ACOs — There must be a pony in here someplace
We've all heard that story. Now, CMS is in that proverbial barn and with the proposed rules, have doubled down on the time they're taking to look for ACO success at managing risk. Does it make sense given that only two current ACOs have gone to the two-sided risk model? My guess is that is not what they are really looking for in just another three years.
CMS is really looking at how many beneficiaries are in the fee-for-service Medicare world and they're taking the long view. So, that's the 70% who can't be absorbed overnight into Medicare Advantage. It wasn't hard to think that CMS would change how payment formulas could be adjusted to affect success especially when they were given a quick stake of 5 million fee-for-service beneficiaries who are served by 330 ACOs with another 89 added on January 1. First, CMS always does that. Second, getting to those numbers in just three years took years in the various editions of Medicare managed care. So, there just might be something here.
Another point, for now ACOs have a political advantage. Just follow the ying and the yang between fee-for-service and managed care when the White House changes. Republicans have fed managed care but Democrats have looked for ways to avoid insurance companies and entice provider entities. Nothing could be clearer; the ACA was passed in 2010 by the Dems, funding for the ACA came from Medicare Advantage and "ACO" is nomenclature born in the ACA. Also, the additional three-year term extends ACOs into the next administration and, just maybe, provider-operated organizations will evolve into viable risk bearing entities.
Further, the advances in data management and technology along with their combined effects are telling CMS that a sweet spot is developing for a population-based approach to managing chronic conditions, the current Holy Grail. Mega investments in IT by HHS and micro changes in capability to manage and share individual health information will help. But other changes also include diverse things like developing methods to avoid penalties for readmissions. Care management programs are actually touching patients who are no longer in the hospital by the hospital. All of these are encouraging a long view and the belief that there is a nearby tipping point. So, why not keep ACOs going?
Finally, CMS has committed to care coordination and value-based services with a myriad of programs and demonstrations that encircle the underpinnings of ACOs. The latest and largest is the $670 million Practice Transformation demonstration aimed at engaging 150,000 physicians and 5 million beneficiaries. The CMS long view understands that none of these work overnight and that waiting for 70% of the Medicare population in fee-for-service to be absorbed into Medicare Advantage is beyond myopic. So, make comments on these proposed rules, expect more tweaks, and expect evolution. CMS will continue building the infrastructure to deal with this entrenched population. Clearly, ACOs are in the mix for some time to come.
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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. Visit our website to learn more >>
Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. Contact us today to get started >>
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New Year's Resolutions for Your Organization!
Every January 1st we have the opportunity to reflect on our prior year. We make lists of all the things we want to do or maybe do better in the upcoming New Year. The typical resolutions are lose weight, quit smoking, save money, exercise more, eat healthier, create a budget or plan a trip. The practice of evaluating our personal life is a good way to celebrate our accomplishments while thinking about ways we can improve in the New Year.
Our professional, workplace life should be no different. Now is the time to evaluate current practices. Take time to list all your departments' processes and functions. Evaluate each one. Is the process working well? Is it efficient? Is there room for improvement? Should it be replaced?
The future of organizations will rely on operational cost management. Each department within an organization should be continually looking for process efficiencies to reduce costs, and ways to boost productivity.
If you think this sounds overwhelming, use GHG's simple tool to start the operational evaluation process. It can be as simple as Keep, Fix or Replace.
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GHG has experienced consultants that can assess and review the operational areas of your organization. We can review current processes and look for efficiencies to improve outcomes and better compliance. Make a resolution to improve your organization's operational areas — GHG can help make it happen in 2015. Visit our website to learn more >>
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ICD-10 Transition — Ready or Not?
It's a New Year and there are 262 days left until the October 1, ICD-10 implementation deadline. The road to ten has been very challenging with respect to "Go or No-go" implementation timelines. Due to several delays, many organizations literally stopped transition efforts and redirected funding budgets to other priority projects.
The big day is coming! Currently, it is a known fact that CMS is operating under the October 1, 2015 scheduled deadline. It is now crunch time and with the compliance deadline set organizations have minimal time to complete the transition. Thoughtful planning, and executing conversion plans, will overall make the difference between a successful transition and missing the deadline.
What happens if your organization is not fully ready?
What is your plan for remediation?
The transition does not have to be painful. Timing is everything. Health plans and organizations, such as providers, clearinghouses and vendors can still benefit by using the time left to focus and implement additional readiness and deployment strategies for the code switchover.
The International Classification of Diseases, Tenth Revision (ICD-10), consists of two new areas, clinical modification (ICD-10 CM) for diseases and procedural coding system (ICD-10 PCS) and will replace ICD-9. The switch in code sets will provide expanded detail for inpatient, ambulatory and managed care organizations to better define medical conditions. The conversion is a significant change to the standard healthcare coding systems.
So what exactly are the differences between ICD-10 and ICD-9?
- ICD-9 codes have three to five numeric digits, while ICD-10 has three to seven alphanumeric digits - the switch in 2012 to HIPAA 5010 transaction standards for electronic claims paved the way for practices and payers to be able to accommodate ICD-10 changes
- CMS will transition all diagnosis codes from 13,000 old codes to approximately 68,000 codes included in the ICD-10 version
- ICD-10 has more specificity with a lot more codes, which provide more detail and granularity than the old codes
- Diagnosis Procedure Codes Systems (PCS) will increase from 3,000 ICD-9 to 87,000 ICD-10 PCS
Based on these changes, transition to ICD-10 requires extensive detailed planning, and comprehensive readiness efforts organizational-wide. It's virtually more than just a coding function. Diagnosis codes affect almost every core functional and operational process, system and reporting. Failure to prepare for the conversion will have dramatic impacts on financials and ultimately the member experience.
By leveraging in-depth regulatory interpretation and guidance with complete operational knowledge base Gorman Health Group provides ICD-10 best practices through financial analysis and impact assessment, which includes people, process and technology. Gorman Health Group will identify gaps between current operational "as is" process flows and recommend future optimal "to be" process flows required for the implementation. The analysis will highlight the impact on margins by line of business and measured through people, process and technology. Additionally, risks and potential return on investments (ROI) for the identified gaps can be provided.
Gorman Health Group ensures end-to-end operational process re-design including but not limited to the following functions:
- Claims
- Benefits & Product
- Configuration
- Codification and mapping
- Contracting
- Division of Financial Responsibility (DOFR)
- Prior Authorization
- Provider Pricing
- Quality Control
- Revenue Cycle
- Reporting and Analytics
- Metrics
- Vendor Alignment
- Vendor Management and Oversight
- All Other Hand-offs "Operational" Areas
If you are behind the eight ball and not exactly on track let us proactively work with you on an expedited readiness plan, contingency plan development, post-production support, post-transition analysis, knowledge transfer, monitoring and reporting. Gorman Health Group includes some of our industry's most experienced and proficient ICD-10 and operational subject matter experts.
Make your New Year's resolution to stay on track with transitioning to ICD-10. Time is running out and October will be here before you know it.
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At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
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Annual Compliance Program Audit: Your Organization's Achilles Heel?
When it comes to auditing throughout the Organization, the truth is that much of the responsibility often falls directly on the Compliance Department. This can be due to many factors, such as lack of resources or lack of cross-functional expertise. However, one of the CMS Compliance Program requirements is that the Compliance Program itself is audited annually. Fulfilling the requirement to annually audit the Compliance Program can present an issue for some Organizations due to the fact that Compliance Department self-auditing does not fulfill the requirement, and there may be no other department within the Organization with the expertise to conduct the review.
Here are a few ideas that we've seen Organizations use in order to fulfill the CMS requirement:
- Hire an external auditing firm.
- Cross-train another department within the Organization to conduct the annual audit.
- Compliance departments of two different Organizations audit each other. Of course, this option may be a bit tricky depending on the competitive landscape. However, it can be a good option if there is no budget to hire an external firm and if no conflict exists (e.g. competing service areas).
An effective Compliance Program is critical to your compliance and operational success. In addition, a strong Compliance Program can safeguard against many compliance issues recently cited by CMS as the cause for civil monetary penalties (CMPs) and enrollment sanctions. Please contact us for more information about the GHG Compliance Program Effectiveness Audit.
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GHG offers guidance and support in every strategic and operational area to ensure alignment with CMS. Learn how we can help you create early warning systems to ensure that operational inefficiencies and threats to member satisfaction are immediately identified. Visit our website to learn more >>
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Star Ratings: The Moving Target
Recently announced changes to the Star ratings program continue to present Star Ratings as a moving target for Medicare Advantage organizations. While the Centers for Medicare & Medicaid Services' (CMS') recent memo and request for comments on the 2016 Star Ratings program changes illustrates CMS' continued commitment to rapidly driving better care for patients, better health for communities, and lower costs, the proposed changes will simultaneously usher in a new era of accountability and integration within Medicare Advantage health plans.
CMS announced plans to reintroduce three previously-removed measures (breast cancer screening, beneficiary access, call center/TTY), add the long-awaited CMR completion rate measure, retire three HEDIS measures (two LDL screening measures and the LDL control measure), and make a lengthy list of changes to existing measure specifications in the 2016 ratings. CMS also laid the groundwork for the 2017 addition of measures related to asthma, depression and opiod-overutilization.
Since the new 2017 Star measures will likely be officially announced as 2016 Display Measures later this year, and will be computed based upon services provided throughout 2015, the 1st quarter of the year is an optimal time for plans to adjust population health tactics for 2017 Star Ratings success. With the nature and extent of the 2016 and 2017 changes, Medicare Advantage organizations will want to be very strategic as workstreams are developed or adjusted to accommodate CMS' proposed changes.
Given the complex clinical and social issues associated with asthma, depression and overuse of opiods, integrated activities and coordinated services among providers, clinical teams, case managers, and retail pharmacies will help plans achieve Stars success. Executive leaders will want to understand the nature of CMS' new focus areas, and operational and budgetary decision-makers will want to be poised to rapidly understand the changes, as well as deploy new or adjusted tactical workstreams in early 2015 to best ensure Stars success.
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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 >>
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Data Smog - CMS's Clear Vision for the Future of Data & Analytics
We all feel a little bit like hoarders with the vast amount of data we collect and store. We can also agree that it's a challenge to utilize that data for its best purpose and integrate it appropriately across an organization.
Recently in an article, Niall Brennan, the Centers for Medicare & Medicaid Services' (CMS) first Chief Data Officer, said their view about the role of data and analytics is changing. CMS has adopted a core mission to improve data collection and dissemination due to the substantial growth of both the number of data users as well as the vast amount of data it collects.
It's not just about collecting and storing data anymore, it's about aggressive analytics. CMS recognizes the importance of data analytics and the proper use of all that information but continues to struggle with numerous data sources and various systems that don't share data. Mr. Brennan is tasked to optimize and maximize data created by CMS's systems for all users.
This recent announcement is a good reminder for health plans to also take a look at how they collect, analyze, and utilize data. Health plans need to ensure their data is accurate, analyzed diligently and utilized appropriately for it to be relevant. The success of your organization relies on clean accurate records and meaningful data. Accurate data = optimal revenue.
CMS's new vision has elevated the importance of the data and analytics role within an organization. What was once considered a behind the scenes supporting role has now taken center stage. Get ready for your curtain call, the world of data and analytics is changing.
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GHG has experienced Consultants that can help with your Data Analytics. We can review your data architecture and assess processes to look for efficiencies and opportunities. Let us help you optimize your analytics and get all that data under control. Visit our website to learn more >>
John Gorman, GHG's Executive Chairman together with colleagues, Glenn Ellerbe, and Mae Regalado, Senior Consultant, gave an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy, plus shared procedural practices and audit metrics ensuring workflows are best in-class." Access the recording here >>
Rewards and Incentives: Are We There Yet?
Yes, Medicare Advantage is finally catching up to the rest of the health care industry, and we are now permitted to offer enrollees Rewards and Incentives.
On December 4, 2014, CMS released an HPMS memo titled "Rewards and Incentives Program Guidance" which provides additional guidance related to how Organizations must implement Rewards and Incentives Programs, which, as of July 22, 2014, CMS allows for Part C benefits.
Although the implementation of Rewards and Incentives is no easy task, I think the more pertinent question is how could this new guidance impact your Organization and our industry as a whole? Well, some of that, I think, will remain to be seen as these programs are implemented. However, I do think there are a few challenges and strategies that we should consider as we're implementing these programs - here are a few things to mull over as you're ringing in the New Year:
• What is the competitive landscape for Rewards and Incentives, and how will your Organization ensure that it is competitive while still remaining compliant?
• How will your Organization ensure that your Rewards and Incentives program will have an impact on enrollee behavior?
• How will your Organization track information regarding Rewards and Incentives?
• Last but not least, how will your Organization oversee the implementation of your Rewards and Incentives program to ensure compliance?
So, what is the trend? The fact that Medicare Advantage Organizations are now allowed to provide Rewards and Incentives (for Part C benefits) further indicates that CMS' main focus and main objective is the health of the Medicare population — as it should be, of course. However, we in the industry should take note - along with CMS' continued scrutiny via their program audits (and other mechanisms) of those areas that have the potential to cause beneficiary harm, they are also loosening the reigns in certain key areas such as Rewards and Incentives. The objective here is to ensure that Medicare beneficiaries have access to high-quality health care including any incentives that could in fact have a meaningful change in the way that beneficiaries approach their health care.
For more information or support, contact us today and a team member will be in touch with you shortly.
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Become a member of the Point to receive access to the analysis of all HPMS memos by GHG experts. Already a member? Access the HPMS memo mentioned in this article here >>
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A Christmas Wish List for Claims
Here's what I am wishing for all our health plan clients….an uneventful start to the 2015 Plan Year. By that I mean that all the prescription claims that should adjudicate without rejecting actually do, and the claims that should not pay, reject as expected. Either the beneficiary leaves the pharmacy with their medication or the pharmacist is alerted that there is a potential problem with the dose of the medication. Here are some of the issues that we have found from our reviews:
- Test claim for Unbreakable packaging logic for non-formulary drug prescription for a transition eligible member DRUG: NDC=51285008787 SEASONIQUE 0.15-0.03-0.01 TAB #91 tabs (3 months) Claim Rejects with this POS MESSAGE: "7X = DAYS SUPPLY EXCEEDS PLAN LIMITATION; MAX DS = 30 FOR TRANSITION FILL" This claim should have paid because the medication only comes in one size and is unbreakable.
- Test claim for Quantity Limit logic DRUG: NDC=59310057922 Product Description: PROAIR HFA 90 MCG 8.5 gm for 10 days supply HPMS submitted/approved Quantity Limit is 25.5/30 DS Claim Rejects with this POS MESSAGE: "88 = DUR REJECT ERROR " Additional Reject Message: "MX DOSE/DAY= 0.54 OVR/DR APV" The claim is rejecting for max dose incorrectly based on HPMS QL of 25.5/30 or 0.85/day.
- Test claim for maximum daily dosage of Acetaminophen < 4 Grams DRUG: NDC 46672020050 HYDROCODON-ACETAMIN 7.5-325/15 Solution Claim paid for #2365 ml/10 days supply which equates to 5125 mg or 5.1 Gm of Acetaminophen/day The claim should have rejected for exceeding the maximum daily dosage of Acetaminophen.
We continually emphasize the importance of benefit administration testing and retesting as the best Part D formulary quality control effort to ensure there are no questionable claims.
Our Pharmacy experts can create and conduct an in-depth benefit administration test plan for your organization to validate that everything is working precisely as it should on an ongoing basis throughout the year. We can ensure your PBM is processing claims consistent with your CMS-Approved Prescription Drug Benefit.
I hope that your holidays are merry and bright, and that all your claims are right!
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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. Don't chase data points. Spend your time on the things that will impact your audit results when a CMS audit comes — and it always does. Visit our website to learn more >>
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Federal study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act
Federal investigators said in a new report that large numbers of doctors who are listed as serving Medicaid patients are in reality, not available to treat them.
Patients select their physicians from a list of providers associated with each Medicaid health plan. The investigators, led by the inspector general, Daniel R. Levinson, called the doctors' offices and found that in many cases the doctors were unavailable or unable to make appointments.
More than one-third of providers could not be found at the location listed by a Medicaid managed-care plan.
This can create a significant obstacle for an enrollee seeking care, impacting access to important benefits and treatment. Imagine being in the middle of a need for important medical care, picking up the provider directory and over half of the doctor's numbers you call are not valid.
If access to care cannot be relied upon, the foundations of the managed care programs are at risk. With the recent growth in Medicaid managed care, this becomes a more significant concern for the government as well as the industry. With the concern comes the potential for more stringent oversight.
New rules and standards to ensure timely access to care for Medicaid patients are under development. The push from the National Association of Medicaid Directors is to avoid overly prescriptive standards given the variances of State Healthcare markets.
CMS and OIG are in concurrence about tightening the standards, oversight and adequacy requirements.
We can help you wind your way through the new rules and the process for improved access to care. Contact us today.
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Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
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Hepatitis C virus (HCV) and treatment with Sovaldi® (sofosbuvir)
The medication Sovaldi® has revolutionized the way HCV is treated and at the same time has shocked health insurance payers and particularly Medicaid prescription drug budgets. With an estimated cost of $1000 or more per pill for a twelve (12) week course of treatment, the cost to treat one person can exceed $84,000.
According to the Centers for Disease Control & Prevention (CDC) there were an estimated 16,000 acute HCV infections reported in the US in 2009, the latest year statistics are available (http://www.cdc.gov/hepatitis). An estimated 75-85% of the people infected with acute HCV develop the chronic condition. The CDC estimates that there are 3.2 million persons in the US with chronic infection. Most people do not have symptoms and are unaware they are infected with HCV. HCV also affects those in lower socioeconomic classes and therefore the potential impact to Medicaid programs is even greater.
Sovaldi has a cure rate as high as 95%, with mild side effects during a twelve week course of oral therapy. Compare this with the previous drug of choice to treat HCV, interferon. Interferon is injected for up to a year and can have severe, flu like side effects. The cure rate for the most common strain, genotype 1, is 48-56%, depending on the length of therapy (M. Parikh, April 2011). The cost for the interferon treatment is $15,000 - $20,000. It is easy to see that clinically Sovaldi has the upper hand, but what cost can Medicaid programs, and ultimately taxpayers assume?
Some state's Medicaid programs, such as Oregon, are looking at ways to manage the use of Sovaldi by approving it only for their Medicaid clients who are showing signs of liver cirrhosis and have clean drug tests, for example (COOPER, 2014). In addition, what happens if a patient fails to complete their 12 week course of treatment? Should they be allowed to resume another full course of treatment?
This medication is a perfect candidate for coordinated medical and pharmacy management. Adherence is crucial to ensure completion of the twelve week course of therapy. If Medicaid programs are going to invest in paying for these types of expensive therapies it is vitally important that the medications are taken appropriately for the required length of time.
To learn more about how plans are investing in programs to help patients achieve better outcomes with the new Hepatitis C treatments, contact us >>
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Gorman Health Group can work with your organization on blending medical and pharmacy to improve care coordination, outreach and utilization management to meet the complex needs of your membership. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.