Four medical professionals meet to discuss strategy

With Switching Down, MAOs Seek ‘Untapped’ Market Segments

Reprinted with permission from AIS Health from the Feb. 18, 2021, issue of RADAR on Medicare Advantage

Recent data from the 2021 Medicare Annual Election Period (AEP) reflects the anticipated increase in Medicare Advantage enrollment, which is up 9.8% from a year ago and indicates penetration exceeding 43%, according to industry estimates. But multiple factors are making it harder for MA organizations to attract new members, and while plans are enhancing their benefit offerings to stay competitive, they must do so in a way that aligns with their star ratings and other financial goals.

For our occasional series of interviews that examine pertinent issues through the words of the industry’s leading executives, AIS Health spoke with GHG Vice President John Selby, whose long career in the insurance industry includes 10 years in various roles at Horizon Blue Cross Blue Shield of New Jersey. In his new role at the Convey company formerly known as Gorman Health Group, he is responsible for developing and executing growth strategies for GHG and its clients.

Editor’s Note: The following interview has been edited for length and clarity.

AIS Health: According to the latest Medicare Shopping and Switching Study from Deft Research, switching among MA members during the recent AEP fell 21% from the prior-year period and overall switching was down 18%. Do you think insurers should take this with a grain of salt given the disruptions of 2020 (e.g., COVID-19 pandemic, presidential election) or is this indicative of a larger trend?

John Selby: I don’t think it was a surprise that we saw less switching, but I don’t believe that this was entirely an anomaly created by COVID. There’s been a trend toward stabilization over the last few years, particularly as more plans become 4 star [and] as the plans are becoming more stable, experiencing fewer rollercoaster rides — whether it’s related to premiums or benefits. So I think this is a trend that we’ve been seeing and with the plans that we’re working with, as we’re trying to help them find ways to become even more stable, and really it’s driving retention.

If you look at an area like supplemental benefits and the way many plans have been looking at those and increasing the value of the benefits that they have, that’s just creating more stickiness. I think that is a really good example of an area that could continue to move the needle in this direction going forward. The challenge that comes during AEP is members are more satisfied with the plans that they’re in, and that’s an area where it gets more challenging for folks on the carrier side to try and find new ways to market not just during AEP, which is becoming increasingly expensive. Obviously, the turning 65, new-to-Medicare market is critical, but then what other market segments do you start to parse out outside of or even within AEP that are maybe a little bit more untapped? And those are areas we’re looking at with the plans that we work with to try and develop strategies around that, which would include product and marketing and things like that.

AIS Health: What do you think accounts for the people who did choose to switch plans?

Selby: One would be network: The first question people ask is, is my doctor in the network? The second might be mobility: Folks that are in an HMO are maybe looking to go into a PPO and have a little bit more mobility there. And then the third would be — assuming that there aren’t many major changes in the medical benefits — year-over-year, formulary-driven changes (e.g., drugs that were previously lower tier that moved to higher tier).

The other thing, too, is not to ignore the impact of stars. I personally think stars has all sorts of ramifications, not the least of which is if you are 4 stars, you can invest more in your plan which then makes it more competitive. But if you’re in a non-4-star plan in a market that’s got a proliferation of 4-star plans, just word of mouth alone about what you’re hearing from your neighbors and friends who might be in other plans could be a cause of that. And I do think some of that is directly or indirectly related to stars.

AIS Health: You mentioned supplemental benefits and how those are leading to some of consumers’ stickiness. People may be signing up for certain plans because they are attracted to the supplemental benefits and stick with the plan because they like what they are receiving, but some insurers have expressed concern about being able to sustain these offerings from year to year. Is this something you’re hearing from clients, and what are you advising them?

Selby: What we hear from brokers and agents is how critical supplemental benefits are becoming, and have become, really, so that’s part of the validation. The way I view this is, there are a lot of tenets to what you do around plan design. You’re trying to improve quality, you’re trying to improve the member’s experience, you’re trying to provide relevant services to them; and I think that’s where we see some of the creativity around supplemental benefits. But at the end of the day, if you don’t have the revenue you can’t sustain the benefit offering and so stars and risk adjustment are critical, in my mind, to being able to build a strong revenue base and sustain a strong revenue base.

I used the term before about the rollercoaster — that’s what you have to avoid. If your benefits, and premiums especially, are volatile and are not fairly consistent year over year, members are going to lose trust or faith, brokers are going to lost trust or faith, and it becomes an uphill battle because even if you could come back to a zero-premium plan, for example, for one year or two years doesn’t necessarily mean that people are going to be totally comfortable with that. The supplemental benefits are sort of the biproduct of having a strong infrastructure in place that’s keeping your revenue consistent.

AIS Health: How can plans determine which supplemental benefits will be critical to maintain?

Selby: I’m sure some are going to become table stakes more than others. The way we’re trying to guide plans here is to look at the big picture. There’s certainly a marketing value to offering supplemental benefits, and there’s a perceived value to the benefits, but what we like to try to have a conversation around is how are those benefits adding value? If you go back to not that long ago, especially in a D-SNP [Dual Eligible Special Needs Plan] environment, a transportation benefit was valuable and it was logical. If people can’t get to the doctor, they can’t get care, etc. Now there’s that bigger view of the member [and] the things that they need, so what we are trying to do is to solve the bigger problem. Can you address not just the members’ needs and the members’ satisfaction but also look at things from a quality standpoint and a clinical standpoint? And if you can, that’s going to pay off in [the star ratings]. And so that’s where we see things going. Whether the pace of new benefits will continue, I tend to think that’s going to plateau at some point in the not-too-distant future. I think the plans that can figure out how to connect the dots between these things and solve more than one problem through their benefit designs, through supplemental benefits…are the plans that are going to have a more solid foundation and something stronger to build upon going forward, so that’s the conversation we’re having with our clients.

Contact Selby via Alyssa Barone at

By Lauren Flynn Kelly

2021 Risk Adjustment Strategy and Program Readiness

As plans begin to wind down the year, one thing is clear. The COVID-19 pandemic put a strain on the entire healthcare industry and, for risk adjustment in particular, the disruption caused by the pandemic resulted in both adverse consequences (i.e., decreases in preventative encounters such as annual wellness visits) as well as some positive effects like the acceleration of telehealth adoption across providers.

The one certainty is that plans must start vetting out their 2021 risk adjustment strategy.

Here are several strategic planning items to help your organization prepare as we ring in the new year:

1. 2020 MA Final Run Extension

CMS is accepting 01/01/2019 – 12/31/2019 dates of service (DOS) for the 2020 final run until 08/02/21, adding 6 months for risk adjustment data submission. The 2020 interim final run deadline is still 02/01/21.

Keeping the end of January as your goal to submit most, if not all, 2019 DOS supplemental data supports two tracks. First, the strategy allows Medicare Advantage Organizations (MAOs) to accrue and recognize the 2020 final PY revenue as they normally would. Second, MAOs can use the time to capture remaining residual opportunity through interventions they did not deploy earlier.

Plans can take advantage of additional time in these ways:

  • Create a chase project for members who were new to plan in 2020 (not new to Medicare)
  • Launch a second pass (2LR) coding review for targeted populations
  • Perform a data submission reconciliation project to identify any missed or dropped records across the data submission supply chain (e.g., claim, supplemental, RAPS, and EDS)

2. Transition to 100% EDS for Risk Score Calculation

CMS announced the shift to 100% EDS for 2022PY in their Advance Notice Part 1 for CY2022. This makes 2021 DOS claim capture incredibly important as supplemental RAPS diagnoses are removed from risk score calculations. GHG projects a 1-3% impact to risk scores as plans adjust to the new methodology.

  • Create reporting models that rely solely on encounter data responses
  • Invest heavily in deploying prospective risk adjustment programs and capturing diagnoses close to the point of care ensuring they are reported in claim transactions
  • Implement a comprehensive EDS error correction and remediation process
  • Perform a final RAPS to EDS reconciliation to determine the true risk adjustment impact
  • Assess your prevalence of submitting linked versus unlinked chart reviews
  • Confirm your submission partner has a sunset plan in place for RAPS

GHG recently hosted a webinar with Pareto Intelligence and Episource surrounding the best deployment strategies to ensure your upstream encounter data is accurate, complete, compliant, and ready for submission. Click here to watch the webinar recording on demand.

3. Compliance

Lawsuits continue against MAOs referencing the False Claims Act which holds plans accountable for the “accuracy, completeness and truthfulness of the submitted data”. MAOs should continue to assess their risk adjustment programs for accurate and complete submissions of diagnoses data.

  • Perform targeted Hierarchical Condition Category (HCC) reviews for conditions at high risk of documentation errors
  • Assess whether your organization ‘looks both ways’ to identify codes that are not substantiated by proper documentation
  • Consider deploying and investing in prospective and concurrent coding programs that incorporate provider education

4. Evaluate Vendor Performance and Contracts

MAOs rely heavily on vendors to manage successful risk adjustment programs. These organizations specialize in an array of service delivery areas such as suspecting analytics, prospective technology enabled solutions, medical record retrieval, diagnosis coding, in-home assessments, telehealth, RADV/IVA, HEDIS, EDS and RAPS submissions, and data integrity. The contributions from your partners can make or break your final outcomes.

How many vendors are you currently working with? Are they meeting your expectations?

  • Review end-of-project performance and confirm SLAs were met
  • Ensure MSAs and SOWs are current and executed
  • Determine if current fee schedules are market competitive
  • Explore new services and technologies
  • Consolidate where it makes sense

5. Coding and Documentation Updates

Changes in the evaluation and management (E/M) level calculation methodology for 2021 DOS move away from a counting and measuring of the complexity of tasks (e.g., History, Exam, or ROS), into a simpler definitive measurement of E/M.

Physicians can now base the code assignment on either total time related to the visit or medical decision making related to the visit.

A reduction in the amount of historical data required may have a negative impact on the ability for plans to capture chronic conditions documented in the note, but not coded in the encounter. Extensive problems lists, past medical, and past surgical histories are often heavily utilized during retrospective chart reviews. With less focus on these elements in calculation of E/M, this criteria may fall from encounter documentation.

How Health Plans can prepare:

  • Monitor electronic medical record (EMR) encounter templates to ensure changes do not impact the amount of data captured from encounter review.
  • Ensure members are still receiving comprehensive type visits to capture all chronic conditions (i.e., annual wellness visits or initial preventive physical examination).

2021 ICD10 Guidelines Updates

Notable changes in the Official ICD10 Guidelines revolve around new diagnoses of COVID-19 and vape use disorder. Neither of the new codes (U0.70 Vaping-related disorder; U0.71 COVID-19) are included in the CMS or Health and Human Services risk adjustment models, although interactions with other HCCs would follow usual ICD10 protocols of first-listed or additional diagnosis. No combination codes or Hierarchy for COVID-19 have been added.

Below are 2021 updates relevant to risk adjustment (Medicare, Medicaid, and/or HHS models):

Documentation by Clinicians Other than the Patient's Provider

  • “Patient self-reported documentation may also be used to assign codes for social determinants of health, as long as the patient self-reported information is signed-off by and incorporated into the health record by either a clinician or provider.”

Endocrine, Nutritional, and Metabolic Diseases (E00-E89)

  • “If the patient is treated with both insulin and an injectable non-insulin antidiabetic drug, assign codes Z79.4, Long-term (current) use of insulin, and Z79.899, Other long term (current) drug therapy. If the patient is treated with both oral hypoglycemic drugs and an injectable non-insulin anti-diabetic drug, assign codes Z79.84, Long-term (current) use of oral hypoglycemic drugs, and Z79.899, Other long-term (current) drug therapy.”

Diseases of the Circulatory System (I00-I99)

  • Hypertensive Heart and Chronic Kidney Disease
    • “For patients with both acute renal failure and chronic kidney disease, the acute renal failure should also be coded. Sequence according to the circumstances of the admission/encounter.”

Pregnancy, Childbirth, and the Puerperium (O00-O9A)

  • Puerperal Sepsis
    • “Code O85 should not be assigned for sepsis following an obstetrical procedure (See Section I.C.1.d.5.b., Sepsis due to a post-procedural infection).”
  • COVID-19 Infection in Pregnancy, Childbirth, and the Puerperium
    • “During pregnancy, childbirth or the puerperium, when COVID-19 is the reason for admission/encounter , code O98.5-, Other viral diseases complicating pregnancy, childbirth and the puerperium, should be sequenced as the principal/first-listed diagnosis, and code U07.1, COVID-19, and the appropriate codes for associated manifestation(s) should be assigned as additional diagnoses. Codes from Chapter 15 always take sequencing priority.”

The most notable change for Health Plans applies to Social Determinants of Health (SDOH). These have been classically hard to capture, underutilized but growing in importance. Key factors are provider network education around these conditions, and ‘patient’s words’ are sufficient documentation to support capture.


GHG’s subject matter experts can help with the development or remediation of your risk adjustment strategy for 2021. Reach out to GHG’s Senior Director of Risk Adjustment Solutions, Eric Shapiro, to start the conversation.

CMS Program Audit Universes and Protocol Changes Tabled Until 2022

The Centers for Medicare and Medicaid Services (CMS) recently released the 2021 Program Audit Memo, which announced that it will start sending engagement letters in March of 2021, and will continue to do so through July of 2021. CMS also announced that it will continue to use the 2020 protocols for program audits in 2021. CMS initially intended to use the updated protocols in 2021, but is still waiting for approval from the Office of Management and Budget (OMB).

CMS has stated: “Delaying implementation of the updated protocols proposed under CMS-10717 will give stakeholders sufficient lead-time to apply and test the updated protocols prior to CMS using them to conduct audits.”

Health plans should use the time to ensure that they and their Pharmacy Benefit Manager (PBM) have reviewed the updated protocols anticipated for 2022 to ensure compliance with data extraction and population. Of note is one of the new universes, “Universe Table 7: Comprehensive Addiction and Recovery Act (CARA) At Risk Determination (AR) Record Layout”. Plans should verify whether they are aligned with their PBM to define the responsible party and confirm that the layout has been reviewed and is ready for use in 2022.

CMS’s 2019 Part C and Part D Program Audit and Enforcement Report did not include the common conditions cited during program audits, as it has done in years past. This exclusion is unfortunate in that it is typically a helpful learning tool for plans to modify oversight activities and incorporate noted best practices into their operations. That being said, with the goal of ensuring member access to entitled benefits and focusing on noncompliance related to access to care, GHG would expect CMS’s areas of focus to include COVID-19 flexibilities and proper administration of opioids edits in Formulary Administration.

In the 2020 Part C Organization Determinations, Appeals, and Grievances (ODAG) protocol, CMS eliminated the Call Log universe (Table 14). In the Compliance Program Effectiveness (CPE) protocol, CMS suspended the CPE self-assessment questionnaire and made several changes to the CPE universes.

As we head into the 2021 CMS Program Audit season, take the appropriate steps to ensure that your health plan has updated its universe data pulls accordingly.

Where Do We Go from Here?

With all the stressors on health plans in the current environment and the ever-changing landscape of the COVID-19 pandemic, the news from CMS to continue use of the 2020 audit protocols may come as a bit of a relief. However, plans must not be complacent about audit preparation and should remain diligent about their PBM oversight activities. Plans are still encouraged to perform mock audits to evaluate their operations and practice the experience.

Gorman Health Group (GHG) assists plans in implementing process improvements in relation to new CMS requirements. Our team of subject matter experts also conduct readiness assessments and mock program audits to validate adherence and identify potential areas of risk or concern. Contact us today to start the conversation.


Part II of the CY 2022 Advanced Notice: Continued Evolution of the Medicare Advantage Star Ratings

On October 30, 2020, CMS surprised plans with the early release of Part II of the CY2022 Advance Notice. Per CMS, this earlier-than-anticipated issuance may allow for the early publication of the CY 2022 Rate Announcement. This would provide plans with more time to prepare their bids and would provide some level of certainty during this unprecedented global health pandemic.

Part C & D Star Rating updates (detailed in Attachment IV of the notice) have health plans continuing to adjust strategies and recalculate their unique mathematical routes to 4 & 5-Star attainment.

Key Updates from Part II of the Advance Notice

  • A series of Star Year (SY) 2022, COVID-19 related changes adopted in an effort to reduce provider impact (issued in the March 31, 2020, Interim Final Rule): 
    • Delay of guardrail application until the 2023 Star Ratings,
    • Expansion of the hold-harmless provision for the Part C & D Improvement measures to include all contacts for SY 2022, and
    • Revision of the definition of a “new MA plan” (for SY 2021) to mean an “MA contract offered by a parent organization that has not had another MA contract in the previous 4 years”.
  • The COVID-19 IFC (CMS-3401-IFC) issued on August 25, 2020, which modifies the Extreme and Uncontrollable Circumstances (EUC) policy for SY 2022 to allow nearly all plans nationally to receive the higher of SY ‘21 or SY ‘22 measure-level ratings. 

 CMS also reminds plans of the changes and allowances that were made to measures and their specifications effective SY ‘22, including:

  • Replacement of the Medicare Plan Finder (MPF) Price Accuracy measure with the re-specified version that has been on display,
  • Modification of the Controlling Blood Pressure (CBP) measure to allow readings taken by a member with any digital device for the 2020 measurement year, and
  • Addition of outpatient telehealth, telephone visits & e-visits as qualifying numerator/denominator events for numerous HEDIS measures and for HEDIS advanced illness exclusions. 

These modifications help ensure MA recipients have access to needed care in the current COVID-19 environment.

Additional Updates on the Horizon

For SY 2023 (MY 2021), CMS proposes the use of the updated PQA measure specification recommendations for Statin Use in Persons with Diabetes (SUPD). The updates include a list of additional exclusionary criteria and limit denominator inclusion to beneficiaries whose earliest date of service for diabetes medication is at least 90 days prior to the end of the MY.

CMS also introduced the new Kidney Health Evaluation for Patients with Diabetes (KED) measure to the SY 2022 display page. Health plans should watch for future announcements that could propose the addition of this measure to the Ratings (and the potential retirement of the current CDC-Kidney measure) as early as MY 2022 (SY 2024).

A surprise to many payers is the 1-year delay in returning the revised Controlling Blood Pressure & Plan All-Cause Readmissions measures to the Ratings. These delays will allow each measure the codified 2-full-years of data on display prior to returning them to the Ratings in SY 2023 & 2024, respectively.

Future Star Rating announcements forecast continued change and complexity as evidenced by CMS’ potential introduction of a new COVID-19 vaccination measure to the 2023 display page (with possible future inclusion in the Ratings, pending rulemaking). This new measure would be added to the CAHPS survey administered in the Spring of 2022 and would mirror the current flu vaccine measure. CMS is also soliciting comments on the development of a potential new Provider Directory Accuracy measure, a significant pain-point for most plans!

CMS will accept comments on both parts I & II of the CY 2022 Advance Notice through Monday, November 30th. Many plans seek clarity around the impacts of the EUC policy revision to specific measure sets and methodologies as well as the proposed timelines for the retirement of CDC-Kidney & MRP as a stand-alone measure, the addition of TRC, FMC & KED, and detail surrounding proposed changes to the 3Xs weighted HOS measures Improving Physical Health & Improving Mental Health. We anticipate the release of one more Final Rule prior to the close of the calendar year.

Stars 101 Workshop

GHG’s Senior Directors of Stars, Jessica Assefa and Cynthia Pawley-Martin, are leading a Stars 101 Workshop at the Strategic Solution Network’s upcoming Medicare Star Ratings & Quality Assurance Summit on December 1-3, 2020. 

Their workshop titled, “How to Build and Grow Your Stars Program to Integrate All Measures” will include an in-depth review of the technical Star Ratings framework and data sources, as well as a deep dive into the technical specifications for measures used in Star Ratings.

This event is FREE to all health plans and providers. If you haven’t already, click here to register today!

Man writing regulatory rules

2021 Medicare Advantage Readiness Checklist

Every year, CMS releases an annual Readiness Checklist in an effort to remind Medicare Advantage (MA) Plan Sponsors of key contractual responsibilities in the upcoming plan year. The Readiness Checklist is not only a great reminder for existing Sponsors, but is also an excellent guide for plans that are new to the MA market.

This year, the Checklist released on October 2nd includes an assortment of existing and changed requirements to help you and CMS determine if you are ready for health plan operations in 2021.  

CMS expects that Sponsors are utilizing the Checklist for the upcoming contract year. However, the agency also conducts a teleconference with Sponsors to understand any potential challenges and obtain feedback about a plan’s process improvements to mitigate any risks or gaps in meeting obligations. CMS requires plans to report any requirements where they are at risk or where technical assistance is needed. 

Sponsors should carefully review the Checklist for regulatory changes and updates that may have occurred since the previous year. Remember, this Checklist is intended as a summary of critical requirements and it includes references for plans to locate any guidelines that they may need to understand the guidance. Plans should review all Checklist references including Health Plan Management System (HPMS) memos, Final Rules, and the Call Letter for the detailed interpretation of these CMS requirements.

A few examples of focus areas that may be new or expanded upon in 2021 include:

Systems, Data, & Connectivity: Prescriber Real Time Benefit Tool (RTBT) – Part D Sponsors
Contracting, Subcontractor Provisions, and Oversight: MAOs Offering Dual Eligible Special Needs Plans (DSNPs)
Enrollment/Disenrollment: Timing of Annual Enrollment Period (AEP) and Electronic Enrollment Mechanisms (Excluding MMPs)
  • Plans that may have implemented changes to their temporarily absent policies due to the public health emergency (PHE), allowing out-of-area members to remain enrolled, ends on 12/31/2020 or at the end of the public health emergency, whichever is earlier. These members will automatically be disenrolled on 1/1/2021 if they are still absent from the service area or 6 months after the individual left the service area, whichever is later. 
  • Plan Sponsors' ability to accept enrollment on electronic devices or secure internet websites must follow CMS enrollment guidance, including submitting materials and web pages related to enrollment for approval prior to use and complying with CMS data security policies. Sponsors are also ultimately responsible for handling of sensitive beneficiary information including when it is processed by first tier, downstream and related entities (FDRs) and must report security and/or privacy breaches timely.
Grievances, Initial Coverage/Organization Decisions, and Appeals: Continuation of Benefits While an Appeal is Pending
  • This requirement is only for applicable integrated plans.
Where Do We Go from Here?

Outside of program audits and data reporting, the Readiness Checklist is a valuable tool in CMS’ oversight arsenal. Is your MA Plan ready for 2021? GHG conducts readiness assessments for its clients to help identify any areas of risk related to upcoming plan year preparedness. Contact GHG Advisors today to learn how we can help you be best prepared.

MA Plans See Lower 2021 Star Ratings on Average

For many, October signals the beginning of Fall with the weather turning cooler and the smell of pumpkin spice in the air. For Stars leaders at Medicare Advantage plans, it means the nerve-racking public release of their Star Ratings.

For the past several years, the Star Ratings program has been relatively stable. However, because of the COVID-19 Public Health Emergency (PHE), this year’s 2021 Star Ratings specifications were subjected to an unprecedented amount of change as CMS attempted to address the impacts of the PHE on Star Ratings.

CMS Changes to 2021 and 2022 Star Ratings

CMS adopted a series of changes to the 2021 and 2022 Star Ratings to accommodate the disruption in members engaging with their providers, as well as worries about data collection and impacts on performance posed by the PHE for COVID-19 such as:

  • Eliminated the requirement to collect and submit Healthcare Effectiveness Data and Information Set (HEDIS) and Medicare CAHPS data otherwise collected in 2020, and replaces the 2021 Star Ratings measures calculated based on those HEDIS and CAHPS data collections with earlier values from the 2020 Star Ratings (which are not affected by the public health threats posed by COVID-19).
  • Expanded the existing hold harmless provision for the Part C and D Improvement measures to include all contracts for the 2022 Star Ratings.
  • Revised the definition of “new MA plan” so that, for purposes of 2022 Quality Bonus Payments (QBPs) based on 2021 Star Ratings only, "new MA plan" now refers to an MA contract offered by a parent organization that has not had another MA contract in the previous 4 years, in order to address how the 2021 Star Ratings will be based in part on data for the 2018 performance period.
  • Revised the definition of the Extreme and Uncontrolled Circumstances policy (EUC) because the PHE for COVID-19 meets the Star Ratings criteria for an extreme and uncontrollable circumstance in nearly all states/territories (and service areas). Most contracts will be eligible for the extreme and uncontrollable circumstance adjustments to their 2022 Star Ratings as a result of the PHE.

One thing that did not change was the planned increase of the Access, Experience and Complaints measures from 1.5 weight to 2 as codified into rule previously. 

2021 Star Ratings Program Results

At an individual level, most plans fared well with the changes that CMS implemented. However, when looking at the program overall, there was a slightly downward shift to the 2021 Star Ratings:

  • 49% of Medicare Advantage plans received a 4+ Star Rating (down from 52%).
  • 77% of Medicare Advantage beneficiaries are enrolled in contracts that have 4+ Star Ratings (down from 81%).
  • 31 plans lost their 4 Star vs. 19 plans that gained their 4 Star Rating.
  • 6 plans slipped from 5 Stars to 4.5 Stars with the 2021 Star Ratings.

Where Do We Go from Here?

Going forward for the 2022 Star Ratings timeline, as always, it is important that plans stay focused between now and June of 2021. The EUC policy will allow for plans to use the “higher of” Star Rating for most measures in the 2022 Star Ratings.

Additionally, “Hold Harmless” will apply for the Part C and Part D Improvement measures for 2022. MA-PD plans will not want to miss out on these, or any additional changes, that may still come from CMS.

GHG has a long history of working with health plans to develop a data-driven Star Ratings strategy and to improve your organization’s Star Ratings. Contact us to learn more. 

Stars 101 Workshop

GHG's Senior Directors of Stars, Cynthia Pawley-Martin and Jessica Assefa, are leading a Stars 101 Workshop at the Strategic Solution Network's upcoming Medicare Star Ratings & Quality Assurance Summit on December 1-3, 2020.

Their workshop titled, “How to Build and Grow Your Stars Program to Integrate All Measures” will include an in-depth review of the technical Star Ratings framework and data sources, as well as a deep dive into the technical specifications for measures used in Star Ratings.

This event is FREE to all health plans and providers. If you haven't already, click here to register today!

4 Tips to Expand and Grow Your Enrollment in a Fiscally Responsible Way

In the Medicare Advantage (MA) space, we are continually searching for opportunities to grow enrollment, either by adding new products or expanding our service areas. While both are certainly viable methods, it is important to approach the expansion process in a fiscally responsible way. Conducting a feasibility study can help make this process clearer and more achievable.

To help evaluate your potential growth opportunity, consider the following tips from GHG.

When examining service areas, benchmarks (and factors that play into the maximization of benchmarks) are critical.

  • How are benchmark rates trending from year to year?
  • Does the pre-Affordable Care Act (ACA) rate limit growth, or the amount of bonus for new plans and plans that achieve the 5% quality bonus?
  • Do any areas qualify for the double bonus?
  • Is there any upcoming legislation that may impact payment rates?

To evaluate membership potential, conduct a thorough study of the markets under consideration.

  • How many health plans and products are available?
  • What is the growth in the number of beneficiaries joining Medicare Advantage (MA) plans?
  • How much of the population is aging in?
  • What types of plans are growing membership?
  • Do I have existing populations through individual commercial or group pIans to whom I can market?
  • Can I co-brand with a provider group or hospital system?

Existing operations and performance can have a tremendous impact.

  • What kind of “lift” will it take to build my network?
  • Are there any risk arrangements?
  • Will I need a new Centers for Medicare & Medicaid Services (CMS) contract?
  • What amount of effort will it take with my existing systems to add a new service area or product?
  • How is medical management on my current population?
  • Will my Star Ratings positively or negatively impact the benchmarks used?
  • If I’m not already in MA, what kind of lift will it take, and what will it cost? 

Completing a feasibility study and conducting a sensitivity analyses can help plans make these decisions. 

  • For new plans: It is important to know just how sensitive certain factors can be. These factors include provider contracting and expected improvement in contracting rates, utilization management relative to Fee-for-Service and how much improvement there will be from year to year, risk adjustment trends, Star Ratings, administrative costs and trends, and membership. CMS expects plans to have a positive margin by the fifth year of business. 
  • For existing plans: Plans must understand the cost for expansion/growth and any revenue implications that may change. Plans need to be aware and prepare to face revenue adjustments to avoid being surprised during the next bid season.

At GHG, we have provided expertise to government-sponsored plans in conducting feasibility studies. We have extensive experience in the bid process as well as forecasting. Feel free to reach out and discuss how we can assist you in developing a feasibility study for any markets and products in which you may be interested.

Helping Smaller Providers Assess Their Ability to Take on Risk

We often note that when a team works well together, it can collectively accomplish more than its members alone. Your network providers, especially the individual and small groups, have been inundated with information from all directions on how to prepare for a shift to value-based payment models. This shift can seem overwhelming to a small practice without the resources to effectively manage the changes needed to be successful under a new model. 

Here are some things to consider when talking to providers about their ability to take on risk and navigate the new reimbursement model.

A significant portion of the information that providers receive on where they rank compared to their peers on quality metrics comes from benchmarks established by the health plans with whom they are contracted. It is also understood that providers have been wary of the data they have received. For providers, working together to provide real-time and transparent data has been at the top of the wishlist when building trust and long-term partnerships. It is also one of the first items plans and providers can work on together.

In turn, the verbiage of “taking on risk” can have a multitude of meanings for a provider. Working together to determine a collective definition and true ability for a practice to manage upside/downside or full risk is also an area in which plans can support their smaller provider groups.  

As health plans, we have focused on designing incentive plans or risk-sharing arrangements to promote compliance with regulatory requirements, stars, or risk adjustment goals. However, we may not have fully attended to what our providers, especially our smaller providers, have the ability to handle. Our larger system partners have the edge, but with so many providers fighting to stay independent, it is worth taking the time to support their needs as well.

To remain provider-centric, it is imperative that we understand where our smaller providers are – not only in their ability to take on risk and make the shift from fee-for-service to value-based reimbursement – but also in their overall infrastructure. 

During various projects, we have shadowed highly skilled provider relations representatives as they travel in the field to meet with office managers and providers. We have often found plans to have incorrect office addresses and practices to have a lack of staffing – making it difficult for the office to have time to digest the information we are sending, or for the data to get into the hands of the correct person and find a way to effectively integrate via technology to ensure a more effective means of communication for our smaller partners. 

Another observation to note is that while your representative is there with the best of intentions to review provider data and offer suggestions on how to improve and capture bonus dollars left on the table, they are one of many reps sitting in the office vying for a minute to talk with the office staff. It is a juggling act for the provider to be able to provide top-notch clinical care for his or her patients while also meeting the demands of a new value-based world.

In order to ensure your largest asset is prepared, why not empower your network with a checklist on how to evaluate their practices? We have provided a 15-point checklist that providers can utilize to examine the skills, knowledge, systems, and questions they should ask themselves when evaluating their ability to navigate the new reimbursement landscape. Once providers feel more empowered, blending a true engagement architecture can begin.

Checklist: Key Questions for Providers to Discuss Prior to Entering a Risk-Based Contract

  1. What is our experience in accepting risk? 
    • If there is a history of accepting risk, how has it worked out? 
    • What were the challenges? 
  2. How do we define Risk? 
    • Upside only
    • Upside/Downside
    • FFS plus performance-based bonus (P4P)
    • Capitation
    • Episode of care payments (bundled payments)
    • Percentage of premium
    • Full risk
    • Other
  3. What is our income/loss distributions formula?
  4. Will we share risk equally?
  5. What will the total investment for the organization, both in monetary and human resources, be to transition to value-based reimbursement?
  6. Do we have the patient volume, per payer, to make the investment worthwhile? And are we sure our patient attribution is correct? 
  7. Does this shift fit with our overall strategic plan? 
  8. Have we done the predictive modeling needed and how accurate are our projected savings? 
  9. Do we have the data capture, aggregation, analysis, and reporting tools to monitor clinical utilization and medical spend? 
  10. Do the savings include the total cost, i.e. training, new software, maintenance, potential changes in liability insurance? 
  11. How will the shared savings be distributed among the providers and what will we reinvest in infrastructure? 
  12. Do we have the ability and time to evaluate our patterns of care, hospitalizations, readmits and high cost expenditures to determine where we can reduce waste? If not, can we outsource? 
  13. Do we have a physician champion, leadership, and governance to implement and drive the process? 
  14. Are their stakeholders outside of the organization that are critical to the success and if so, do we have a strong alliance or partnership in place? This would include all providers across care settings that would affect your episode of care and thus the reimbursement. 
  15. If taking downside risk, what is the best way to prepare the organization if any money is owed? For example: reinsurance, funds in escrow, line of credit.

GHG is poised to assist your plan in developing a fully engaged provider engagement architecture to ensure the cross-functional needs of all your department “asks” come to the provider at the right time for shared success.

For additional questions and inquiries about how GHG can support your needs, please contact me at

Impacts of CMS' 2022 Advance Notice Part I on Risk Adjustment

On September 14th, 2020, CMS released their Advance Notice Part I for CY2022. CMS published this earlier than in the past to accommodate a potential early publication of the CY2022 Rate Announcement. In light of the uncertainty associated with COVID-19, an early Rate Announcement could benefit Medicare Advantage Organizaions (MAOs) by having information earlier in the year to prepare their bids, which are due the first Monday in June 2021.

While there were not any surprises, MAOs should start to think about how to align their strategies and operations to better prepare for the changes that are coming. 

100% of risk scores will be based on Encounter Data (EDS)

CMS is moving forward with their plan to fully phase in the CMS 2020 HCC risk adjustment model for Payment Year 2022 using EDS. The 2017 CMS-HCC model submitted to the Risk Adjusted Processing System (RAPS) to calculate 25% of the risk score will no longer be used. CMS will also discontinue the use of RAPS inpatient diagnoses to supplement EDS data.

Impacts: CMS is projecting the risk score impact of transitioning to the 2020 HCC risk adjustment model to be 0.25%. The CY2022 impact on MA risk scores being calculated using 100% encounter data is projected to have a neutral impact at 0.00%. Discontinuing the use of RAPS inpatient diagnoses to supplement EDS data is also expected to have an impact of 0.00%.

What MAOs can do:

1.    Perform a RAPS to EDS revenue neutrality impact analysis.

2.    Ensure risk adjustment reporting processes can be run using 100% EDS.

  • Traditional risk adjustment reporting processes (e.g., analytics, targeting, suspecting, RAF projections, and accruals) rely on processing RAPS responses to determine which member diagnoses have been accepted by CMS to drive suspecting, revenue projections, etc. Plans must start to create reporting models that solely rely on encounter data and the associated encounter data CMS response files.

3.    Ensure the completeness of supplemental data being submitted to EDS.

  • MAOs must start to ensure that all risk adjustment supplemental diagnoses data (i.e., chart reviews) are being submitted downstream to CMS via the encounter transactional system. Plans should start to evaluate this as part of a comprehensive EDS to RAPS reconciliation process.

4.    Assess the prevalence (and possible under-reporting) of behavioral health related conditions to inform population health initiatives.

  • The 2020 CMS HCC model adds more behavioral health conditions and substance use disorders. Plans could use this as an opportunity to capture a greater level of detail on behavioral health related conditions. Often times, these conditions may be under-reported and can have an impact on other population health identification and stratification programs. Additionally, behavioral health, and, more importantly, the early detection and ongoing treatment of these types of conditions can improve clinical outcomes.

Long term strategy:

In the longer term, MAOs should start to think about how the shift of 100% EDS to calculate risk scores may start to impact other operational areas:

1.    Shift to more prospective risk adjustment programs.

  • The majority of MAOs rely on retrospective chart reviews to submit supplemental diagnoses records for their MA beneficiaries. CMS will accept these types of supplemental data as linked or unlinked (i.e., linked back to the originating encounter). As CMS relies solely on encounter data for risk score calculation, plans should start the process of evaluating their risk adjustment programs and begin to think about transitioning the supplemental diagnoses submission upstream so that all of the information can flow through the encounter systems.

2.    Ensure a robust error correction and remediation process.

  • PY2021 will be last year RAPS will be accepted for risk score calculation (2020DOS). MAOs that plan on submitting EDS to CMS directly (i.e., without the use of a vendor) need to start assessing their adequacy to have a robust and timely EDS error correction and remediation process. For many plans, this means having a cross-functional business team to ensure that all encounter data records are being submitted to, and accepted by, CMS.

GHG, in partnership with Pareto Intelligence, has worked with numerous MAOs to evaluate encounter data processes and ensure accurate revenue capture. Given the increased emphasis on the EDS submission model and the growing potential for revenue shortfall, MAOs should begin assessing encounter data now to resolve issues in advance of submission deadlines.

WEBINAR: On October 8th, GHG's SVP of Healthcare Analytics and Risk Adjustment Solutions, Jeff De Los Reyes, moderated a webinar with Austin Bostock of Pareto Intelligence and Meleah Bridgeford of Episource to discuss the future of the regulatory environment, as well as steps you can take to ensure that your data is ready in advance of the submission deadline.

If you did not get a chance to attend the webinar, click here to learn more and view the recording.

Network Development Season is Upon Us

At this time of year, we would normally be sunsetting summer, sending the kids off to school, and stepping into the splendor of fall. As we move through the seasons of 2020, we have an odd mix of sharing our kitchen table 'office space' and navigating a new normal with our families and co-workers.

At the same time, CMS' new network adequacy requirements merit taking a look at where new Medicare Advantage (MA) plans have the opportunity to plant or where existing plans have the chance for a service area expansion (SAE) that may have been unattainable in previous years. 

In previous years, network changes placed many MA plans in flux and exposed serious issues ranging from policy to process and staffing to technology. With that in mind, it’s crucial that we look at the changes with a clear lens -- and with ample lead time -- as we enter the contracting period for network expansion and Health Service Delivery (HSD) submission for 2020/2021 and Plan Year 2022.

As with years past, plans previously submitted their HSD tables with their applications, and, by the end of April, there was clear insight into which counties the Centers for Medicare & Medicaid Services (CMS) deemed to have an adequate network, and product teams were able to quickly move forward with the product development process. With the timeline changes, however, bids are submitted prior to HSD tables being uploaded and reviewed by CMS. 

Plans must implement their own internal deadlines on the contracting process and decide whether to file a county that is on the edge of meeting network adequacy. The extra time and latitude offered by CMS in the network submission process resulted in additional contracting time. However, it also exposed the increasing importance for strong network management, blending network and product strategy, and setting firm internal timelines for network expansion. 

For example, we saw plans suppressed from Plan Finder during the Annual Enrollment Period (AEP) due to unresolved network deficiencies. The resulting loss of anticipated membership budgeted via AEP became a last-minute challenge for sales and marketing as well as a reset on the plan budget process. As plans prepare to submit their Notice of Intent to Apply in November, the Network Management Team needs to be at the table and be able to share with the C-suite how the new flexibilities in network adequacy standards afford the opportunity to expand into areas previously out of reach. 

As MA plans gain greater flexibility to design and offer new types of benefits to service their members, there becomes a critical juncture to blend our network and product strategy. When MA plans formulate their sales and marketing strategy to determine the impact that a variety of benefits could have based on addressing the particular social determinates of health that most impact their geographic area and member population, we begin to see a vast gap in the playing field from plans staying close to the basics with meals and non-emergent transport to plans on more risk and the willingness to invest in innovative benefit options without knowing the exact return on investment the benefit will have on patient outcomes or financial upside/downside cost. 

With the changes, we may see an upswing in partnerships with post-acute providers, such as, transitional assisted living and skilled nursing facilities and vendors offering adaptive aids to keep patients in their homes longer, meal or grocery delivery services, as well as an expansion on transportation services.

From a Provider Network perspective, the move forward with new partnerships will likely present a few stumbling blocks along the way, such as how to code and pay for services, and require a ramp-up period we do not see with traditional MA providers. We encourage you to start the planning process early and break down the silos by having group discussions to include Sales & Marketing, Medical Management, Star Ratings, Operations, Credentialing and Provider Network departments. The new providers are likely going to be dipping their toes in the same deep end of the pool, and extra lead time and planning will serve you well across the board.

Moving forward, as you internalize the contracting timeline to include standard MA providers as well as new non-traditional supplemental benefit providers, there can never be too much communication and oversight in managing provider network contracting and credentialing data – especially when using outside sources to assist in contracting or credentialing verification organization (CVO) to manage the initial credentialing process. Ultimately, the plan is held accountable for the compliance of contracting and credentialing its provider networks. Plans submitting initial and SAE applications should work back from the mid-June submission date and develop an actionable deadline(s) to ensure the network submitted meets CMS network adequacy requirements. 

Step one in any timeline is being prepared with a solid network strategy. In today’s marketplace, it is no longer acceptable to meet the bare minimum of network requirements. A network must be robust and marketable. Consumers – and CMS – are demanding plans offer choices that include quality and cost efficiency as well as supplemental benefits. With consumer-savvy, newly aged-in Medicare beneficiaries, there is also a shift in patient expectations and the services available for their dollar. The new beneficiary is aging into a world of patient engagement and incentive and reward programs and will expect the same level of service. Plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals. 

Where Do We Go from Here?

As you start your initial or expansion planning process and set new network monitoring processes in place to ensure preparedness, consider this: Gorman Health Group has a long history of providing the following:

  • Leveraging long-standing relationships and nationwide experience coupled with a cost-effective team of Senior Consultants, Network Analysts, and a Call Center to stand up a contracted provider network effectively and efficiently.
  • Designing and developing a network strategy and product strategy that consider the quality, financial, risk adjustment, and Star Ratings goals for success within the competitive landscape of your market(s).
  • Developing the oversight and monitoring P&Ps needed to address the new network and directory requirements.
  • Developing a network to support a competitive supplemental benefit program.
  • Preparing plans’ HSD tables for a CMS filing as well as preparing network exceptions to include all the required elements.

Let us know how we can work together now to support your plan’s goals for the upcoming submission and plan year. Contact us today to start the conversation.