It's a Marathon - Not a Sprint
Plans will shortly be receiving the Readiness Checklist from CMS. At first glance it looks like just a bunch of boxes to check off and answering yes and no questions. Here's the rub:
Starting to figure out whether or not you have 30 boxes of non-readiness to report to your Account Manager is not a good way to roll into 2015. The previous year's readiness checklist should inform your priorities for the year's operations. Your relevant questions are: Who and what department owns this? Do we have policies and procedures, business processes and reports for this? Have we had any CMS outlier notifications about this? Did we audit this? Anything that you answer as "not ready" is automatically a priority.
You can't start being ready when the checklist arrives. Plans should be preparing to "be ready" all year long. For instance, here's what has to be done for Coordination of Benefits readiness:
CMS expects health plans to establish/maintain systems and procedures for at least weekly COB data report/file processing by not only receiving COB information from various sources, but also applying the COB information to claim payment system(s). Health plans may not understand how to interpret the CMS COB file and use internal sources, such as enrollment forms, claims, provider services, and member services to identify other health information for COB. Health plans need to be able to clearly categorize the various types of records and perform distinct validation, outreach and processing for group coverage, non-group coverage, third party liability, federal/state programs, as well as charities.
The important step of validating the other health information from CMS and other internal sources is often overlooked and a critical step to maintaining COB information in CMS systems. Without this step, information is outdated causing incorrect claim processing, member abrasion and escalated issues. CMS expects that organizations utilize the Electronic Correspondence Referral System (ECRS) to send COB updates to CMS timely and accurately, but health plans often fail to work the ECRS response file rejections and update internal claim system COB flags or other coverage information. Readiness planning should include the final, most often overlooked, yet most vital step: Reconciliation. An effective reconciliation process will work all COB related reports including TrOOP Balance Transfer exception reports, COB error reports, reconcile enrollment, claim and pharmacy systems, as well as monitor claim payment accuracy and recovery of other liabilities.
Resources
The biggest risk health plans face in government programs is managing membership and financial data. With Gorman Health Group's Valencia, you'll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments.. Learn more about how Valencia can help you >>
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 >>
Important strategies for a plan's medical management team
It wasn't too long ago that the clinical staff and practitioners in the medical management arena of health plans only focused on the quality and continuity of care with their members. These objectives were very important, and should continue to be the focus of any medical management team. However, in more recent times, it has become just as important for the clinical areas of health plans to become aware of the costs of care they incur and to become involved in the control of those costs.
The Patient Protection and Affordable Care Act of 2010 mandates that health insurers report plan costs for the purpose of calculating their medical loss ratio (MLR), which is defined as the percentage of insurance premium dollars spent on reimbursement for clinical services and activities to improve health care quality. Large group insurers must spend at least 85 percent of premium dollars on claims and activities to improve health care quality, while individual and small group insurers must spend at least 80 percent of premium dollars to improve health care quality. If insurers fail to meet these minimum MLRs in a given year, they are required to provide a rebate to their members.
Thus, as a barometer of a health plan's solvency, management of the MLR is an important strategy for the plan's medical management arena. For example, the effective use of health information technology, or medical economics, can be one of the best assets for a health plan in controlling costs and service levels, especially when there may be an increase in plan membership. In addition, investing in quality improvements, such as electronic health records for the plan's provider network, or a web portal for the exchange of health care information can indirectly help to improve the health plan's MLR by reducing administrative costs. Reviewing the utilization data of the health plan's services to determine areas of over or under utilization, and monitoring the process for the authorization of member services are two additional important means for medical management to identify unnecessary costs that may be occurring.
Although there are multiple ways to look for an optimal MLR for health plans through medical management functions, the ultimate goal should be to monitor and take action to improve key indicators affecting MLR, such as the management of complex / high cost members, network contracts with providers and ancillary groups, inpatient performance, and pharmacy utilization, all of which can help to improve a health plan's overall financial performance.
Resources
On Friday, September 26 Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register today >>
On Tuesday, August 19, GHG's Senior Vice President, Bill MacBain and Senior Vice President of Healthcare Innovations, John Nimsky, explored the drivers and trends in cost and revenue which affect your MLR. Access the webinar recording here >>
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 >>
Data the Silent Killer
As a seasoned veteran in healthcare operations I've seen firsthand the progression of data utilization by health plans. Despite decades of growth we're not there yet.
In the 1950s and 60s data processing began to take hold. Unfiltered data was the norm. Not much was done with it. Data validation was in its infancy. Business decisions were mostly driven by non-analytical factors.
In the 1970s and 80s information management began grouping similar data and identifying patterns. Basic analytics such as the categorization of data facilitated the ability to draw certain assumptions. On occasion those assumptions were valid but, more often than not, not broadly applicable. We realized what making "assumptions" yielded.
Data usage and sophistication improved considerably in the 1990s and early 2000s. The ability to dig much deeper into the groupings of data to find those unique characteristics to either prove or invalidate business assumptions became the mainstay. Better analytical processes improved knowledge and predictability in business decisions. Data management was equated to business intelligence, highlighting the awareness that data functions effectively drive business operations. Improved ability to manage and report data ushered the evolution of Big Data. Analytics and reporting is assumed (there's that word again) to be truthful...the data doesn't lie!
Today, health plan data is heavily relied upon. Data must be valid, accurate, and reproducible; it is the sole factor for health plan payments, performance ratings, patient care plans, and just about every other aspect of health plan operations. Data has become the lifeblood of a managed care organization. But…what if your data is distorted and data leakage is occurring?
What if claims and encounters are improperly adjudicated and reported?
What if membership and provider data is inaccurate?
What if the data used in Disease Management programs relies incorrect metrics to optimize interventions?
What if the data required for risk adjustment submission and payment is inaccurate? How much will it cost your plan?
Poor data management, inaccurate and inadequate analytics can slowly drain a health plan of its revenue and ability to make strategic business decisions. Consider this much like high blood pressure is the silent killer in human beings; data leakage is the silent killer of health plans.
Gorman Health Group has decades of experience assisting health plans with their data management. Please contact us for an End-to-End Data Management Assessment. We will assess the current state of your Data Management against industry best practices and your desired future state, and we'll assist you in getting there. Let us help you identify and control your health plan Silent Killer.
Resources
Join us on September 19 for 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. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Groundhog Day: CMS Issues Best Practice Memo Related to Common Audit Findings
Is it Groundhog Day or does this memo say the same thing as last year? Nope you're not imagining things - In CMS' Memo titled "Common Conditions, Improvement Strategies, and Best Practices based on 2013 Program Audit Reviews" that was released on August 27th, CMS outlines again the industry pitfalls and best practices around common areas of noncompliance identified as a result of CMS Program Audits. You may be saying to yourself "some of this looks familiar" well — you're right.
In fact, it appears that CMS is getting weary of repeating themselves year over year and they've included some language with teeth in this most recent memo. CMS makes two key statements in the 2014 memo — the first is that due to the number of repeat findings year over year, it has been determined that Organizations are not using this memo as CMS intended. The second, and more pointed statement is that Conditions noted in one or more memo will be considered "aggravating circumstance" during an audit and this may adversely affect the overall audit score.
So — what does this mean to your Organization? It means that if you haven't yet done so, now is the time to review each best practice memo provided by CMS and ensure that the recommended process is in place. If not, it's time to create and implement a corrective action plan for each best practice mentioned by CMS that would apply to your Organization. Remember, CMS understands that Organizations aren't perfect, but demonstrating that you're able to identify issues and put a plan in place to remediate those issues is always required.
Resources
GHG's team of experts can help you minimize your compliance risk and maximize your time and resources. Contact us today to learn how we can help ensure you are audit ready all the time >>
On September 10, join us for an exploration of why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Passing Marketplace Reasonableness — One More Chance
September 4th was final submission day for Marketplace plans but some worried health plans were asking "what ifs" about their last submission for network access. These plans have re-submitted network updates after two CMS rejections that required correction for failing reasonable access. They have three consecutive wrong guesses on whatever standards CMS believes they have not met. They want to know what happens if CMS doesn't approve their network access plan. Of course, they are still asking what standards need to be met.
Rest assured, CMS says they will have another bite to justify reasonable access. However, time periods shrink. The window opens on September 23 when CMS notifies health plans about needed corrections and responses are due on September 25.
CMS is well aware that failure to get a pass has unwanted consequences for everyone. Service areas will need to be reduced with compounding changes to plan packages that necessitate more CMS re-review and approval. So, everyone wants a good justification but CMS is not backing off given the potential for political backlash. Failure is an option. Health plans worried about their last re-submission can't count on CMS reviewer fatigue. Health plans asking these "what if " questions need to prepare a contingency narrative by either finding and fixing any weaknesses or documenting metrics that demonstrate access. Waiting to correct over a two-day window, is not sufficient time to prepare the last chance narrative justification for reasonable access.
Resources
Gorman Health Group's network evaluation service deploys an automated software solution that uses metrics based on population, provider ratios and time/distance standard. Learn more >>
Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Em El AR Passive Statistic or Call to Action?
For many, the medical loss ratio (MLR) is the ratio of the health plan's incurred medical claims to the total premiums earned. However under the Affordable Care Act and for government health programs, the MLR is the ratio of medical claims plus quality improvement costs divided by earned premiums minus federal and state taxes and fees and payments in lieu of taxes.
This is not the time or place to get into a discussion about the rules for what is included in the calculation of the Medicare Advantage MLR, but rather focus on what are some of the drivers of the medical spend which makes up the greatest proportion of the MLR and what health plans should be focused on to control that medical spend without sacrificing the quality of services provided or the expected outcomes.
Most payers and provider sponsored health plans collect data based on provider submitted claims, and in most cases translate the data into an annual statistic referred to as the MLR. That is where the common ground begins to turn into quicksand. Why? Because not every health plan has either the capability or knows what to do next with the data that is being collected. Some plans will ask the questions related to what are the drivers behind the MLR, such as: what are the medical utilization outliers; are the providers coding inaccurately; are the referrals and referral patterns from PCP to Specialist or from Specialist to inpatient settings appropriate? What about the use of the ER, or the use of pharmaceuticals? Is the claims configuration process and adjudication process supportive of the provider contracts that have been negotiated? And so it goes.
The point is that even the more sophisticated Plans at times, are at a loss to identify all the drivers that impact the MLR, and therefore Plans are not able to address completely all the existing outliers that drive the MLR. Without that information, a Plan's success in developing short, intermediate and long term strategies and initiatives focused on population management, medical management and financial planning is not fully realized.
A comprehensive understanding of the various elements that drive medical expenses and hence the MLR will enable Plans to develop forward looking assumptions regarding premiums for lines of business, projections on utilization of clinical services, and provider contracting budgets, just to name a few. Recognizing specific drivers of medical expense can assist health plans in transitioning from fee for service (FFS) driven contracted networks to "value based" networks as well as working proactively to lead a transformation of population management .
Such understanding can lead to health service initiatives around how to best impact provider practice patterns regarding member access, coordinated treatment planning, appropriate referral patterns and improved coordination of care via elimination of duplicative or unnecessary procedures.
Ultimately, the goal should be the development by the Plan of a medical expense management plan that is characterized by a forward looking and dynamic approach to proactive medical management and includes provider initiatives supported by performance based measures.
The bottom line is that for many of the health plans, the issue is not lack of data but how to ask the right questions of the data in order to create actionable efforts that lead to improved performance by the plan and provider and results in improved outcomes to the member.
And sometimes it takes an outside objective partner with a fresh approach to data analysis and understanding of industry best practice to interpret what the data implies. That is where we at the Gorman Health Group can help. Contact us today. You will be glad you did.
Resources
On September 26, Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register today >>
On Tuesday, August 19, GHG's Senior Vice President, Bill MacBain and Senior Vice President of Healthcare Innovations, John Nimsky, explored the drivers and trends in cost and revenue which affect your MLR. Access the webinar recording by becoming a member of the Point >>
In addition to our continued work launching new entrants into the MA market, we are helping many experienced plans develop smart networks: accountable care, shadow capitation, and payment bundling within their current service areas and networks. Contact us today to learn how we can help you >>
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 >>
So, what does “Unreasonable Delay" really mean in Federally Facilitated Marketplaces?
As expected, CMS has been sending correction notices to health plans about their networks. Also, as expected, some plans have received a second rejection of their response to the first rejection. Now, time is limited since final corrections are due by September 4. Health plans are asking CMS to give them some idea about how to meet CMS expectations.
Plans are asking—
- What standards does CMS use that makes for a rejection?
- What do we need to do?
- What exactly is deficient?
Given the short timeline, most of these plans are asking "how can we know when we jumped high enough?"
Currently, there are no reasonable standards that CMS or plans can look to. CMS responses to these questions remain vague and unspecific as plans complain that the rejection notices give no direction on what is really wrong. Instead, CMS wants plans to respond with another narrative that explains the pattern of care, any extenuating circumstances, or even a confession of network complaints. Health plans aren't feeling too comfortable with CMS' responses. They are still not sure they will get a "pass" with the next and final submission. Given that multiple CMS reviewers can result in varying opinions on what is sufficient, health plans are worried about the final CMS judgments.
At the same time, CMS assumed responsibility for assuring network adequacy when they initiated these reviews for 2015. So, the focus on narrow networks has placed CMS in the cross-hairs again if network complaints re-surface.
While CMS acknowledged that there might be another window after September 4th, at this point, plans should use metrics using technology support to make their case to support the narrative. Numbers and metrics plus persistence may count.
Resources
Gorman Health Group's network evaluation service deploys an automated software solution that uses metrics based on population, provider ratios and time/distance standard. Learn more >>
Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
The Clock is Ticking...
If you are a veteran of Medicare Risk Adjustment reporting, you are probably in high gear planning or implementing year end programs to optimize 2014 and 2015 revenue. But is the same old approach you used last year the right approach for this year? Or maybe you are new to Medicare Risk Adjustment or Commercial Risk Adjustment reporting and not quite sure of what programs you should be doing this time of year.
GHG has experienced Risk Adjustment analysts and consultants that can help you meet and exceed your yearend goals. Below is our checklist of processes you should be doing now to help ensure complete and accurate Risk Adjustment data reporting for yearend:
- Implement analytics that appropriately consider the new Medicare blended HCC model.
- Suspect targeting for Medicare and Commercial chart reviews — Employ a targeted approach to cast a wide net, but optimize program results.
- Suspect targeting for 2014 Medicare and Commercial member outreach — Member calls, in-home assessments, provider interventions — one approach alone won't get you there.
- Chart review execution — Know what your vendors are coding (do they include Rx HCCs?). Could computer aided coding reduce costs and improve ROI? What is the quality of the vendor reviews...would they hold up in an audit? Are they also looking to delete codes?
- Commercial Risk Adjustment — Select an independent vendor to perform your required audits.
- Audit Readiness — Execute the appropriate data quality audits now to minimize audit risk next year.
- ICD — 10 — Revisit or develop an implementation plan…ready or not here it comes!
Plans need to be proactive in their data capture to submit data before the January 31, 2015 deadline for Medicare and April 30, 2015 deadline for Commercial. Data accuracy also needs to be a priority with both programs to minimize audit risk and government take-backs.
Our team of experts can show you the way. Please contact us today.
Resources
Gorman Health Group can help ensure that your procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete. Visit our website to find out how GHG can help ensure you are ready for that RADV audit when CMS calls >>
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 >>
Join us on September 19 for 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." Register today >>
Outbound Enrollment Verification (OEV) - To call or not to call?
With the release of the 2015 Marketing Guidelines, CMS made a few key updates to the Outbound Enrollment Verification (OEV) Process. One of the most significant updates is that CMS now allows organizations to complete the OEV process via direct mail or email (if the beneficiary opted-in for email). This change actually provides significant opportunity for organizations. The way we see it, organizations will now need to choose one of two paths. The first path is to continue using outbound telephone calls to fulfill the CMS requirement. If your organization has developed and implemented an effective OEV process, by all means continue with this process. However, if you're thinking "why would we continue the current process when our OEV process has been riddled with issues of non-compliance?" Well, we agree.
If your organization has seen significant and ongoing issues with the OEV process, this is your opportunity to change that by fulfilling the requirement via another mechanism. However, if you do choose this path, it is critical that your organization develop a top notch welcome call for those new members who would have previously received the OEV call. This first touch is key in terms of identifying any possible gaps in the member's understanding of plan benefits and rules, identifying any issues of sales misconduct, as well as ensuring that your member retention program gets off on the right foot. Remember, it is always better (and less expensive) to retain a member than to obtain a member!
Please note: In CMS' memo titled "Clarification of Medicare Marketing Guidelines and Additional Agent/Broker Compensation Guidance" that was released on August 13, 2014, CMS revises current guidance language to clarify that the OEV process applies exclusively to enrollments in which employed, captive or independent agents/brokers were involved.
Resources
On July 23, GHG leadership spoke about what provisions in the final guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes. Download the recording >>
On September 10, join John Gorman, GHG's Founder and Executive Chairman for an exploration of why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Register now >>
On September 12, join us for GHG's perspective on trends relating to CMPs, the CMS audit findings and oversight activities that have taken place in the last six to 12 months, as well as tips on how to avoid and remediate CMS findings." Register today >>
It's silly season again, so let's sue the President
The Speaker of the United States House of Representatives, one of the most senior elected officials in the US government, has announced that the House is going to sue the President because he has delayed enforcement of a provision of the 2010 health care law; a provision that a majority of that same House has vociferously criticized as unfair to business and a "job killer." In 2014 Washington, this makes perfect sense.
President Obama has delayed enforcement of the mandate that requires most employers to offer health insurance to their employees, starting in 2014. The President has delayed enforcement until 2015 or 2016 (depending on the size of the employer). The Administration argues that the Internal Revenue Code allows for transitional relief in the implementation of new legislation (the mandate's fee would be collected by the IRS, and so this ostensibly falls under the authority of the Internal Revenue Code). The Speaker says not so much.
So here's the scenario. The employer mandate is set to take full effect by 2016, less than 18 months from now. The House's lawsuit will make its way through the federal court system, with appeals ultimately taking it to the Supreme Court. By then, the mandate will be in full effect, and the Supremes could decide that the case is moot and reject it. Or, even if they decide in favor of the House, there will be no immediate impact since the mandate will already be in effect.
So what's the point? My guess is that the Speaker is hoping to suck some energy from his back benchers who want to impeach the President. Impeachment would fill the newscasts with images of issue conservatives and libertarians competing to load up the articles of impeachment with every criticism of Mr. Obama that has been rendered from the Right since 2009. Having this public spectacle just as voters are going to the polls this November must be one of the Speaker's worst nightmares. So sue the guy. Anyway, it's one of the few things that the GOP majority in the House can accomplish without help from Democrats or concurrence of the Senate.
There is risk for the Speaker in this. He only has a 35 vote majority at present (with 2 vacancies). If half of them vote against the lawsuit, on the grounds it's too wimpy and only impeachment will do, he's going to suffer a major political embarrassment. That's a margin of 18 votes, and 15 members have already voiced support for impeachment.
Even with the Nats in first place in their division, Congress is still the best spectator sport in DC. So pull up your lawn chair, grab a brew, and try to forget for a while that these are the people to whom we have entrusted the governance of our homeland.
Resources
Find out what provisions in the final marketing guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes in a webinar next Wednesday, July 23. Register now >>