2017: Taking Stock to Inform Next Steps
As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if you believe in the effects of Mercury in retrograde.
- The audit protocols continued to be a work in progress not only for sponsors, vendors, and industry partners like Gorman Health Group, but also for the authors at the Centers for Medicare & Medicaid Services (CMS). A myriad of industry comments were submitted for consideration as they relate to the draft 2017 version. By now, most sponsors should have already incorporated similar methodology into audit and monitoring processes as a complement to existing methods.
- Sponsors without established monitoring and oversight focus on the accuracy of their network information have been subject to CMS review, have sought outside assistance to verify network accuracy, or have worked or are working internally to varying degrees to remediate known gaps in their processes. Per CMS, the Medicare Parts C & D Oversight and Enforcement Group (MOEG), in coordination with the Medicare Drug & Health Plan Contract Administration Group (MCAG), are taking a comprehensive approach to monitor, audit, and validate compliance with network accuracy requirements. MOEG’s pilot will use MCAG’s monitoring results to audit and validate correction of deficiencies. Some of the highest Star-rated plans can tell you about their network validation efforts and best practices, and it’s not a one-way street ‒ providers need to collaborate with sponsors and be proactive when information changes. We may expect to see enforcement actions stepped up as a result of CMS’ maturing efforts in validation of network accuracy.
- Earlier in 2016, our Operations team highlighted areas to keep an eye on based on the 2017 Draft Call Letter. They included the one-third financial audits, timely processing of coverage determinations and redeterminations, as well as data integrity. CMS has since noted they will increase penalties for outliers of Coverage Determinations, Appeals, and Grievances (CDAG) auto-forward rates, and they confirmed they will continue to raise the consequences for ongoing noncompliance in this area in 2017. The appeals timeliness monitoring effort announced on November 29 will provide CMS even more data for review and action.
- Later in the year, our Pharmacy team recommended key strategies to prepare for the coming year, including conducting Pharmacy Benefit Manager delegation oversight audits and conducting targeted audits. Most, if not all, of the mentioned strategies require a group effort, which begs the question: Did you have the time and the resources to accomplish all you wanted to do by end of year?
This is a good time to rethink methodologies and reorganize in preparation for changes to come. The key here, especially this month, will be to take stock of what we do not have control over, set those things aside, and plan to take action where we can.
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Preparing For The 2017 Call Center Monitoring
On November 16, 2016, the Medicare Drug Benefit and C & D Data Group of the Centers for Medicare & Medicaid Services (CMS) issued the “2017 Part C and Part D Call Center Monitoring and Guidance for Timeliness and Accuracy and Accessibility Studies”.
In an effort to ensure continued call center compliance in 2017, CMS has contracted with IMPAQ International, LLC, to monitor plan sponsors’ call centers. Although the call center requirements are nothing new for health plans, CMS describes the elements which will be monitored and provides tips on how to prepare for the monitoring studies. IMPAQ will conduct two studies – the Timeliness Study and the Accuracy and Accessibility Study.
As we are quickly approaching January 1, now is the time for plan sponsors to identify call center compliance issues and work to not only clean up any messes but to also beef up your call center staff. Compliance actions may be on the line, but so is the face of your organization – besides providers, your call center staff engages your members and prospective members most often. A confident and well-trained call center staff is crucial to your prospective and current member experience! Carrie Barker-Settles, Director of Sales & Marketing Services, says, “One of the most important beliefs in developing a strong member experience is effective communication to the member. A health plan may want to consider what messages, tone, look, and feel they want the member to see, read, and hear with every touchpoint.
Contact us for ideas on how we can partner with you to efficiently monitor your call centers in preparation for the 2017 CMS Call Center Monitoring and to empower and revitalize your call center staff and strengthen your member experience.
Below are further details on the 2017 CMS Call Center Monitoring:
Timeliness Study
- Measures plan sponsor’s current member call center phone lines and pharmacy technical help desk lines to determine average hold times and disconnect rates.
- Conducted year-round with quarterly compliance actions.
- Plan sponsor’s will receive a compliance action for the Timeliness Study if: 1) it fails to maintain and average hold time of two minutes or less; and 2) it fails to limit the disconnect rate of all incoming calls to 5% or less.
- Results will be available quarterly through the Health Plan Management System (HPMS).
Accuracy and Accessibility Study
- Measures plan sponsor’s prospective call center phone lines to determine: 1) the availability of interpreters; 2) TTY functionality; and 3) the accuracy of plan information provided by customer service representatives.
- Conducted from February through May with compliance actions taken when an organization’s interpreter availability is less than 75%, its TTY score is lower than 65%, or its rate of accurately answering questions is below 75%.
- Results will be provided via HPMS and announced via an HPMS email.
Do this now:
- Verify the accuracy of your 2017 Part C and Part D call center phone numbers in HPMS by January 2, 2017.
- Conduct internal monitoring to identify any compliance concerns for timeliness.
- Ensure interpreter availability and monitor call center calls to ensure foreign-language calls are handled according to your policies and procedures.
- Ensure your call center staff is prepared to promptly respond to beneficiary questions – CMS has their timer set at seven minutes!
- Test all your call center lines to ensure your ability to accept calls.
- Regularly test your TTY device to ensure proper functionality.
- Ensure your call center staff is trained and ready to respond to questions regarding items listed in the Medicare Marketing Guidelines, Section 80.1.
- Ensure your call center staff is trained on the 2017 benefit information.
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At Gorman Health Group, we want to change the perception that member experience is the responsibility of Sales and Customer Service, instead showing organizations that member experience is a comprehensive approach with full transparency and cross-functional leadership. Visit our website to learn more about our Member Experience Services >>
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Preparing for the 2018 Medicare Advantage and Part D Application Season
On October 31, 2016, the Centers for Medicare & Medicaid Services (CMS) posted the 30-day releases of the 2018 Medicare Advantage and Part D new application and service area expansion instructions for public comment.
While this is not an annual process for each Sponsor, it is a yearly undertaking for Gorman Health Group. It is also a busy time for CMS staff who field the Notices of Intent to Apply and subsequent application submissions. Substantive proposed changes include the following:
- Chart of Required Attestations by Type of Applicant – The chart was revised to provide the applicants with clarification in identifying fiscal soundness requirements.
- Administrative Management – CMS clarified the information for the two-year ban period and inserted the date for the two-year period for the current application cycle.
- State Licensure – CMS clarified the information regarding licensure requirements, which should reduce the number of deficiencies related to licenses that automatically renew after the applications are due.
- CMS Provider Participation Contracts and Agreements – CMS removed the attestations due to duplicative and redundant language.
- Health Services Management and Delivery (HSD) –
- CMS clarified the information for applicants regarding Medicare certification requirements based upon public comments received in response to the 60-day comment period. Medicare certification is only required for applicable providers and facilities.
- CMS clarified the information for Regional Preferred Provider Organization (RPPO) applicants regarding the network requirements and contract agreements. The volume of RPPO applicants has been extremely minimal in previous application cycles.
- CMS clarified the instructions for applicants regarding the submission and process for HSD tables and Exception Requests based upon public comments received in response to the 60-day comment period.
- Revised attestation in Eligibility, Enrollment, and Disenrollment to include an additional option for beneficiaries to make a disenrollment request by calling 1-800-MEDICARE.
- CMS revised the signature authority for a Special Needs Plan upload document to include both Chief Executive Officer (CEO) and Chief Operating Officer (COO) based upon feedback from the previous application cycle.
- CMS clarified the information for applicants related to the regulatory requirements in the development of the Model of Care (MOC).
The Part D application documents note they made no substantive changes, instead providing a redlined version to outline updates made to reflect the 2018 cycle and instruction clarifications. Keep your eyes open for the final applications to be released sometime in January, along with the no-cost training calls CMS will hold prior to the submission date of February 15, 2017.
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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.
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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First Year Communication – Building Loyalty and Trust
How can you deliver customized and personalized products, services, and experiences to members? You and your team need to begin with understanding your membership. Defining your membership by both value and their needs provides line of sight to information that will influence loyalty and trust.
Questions that should be asked by you and your team to better understand your customers to build loyalty and trust:
- Does the health plan know what the customer really wants and needs?
- Is there a shared understanding of who the health plan’s most valuable customers are and how to meet their needs?
- How does the health plan communicate with their members to better understand their needs?
- Is health plan customer data integrated and easily accessible across the health plan?
- Do the right employees have access to the right information about the health plan’s members?
- Does the health plan have knowledge of the current inventory of member touchpoints that exist today?
- How does the health plan define “member?” Who is the member?
- How is the health plan currently perceived in the market today, not just by current members but by prospects, providers, employers, and community influencers?
Now more than ever, websites are becoming the primary resource by which Medicare beneficiaries not only research health plans in the buying process but also seek out information regarding their coverage once they are enrolled. The member website can support member communication by being clear and easy to navigate and, most importantly, by including a password-protected Member Portal. The Member Portal should include the following:
- Calendar of local events
- Health screening reminder banners
- Monthly member newsletter
- Real-time access to:
- Eligibility
- Benefit information
- Formulary information
- Claims information and status
- Care gaps information
- Wellness resources
- Access to plan documents
Diane Hollie, Gorman Health Group’s Senior Director of Sales & Marketing Services, says, “Medicare beneficiaries, especially baby boomers, want to access information in the format they are most comfortable with, and, for many, that is the web. Many beneficiaries want to access their information online, and having a strong interactive member web experience that is easy to navigate will reinforce the health plan’s initiative to drive first year communication.” This first year communication builds a foundation for future dialog that provides the member with valuable and time-saving information relating to the member’s personal healthcare.
Trust is essential to Medicare beneficiaries, and building relationships with members will harvest that trust. Taking an interest in your clientele, cultivating shared values, and implementing solutions to customer inquiries will support any customer service department in exceeding member expectations.
Instead of waiting for problems to occur, implement preventive services that can eliminate problems before they happen. By creating a path for customer inquiry resolution, you and your team can ensure member loyalty and trust, which ultimately results in member retention. There are two options for the member retention-focused customer resolution:
- Option One: Utilizing Existing Customer Service Department
- Enable existing customer service department to solve customer issues
- Become the customer’s trusted advisor and build customer loyalty
- Reduce customer complaints and create solutions to common customer problems
- Online communication – “click to chat”
- Option Two: Designated Member Experience Department
- Assign each member a single point of contact
- Execute on key member communication
- Drive attendance to member meetings
- Second-tier customer resolution
- Monthly complaints review
- Denied claims outreach, if applicable
- Welcome home call after discharge from hospital or nursing home
- Help navigate inquiries about provider access
This Annual Election Period (AEP), don’t just think about how to get new membership, think about how you will build that loyalty and trust for years to come.
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
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Gorman Health Group's member experience assessment is designed to meet a health plan’s concerns for retention and service to the member while remaining compliant and also providing strategies to enhance cultural competence, presenting opportunities for the health plan and providers to efficiently deliver healthcare services that meet the social, cultural, and linguistic needs of members. Visit our website to learn more >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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PBM-Supported Part D Measures Impact Quality Bonus Payment Revenues
Regulatory time frames around coverage determinations and appeals have existed since the inception of the Part D benefit. Timely access to medications has been a hallmark of the “member protective” stance the Centers for Medicare & Medicaid Services (CMS) has taken since Day 1. So how is it, even 10+ years into the delivery of the program, compliance with these time frames continues to be the bane of health plan Compliance and Star Ratings teams?
When CMS posted the 2017 ratings in October, the Medicare Advantage Prescription Drug (MA-PD) plan averages actually fell from 4.5 and 3.3, respectively, in 2016 to 3.9 and 2.9 in 2017. How can this trend be accounted for in the wake of ongoing CMS pronouncements regarding its dismay at the large number of auto-forwards sent for external review and that it would closely watch outliers and take vigorous enforcement actions against plans?
Even with all of the prodromal warnings by CMS, we have started to see the impact of low scores in these two measures in the newly released 2017 Star Ratings. Thirty-four plans that earned ≥4 stars in 2016 dropped below 4 stars in 2016 and will lose their Quality Bonus Payment (QBP) revenues. Of these, 53% earned only 1 star on both the Part D Appeals Upheld and Appeals Auto-forward measures, which, even if “artificially” reduced via unsatisfactory performance in CMS audits, were found to have substandard performance in this area.
Are Pharmacy Benefit Managers (PBMs) the culprit? Minimally, it must be restated the origin of these Star Ratings stemmed from compliance and member protection concerns, and if they were performing adequately, would have gone the way of, say…. call center hold times (by the same PBMs), which improved enough to be dispatched to the display measure list. Even with performance guarantees, intensive oversight by plans, onsite inspections, and internal audits, these misadventures continue to occur, and dire consequences follow. In general, PBM performance guarantees cannot begin to compensate for the potential lost bonus revenue, and plans are re-evaluating performance criteria, degree of health plan oversight required, and, in some cases, pondering the insourcing of all coverage determination-related activities. It may be time for “zero tolerance” in the health plan stance toward vendor-provided coverage determination services, as even one missed time frame may be a harbinger of more to come.
For questions or inquiries about how Gorman Health Group can support your organization’s Part D Star Ratings efforts, please contact me directly at lerwin@ghgadvisors.com.
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GHG anticipates that CMS will continue adjusting thresholds, curving the Star Ratings year after year in an effort to separate the remarkable from the ordinary. Now is a critical time – MA Plans must examine not just this year’s score and what contributed to it, but their Plan’s score history in the Stars program and what it says about the enterprise’s overall approach to key issues. Visit our website to learn more about how we can help your organization >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
CMS Provides Reminders on Key Dates in the MA-PD Application Process
Open Enrollment for the Affordable Care Act Marketplaces and the Annual Election Period for Medicare is underway. But this month also marks the start of required Centers for Medicare & Medicaid Services (CMS)-facing activities necessary for the application process.
Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group, points out “for many MA-PD applicants, activities are already underway. Oftentimes, Sponsors do not realize that the application requires all hands on deck until it is too late. It is a multi-disciplinary effort that requires attention to detail and collaboration at all levels of the organization.”
CMS recently released the following memos, providing reminders on key dates in the application process.
Release of Notice of Intent to Apply for Contract Year 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) and Related CY 2018 Application Deadlines
CMS released information and key dates about the Contract Year (CY) 2018 Notice of Intent to Apply (NOIA) web tool and key dates for the CY 2018 Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) application cycle.
2018 Application Activity Key Dates
NOI deadline to ensure access to CMS’ HPMS..............................................................November 14, 2016
CMS sends NOIA confirmation e-mails…………………………........................................November 30, 2016
CMS User ID connectivity form submissions must be received.....................................December 2, 2016
CY 2018 applications posted on CMS websites..................................................................January 10, 2017
Final day to submit NOIA for 2018……………………….....................................................January 27, 2017
CY 2018 applications submission deadline.......................................................................February 15, 2017
Medicare-Medicaid Plan (MMP) Notice of Intent to Apply for CY 2018
CMS released information and key dates about the CY 2018 NOIA web tool and key dates for the CY 2018 MMP application cycle.
CY 2018 Application Key Dates
NOIA deadline to ensure access to CMS’ HPMS..............................................................November 14, 2016
CMS sends NOIA confirmation e-mails……………………...............................................November 30, 2016
CMS User ID connectivity form submissions must be received by...................................December 2, 2016
CY 2018 applications posted on CMS websites................................................................January 10, 2017
Final day to submit NOIA for 2018……………………….....................................................January 27, 2017
CY 2018 applications submission deadline........................................................................February 15, 2017
Value-Based Insurance Design (VBID): Year 2 (CY 2018) Request for Applications
The Center for Medicare and Medicaid Innovation also announced the release of the Medicare Advantage (MA) VBID model test’s Request for Applications (RFA) for CY 2018. MA-VBID is an opportunity for plans to offer supplemental benefits or reduced cost sharing to enrollees with certain chronic conditions. Organizations that wish to participate in the model test in 2018, including those participating in 2017, must respond to the CY 2018 RFA by January 20, 2017, at 4:00 p.m. Eastern Time.
The application process is an arduous one. Completing the application requires 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. As always, Gorman Health Group is here to assist your organization with the application process.
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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.
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Open Enrollment for the Health Insurance Marketplace Begins: Issuers and Enrollees Forge Onward with the Chaos
Beginning next week, consumers will start actively enrolling in the Health Insurance Marketplace for the fourth year of the Affordable Care Act (ACA). The open enrollment period for the Marketplace begins November 1, 2016, and runs through January 31, 2017. Consumers who would like to actively enroll for January 1 coverage are encouraged to enroll through healthcare.gov by December 15 to ensure they will have coverage in their selected plan the first of the year.
Specific to Qualified Health Plan (QHP) Issuers in the Marketplace, the Centers for Medicare & Medicaid Services (CMS) will once again challenge Issuers with navigating through a multitude of enrollee stressors this season. Here are just a few challenges:
- Redistribution of Enrollees to an Alternate QHP Issuer:Based on a number of QHP Issuers either exiting the Marketplace in specific counties/states or exiting altogether, 2016 enrollees are left to identify a new plan for next year en masse. As a means to encourage consumers to choose a new plan, CMS has targeted November 16 as the next notice date to urge consumers to actively select a new 2017 plan because their current plan will not be available through the Marketplace. Unique to other notices consumers have received, this notice will be the first time CMS will communicate an “Alternate Plan Option” by defining the health plan name CMS has matched to the enrollee for each member currently enrolled in the household. Included in the notice is language related to how the alternate plan will communicate with the consumer through a welcome letter and a bill for the first month of coverage if they choose to activate. Enrollees are encouraged to either select a new plan altogether or activate the alternate plan to avoid a gap in coverage.Issuers have the opportunity to gain membership in this scenario, but there is no way to predict consumer behavior, especially for consumers who have been inundated by communications regarding this shift.
- Renewals to 2017 Coverage Year:A week leading up to the opening of enrollment on November 1, QHP Issuers are receiving state-by-state files detailing current enrollees who are being passively re-enrolled into 2017 plans. As the renewal process is a constant challenge for Issuers and CMS, ensuring the right members are being rolled into the correct plan is critical. A major component of the renewal process is to pause and identify inaccurate renewal data and ensure membership is updated within both systems (Issuer and CMS). This also includes recalculated eligibility for Advanced Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR).
Now that policy-based payments (PBPs) are in place, errors generated from inaccurate Batch Auto Renewal (BAR) processing will create an immediate financial impact to the Issuer for January 2017 payment. Financial impacts based on bad membership data were not realized in previous Q1 periods, but with operationalized PBPs, CMS now pays Issuers based on the Federally-Facilitated Marketplace (FFM) system. In other words, if CMS passively enrolls a member but the Issuer does not, it will automatically generate a non-member payment to the plan.
- Unaffiliated Issuer Enrollments (UIEs) or Issuer Orphans:Based on comparing Marketplace membership data between the Issuer system and the FFM system through the reconciliation process each month, UIEs are identified which represent members who are present on the Issuer system but not found on the FFM. Understanding UIEs represent enrollees who would not receive an initial 1095A notice for coverage nor would the Issuer receive payment from CMS for providing the benefit, CMS has acknowledged a solution needs to be extended to all interested parties this year. While guidance is still pending, CMS has assured the industry 2016 members will receive a manual 1095A, and Issuers will receive a payment adjustment through an undefined process.
As for the good news, CMS is addressing the fix prior to year-end, but it is yet to be seen whether the solution includes a front-end fix to end the generation of UIEs altogether.
- Periodic Data MatchingOn a periodic basis, CMS uses data criteria to identify individuals who are receiving financial assistance by enrolling in the Marketplace but at the same time are eligible or are enrolled in other Minimum Essential Coverage (MEC) such as Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). If enrollees choose to stay dually-enrolled in a Marketplace plan, they will no longer receive APTCs or income-based CSRs per the regulation.
Issuers continue to receive files from CMS to aid in outreach efforts to elicit action by the consumer and ensure they understand the loss of financial assistance before receiving a bill. Part of the process is helping consumers understand they are eligible for other coverage and to determine the appropriate MEC for them.
With the interim processes that are all too common for QHP Issuers, one fact is evident with managing membership – the data always tells the truth. Issuers will commit to working through the requirements as detailed above, support all open enrollment functions, and diligently work to resolve immediate membership issues that arise with January coverage. As with every new challenge that impacts enrollment, Issuers who have a robust reconciliation process to detect and resolve issues will be best positioned to measure and respond.
In parallel, the member experience leading into 2017 will be reacting to the some of the same challenges and a few more, including a 25 percent rise in premiums as stated by Health and Human Services (HHS) this week. Some enrollees will need a new plan, receive a manual 2016 tax notice, or be confused by notifications regarding their re-enrollment or other data matching issues. Others may receive a welcome kit and bill from a plan they did or did not select. When you review all the consumer touchpoints, it is evident the work ahead is a shared responsibility between the Marketplace, the member, and the QHP Issuer to ultimately get the member record right on all fronts. Collectively, the industry has made great progress this year, but we are still dealing with the chaos of a new government program.
Gorman Health Group’s proprietary tool, Valencia™, which currently reconciles 45 percent of the 11.1 million Marketplace enrollees, supports clients’ reconciliation processes with a comprehensive approach. Aside from managing enrollment and payment reconciliation, Valencia™ provides compliant and transparent workflow to ensure your operational processes – and the resulting payment – are as accurate as possible. Our goal is to help Issuers manage the chaos and be audit ready.
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To learn more about our Valencia™ product, reconciliation services, and how they support enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com.
New Webinar: The 2017 Star Ratings are out! Join John Gorman, GHG’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on October 27 at 1 pm ET for a cross-functional review of the 2017 Star Ratings ― from key program updates and 2017 Part D insights to emerging Pharmacy and Pharmacy Benefit Manager issues, new medication measures, and strengthening the connection between risk adjustment and Star Ratings. Register now >>
New Webinar: On November 1 at 2:30 pm ET, join GHG’s John Gorman and Melissa Smith as well as Eric Letsinger, President of Quantified Ventures, a firm committed to supporting the progress of the social enterprise community, and his colleague Brendan O’Connor, an Impact Manager, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
MACRA Final Rule: CMS Announces Flexible Approach
No doubt sighs of relief could be heard from across the industry when the Centers for Medicare & Medicaid Services (CMS) announced its flexible approach to next year’s reporting requirements under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS took these flexibilities even further in its final rule released last Friday. Below I dive into some of the changes CMS made for the 2017 “transition year” and beyond.
- Relief for Small Providers – The final rule steps back even further from its requirements that providers billing more than $10,000 under Medicare are required to comply with reporting requirements. CMS finalized that Merit-Based Incentive Payment System (MIPS)-eligible clinicians who do not exceed $30,000 of billed Part B allowed charges or 100 Part B enrolled beneficiaries are excluded from MIPS. According to CMS, this is about one-third of Medicare clinicians but only represents about 5% of Part B spending.
- CMS also previously announced it will allow for virtual groups where up to ten clinicians could combine into one group, however, virtual groups will not be implemented during 2017
- “Pick Your Pace” – CMS also codifies its prior announcement that it will allow for a “pick your pace” approach for the first reporting year, 2017. The first year essentially now contains five options:
- Report a full 90-day or one-year period to maximize chances to qualify for a positive payment adjustment.
- Report for less than one year but more than 90 days: more than one quality measure, more than one improvement activity, or more than the required advancing care information performance category in order to avoid a negative adjustment and possibly receive a positive adjustment.
- Report one measure in the quality performance category, one activity in the improvement categories, or the required measures of the advancing care information performance category and avoid a negative adjustment.
- Participate through an Advanced Alternative Payment Model (APM) and qualify for a 5% bonus incentive payment in 2019.
- Don’t report anything for a hefty 4% negative adjustment.
- Basics of MIPS and Changes for 2017 – Eligible clinicians will see either a negative, neutral, or positive payment adjustment of up to 4% under the MIPS program. CMS will also pay out bonus payments for exceptional performers between 2019 and 2024 (beginning with the 2017 reporting year). The payments are based on four categories, and CMS made some significant changes from its proposal:
- Quality – Full participation requires reporting on six quality measures or one specialty-specific or sub-specialty-specific measure set, five required advancing care information measures, and engage in up to four improvement activities for the highest score. For 2017, full participation is met by submitting at least one out of the six quality measures. However, higher points may be awarded for higher performance in the measure.
- Improvement Activity – CMS reduced the number of activities from six to up to four medium-weighted or two high-weighted improvement activities. Attesting to at least one improvement activity will be sufficient in 2017.
- Advancing Care – CMS reduced the number of total required measures from 11 to five. Reporting on all five would earn 50%, and reporting on the optional measures would allow for a possible higher score. CMS will also award a bonus score for improvement activities that utilize Certified Electronic Health Record Technology (CEHRT) and for reporting to public health or clinical data registries.
- Performance Category – Although CMS will raise the weight of this category, it will be weighted at 0% for the 2017 reporting year.
- Advanced APMs – Clinicians who are eligible to participate through an Advanced APM are exempt from the above MIPS requirements. Additionally, the Advanced APM track is eligible for a 5% bonus payment. In order to qualify as an Advanced APM, CMS finalized that a provider must bear a risk of a potential downside of 8% of all Medicare reimbursements or 3% of the expected expenditures for which the provider is responsible under the APM. Notably, CMS retracted its proposals relating to marginal risk and medical loss ratio (MLR) for now.
- “MIPS APMs” – CMS noted the significant criticism that many APMs will not meet the requirements to participate in Advanced APMs in 2017. For example, participants of Track 1 Medicare Shared Savings Program (MSSP) are not eligible as an Advanced APM. CMS moved forward with their proposal that these “MIPS APMs” are subject to MIPS reporting requirements, however, they will be scored using an APM scoring standard in 2017. CMS did announce it is developing an MSSP Track 1+ Model under which Accountable Care Organizations (ACOs) participating in Track 1 and new ACO participants could take more limited downside risk than Tracks 2 and 3 and still be eligible as an Advanced APM. CMS also announced it plans to reopen applications for some current APMs, such as the Medicare All-Payer Model and the Comprehensive Care for Joint Replacement (CJR) Model.
While CMS took the job of responding to industry feedback and “simplifying” the jump into the Quality Payment Program (QPP) for 2017 while moving forward with the move to QPP to an art form, the gargantuan 2,400-page final regulation is a hint of what’s to come. Reinventing the Medicare payment wheel is no simple task and will undoubtedly come with a slew of interim proposed rules as well as fixes to encountered problems during the first transitional years. This payment overhaul is only going to get more complicated, and the time to roll up those sleeves and get to work is now.
Resources
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
Directory & Provider Data: How Small Inaccuracies Could Lead to Big Risks
For the past year, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data Integrity is at the forefront of the initiatives enforced by government mandates, and provider data has topped the list of areas that not only need the most improvement, but the most oversight, correction, and potentially sanction. As we saw last year with the CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. By moving the online directory guidance in the Medicare Managed Care Manual from Chapter 3 (Marketing) to Chapter 4 (Beneficiary Protections), CMS has solidified the fact it is no longer acceptable to have inaccuracies in an area key for members to evaluate their health plan choices and find access to care. Now is the time to set new ongoing network monitoring processes in place that ensure your CMS network submissions and Health Service Delivery (HSD) tables mirror your online provider directories, guaranteeing you are prepared to address provider and member complaints stemming from directory inaccuracies.
A recent investigation by the Government Accountability Office (GAO)[1] identified serious deficiencies in CMS’ oversight and enforcement of Medicare Advantage (MA) network requirements and recommended greater scrutiny of the plans’ networks. The GAO found CMS reviews less than 1% of all networks and does little to assess the accuracy of the network data submitted by plans. It was found CMS relies primarily upon complaints from beneficiaries to identify problems with networks and does not assess whether plans are renewing their current contracts to continue to meet network requirements.
For MA plans who currently have the least stringent directory requirements of all government-sponsored health plans, this means plans are only required to outreach to the providers on a quarterly basis to validate the following information is correct:
- Provider’s ability to accept new patients,
- Provider’s street address,
- Provider phone number, and
- Any other changes that affect availability to patients.
Although seemingly straightforward, when coupled with several other nuances, the task becomes daunting and, in some cases, an operational impossibility. Real-time updates to provider demographics, grievance resolution, reconciliation of provider location, and notation of individual providers accepting new patients are a few examples of where a simple requirement can reveal so many gaps and pose so much risk. Inefficiencies capturing, storing, and governing provider data at the onset of the contracting and credentialing processes is a place to start, but what about the historic legacy information that needs to be sanitized? Add the individual specifications and data requested by and delivered from industry vendors and delegated entities, risk adjustment, the Healthcare Effectiveness Data and Information Set (HEDIS®), behavioral health, and the large, delegated provider and academic groups that should be providing the plan with a current roster each month – this is no small task.
At this point, you might be asking yourself:
- How do we bridge the gap between understanding our compliance risk and deploying a successful change in operations to ensure the loop is closed and successfully maintained at every point in the contract life cycle?
- How do we ensure vendor partners are supporting us and aligning their business practices with both the regulatory requirements and our key performance indicators for Star Ratings, risk adjustment, care management, and member experience?
- Is it possible to fix my content management system as it exists today, or do I need to rip and replace?
Gorman Health Group (GHG) can answer these questions, and we encourage you to follow along with us as we explore these questions and how they relate to the results from the first CMS pilot audit. Next week, we will provide in-depth detail on the operational and cross-functional elements of how this regulatory change will impact the entire industry. We’ll have commentary from several leading vendors in the industry and dig deeper into the downstream implications provider data inefficiencies can have on your plan as a whole. In the meantime, please contact us directly if you have questions or would like to schedule a time to meet with one of our industry experts to discuss how GHG can support your efforts to avoid risk and improve results.
[1] http://www.gao.gov/products/GAO-15-710
Resources
GHG can assess the alignment of your products, your current network, your market, and your network requirements. We’ll help you track results – both positive and negative – back to related network components. From there, we assist in developing and executing a networking strategy, from contracting targets to model contract terms, to payment terms that match your budgets and the capabilities of your claim payment systems. Visit our website to learn more about how we can help you address your needs >>
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
AEP Marketing: It's Not Too Late
It’s Not Too Late…
To Make Your Marketing Lead and Sales Goals.
During Presidential election years, it can be difficult to book media time, especially with direct response television. If you live in an area with hotly-contested political races, you may be finding it hard to break through the clutter to get the number of marketing leads needed to make your sales goals.
There is still time to make it work, but to do it correctly requires a considerable amount of teamwork and cooperation, especially with your vendors, during this very busy time of year. Although we know every situation is very different, here are some tips to consider:
- Increase online media. If you have not tried remarketing, now might be the time to try it.
- Direct mail – but don’t use oversized postcards that may get confused with political propaganda until after the election. Having a direct mailing with a very colorful envelope may help break through the clutter. Make sure you mail your best prospects first class.
- Move more money into co-op dollars with your most productive agents or Field Marketing Organization.
These are just a few tips to jumpstart the thought process. This is a great time for the Marketing and Sales teams to come together and develop a “unified action plan” to recoup the leads and sales needed to make your goals. Carrie Barker-Settles, Director of Sales & Marketing Services at Gorman Health Group, stated, “It’s not too late to evaluate lead distribution by ensuring marketing leads go to the ‘closers.’ No need to try out new agents/brokers if leads are limited – put company leads in the hands of those agents/brokers who have proven results.”
If you need help brainstorming ideas or assistance with an action plan, don’t hesitate to contact Gorman Health Group ― it’s not too late to make a difference.
Resources
The 2017 Star Ratings are out! Join John Gorman, Gorman Health Group’s Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on Thursday, October 27, from 1-2 pm ET, for a cross-functional review of the 2017 Star Ratings. Register now >>
Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>