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Medicare Secondary Payer — A Simple Process with a Big Impact

We've heard many organizations say, "We do MSP" or "MSP, it's easy, we've got it covered". MSP processing may not be rocket science but it's a regulated process with steps that need to be executed correctly. The MSP transactions that your organization submits directly affect the monthly payment to your Plan and impact your financial reports. Your organization needs to have a confidence level that is equipped with the proper tools to be efficient and compliant, and most importantly feel confident that the financials related to MSP are accurate.

If youâ€˜re uncertain about your end to end process, then you may be missing something and that something could relate to millions of dollars.

Take a moment to review your current process with our MSP Quick Assessment Checklist:

Tracking Tool: A comprehensive tracking tool is essential for a complete picture of your MSP population and should be:
- User friendly, efficient and compliant
- Provide inventory totals of open and closed cases
- Provide potential A/R of outstanding cases
- Show case responses (accepted and rejected)
- Types of outreach performed and number of attempts
- Dash board reports that provide up to the minute status of cases and financials
- Flexibility to create customized reports
Audit Trail
- An easy way to be CMS compliant is to have an audit trail for each MSP case. Each step of the process, including outreach attempts, follow ups, responses and letters should be documented with a date and time stamp.
Prioritize your MSP cases for efficiency
- Group your MSP cases by premium impact or carrier in order to increase efficiency and obtain the best results.
Persistence
- One of the most difficult tasks in the MSP process is outreach. Many cases require multiple outreach attempts to carriers or employer groups to obtain validation. Ensure staff is provided proper training and sufficient time to perform outreach and the follow up that's necessary to resolve cases. Practice due diligence — do not submit cases for "development" as doing so could delay potential recovery for up to 100 days.
Responses & Rejections
- Many times organizations fail to review ECRS responses or rejected records. Each rejection code should be reviewed and resubmitted if necessary. Always check your initial submission for keying errors. Don't miss out on money because you're failing in this area.
Communication
- As a result of an enhancement to ECRS and Part D (4/2012) terminations or delete requests to an MSP occurrence will automatically be applied to a linked drug occurrence record. For example, if a CWF Assistance request is submitted to add a termination date (TD) to an MSP occurrence, the termination date will automatically be applied to the linked drug occurrence. There is no need to submit a separate Prescription Drug Assistance Request. Partner your Part C and Part D areas within your organization to streamline processes, share information and look for efficiencies.

GHG has tools and experienced consultants that can assess your MSP process and provide analytics on your current state process to look for gaps or processes that may be negatively impacting MSP. We can work to create Business Process Redesign plans for a more complete and compliant process.GHG can also provide MSP Analysts to work remotely or onsite for large scale reviews, backlogs, or current work support.

If you're currently tracking your MSP cases on Excel spreadsheets, then it may be time to set up a demo of GHG's Valencia— MSP Module. Valencia is the software solution we use when we work with organizations to recover revenue and clean up data.

Resources

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.

by GHG Advisors

Republican Congress to Use "Inside Baseball" and Courts to Maim ObamaCare

Blowing in like a flu outbreak as year-end approaches, ObamaCare Derangement Syndrome has enveloped the Capital. Republican leaders in Congress are plotting to use arcane parliamentary procedures and the courts to do further violence to ObamaCare, and by extension, to the millions who have gained insurance through it. While it's red meat for the conservative base, the strategy presents a huge political problem for the GOP: they have nothing to replace it with.

Since the midterms last month, Republican Congressional leaders have been locked in a furious, behind-closed-doors planning effort to gut ObamaCare once and for all. While the GOP has finally awakened to the fact that repealing the Affordable Care Act ain't gonna happen on Obama's watch, Republicans are licking their chops to use an obscure fast-track budget process called reconciliation to deal it a mortal wound with only a simple majority. It's a longshot with many difficult parliamentary steps, but if successful, could deal a fatal blow to the marketplace subsidies, the Medicaid expansion, and/or the individual mandate. But I've consistently underestimated the effects of ObamaCare Derangement Syndrome, so I'm making no bets this time around.

Barring that, plans are also being laid to craft a bipartisan bill that would strip out more minor provisions like the device tax, the Independent Payment Advisory Board (IPAB), and restoring a 40-hour workweek. That seems to have a better shot, assuming the reconciliation effort doesn't poison the already toxic well on the Hill.

The second prong of the Republican attack is through the courts, with a goal of "repeal by Justices." GOP leaders are convinced that where repeal may fail legislatively because the President won't kill his signature domestic achievement, the Supreme Court just might do the dirty work for them.

The first test, of course, is King v. Burwell, the challenge to the Federal marketplace subsidies the Court accepted in a surprise move last month. The case hinges on payment of Federal subsidies to people who enroll in insurance marketplaces run by CMS, and not by states. It was basically a drafting error that now threatens to put ObamaCare into a death spiral if the plaintiffs win.

The Court has acted to hear the case early in its session in March, but we won't know their ruling until June 2015. I put it at 50/50, because four Justices don't vote to hear a case unless they're confident they can get a fifth for a majority ruling. That fifth vote, of course, is Chief Justice John Roberts, and he's a total wild card. He has voted for both sides of the Court, and is very mindful of his legacy and the institution's legitimacy. He said recently that the partisanship shouldn't penetrate the walls of SCOTUS, and that's encouraging for ObamaCare supporters.

Most Constitutional scholars here in DC seem to think the merits of the case favor the Administration, but there's a whole lot of liberal hand-wringing going on here. A win for the plaintiffs and the end of Federal subsidies to 4.5-7 million Americans would of course be lethal to the marketplaces, and there's little activity underway at the state level for that contingency. It would effectively wipe ObamaCare off the map entirely in Red States with no exchange and no Medicaid expansion. If it fails and the ACA's subsidies are upheld, Republicans are lining up multiple other challenges to the Affordable Care Act, all with a goal of getting them to SCOTUS.

I think a win for Republicans in King creates a huge political problem: they will tear health insurance away from millions of Americans, with no alternative or replacement in sight. Not even Medicaid expansion. And that would take some "splainin'" to do in 2016, when Hillary gets her second act on health reform.

Resources

Don't miss GHG Founder & Executive Chairman, John Gorman, at the ICE 2014 Annual Conference, delivering the keynote address titled "Evolve or Die: A Darwinian Moment in Government-Sponsored Health Programs. To find out what other events GHG experts will be speaking at, visit our website >>

by GHG Advisors

Medicare and Exchange Risk Adjustment: Data Quality Matters

Plans/Issuers participating in the Exchange may think they have dodged a bullet because HHS has stated payments will not be adjusted during the first two years of the program as a result of RADV audits. However, other remedies such as prosecution under the False Claims Act may still be applied to non-compliant issuers (health plans).

With CMS processing the results of the first Medicare RADV audit subject to extrapolation and with the inaugural audits for the Exchanges kicking off in just a few months, plans need to have a blueprint of how they are going to minimize their audit exposure through data analytics. Because of the different demographics of the Exchange population vs. the Medicare population, health plans in the Exchanges have a learning curve to overcome to address some of the more common coding issues associated with diagnoses for this younger population. The HHS-HCC model is more complex than Medicare and has 15 different payment models based on 5 metal levels and 3 different age bands: the adult model (ages 21+), the child model (ages 2-20) and the infant model (ages 0-1). Pregnancy, newborn and congenital coding rules need special focus in order to receive the appropriate reimbursement. Plans need to be proactive in their approach to data integrity in order to remain competitive and minimize government take-backs.

Whether you rely on multiple vendors, an internal team, or a combination of the two, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping stride with CMS and HHS expectations in both compliance and health care outcomes. Our services include:

Risk Adjustment Strategies — Retrospective, Prospective and Concurrent Outreach strategies, evaluation of staffing structure and levels
Quality Assurance Programs — Proactive programs to improve data accuracy
Data Analytics — Identifying data gaps and appropriate gap closures
End to End Process Review — Testing for dropped data and recommendations for best practices in data processing
Provider and Coder Education/Coding - including ICD 10
Risk Mitigation - Identifying unsubstantiated diagnosis codes
Data Validation — Mock Audits
Vendor Audits — Coding accuracy, data completeness
Requests for Proposals (RFP) - Developing RFPs and/or the evaluation of RFP vendor responses

Resources

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 out website to learn more >>

by GHG Advisors

Medicare Advantage Rates for 2016: Chanel No. 5 or Another Unicorn Fart?

This week CMS issued a surprise announcement on payment rates for Medicare Advantage in 2016. The 2.02% increase is in line with projections we have been using for 2016, and is also consistent with other projections for Medicare FFS per capita cost growth. But there should be no confusion: this is NOT the final rate, and this will either end up smelling like Chanel No.5 or another "unicorn farting rainbows" like 2015.

First, as CMS says in their release, they reserve the right to change this trend, both in the February advance notice, and in the April final rate notice. So we're nowhere near done with the 2016 rate development process. In fact, we're pretty convinced this announcement was done to avoid the market-twisting "business intelligence" mess of 2014's process and keep it more transparent.

Second, the 2016 benchmarks to be announced in April will also reflect corrections to the 2015 benchmarks. The CMS release indicates that they may have underestimated the 2015 trend, and that 2015 benchmarks may be too low as a result. If this calculation holds through next April, it will increase the 2016 benchmarks by another 0.7%. However, this may change as well. For 2015, corrections to the prior year estimate served to lower the effective trend.

Some counties will receive a blended benchmark in 2016, with the new Affordable Care Act (ACA) benchmark representing 5/6 of the total, and the old pre-ACA benchmark representing the remaining 1/6. The pre-ACA benchmarks are corrected for cumulative forecasting errors over several years. If the current calculations remain unchanged, this will increase the pre-ACA benchmark by another 2.2%, of which 1/6 will find its way into the blended benchmark. This will add about 3/10 to 4/10 of a percent to the blended benchmarks in these counties. But, again, this is subject to change between now and next April.

Presumably CMS will continue to phase in the new risk adjustment scoring system. CMS has estimated that the average impact of the changes will reduce risk scores by 2.6% when fully phased in. The changed scores were phased in at 1/3 for 2015. If CMS continues this three-year phase-in, the second year's 1/3 will reduce average risk scores by 0.87%. This is an average, and plans will see some variation on how the change affects them individually. CMS may decide that they want to phase in the whole thing in 2016, when there is a positive trend to offset the impact. So the net reduction in payments could easily be doubled to a negative 1.7%, on average.

Another hit to payment is the continued increase in the amount that CMS deducts from plan payments to compensate for the impact of improved diagnosis coding by plans. These deductions increase by 0.25% per year, through 2018. So the effective rate, whatever it turns out to be, will then be reduced by 0.25%. There is also the "wild card" of the fee-for-service normalization factor, which adjusts risk scores for changes in the statistical database used to calculate risk scores. This may be a positive or negative adjustment. And we can expect CMS to revisit the matter of risk scores that are documented in home visits, as they have the last two years, and that in 2016 they may actually do something about it. This would obviously have a negative effect on payments.

Finally, unless the new Congress makes an unexpected change, sequestration will continue to slice off 2% of the amount that plans are actually being paid. This is current law, so it's not a change, just an ongoing challenge. There is always the possibility that a Republican Congress may find a way to rescind the Medicare 2% sequestration and allow plans to receive their full payment, but in this environment, seems very unlikely.

It is encouraging to see that CMS is currently expecting an increase rather than a decrease in the per capita cost for fee-for-service Medicare, since this is the trend that drives the Medicare Advantage benchmarks. However, there are many moving parts, some of which are still unknown, and all of which are subject to change until next April.

It's all very reminiscent of former Defense Secretary Donald Rumsfeld: "There are known knowns. These are things we know that we know. There are known unknowns. That is to say, there are things that we know we don't know. But there are also unknown unknowns. There are things we don't know we don't know." So keep your nose in the air. I'm betting on a scent closer to magical horse flatulence come April.

Resources

by GHG Advisors

Best Practices in Medicaid Claims Administration and Oversight

Every Medicaid operation needs high-performing claims administration. With strict medical loss ratios as required by healthcare reform, ongoing regulatory changes, timeliness, and payment accuracy relevant to provider pricing and benefit administration, covering operating costs poses significant challenges. Claims adjudication must be efficient and cost effective.

Claims adjudication is the process of paying or denying claims after a series of comparisons (automated system logic or manually by claims staff) against a comprehensive set of requirements. These requirements are as follows:

Eligibility verification
Benefit administration (deducible, coinsurance, copayment, accumulators and Maximum Out of Pocket (MOOP))
Authorization criteria
Provider verification
Financial data and reimbursement guidelines (contracted or non-contracted)
Claim edits
Encounter edits
Correct coding edits (based on line of business and state or federal guidelines)
Medical review
Coordination of benefits

Best practices of efficient Medicaid claims operations are as follows:

Develop a strategy in enhancing claims quality control and oversight activities
Implement quality control auditing through pre-payment auditing reviews
Create a comprehensive oversight and monitoring reporting system
Ensure that processes starts ticking when the claim reaches the organization, not necessarily when it reaches the claims department
Increase auto-adjudication by complete set-up of pre-processing and routing logic. This results in higher first-pass rates and reduction in manual handling, which provide significant savings in operating costs
Continue to redefine procedures, as well as provide a mechanism to understand all terms and conditions of the State contractual agreement relating to overall operations, claims and encounter processing
Define and design configuration build at the product level by delineating lines of business (i.e., Medicare rules vs. Medicaid rules) which results in compliance with applicable regulations
Continue to define or redefine claims adjudication policies and procedures, and data management, including consistency within each product
Implement processes that monitor end-to-end claims adjudication

Execution of these best practices, and automating each procedural step of the claims cycle, results in quicker claim resolution. Monitoring operational performance helps track, adjudicate and measure claims as they flow through claims administration operations. As operational performance improves, auto-adjudication rates rise and the total cost per claim falls.

Gorman Health Group includes some of our industry's most experienced and proficient claims administration subject matter experts. Our consultants can help your organization implement best practices in claims administration. Please contact us at ghg@ghgadvisors.com to get started.

Resources

GHG will help you by providing creative solutions to maximize cost effectiveness while building a solid framework to deliver results from eligibility to provider contract management to claims. Visit our website to learn more >>

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 >>

by GHG Advisors

Exchanges - Risk Adjustment - Ladies and Gentlemen, Start Your Engines

Seriously, the first question is, "what do you have under the hood for risk adjustment in your health plan?" If you're running a stock claims engine that merely matches up with your enrollment file for CMS Edge Server processing, and you don't have a risk adjustment operation, you may be breathing fumes from your competitors. Now, for health plans accustomed to competing against each other, we have a new type of competition. Further, it's not just plans on the Exchanges, it's all health plans on or off the Exchanges. Up to now, health plans have been competing for market share on the basis of premiums, benefits or brand; but with Exchange risk adjustment, competition takes on new meaning. You can gain or lose dollars. Some plans will transfer dollars to competitors on the market share they painstakingly managed to enroll. Ouch!

The process is very much underway at CMS with Edge Server testing. Plans are calibrating their systems. This means passing CMS testing for submission of test files, as well as understanding processing for acceptance and rejection of individual claims. Health plans must submit their first production by December 5, 2014. Beginning in mid-December, CMS will provide the first estimate reports to health plans for their review and feedback. After that, CMS will process files monthly until the final processing that occurs in May 2015, when risk scores are finalized for 2014. By July 2015, CMS expects to notify plans of any payments due when their risk scores indicate lower risk. For those receiving dollars, getting risk score payments will be no accident. So, while appeals can be filed, the process is upon us and, it will be too quick for any plan giving up dollars.

Right now, most plans' IT staffs are clarifying processing details. However, it is clear that some IT staffs are struggling with the basics, indicating few supports and a lack of horsepower in their risk adjustment engines. Most likely, these are plans that are not offering products on the exchange, and have limited familiarity with CMS requirements. To say they are back of the pack in this new form of competition, and have failed to understand this threat, is an understatement. Being caught unaware of their unknown risk score values relative to competitors' scores should be significantly unnerving to their leadership.

These leaders need to gauge their understanding and determine how quickly and sophisticated they can get. This includes ensuring that leaders develop the processes needed to identify proper risk scores, develop coding necessary to support diagnoses, and initiate analytics needed to identify gaps that require further investigation. So, the right time is now to lift the hood. Getting a risk adjustment engine to run over the next six months will be crucial to getting the most optimal risk score that properly reflects the health status of the members they have enrolled.

Resources

Gorman Health Group supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure that the procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete. Visit our website to learn more >>

Listen as Janet Fina, GHG's Vice President of Risk Adjustment, together with colleague, Carol Olson, GHG's Director of Risk Adjustment, addressed areas for documentation improvement that will allow for accurate reimbursement and disease and case management opportunities. Become a member of the Point to access the recording >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>

by GHG Advisors

A Bad Couple Weeks for ObamaCare

It's been a bad couple weeks for ObamaCare. It started with a Republican gorilla-stomp in the midterms, a rout that included several Governors' mansions and state legislatures that essentially froze in place the Medicaid expansion map. Then, in a shocker, the Supreme Court decided to consider King v. Burwell, the case that could undo ObamaCare's marketplace subsidies and threaten the coverage of more than 4 million Americans. It's enough to give weekend bedspins.

Ice Age for Medicaid Expansion

In many states with rampant uninsurance, Republican candidates won critical Governors' races and in others the GOP solidified seats in their legislatures. The net effect: it's a new Ice Age for the Medicaid expansion map, with states taking the Affordable Care Act's (ACA) 100% Federal match for uninsured adults essentially now frozen in place. We may even see some backsliding.

Some 24 states have accepted the ACA deal and expanded their Medicaid programs in the wake of the last big SCOTUS ruling on ObamaCare. In fact, more Americans have gained coverage from Medicaid expansion than ObamaCare's subsidies in the new insurance marketplaces. But despite the fact that holdout states continue to pay their share for Medicaid expansion through Federal taxes, over two dozen mostly Red State governors continue to throw the middle finger at the guy in White House. Most notably, reelection of Rick Scott in Florida, Scott Walker in Wisconsin, Sam Brownback in Kansas, Nathan Deal in Georgia, and Rod LePage in Maine stuck a fork in coverage for the uninsured there.

Utah Gov. Gary Herbert will outline a formal Medicaid expansion plan this month. Republican governors in Tennessee, Wyoming, South Dakota and North Carolina have also flirted with Medicaid expansion plans in 2015. And a late recount win in Alaska for left-leaning Bill Walker may open prospects for coverage for 43,000 residents in 2015.

But we could see real retreat on Medicaid expansion in GOP states that were already moving forward. New Republican governors in Arizona, Arkansas, and Illinois have the power to threaten health coverage for hundreds of thousands who have enrolled in expanded Medicaid, and have done so during the campaign. Indiana Governor Mike Pence was negotiating a plan with the Obama administration pre-election, but now appears to have his own Presidential aspirations in mind and may put the plan on ice. Arkansas' controversial Medicaid expansion waiver to use Federal dollars to buy private coverage was already approved, but its new governor, former US Rep. Asa Hutchinson, is no fan of the plan, which requires annual approval by the legislature and is now very much in doubt.

It was a bad midterm election for the uninsured, especially childless adults. What remains to be seen is how hard a line the Obama Administration takes to force holdout Red States to take the money, using existing Medicaid funds as leverage. My guess is that hard line will be pretty limp. As George Burns said, "like shooting pool with a rope."

The SCOTUS Subsidy Surprise

The day after the election the Supreme Court made a surprise decision to hear arguments in King v. Burwell, what many thought to be a sideshow case in the lower courts around the Constitutionality of ObamaCare subsidies in the 36 states using the Federal exchange. It was basically a case challenging a drafting error in the law, which didn't make clear enough distinction between state-based and Federal marketplaces, and ACA opponents saw their opening.

Even being "strict constructionists" in their jurisprudence, one has to believe the conservative activist Court didn't take this case to rubber-stamp ObamaCare's subsidies. If the justices find for King, some 4-4.5 million Americans will see their martketplace subsidies at risk. Without subsidies, the vast majority of those insured will drop coverage like a hot rock, leaving only the sickest in the pool — what economists call a "death spiral" for insurers operating in the marketplaces. It would essentially lay a mushroom cloud on all private coverage options in those states, leaving ObamaCare a smoking wreck of mostly Blue State Medicaid expansions.

There's no ignoring this point: in Republican territory, the ACA and its marketplaces and Medicaid expansion are more vigorously opposed than in states that elect Democrats. If SCOTUS upholds King, then coverage and politics will truly converge in Red States. A win for King means Red States can effectively purge themselves of all vestiges of ObamaCare, by not expanding Medicaid and not establishing an exchange.

I think this would be a huge problem for Republicans, forcing them to come up with solutions that are politically palatable to them. All these new GOP Members of Congress, and Red State holdout governors, need to start thinking, now, about what to do if SCOTUS announces a decision in June 2015 denying tax credits to millions of their citizens, while they in turn continue to deny Medicaid coverage.

Resources

On Friday, November 21, join John Gorman, GHG's Executive Chairman, together with colleague, April Fleming, GHG's Senior Vice President of Products, as they discuss the challenges of non-compliance, and introduce the new Appeals & Grievances solution from 1-2 pm ET. Register now >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>

by GHG Advisors

The Importance of a Proactive Call Center

During the AEP we know how critical a role our Member Services team plays. During this time, they are integral to helping prospective enrollees understand the benefits of your Plans, and play an important part in the retention of your current members. Having a strong proactive Member Call Center is crucial in today's environment. Test your call center — see if they pass the test. A proactive Member Service Call Center Department should at a minimum, do all of the following:

Highly trained call center representatives develop "one on one" member relationships
Becomes a one stop resource for seniors (meal on wheels, etc.)
Track and trend Members' problems and resolutions (problem solving)
Reduce members voluntary disenrollment with focus on first-time call resolution of Member's problems
Take the time to educate members (benefits, Providers, and Claims)
Look for opportunities to engage the member in Care Management services
Provide outreach reminders to members (Member Newsletters, appointment reminder postcards, etc.)
Proactively, through outbound calls, identify first level problems and implement resolutions
Provide new members orientation (an educated member is a happy member)
Provide consistent training to help reduce the number of members' appeals and grievances
Have Quality Improvement initiatives consistently in play to help improve the Star measures
Support members in accessing care, even making appointments for them if necessary

If you can answer yes to all the bullets above regarding your current Member Service/Customer Service Department, then you are on the right road to increased retention. If not, then leveraging member's satisfaction is an important retention tool that should be looked at going forward. Now is the time for forward thinking initiatives!

Stats: 30% of Medicare beneficiaries are enrolled into a Medicare Advantage Plan (MA/MAPD). And over 15% of Medicare Advantage Companies Fail to meet the government standards for customer service through a call center for 2014. (Source: https://www.healthpocket.com/healthcare-research/infostat/medicare-advantage-customer-service-ranking.)

Resources

John Gorman, GHG's Founder and Executive Chairman discussed why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Become a member of the Point to access the webinar recording >>

Gorman Health Group can work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>

by GHG Advisors

CMS Validation Process: The Silver Lining

We've seen quite a few changes over the past few years in the way that the Centers for Medicare & Medicaid Services (CMS) is approaching the program audit and audit validation process. The most notable trend this year is continued push back of responsibility onto the Organization. In recent sanction reports, CMS states that it will require the Organization "to hire an independent auditor to conduct validation in all operation areas cited in this notice and to provide a validation report to CMS." In addition, CMS presenters at the CMS Fall Conference, which took place on September 11, 2014, stated that "The onus of correction overall is on the sponsor. Therefore, CMS this year will not request universes to conduct sample testing unless the sponsor is unable to demonstrate through its presentation and from the responses to CMS questions, that it has not corrected the findings."

CMS is sending a clear message here. They expect the Organization, and not CMS, to do the work in the validation process. So, is there a silver lining? Why of course there is.

While it's clear that CMS is tightening the reins, they are also providing an opportunity - the opportunity to get it right the first time, and not go through the full CMS validation audit process. If you don't know the best way to proceed, in order to avoid a validation re-audit, we have the roadmap. Contact us today to get started.

Resources

While it may be difficult (too much so, for our tastes) for many compliance officers to effectuate the necessary change in the business units, it is not impossible. Let us help you create a culture of compliance. Visit our website to learn more >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>

by GHG Advisors

CMS Initiates New Program to Support Care Coordination Among ACOs

Many of you are aware of the recently published Centers for Medicare & Medicaid Services (CMS) Affordable Care Act (ACA) initiative to support care coordination nationwide.

CMS announced the availability of a new initiative for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. The initiative is designed to encourage ACOs to realize quality improvement and care coordination through the use of health information technology; thereby helping to move the health care system to one that values quality over quantity, and preventative care over treating people after they get sick. The new ACO Investment Model is designed to bring these efforts of better coordinated care to rural and underserved areas by providing up to $114 million in upfront investments to up to 75 ACOs across the country.

"The ACO Investment Model will give Medicare Accountable Care Organizations more flexibility in setting quality and financial goals, while giving them greater accountability for delivering quality care efficiently," said CMS Administrator Marilyn Tavenner. "We are working with these organizations to make necessary investments that encourage doctors, hospitals and other health care providers to work together to better coordinate care and keep people healthy."

Through the CMS Innovation Center, this initiative will provide up front investments in infrastructure and redesigned care process to help eligible ACOs continue to provide higher quality care. This will help increase the number of beneficiaries — regardless of geographic location — that can benefit from lower costs and improved health care through Medicare ACOs. CMS will recover these payments through an offset of an ACO's earned shared savings. Eligibility is targeted to ACOs who joined the Shared Savings Program in 2012, 2013, 2014, and to new ACOs joining the Shared Savings Program in 2016. The application deadline for organizations that started in the Shared Savings Program in 2012 or 2013 will be December 1, 2014. Applications will be available in the Summer of 2015 for ACOs that started in the Shared Savings Program in 2014 or will start in 2016.

Gorman Health Group has assisted numerous organizations for the past three years in achieving Pioneer and Shared Savings ACO status. Additionally, GHG has assisted operating ACO's in analyzing operating and medical spend performance. If you, as an ACO, are wondering why shared savings expectations are not being realized, or how to improve on your internal analytical and decision support competencies -- we can meet your needs. Contact us today.

Resources

On Friday, September 26, John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, discussed the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Join the Point today to access this webinar recording.

Don't let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.

From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation - we can help design and implement these arrangements. Find out how GHG can help >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>

by GHG Advisors