Distance — The Medicare Advantage standards require that 90% of beneficiaries are able to reach the minimum number required for a certain provider type within the time and distance standards established. These new network standards adjusted the time and distance for certain provider and facility types in certain counties.
To ensure your health plan's Medicare portion of the network adequately reflects and supports the beneficiaries served by this demonstration, Gorman Health Group (GHG) can analyze your existing provider file, assist in uploading the prepared files into NMM, and provide strategic planning should any deficiencies be found. The gates in the NMM will be open on the following dates:
- March 31, 2015
- May 26, 2015
- August 4, 2015
GHG advises all MMPs to be proactive and take advantage of the pre-checks available. The annual network submission deadline is September 17, 2015, with an exception request period to follow. Let's work together to ensure your provider network not only meets CMS standards but is working to meet the strategic initiatives of your plan.
Contact us today to start a conversation >>
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Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
The Annual Full Replacement COB Files Are on Their Way
It's that time of year again when Part D plans will receive full replacement Coordination of Benefits (COB) files from the Centers for Medicare & Medicaid Services (CMS). The Health Plan Management System (HPMS) memo dated 3/6/15 states that the 2015 Full Replacement COB files will be sent to organizations beginning March 19th. Plans will need to distinguish these files from daily COB notification files by the date of receipt and the file size. Easy enough? Not exactly.
Opportunity to Review and Correct Your Records
The full replacement COB files offer organizations a great opportunity to review their current records, make corrections, and re-sync with CMS. When a Medicare Part D enrollee has other prescription drug coverage, coordination of benefits allows the plans that provide coverage for this same beneficiary to determine each of their payment responsibilities. This process is necessary in order to avoid duplication of payment and to prevent Medicare from paying primary when it is the secondary payer. Unfortunately, many times plans will "just load" the data file when received. This is a very risky decision, as doing so will override information you have already validated with outdated information from CMS. File analytics is a necessary step in the process.
GHG can evaluate your file to determine actions needed, including verification letter mailing
- Part D sponsors are required to notify each beneficiary of other prescription drug coverage information as reflected in the COB file from CMS. The beneficiary should review the information and report back any updates. It's important to analyze the file and not send out verification letters to members unnecessarily, especially if a letter was recently sent to a member or if the member is terminated. Plans that use the "send letters to all" approach will realize this just overloads your customer service call center.
GHG can assist with the Primary record validation and correction
- Many times erroneous information is on the data file and gets loaded time and again. This can cause multiple problems such as bad COB flags at the Pharmacy Benefit Manager (PBM) or, worse, point-of-sale (POS) issues at the pharmacy which could lead to Complaint Tracking Module complaints (CTMs). It's important that information submitted to the Electronic Correspondence Referral System (ECRS) is valid, complete, and consistent. Transactions submitted that are incomplete or fail ECRS system edits will be submitted for development, which will place a freeze on the record for up to 100 days.
Unsure where to start? Contact me at ctobin@ghgadvisors.com, and let us help you maneuver through the COB file verification process.
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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 >>
Registration for the Gorman Health Group 2015 Forum is underway! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Room Rate expires on March 23. Register your team for The Gorman Health Group 2015 Forum today!