Three Costs of Marketing Material Errors

Now that bids have been submitted and the Centers for Medicare & Medicaid Services (CMS) is in the process of finalizing their posted models (check the dates on those versions, people!), it’s time to think about material development and review.

If you are in Compliance or Product Development, chances are you have some responsibility for the material creation and review process. If you have had your hand in the process for a few years, your process has surely evolved, but some things stay the same such as:

  • CMS continues to issue enforcement actions for erroneous or late materials.
  • Your competitors are always on the lookout for non-compliant and misleading material, and they have no hesitation to contact your Regional Office.
  • You nail down a project plan, chock full of deadlines for your creative vendor to provide you versions, for business areas to confirm accuracy of language, to deliver pieces in a staggered manner, and it never seems to stay on track.

CMS is pretty prescriptive when it comes to their model materials. The agency is going through their internal overhaul of the guidelines for Medicare Advantage, Part D, and 1876 Cost plans (released July 20 of last year), and Gorman Health Group is preparing our team to review these ever-important documents for compliance and accuracy. Each year, we support organizations to ensure materials follow CMS’ strict requirements. And with proposed changes to marketing rules (for example, disclaimers), it is more important than ever to have experienced reviewers aiding you in the process.

The costs associated with errors in this area are threefold. The first and most visible are the Civil Money Penalties (CMPs) levied on a handful of sponsors each year. If you are new to the industry (or short-sighted), you might see these CMP notices and think the cost is a drop in the bucket. That’s where I bring you to a second and less visible cost, known only to affected plan sponsors. When errors are identified, there are added internal operations costs, not only in reprint and redistribution fees, but also in staff time to correct erroneous materials in a swift, drop-everything manner.

The third cost, which I believe is the least visible but most important, is the effect this impact takes on enrollees, especially on their perception of your plan. If a member enrolled due to misinformation, this is highly disruptive. This type of issue plants serious misgivings into enrollee and caretaker minds. Materials must be clear and accurate, and with pre-enrollment packet development in mind, you only have one chance to make a first impression.

Trust me – I do not love my own plan deductibles and cost sharing, but the materials provided to me clearly outline my obligations. When I or my family members have been provided inaccurate or incomplete information, I have dropped plans at the first open enrollment period, and I have been vocal about my experience. If you are striving for retention, do not cut corners when it comes to the review of your materials.

 

 

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The 2019 Model Marketing Materials Are Posted. Ready for What's Next?

As we await the Medicare Communications and Marketing Guidelines (MCMG), The Centers for Medicare & Medicaid Services (CMS) released the 2019 Model Marketing Materials which includes standardized outreach and educational materials for Medicare Advantage Plans, Medicare Advantage Prescription Drug Plans, Prescription Drug Plans, and 1876 Cost Plans.

Bids are due in a little over a week. You probably have an audit or two going on, and also your day-to-day work needs to be accomplished. CMS will continue to issue enforcement actions for reasons such as delayed and inaccurate materials. Don’t let other activities impact your attention to this area.

Here are three pieces of advice while we wait for the chapter:

  • Do not reduce your internal quality control and compliance reviews of materials. While certain pieces will no longer be considered “marketing” and therefore will not require submission to the agency, you should anticipate that CMS (and your competitors) will be on the lookout for misleading and confusing communications.
  • Formulate your questions after the release of the MCMG. If something is unclear, ask before you do. I am a huge fan of the adage, “it’s better to say sorry later than to ask permission now,” but I generally save that for when I am encouraging my precocious nephews. I do not recommend employing that strategy when working with Government Programs. The agency often releases FAQs, so get your questions in.
  • Continue to plan for your review season. The deadline for plans to provide the ANOC/EOC, formularies, LIS rider and directories is September 30. That means it needs to be in their hands by that time so they can make informed decisions.

Once you have your Plan Benefit Packages in place (we are actively helping with that, too), Gorman Health Group's experienced staff can review your sales collateral to ensure your content is compliant. Our marketing material review service includes:

  • Staff members with over 10 years of experience in CMS marketing material review
  • A compliance review to ensure model instructions and MCMG are followed
  • A benefit review to ensure accuracy of approved Part C and Part D services
  • A structured process with quality checkpoints and full project management support

Contact me directly at rpennypacker@ghgadvisors.com for more information.

 

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In a recent HPMS memo, CMS confirmed the Medicare Marketing Guidelines will be renamed the “Medicare Communication and Marketing Guidelines.” Read more here.


2018 Audit & Enforcement Conference: Program Audit Changes on the Horizon

On Monday, I provided some highlights of last week’s conferences during our weekly Insider call. The Centers for Medicare & Medicaid Services (CMS) hosted the Spring Conference on May 9 and the Audit & Enforcement Conference on May 10. The Program Audit tools and methodology continue to evolve. The agency gave the industry a heads up about the changes when the data collection tools were posted for public comment. Today I focus on one session, New Approach to 2019 Audits and Universes.

Before the 2019 proposed changes, protocols were made up of audit process and data request documents and questionnaires. CMS also maintained internal information such as how samples are targeted and how Compliance Program elements are assessed. I have outlined some highlighted points from the session:

  • CMS refers to the data collection tools as the “what” and refers to the audit process documents as the “how.” Going forward, the industry should see the data request documents released for public comment and the reformatted audit process documents posted on CMS’ Compliance and Audits
  • Gone are the Excel impact analysis documents. Instead, CMS will follow the universe record layout for requesting impact data in an effort to make audits more efficient.
  • Root cause analysis is still of paramount importance to the agency. Often we see why a specific case fails during a webinar, but determining the overall issue beyond the case-level detail of failure will still be requested.
  • Timeliness metrics will be broken out; for example, ODAG timeliness will be evaluated, and sub-element results will be provided such as timeliness of notification. This change could help sponsors better identify root cause and correction steps.
  • In addition to the arguably broadest change of consolidating certain CDAG and ODAG universes (still separated by Part C and Part D), the agency removed data points that were no longer meaningful and removed questionnaires that were no longer necessary or were not being used as intended.
  • Universe integrity will be extended to all program audit areas. In 2018, the agency will pilot this in a few audits. We expect this to add additional webinar time for the agency, plan sponsors, and delegates. For data integrity webinars, the agency will still select five cases of standard and five cases of expedited (for a total of 10), even though the two case types will be in one table.

Normally, the video recordings would have been posted by this point. However, the agency notes it has a new process for releasing and posting the videos. Once management approval is obtained, registered participants will be notified when the videos are available for viewing. If you were not registered for the conference, periodically check the “Event Archive” webpage for updates. Stay tuned to this page for more insight on these conferences and other agency activity.

 

 

Resources:

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Lack of Staff: Biggest Hurdle to Success

Staffing continues to be a major hurdle in the healthcare industry. A recent poll conducted by Gorman Health Group showed that 38% of respondents believed the biggest hurdle to success in their organization was lack of knowledgeable staff or lack of staff.

regan blog_hurdle to success
What is the meaning of success? Is it reaching financial targets? Meeting and exceeding service level agreements? Achieving high marks in customer satisfaction? Being one of the best places to work? Having a great reputation in the community? I am not sure we have seen an organization that is meeting all of these factors. Then again, those are not the organizations that typically call John Gorman for help.

Most places have an ironed-out Human Resources process that includes job description drafting, salary grading, recruitment, and interview process, which may take weeks or sometimes months. However, regulatory agencies wait for no man in terms of expecting compliance metrics to be met. As I observed my colleague tell a group of client trainees, “Your contract is with the federal government.” I can think of no finer way to articulate the commitment made to offer Medicare Advantage and Part D.

Our industry experts currently hold interim staffing positions in all areas, including risk adjustment, compliance, strategy, operations, network management, and pharmacy. While organizations search for their full-time candidate, Gorman Health Group provides experts who have done the job, can manage the department, can report to their C-suite, and much more. Do not let a temporary lack of staff hinder your success. If lack of staff is preventing you from meeting requirements, we can tell you from experience that it by no means sways the Oversight and Enforcement Group from their obligations.

Resources:

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe


Latest Audit Enforcement Actions Issued by CMS

Like clockwork, the Centers for Medicare & Medicaid Services published the enforcement action notices issued to sponsors related to 2017 program audits. Additional detail regarding conditions, audit scores, and enforcement is expected to be included in the 2017 Program Audit Enforcement Report, which the agency hopes to release before their conferences taking place May 9-10. In the meantime, we break down the published data, which includes not only program audit actions but others as well:

  • Eighteen sponsors were issued almost $2.6 million in Civil Money Penalties (CMP) between September 2017 and February 2018 based on their 2017 program audit findings.
    • 72% of sponsors cited for Coverage Determinations, Appeals, and Grievances violations
    • 61% of sponsors cited for Formulary and Benefit Administration violations
    • 39% of sponsors cited for Organization Determinations, Appeals, and Grievances violations
    • 22% of sponsors cited for Part C Beneficiary Protections/cost sharing violations
  • A Program of All-inclusive Care for the Elderly (PACE) sponsor was issued a CMP in November of 2017, and two PACE sponsors had enrollment suspended in the fourth quarter of 2017.
    • PACE plans: You are small but have a mighty sense of responsibility. If you have not done so already, review the posted enforcement notices, distribute within your organization, and create an action plan if you identify any similar findings.
  • One Prescription Drug Plan sponsor had enrollment suspended due to medical loss ratio.
  • Two sponsors were issued CMPs in 2017 based on outlier status of auto-forwards to the Independent Review Entity.

CMS noted in their draft call letter the agency is considering adding a CMP icon in Medicare Plan Finder (MPF) starting in 2019. If the agency proceeds that way, sponsors undergoing audits this year and incurring CMPs will be impacted by this new indicator. We support efforts such as this which promote beneficiary transparency. As I outlined in our analysis, sponsors should take note. Low Performing Icon information has not been limited to the MPF. Marketing organizations and other industry publications have taken that information and run with it, which may give an advantage to competitors of affected plans. In a recent Bloomberg Law article, I further discuss enforcement actions and the implications of this Low Performing Icon.

Remember that enforcement actions can be levied not just for program audit performance but also for a host of other violations. While I have provided some recent statistics, an analysis of actions taken year over year show patterns in some regards, and no rhyme or reason in other regards. Don’t spend too much time slicing and dicing these figures for your management; let us do that here in these articles. Focus on plan performance and continuous improvement. The goal should be to ensure your organization does not end up with enforcement actions in the first place.

 

 

Resources:

Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe


CMS Timeliness Monitoring Underway

The Centers for Medicare & Medicaid Services (CMS) timeliness monitoring is currently underway at organizations with active contracts in 2017 and 2018, with a few exclusions, such as Medicare-Medicaid Plans and organizations that underwent a program audit in 2017 and did not have any invalid data submissions in key audit areas. Is your organization excluded? See the Health Plan Management System memo dated December 12, 2017. If I had a nickel for every time someone referred to this activity as a timeliness audit, I’d have quite a pile of nickels. While it is not an audit, it sure feels like one as the validation activity is the same.

The first of three waves of letters is being issued this month. After upload, a data review will be conducted and a validation webinar scheduled. Once complete, timeliness rates will be calculated. To make sure this is an efficient process, here are some ways we have recently assisted clients:

  • Coach and guide delegates in the timeliness monitoring requirements
  • Evaluate universes for adherence to instructions
  • Review both timely and untimely case samples for data accuracy
  • Review systems to validate accurate population of fields

Data integrity continues to be a priority not only for informing Star Ratings and Independent Review Entity data accuracy but also for required Part C and Part D reporting and for the compliant operations of plan administration. Universe preparation steps are not one size fits all, as the methodologies for a small plan delegating very few activities and the steps a larger, more delegated model plan takes will vary. Not surprisingly, during the course of our review, our team often finds potential issues or concerns unrelated to timeliness. This gives our client partners the opportunity to conduct a deeper review to address and mitigate.

We currently provide guidance, suggestions, and best practices for universe development to address quality and identify potential risks. If your organization is not getting these data universes correct, you should ask yourself, what other reports might be flawed? Dashboard metrics? Board reporting? Identify and correct these issues before CMS and their contractors find them for you.

 

 

Resources:

Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>


Second NOIA Deadline Approaching

Applicants looking to enter Medicare Advantage, Part D, or the Medicare-Medicaid Plan space have two deadlines to submit a Notice of Intent to Apply, commonly referred to as a “NOIA,” for contract year 2019: November 13, 2017, and January 26, 2018. The first submission allows the Centers for Medicare & Medicaid Services (CMS) team to gauge what resources might be needed during this critical time of year. The second date is provided to allow potential suitors to review the final 2019 application requirements, which should be released here, here, and here around January 9, and then make a decision.

CMS initiated the NOIA process in 2007 for the 2009 application season and have always noted the NOIA submissions should be completed by the due dates, stating those that miss the date might experience delays in being assigned a contract number. Six years ago, CMS implemented a second NOIA submission date into their application activity timeline, noting they would continue to process NOIAs through the second date.

Remember, the NOIA is non-binding. Based on Gorman Health Group experience, CMS would prefer you make any decisions not to pursue the application as early as possible. The deeper you get into the process, the more taxing it is on the agency, on actuaries, and on your resources.

NOIA Links

  • New/Initial Medicare Advantage or Part D Plans, click here
  • Medicare Advantage or Part D Service Area Expansions, including adding a Special Needs Plan, click here
  • New/Initial Medicare-Medicaid Plans, click here
  • Medicare-Medicaid Plan Service Area Expansions, click here

 

 

 

Resources:

Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>


Three Considerations For Those Entering Medicare Advantage

Every few months the industry hears news of new players getting into the Medicare Advantage (MA) game. And why not? According to the Kaiser Family Foundation, more than 19 million Medicare beneficiaries are enrolled in MA plans this year. Either someone is building from the ground up or purchasing an existing structure, such as CVS Health Corporation’s recent agreement to acquire Aetna. I don’t expect this will be the last pharmacy benefit manager to look for an insurer partner with the promise of being able to lower healthcare costs. While analysts argue over the benefits and concerns, one thing is for certain: you need experienced administrators at the helm. I borrow from the late Mitch Hedberg who summarized just because you can do something really well in one field doesn’t make you an expert in everything:

quote_regan blog

Whether you are building from scratch or partnering with an established entity, you might be adept at one thing but not necessarily everything related to it, nor should you be. In Hedbergian spirit, I’ve outlined three pieces of advice for those entering this arena.

  1. If preparing for the Part C and Part D Application process, the clock is ticking. Make sure the right people are in place to implement this product. If the application submission is the wedding day, the implementation and execution are the marriage. What vendors are being considered vs. what will be built in-house?
    1. For those undergoing mergers, I speak from experience about its arduous process. Integration activities do not happen overnight, nor should they, but it is possible the drivers of success may get derailed during integration. Thoughtful engagement of the right people with the experience and skillset in the delivery of this product is imperative to make sure successful practices are not lost.
  2. Focus on what needs to be done in order to be successful, but first, make sure everyone agrees on the definition of success. Is it fiscal success for long-term viability? Is it the establishment of a sustainable product set with steady membership growth? Are Star Ratings and other quality measures part of the equation? We always hear about top-down communication strategy, but for those responsible for implementation, lateral communication is essential. Ensure everyone understands the organization’s priorities, and remove silos that impede progress.
  3. Know your members well. What does the market look like? What are their health and cultural needs? What are the product, benefit, and premium trends in the area? If you are submitting an application, you have likely already gone through these studies as outlined recently by my colleague Diane Hollie in a recent article on expansion strategy.

You do not want to set up your organization or team to fail – no one sets out that way. Before you apply for the first time, expand, or acquire an existing plan, establish the right team, be on the same page, and understand your market. If you need assistance, please contact me directly at rpennypacker@ghgadvisors.com.

 

 

Resources:

Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>


The 2019 Application - Key Dates

As a follow up to my last article on the Notice of Intent to Apply, I give you an enhanced chart of 2019 application activities outlining things you should have been doing or should be in the middle of now. Thanks to the Centers for Medicare & Medicaid Services (CMS) for creating a base, published recently via memo – my colorful additions peppered throughout for your perusal. If past activities have not been done yet, it is time to get a move on, or you risk missing the deadline.

Calendar Year 2019 Application Activity Date
Determine the feasibility of applying for a new plan or expanding an existing plan; identify vendor partners to contract with who will support administrative or health services, begin contracting process or review existing contracts to ensure application requirements will be met Ongoing process
Review past finalized application guidance, determine licensure needs, contact pertinent state(s) to establish their needs and timeline June 1, 2017
Review the 60-day release outlining the proposed changes to the 2019 applications August 1, 2017
Tell Provider Contracting not to rest on their laurels August 2, 2017
Comments due on the 60-day release of the applications October 2, 2017
Read CMS’ Notice of Intent to Apply (NOIA) memo dated October 13, realize there are 36 calendar days between the release of the final application and submission, suppress panic October 13, 2017
Read this chart, and if anything is making you twitch, let me know October 16. 2017
Create a draft project plan, assigning specific tasks to your application project team; establish an earlier submission date; field angry emails from the team but hold firm; obtain the team’s vacation schedules now through submission date, establish back-ups October 30, 2017
Review the 30-day release of the draft 2019 applications (approximate time) November 10, 2017
NOIA deadline to ensure access to the CMS Health Plan Management System (HPMS) November 13, 2017
New applicants should download the CMS User ID connectivity form (aka CMS Access Request Form) and distribute to the application submission team and C-suite team members who will need to complete attestations. Provide specific instructions on filling out the application, or don’t, if you like a lot of re-work. Ensure back-ups. Send originals via traceable carrier to CMS. November 15, 2017
CMS sends NOIA confirmation e-mails to entities meeting the November 13 NOIA deadline to ensure timely HPMS access November 30, 2017
CMS User ID connectivity form submissions must be received by this date to ensure user access to HPMS by January 9, 2018 December 1, 2017
Try to enjoy the holidays, because that application work is coming January 1, 2018
Calendar Year 2019 Medicare Advantage (MA), Part D, and Medicare-Medicaid Plan (MMP) applications posted on CMS website January 9, 2018
Finalize project plan based on the final guidance, adding any new tasks and team members required; register for CMS user calls; re-communicate internally established submission date January 9, 2018
Final day to submit NOIA for 2019 January 26, 2018
If you believe stragglers will cause you to be working up to CMS’ deadline, order flowers for your significant other so Valentine’s Day isn’t completely ruined February 12, 2018
CY 2019 MA, Part D, and MMP applications submission deadline February 14, 2018

 

 

Resources:

GHG can now efficiently analyze health plan data to pinpoint key areas needing improvement, assess the root causes of these pain points, and deliver a data-driven action plan to increase your ratings. Learn more about our new service >>

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>


CMS Notice of Intent to Apply

The Centers for Medicare & Medicaid Services (CMS) Annual Call Letter calendar marks November 13, 2017, as the first due date for the Notice of Intent to Apply. It is expected the Center for Medicare will release a reminder memo this month outlining the details. In general, the agency requires a Notice of Intent to Apply to be submitted when an organization plans on submitting a request for any of the following:

  • Offering a new product type (such as a Medicare Advantage Prescription Drug plan or Prescription Drug Plan)
  • Transitioning an existing non- or partial network Private Fee-for-Service (PFFS) to a full network PFFS
  • Expanding the service area of an existing contract
  • Expanding only an employer-only service area
  • Adding prescription drug benefits to an existing contract for the first time
  • Adding Employer Group Waiver Plan (EGWP) market to an existing individual-only service area for the first time
  • Adding individual market to an existing EGWP-only service area for the first time
  • Adding or expanding the service area of a Special Needs Plan
  • Expanding the service area of an existing Medicare-Medicaid Plan

While organizations will have another opportunity once the final application guidance is released in January, for the most part, those who have properly planned are generally certain by November if they intend to pursue this initiative. Feasibility discussions have occurred to help leadership make that “go/no-go” decision. “Along with feasibility discussions, network analysis to determine adequacy and potential gaps is a critical component to consider as you decide on submitting your Notice of Intent to Apply,” states a colleague on the Operational Performance team. “Those steps will help set up the plan to move forward with their application filing.”

Turning to the application, interested parties have certainly already gone through the draft Part C and Part D applications with a fine-tooth comb to determine what’s new for the coming submission and what isn’t needed. If you haven’t reviewed the documents by now, what’s changed may surprise you.

The Notice of Intent to Apply is due in about a month. If you’ve conducted a feasibility study but are still unsure of what to do, don’t be alarmed. (Well, ok, be a little alarmed, but take a step in the right direction and contact us.) Then, once you have made the decision to pursue an application, ask us for assistance. Gorman Health Group has a proven track record of successful application assistance and support. Going in with a clear understanding of the process and expectations helps you put your organization’s best foot forward in the pursuit of this new endeavor.

Resources:

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>