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Star Ratings: The Moving Target

Recently announced changes to the Star ratings program continue to present Star Ratings as a moving target for Medicare Advantage organizations. While the Centers for Medicare & Medicaid Services' (CMS') recent memo and request for comments on the 2016 Star Ratings program changes illustrates CMS' continued commitment to rapidly driving better care for patients, better health for communities, and lower costs, the proposed changes will simultaneously usher in a new era of accountability and integration within Medicare Advantage health plans.

CMS announced plans to reintroduce three previously-removed measures (breast cancer screening, beneficiary access, call center/TTY), add the long-awaited CMR completion rate measure, retire three HEDIS measures (two LDL screening measures and the LDL control measure), and make a lengthy list of changes to existing measure specifications in the 2016 ratings. CMS also laid the groundwork for the 2017 addition of measures related to asthma, depression and opiod-overutilization.

Since the new 2017 Star measures will likely be officially announced as 2016 Display Measures later this year, and will be computed based upon services provided throughout 2015, the 1st quarter of the year is an optimal time for plans to adjust population health tactics for 2017 Star Ratings success. With the nature and extent of the 2016 and 2017 changes, Medicare Advantage organizations will want to be very strategic as workstreams are developed or adjusted to accommodate CMS' proposed changes.

Given the complex clinical and social issues associated with asthma, depression and overuse of opiods, integrated activities and coordinated services among providers, clinical teams, case managers, and retail pharmacies will help plans achieve Stars success. Executive leaders will want to understand the nature of CMS' new focus areas, and operational and budgetary decision-makers will want to be poised to rapidly understand the changes, as well as deploy new or adjusted tactical workstreams in early 2015 to best ensure Stars success.

Resources

Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.

GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. Visit our website to learn more >>

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 >>

by GHG Advisors

Data Smog - CMS's Clear Vision for the Future of Data & Analytics

We all feel a little bit like hoarders with the vast amount of data we collect and store. We can also agree that it's a challenge to utilize that data for its best purpose and integrate it appropriately across an organization.

Recently in an article, Niall Brennan, the Centers for Medicare & Medicaid Services' (CMS) first Chief Data Officer, said their view about the role of data and analytics is changing. CMS has adopted a core mission to improve data collection and dissemination due to the substantial growth of both the number of data users as well as the vast amount of data it collects.

It's not just about collecting and storing data anymore, it's about aggressive analytics. CMS recognizes the importance of data analytics and the proper use of all that information but continues to struggle with numerous data sources and various systems that don't share data. Mr. Brennan is tasked to optimize and maximize data created by CMS's systems for all users.

This recent announcement is a good reminder for health plans to also take a look at how they collect, analyze, and utilize data. Health plans need to ensure their data is accurate, analyzed diligently and utilized appropriately for it to be relevant. The success of your organization relies on clean accurate records and meaningful data. Accurate data = optimal revenue.

CMS's new vision has elevated the importance of the data and analytics role within an organization. What was once considered a behind the scenes supporting role has now taken center stage. Get ready for your curtain call, the world of data and analytics is changing.

Resources

GHG has experienced Consultants that can help with your Data Analytics. We can review your data architecture and assess processes to look for efficiencies and opportunities. Let us help you optimize your analytics and get all that data under control. Visit our website to learn more >>

John Gorman, GHG's Executive Chairman together with colleagues, Glenn Ellerbe, and Mae Regalado, Senior Consultant, gave an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy, plus shared procedural practices and audit metrics ensuring workflows are best in-class." Access the recording here >>

by GHG Advisors

Rewards and Incentives: Are We There Yet?

Yes, Medicare Advantage is finally catching up to the rest of the health care industry, and we are now permitted to offer enrollees Rewards and Incentives.

On December 4, 2014, CMS released an HPMS memo titled "Rewards and Incentives Program Guidance" which provides additional guidance related to how Organizations must implement Rewards and Incentives Programs, which, as of July 22, 2014, CMS allows for Part C benefits.

Although the implementation of Rewards and Incentives is no easy task, I think the more pertinent question is how could this new guidance impact your Organization and our industry as a whole? Well, some of that, I think, will remain to be seen as these programs are implemented. However, I do think there are a few challenges and strategies that we should consider as we're implementing these programs - here are a few things to mull over as you're ringing in the New Year:

â€¢ What is the competitive landscape for Rewards and Incentives, and how will your Organization ensure that it is competitive while still remaining compliant?

â€¢ How will your Organization ensure that your Rewards and Incentives program will have an impact on enrollee behavior?

â€¢ How will your Organization track information regarding Rewards and Incentives?

â€¢ Last but not least, how will your Organization oversee the implementation of your Rewards and Incentives program to ensure compliance?

So, what is the trend? The fact that Medicare Advantage Organizations are now allowed to provide Rewards and Incentives (for Part C benefits) further indicates that CMS' main focus and main objective is the health of the Medicare population — as it should be, of course. However, we in the industry should take note - along with CMS' continued scrutiny via their program audits (and other mechanisms) of those areas that have the potential to cause beneficiary harm, they are also loosening the reigns in certain key areas such as Rewards and Incentives. The objective here is to ensure that Medicare beneficiaries have access to high-quality health care including any incentives that could in fact have a meaningful change in the way that beneficiaries approach their health care.

For more information or support, contact us today and a team member will be in touch with you shortly.

Resources

Become a member of the Point to receive access to the analysis of all HPMS memos by GHG experts. Already a member? Access the HPMS memo mentioned in this article here >>

Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.

by GHG Advisors

A Christmas Wish List for Claims

Here's what I am wishing for all our health plan clientsâ€¦.an uneventful start to the 2015 Plan Year. By that I mean that all the prescription claims that should adjudicate without rejecting actually do, and the claims that should not pay, reject as expected. Either the beneficiary leaves the pharmacy with their medication or the pharmacist is alerted that there is a potential problem with the dose of the medication. Here are some of the issues that we have found from our reviews:

Test claim for Unbreakable packaging logic for non-formulary drug prescription for a transition eligible member DRUG: NDC=51285008787 SEASONIQUE 0.15-0.03-0.01 TAB #91 tabs (3 months) Claim Rejects with this POS MESSAGE: "7X = DAYS SUPPLY EXCEEDS PLAN LIMITATION; MAX DS = 30 FOR TRANSITION FILL" This claim should have paid because the medication only comes in one size and is unbreakable.

Test claim for Quantity Limit logic DRUG: NDC=59310057922 Product Description: PROAIR HFA 90 MCG 8.5 gm for 10 days supply HPMS submitted/approved Quantity Limit is 25.5/30 DS Claim Rejects with this POS MESSAGE: "88 = DUR REJECT ERROR " Additional Reject Message: "MX DOSE/DAY= 0.54 OVR/DR APV" The claim is rejecting for max dose incorrectly based on HPMS QL of 25.5/30 or 0.85/day.

Test claim for maximum daily dosage of Acetaminophen < 4 Grams DRUG: NDC 46672020050 HYDROCODON-ACETAMIN 7.5-325/15 Solution Claim paid for #2365 ml/10 days supply which equates to 5125 mg or 5.1 Gm of Acetaminophen/day The claim should have rejected for exceeding the maximum daily dosage of Acetaminophen.

We continually emphasize the importance of benefit administration testing and retesting as the best Part D formulary quality control effort to ensure there are no questionable claims.

Our Pharmacy experts can create and conduct an in-depth benefit administration test plan for your organization to validate that everything is working precisely as it should on an ongoing basis throughout the year. We can ensure your PBM is processing claims consistent with your CMS-Approved Prescription Drug Benefit.

I hope that your holidays are merry and bright, and that all your claims are right!

Resources

Our Part D services are designed with your staff in mind, ensuring that with a mix of counsel and DIY tools your staff will have access to actionable information — faster. Don't chase data points. Spend your time on the things that will impact your audit results when a CMS audit comes — and it always does. Visit our website to learn more >>

by GHG Advisors

Federal study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act

Federal investigators said in a new report that large numbers of doctors who are listed as serving Medicaid patients are in reality, not available to treat them.

Patients select their physicians from a list of providers associated with each Medicaid health plan. The investigators, led by the inspector general, Daniel R. Levinson, called the doctors' offices and found that in many cases the doctors were unavailable or unable to make appointments.

More than one-third of providers could not be found at the location listed by a Medicaid managed-care plan.

This can create a significant obstacle for an enrollee seeking care, impacting access to important benefits and treatment. Imagine being in the middle of a need for important medical care, picking up the provider directory and over half of the doctor's numbers you call are not valid.

If access to care cannot be relied upon, the foundations of the managed care programs are at risk. With the recent growth in Medicaid managed care, this becomes a more significant concern for the government as well as the industry. With the concern comes the potential for more stringent oversight.

New rules and standards to ensure timely access to care for Medicaid patients are under development. The push from the National Association of Medicaid Directors is to avoid overly prescriptive standards given the variances of State Healthcare markets.

CMS and OIG are in concurrence about tightening the standards, oversight and adequacy requirements.

We can help you wind your way through the new rules and the process for improved access to care. Contact us today.

Resources

Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>

by GHG Advisors

Hepatitis C virus (HCV) and treatment with SovaldiÂ® (sofosbuvir)

The medication Sovaldi® has revolutionized the way HCV is treated and at the same time has shocked health insurance payers and particularly Medicaid prescription drug budgets. With an estimated cost of $1000 or more per pill for a twelve (12) week course of treatment, the cost to treat one person can exceed $84,000.

According to the Centers for Disease Control & Prevention (CDC) there were an estimated 16,000 acute HCV infections reported in the US in 2009, the latest year statistics are available (http://www.cdc.gov/hepatitis). An estimated 75-85% of the people infected with acute HCV develop the chronic condition. The CDC estimates that there are 3.2 million persons in the US with chronic infection. Most people do not have symptoms and are unaware they are infected with HCV. HCV also affects those in lower socioeconomic classes and therefore the potential impact to Medicaid programs is even greater.

Sovaldi has a cure rate as high as 95%, with mild side effects during a twelve week course of oral therapy. Compare this with the previous drug of choice to treat HCV, interferon. Interferon is injected for up to a year and can have severe, flu like side effects. The cure rate for the most common strain, genotype 1, is 48-56%, depending on the length of therapy (M. Parikh, April 2011). The cost for the interferon treatment is $15,000 - $20,000. It is easy to see that clinically Sovaldi has the upper hand, but what cost can Medicaid programs, and ultimately taxpayers assume?

Some state's Medicaid programs, such as Oregon, are looking at ways to manage the use of Sovaldi by approving it only for their Medicaid clients who are showing signs of liver cirrhosis and have clean drug tests, for example (COOPER, 2014). In addition, what happens if a patient fails to complete their 12 week course of treatment? Should they be allowed to resume another full course of treatment?

This medication is a perfect candidate for coordinated medical and pharmacy management. Adherence is crucial to ensure completion of the twelve week course of therapy. If Medicaid programs are going to invest in paying for these types of expensive therapies it is vitally important that the medications are taken appropriately for the required length of time.

To learn more about how plans are investing in programs to help patients achieve better outcomes with the new Hepatitis C treatments, contact us >>

Resources

Gorman Health Group can work with your organization on blending medical and pharmacy to improve care coordination, outreach and utilization management to meet the complex needs of your membership. Visit our website to learn more >>

by GHG Advisors

Medicare Secondary Payer — A Simple Process with a Big Impact

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

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

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

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

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

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

Resources

by GHG Advisors

Medicare and Exchange Risk Adjustment: Data Quality Matters

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

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

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

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

Resources

GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit out website to learn more >>

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

by GHG Advisors

Best Practices in Medicaid Claims Administration and Oversight

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

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

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

Best practices of efficient Medicaid claims operations are as follows:

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

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

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

Resources

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

by GHG Advisors

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

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

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

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

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

Resources

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

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

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

by GHG Advisors