In 2015 a Slap on the Wrist Can Be the Kiss of Death
It is truth that in the second term of Democratic administrations, scores get settled between Washington regulators and business partners of the Federal government. 2015 will be no different for our favorite agency, the Centers for Medicare & Medicaid Services (CMS). It's already on a pace for 2015 to be the toughest year ever in enforcement actions against Medicare Advantage plans. And generally speaking, the regulatory bar is rising faster than anyone imagined. Consider:
- So far in 2015 CMS has issued significant new Medicare Advantage and Part D regulations, and this year's Advance Notice for 2016 rates and rules for Medicare and Part D health plans is the most anticipated I can remember in more than 20 years.
- 2015 is the toughest year in benchmark payment rates thanks to the approximately $200 billion in cuts from the Affordable Care Act.
- 2015's technical corrections for Star Ratings are almost bewildering in their complexity in raising the clinical bar. Indeed, in 2014, an election year, CMS famously told Medicare Advantage plans below 3 Stars for 3 consecutive years that a stay of execution was granted. In the fall, many of those low performers were quietly shown the door and were non-renewed. In 2015, however, the agency is handing out live ammunition to its firing squad. Now an intermediate sanction freezing marketing and enrollment automatically knocks the plan down to 2.5 Stars, often meaning loss of millions in bonus payments and rebate dollars. In competitive markets now, the first plan sanctioned is the first hunk of roadkill.
- The HHS Office of Inspector General, the guys with the badges and guns in Medicare, have made data validation audits for Medicare Advantage risk adjustment one of its top priorities in its 2015 workplan. And the President's budget includes over a half-billion dollars in recoveries from these RADV audits.
- But nowhere is there better evidence that the paper tiger is growing its claws back than in CMS' track record in enforcement actions against MA plans. In January, the agency levied the highest monthly toll of civil monetary penalties ever -- and if it keeps up the pace, 2015 will be nastiest enforcement environment in Medicare history.
*January 2015
Granted, CMPs don't typically amount to much, usually no more than a couple hundred grand, rarely 7 figures plus. But the damage is actually far greater, when considering damage in the local and national press; the chatter factor among beneficiaries; lost membership, and damage to the Star Rating and the relationship with CMS, which for many plans is or is becoming its biggest customer. A slap on the wrist is now the kiss of death in this environment.
Last week, my colleague conducted a webinar on the "Top 10 Things Killing Your MA Plan." CMS' top infractions, in order, are coverage determinations and grievances, and formulary administration, or performance of your pharmacy benefits management vendor. Those findings are driven by these 10 root causes:
Now is the time to ensure your compliance function and Medicare operations have the right tools, processes and people to be successful in the toughest environment we've ever seen in government health programs. In 2015, Gorman Health Group launched its latest product, CaseIQ™ , providing a new way to ensure your Appeals & Grievance cases come to a timely and compliant resolution. The tool not only captures all the data points needed to categorize, work and report coverage disputes and complaints; it also guides users through the appropriate processing of each case, minimizing the risk of non-compliance due to user error. Built and governed by GHG Medicare compliance subject matter experts, CaseIQ™ aims to keep our clients out of CMS' audit crosshairs. Learn more in our recent press release.
In addition, in the Common Conditions, Improvement Strategies, and Best Practices memo based on 2013 program audit results, CMS outlined areas where plans have been consistently non-compliant and described best practices to address failings. Ongoing monitoring is at the heart of non-compliance. Our solution, the Online Monitoring Tool(OMT™), is a highly flexible oversight tool and dash boarding software that brings together key metrics, documents, and tasks for ongoing monitoring and auditing, which results in the Organization being audit ready. This integrated solution also streamlines vital compliance activities, such as the implementation of new requirements and corrective actions. Read our recent White paper to learn more.
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CaseIQ™, GHG's latest solution, offers built-in reports that allow for tracking of past performance, current backlog as well as trends, and is designed to assist the caseworker to a complete and compliant resolution in Part C (MA) appeals, Part D appeals, and Part C and Part D grievances. Learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Medicare Secondary Payer (MSP) is all about the money.
Money going out as a result of paying claims as primary payer when it's possible you should be paying as secondary payer. CMS reduces plan payments for members with MSP, shown on the Monthly Membership Report (MMR) as an MSP adjustment (reduction).
Money coming in results when research and outreach attempts validate paying as secondary payer; transactions are submitted to change or delete the occurrence records in Electronic Correspondence Referral System (ECRS). The recovery results are shown as favorable MSP adjustments (increase) in your Monthly Membership Report (MMR) payment. Claims recovery also produces additional revenue.
Medicare Secondary Payer shifts the burden from Medicare to commercial insurance companies. The burden is shifted to both employer plans (Group Health Plans) as well property and casualty insurers (Non-Group Health Plans). For Medicare Advantage plans, MSP is when an employer group sponsored health plan pays primary over the Medicare Advantage plan.
MSP validation is not a one and done process. Information can change, be inaccurate or out of date. Outreach validation requires diligence and persistence. ECRS submissions need to be monitored for non-responses and records under development. Other coverage information and system flags need to be updated for claims reprocessing and recoveries from other insurers for claims that were paid as primary in error.
GHG's MSP Reconciliation Team has delivered exceptional outcomes for our clients by recouping millions of dollars in MSP recoveries — much more than our clients expected! Each time we're able to obtain a positive validation and submit a correction to ECRS it means money for the client. That's a satisfying feeling!
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When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
2016 CMS Applications: Highlights and Basics
This week's CMS industry training on applications was quite informative, and contained many audience questions that you will want to hear. The recording is already available to registrants for those who missed it. There was way too much information for me to summarize, so I have included here a few highlights from the call and some basics that are easily overlooked.
Highlights
All new Part D applicants (MA-PD and PDP) who do not have a Part D contract with CMS that has been in effect for one year prior to application submission, must use a contracted first tier, downstream, or related entity (FDR) that has one year experience in the last two years performing functions in support of another Part D contract. Also, new PDP applicants must have two continuous years' experience offering health insurance immediately prior to submitting the application or five continuous years actively managing prescription drug benefits. CMS confirmed that the applicant can use the experience of a parent or subsidiary of its parent to comply with these requirements.
CMS also highlighted that applicants must validate their home infusion (HI) and long term care (LTC) pharmacies prior to submission. They must have valid NPIs. If you upload invalid information, the application will be considered deficient. This reminder is certainly a result of last year's CMS exercise of calling HI pharmacies directly to ask them about the services they perform. Based on the tone of yesterday's call, there is low tolerance for applicants that do not verify this information. They further mentioned that applicants must make sure their ITU file matches ITU reference file. "Even if the spelling is wrong, please use the wrong spelling." You will need to listen to the entire call recording to catch all the information provided, but the slides are a good start.
Nail down the basics.
- It may seem trivial, but make sure you have the right contact name in the Part C Application Contact and Part D Application contact fields. Earlier last year when CMS sent their first round of deficiency notices, only the application contacts received the emails at the plan — no one else. With only one week to address deficiencies or gaps after that first notice is received, it is imperative that the right contact is in place and that they are aware that they need to monitor notices from CMS quite closely.
- Cross-walk documents using pdf page numbers. CMS has quite a bit of information to review so point them directly to the requirement in your document, be it the Quality Improvement Plan or the PBM contract.
- CMS stresses to follow instructions and use the new templates for the Part D application; do not use anything from previous years. Also, do not submit such a thin application that is indicative that it is simply a placeholder for more time.
Make sure your effective dates are in line with the application requirements.
· Consider your licensure and contract effective and end dates. For example, your state license or certificate of authority needs to be in effect to cover the entire 2016 plan year. If yours expires mid-year, you can expect a deficiency unless you upload documentation showing the certificate covers the entire plan year, or other documentation such as proof of payment for the renewal.
· If you have a subcontract of an FDR that you must upload to CMS based on the fact they are performing a key Part D function, ensure that the effective date is appropriate. For example, one key Part D function is enrollment processing. Enrollment functions must be in place and operational during the AEP. Therefore, ensure that the effective date of a contract is in line with the time frame for which they will begin working with Part D beneficiaries on your behalf. (Remember: if delegating this or other key Part D functions to a parent organization, that executed subcontract must be uploaded. As mentioned in last week's call, the Part C agreements are not required this year for upload. )
In a couple days, I'll post some interesting things that our team has encountered along the way that may help shed light on the application documentation. For example: is there an upload missing from the Part D readme file? There sure is. Is there something in the PDF application that doesn't quite match HPMS? A couple things, actually. If you have questions, by all means follow CMS' instructions for questions! However, if you find anything that doesn't quite make sense that you'd like to share, we'd love to hear from you.
Resources
The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization. The actual submission leaves no room for error, and the review process requires quick thinking and prompt responses to CMS follow up questions. Visit our website to learn how GHG can help >>
Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>
How to Maintain the Accuracy & Consistency of Data through an Entire Life Cycle
It doesn't matter whether you call it the Annual Election Period (AEP), Open Enrollment Period or Fall Open Enrollment; it's that busy time of the year when beneficiaries are on the move. Now that the dust has settled, it's time to take a thorough look at your member data. Your members are your revenue. Accurate member data and continuous maintenance will yield the maximum, most accurate level of revenue to your organization.
While Plans strive to have correct data in their systems right from the start, it doesn't always work out that way. The result is inconsistencies in data and the need for an "AEP Reconciliation". That's the process of identifying a discrepancy, correcting it and not only making it right, but keeping it right. Reconciliation is about maintaining and assuring the accuracy and consistency of data from the start and over its entire life cycle.
Member data is the heart of an organization and the driver for many processes. It's critically important that this data is correct in all of your organization's systems. All systems need to be in sync, CMS to Plan, Plan system to Plan system, Plan system to PBM — it's a continuous circle of checks and balances.
Accurate data not only helps create that important first contact experience with your member but keeps you connected to your member. Correct member data reinforces your organizations credibility and promotes a feeling of value to your member.
Data Reconciliation Tips
- Member Demographic Information — Maintain and update any changes to names, DOB, addresses (permanent, billing, personal representatives, POA's), telephone numbers, email addresses.
- Enrollment Spans— Verify that the Plan/PBP/LIS is correct in all spans within the enrollment — not just the current span.
- Payment Method — Validate that the correct payment method is set up (SSA, Direct, RRB, EFT, etc.)
- Special Status — Update special status or status flags in the appropriate systems to ensure proper claims payment and plan payment. (i.e. ESRD, Hospice, MSP, Medicaid, Institutional etc.)
- Optional Supplemental Benefits — If your enrollee elects supplemental benefits, verify the Part C premium change was submitted to CMS.
- CMS Reports — Work monthly CMS reports promptly and completely. (List of CMS reports is available in PCUG v8.3, Table K-1 All Transmissions Overview)
- Plan Discrepancy Reports — Compare data within your own plan systems and with your PBM. Create discrepancy reports and work them daily or weekly.
Don't forget about Medicare Secondary Payer (MSP) Reconciliation!
Now is the best time to tackle all that MSP information you've received. Many plans get overwhelmed with MSP data, especially at this time of the year, and find it difficult to perform the time consuming outreach and research that's necessary to obtain validation results.
This simple process carries a powerful financial punch — efforts here can yield big results! GHG can assist with MSP Reconciliation. We have experienced analysts that can research, perform outreach and reconcile your MSP data.
Start the year off right - with clean, accurate data.
GHG's Consultants and Reconciliation Analysts have the expertise, knowledge and experience for all your reconciliation projects.
Resources
To hear more information on reconciliation, including detailed evaluations of the MMR & MOR reports, come hear GHG's expert, Jennifer Young explain the Fundamental of Membership Accounting & Reconciliation, January 26-27th at the Medicare Advantage Membership Accounting & Reconciliation Conference, Sanibel Harbour Marriott Resort & Spa, Ft. Myers, FL.
Let GHG check the box in each and every operational area of your organization. Our team of veteran experts can assist in AEP preparation, transmitting of timely and accurate membership information, recommending staff levels and utilization, and maintaining and improving all enrollment processes. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>
Operational Assessment — time for a “Check-Up"
It's time for an operational assessment.
Here's why….
An operational assessment is an opportunity to review your day to day operations to ensure processes are accurate, running efficiently and most importantly, compliant. Over time employees tend to reinvent the wheel - they stray from the documented processes and before you know it, the way it's being done is now the accepted "norm". If management isn't close to the work being performed or not working with a "sleeves rolled up" attitude, then you may be unaware of exactly what's going on in your operational areas. You may believe the staff is doing "this" but they're actually doing "that".
Here's another reason .…
You don't know what you don't know.
GHG's Operational Assessment starts with a period of discovery through observation and interviews. We get people talking. Individuals will have a chance to demonstrate and explain their role and tasks within the operational area. It's through this review and discovery phase we uncover the good, the bad, and the ugly. Typically, an operational assessment will consist of reviewing processes, policies & procedures, production reports and performance metrics, training materials, and systems.
The only thing you have to fear….
Organizations shouldn't fear finding gaps or process failures — they should fear not finding them. Assessments are meant to identify problems, make best practices corrections, and implement changes for excellence; there are no blame games.
Don't delay….
There's no time like the present for an operational assessment. The benefits of improved operational performance can be compelling, including better performance, efficiencies, and increased revenue.
Achieving excellence is a process. Begin the journey with a Gorman Health Group Operational Assessment and we will guide you on the road to excellence.
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Let GHG check the box in each and every operational area of your organization. Our team of veteran experts can assist in AEP preparation, transmitting of timely and accurate membership information, recommending staff levels and utilization, and maintaining and improving all enrollment processes. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>
2016 CMS Application Season Begins
Yesterday CMS released the 2016 Part D application, and this afternoon the 2016 Medicare Advantage (MA) application was released. Despite the applications' release dates, potential and current Plan Sponsors should be well under way in the preparation of the upload that is due on February 18th. Aspects of the application that require significant lead time to accomplish include the establishment of an adequate network and the acquisition of the required state licensure.
If you haven't done so already, register for the industry user calls; these are scheduled to be recorded and available on the MSCG website a few days after each call. Today's industry training was delivered by CMS' Arianne Spaccarelli, Paul Foster, Nisha Sherry, Melissa Cooley and Greg Buglio. They provided an incredible amount of detail regarding the Part C application process, Special Needs Plans (SNP) proposals, and automated application training. It is worth listening to the recording, but here are some highlights:
Past performance will be considered — 14 month look-back. This was provided as a reminder in the past but this is in the regulation. See 422.502(b)(1-2) for the detail; boiled down, if during the past 14 months the MA organization fails to comply with the requirements of the Part C program under any current or prior contract, or in absence of 14 months of performance history, CMS may deny the application. You might be wondering if this is also outlined in the Part D regulations. It certainly is; in 423.503(b)(1-2) CMS also outlines the same for Part D organizations.
A major change that appeared in the draft 2016 MA application and made it to the final version was the deletion of the upload requirements for provider contract templates, executed administrative contracts/LOAs, and their respective crosswalks to regulations. This change reduces the burden to applicants in the short term. CMS stressed that attestations are still required to comply with these requirements and CMS may request that documentation at any time. (From our perspective, it is highly recommended that applicants consider incorporating the CMS-developed model contract amendment for MA administrative and management contracts, and for first tier or downstream entity provider contracts. You can find that on the MA applications site. Plans who do not use the model amendment may find themselves missing the spirit of the requirement if they do not include the exact required language. Worst case scenario? CMS comes a-calling, and picks apart your contracts. Why risk it? )
As in past years, there is an order to completing the steps of the application, and those steps have been outlined in the training. A number of inexcusable reasons for requesting an extension were described in delightful detail. They include trying to upload your provider and facility tables at the last minute, forgetting to hit the Final Submit button, or simply being unaware of your service area needs for your application. Listen to the call — they just aren't having it!
Keep track of the GHG blog where I will provide some additional lessons learned from past applications, quirky issues that applicants often face, as well as important things to remember. Don't go it alone if you can help it; many hands make light work with this type of project.
Resources
The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization.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. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
ACOs — There must be a pony in here someplace
We've all heard that story. Now, CMS is in that proverbial barn and with the proposed rules, have doubled down on the time they're taking to look for ACO success at managing risk. Does it make sense given that only two current ACOs have gone to the two-sided risk model? My guess is that is not what they are really looking for in just another three years.
CMS is really looking at how many beneficiaries are in the fee-for-service Medicare world and they're taking the long view. So, that's the 70% who can't be absorbed overnight into Medicare Advantage. It wasn't hard to think that CMS would change how payment formulas could be adjusted to affect success especially when they were given a quick stake of 5 million fee-for-service beneficiaries who are served by 330 ACOs with another 89 added on January 1. First, CMS always does that. Second, getting to those numbers in just three years took years in the various editions of Medicare managed care. So, there just might be something here.
Another point, for now ACOs have a political advantage. Just follow the ying and the yang between fee-for-service and managed care when the White House changes. Republicans have fed managed care but Democrats have looked for ways to avoid insurance companies and entice provider entities. Nothing could be clearer; the ACA was passed in 2010 by the Dems, funding for the ACA came from Medicare Advantage and "ACO" is nomenclature born in the ACA. Also, the additional three-year term extends ACOs into the next administration and, just maybe, provider-operated organizations will evolve into viable risk bearing entities.
Further, the advances in data management and technology along with their combined effects are telling CMS that a sweet spot is developing for a population-based approach to managing chronic conditions, the current Holy Grail. Mega investments in IT by HHS and micro changes in capability to manage and share individual health information will help. But other changes also include diverse things like developing methods to avoid penalties for readmissions. Care management programs are actually touching patients who are no longer in the hospital by the hospital. All of these are encouraging a long view and the belief that there is a nearby tipping point. So, why not keep ACOs going?
Finally, CMS has committed to care coordination and value-based services with a myriad of programs and demonstrations that encircle the underpinnings of ACOs. The latest and largest is the $670 million Practice Transformation demonstration aimed at engaging 150,000 physicians and 5 million beneficiaries. The CMS long view understands that none of these work overnight and that waiting for 70% of the Medicare population in fee-for-service to be absorbed into Medicare Advantage is beyond myopic. So, make comments on these proposed rules, expect more tweaks, and expect evolution. CMS will continue building the infrastructure to deal with this entrenched population. Clearly, ACOs are in the mix for some time to come.
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From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Visit our website to learn more >>
Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. Contact us today to get started >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
New Year's Resolutions for Your Organization!
Every January 1st we have the opportunity to reflect on our prior year. We make lists of all the things we want to do or maybe do better in the upcoming New Year. The typical resolutions are lose weight, quit smoking, save money, exercise more, eat healthier, create a budget or plan a trip. The practice of evaluating our personal life is a good way to celebrate our accomplishments while thinking about ways we can improve in the New Year.
Our professional, workplace life should be no different. Now is the time to evaluate current practices. Take time to list all your departments' processes and functions. Evaluate each one. Is the process working well? Is it efficient? Is there room for improvement? Should it be replaced?
The future of organizations will rely on operational cost management. Each department within an organization should be continually looking for process efficiencies to reduce costs, and ways to boost productivity.
If you think this sounds overwhelming, use GHG's simple tool to start the operational evaluation process. It can be as simple as Keep, Fix or Replace.
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GHG has experienced consultants that can assess and review the operational areas of your organization. We can review current processes and look for efficiencies to improve outcomes and better compliance. Make a resolution to improve your organization's operational areas — GHG can help make it happen in 2015. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
ICD-10 Transition — Ready or Not?
It's a New Year and there are 262 days left until the October 1, ICD-10 implementation deadline. The road to ten has been very challenging with respect to "Go or No-go" implementation timelines. Due to several delays, many organizations literally stopped transition efforts and redirected funding budgets to other priority projects.
The big day is coming! Currently, it is a known fact that CMS is operating under the October 1, 2015 scheduled deadline. It is now crunch time and with the compliance deadline set organizations have minimal time to complete the transition. Thoughtful planning, and executing conversion plans, will overall make the difference between a successful transition and missing the deadline.
What happens if your organization is not fully ready?
What is your plan for remediation?
The transition does not have to be painful. Timing is everything. Health plans and organizations, such as providers, clearinghouses and vendors can still benefit by using the time left to focus and implement additional readiness and deployment strategies for the code switchover.
The International Classification of Diseases, Tenth Revision (ICD-10), consists of two new areas, clinical modification (ICD-10 CM) for diseases and procedural coding system (ICD-10 PCS) and will replace ICD-9. The switch in code sets will provide expanded detail for inpatient, ambulatory and managed care organizations to better define medical conditions. The conversion is a significant change to the standard healthcare coding systems.
So what exactly are the differences between ICD-10 and ICD-9?
- ICD-9 codes have three to five numeric digits, while ICD-10 has three to seven alphanumeric digits - the switch in 2012 to HIPAA 5010 transaction standards for electronic claims paved the way for practices and payers to be able to accommodate ICD-10 changes
- CMS will transition all diagnosis codes from 13,000 old codes to approximately 68,000 codes included in the ICD-10 version
- ICD-10 has more specificity with a lot more codes, which provide more detail and granularity than the old codes
- Diagnosis Procedure Codes Systems (PCS) will increase from 3,000 ICD-9 to 87,000 ICD-10 PCS
Based on these changes, transition to ICD-10 requires extensive detailed planning, and comprehensive readiness efforts organizational-wide. It's virtually more than just a coding function. Diagnosis codes affect almost every core functional and operational process, system and reporting. Failure to prepare for the conversion will have dramatic impacts on financials and ultimately the member experience.
By leveraging in-depth regulatory interpretation and guidance with complete operational knowledge base Gorman Health Group provides ICD-10 best practices through financial analysis and impact assessment, which includes people, process and technology. Gorman Health Group will identify gaps between current operational "as is" process flows and recommend future optimal "to be" process flows required for the implementation. The analysis will highlight the impact on margins by line of business and measured through people, process and technology. Additionally, risks and potential return on investments (ROI) for the identified gaps can be provided.
Gorman Health Group ensures end-to-end operational process re-design including but not limited to the following functions:
- Claims
- Benefits & Product
- Configuration
- Codification and mapping
- Contracting
- Division of Financial Responsibility (DOFR)
- Prior Authorization
- Provider Pricing
- Quality Control
- Revenue Cycle
- Reporting and Analytics
- Metrics
- Vendor Alignment
- Vendor Management and Oversight
- All Other Hand-offs "Operational" Areas
If you are behind the eight ball and not exactly on track let us proactively work with you on an expedited readiness plan, contingency plan development, post-production support, post-transition analysis, knowledge transfer, monitoring and reporting. Gorman Health Group includes some of our industry's most experienced and proficient ICD-10 and operational subject matter experts.
Make your New Year's resolution to stay on track with transitioning to ICD-10. Time is running out and October will be here before you know it.
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At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
Annual Compliance Program Audit: Your Organization's Achilles Heel?
When it comes to auditing throughout the Organization, the truth is that much of the responsibility often falls directly on the Compliance Department. This can be due to many factors, such as lack of resources or lack of cross-functional expertise. However, one of the CMS Compliance Program requirements is that the Compliance Program itself is audited annually. Fulfilling the requirement to annually audit the Compliance Program can present an issue for some Organizations due to the fact that Compliance Department self-auditing does not fulfill the requirement, and there may be no other department within the Organization with the expertise to conduct the review.
Here are a few ideas that we've seen Organizations use in order to fulfill the CMS requirement:
- Hire an external auditing firm.
- Cross-train another department within the Organization to conduct the annual audit.
- Compliance departments of two different Organizations audit each other. Of course, this option may be a bit tricky depending on the competitive landscape. However, it can be a good option if there is no budget to hire an external firm and if no conflict exists (e.g. competing service areas).
An effective Compliance Program is critical to your compliance and operational success. In addition, a strong Compliance Program can safeguard against many compliance issues recently cited by CMS as the cause for civil monetary penalties (CMPs) and enrollment sanctions. Please contact us for more information about the GHG Compliance Program Effectiveness Audit.
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GHG offers guidance and support in every strategic and operational area to ensure alignment with CMS. Learn how we can help you create early warning systems to ensure that operational inefficiencies and threats to member satisfaction are immediately identified. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>