Preparing Your Care Management Team for Optimal Performance

As many plans are preparing to write a new Model of Care (MOC) for a new service area, an expanded service area, or redlining or revising an existing document, many plans miss the opportunity of evaluating the readiness of their Care Management team for change. The critical part of this team? The leadership.

I would like to challenge you as a leader of a care team or a care team member to think about the following and investigate or discuss these topics within your own organization:

Team Overview and Participants: Do you have the right design, or is a new design in order? Does your team have the right leadership? If so, does the leadership challenge the care team design by:

  • Ensuring all lines of communication are open? This requires reviewing not only the data flow internally but also by spending time with the actual care team process and observing each and every person who touches your members and how effectively they carry out their roles.
  • Establishing the correct protocols for care plan interventions? Many Special Needs Plan mock and CMS audits identify issues where the care team does not effectively identify the right intervention for the right member need. This can include associating a correct measurable outcome to the intervention. Often, systems auto-populate suggested interventions or suggested outcomes, but what really needs to happen is frequent, detailed review of the care plan content and how the members of the care team are associating outcomes and their due dates. Are they realistic? Are the time frames too far away from the actual identification of the need for an intervention?
  • Establishing effective use of information and data points? How do you as a care team leader ensure your care managers, social workers, and care navigators know how to use or interpret lab or pharmacy data, not to mention where to find the data? As a care team leader, be sure to review all data sources from an IT perspective, that the data feeds are timely, and that staff knows how to interpret and use what they have access to.
  • Ensuring community resources are appropriately identified? Many care plans miss the simple and free connections to community-based resources. The typical meals or transportation are often covered, but what about the more difficult items such as the actual office location where the member can obtain rental income assistance OR where is the address in the care plan/care plan notes that identifies the community loan closet where the member can obtain a raised toilet seat as it may not be a covered benefit? As their leader, help your care teams learn by ensuring they have the most up-to-date access to what they need when it comes to using community resources as, sadly, these connections could make a difference in whether a member is able to stay home and keep his or her independence.

An excellent leader of a care team digs into the actual work the care team members are doing, reviews the output of the Health Risk Assessment, and how the care team members translate the findings into a real member care plan – not a system template or repeatable care plan.

Many of these items could be included in an overall MOC performance marker to ensure the care team is measured not only on how many members they care for, but the actual true content of their care plans and recognizing all the needs of the member – not just those that can be quickly pre-populated by a basic care plan or system.



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Bundled Payments Report Issued

Bundled payments capitate medical care at the episode level. It is one of the few “value-based” approaches the Centers for Medicare & Medicaid Services (CMS) and the Innovation Center have fielded that works. But it doesn’t work for the taxpayers, at least not yet. If you stop and think about it, the whole Prospective Payment System (PPS) is basically a bundle approach. It tied together a lot of individual hospital services that used to be separately billed and gave hospitals an incentive to be efficient. And were they ever: the average length of stay dropped 17%! The newer approach expands the bundle, in some cases to every part of the episode, including physicians, hospital, post-acute, and home health. Before the Affordable Care Act (ACA), CMS ran some demonstrations that proved the concept, yielding savings a bonus for doctors, and savings for the government and the patient, too, with reduced copayments. A further expansion under the ACA was promising, so the Obama Administration jumped ahead with a mandatory program for hip and knee replacement in 66 localities. The hospitals cried foul, but many had success and enjoyed bonuses. After the 2016 election when Tom Price became Health and Human Services (HHS) Secretary, he pared back that program just as results showed it was successful.


Keep in mind Medicare spends between $16,500 and $33,000 on knee or hip cases. Average charges in total approach $50,000 in the U.S. If you are mobile, you can get it done for less than $10,000 in India!


The Lewin Group delivered a report to CMS this week on the fifth year of the voluntary bundled payment initiative that was started under the ACA's Innovation Center in 2012. As in earlier years, the great majority of activity was in joint replacement episodes, and while there was little impact on quality for better or for worse, there were savings in spending on the services. Those savings were generated by reductions in post-acute care, both inpatient and home health. Unfortunately, the government didn't get any benefit, and the providers did because it was an upside-only risk approach. The newer “advanced” Bundled Payments for Care Improvement (BPCI) initiative, which is getting started now, will put providers at risk. Sophisticated providers are ready to play in this new space. This is where health reform is happening – initiatives that align providers’ incentives with the goals of public programs. Health plans and provider groups that stay focused on CMS’ strategy will be the winners going forward.



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Focus on Rural Population: What Your Plan Still Has Time to Do

Here we are at the end of July already! Time flies, especially when we are busy preparing for enacting our bid submission approvals and planning for rollout of plan year 2019 activities and new members. It is not too late to still enhance this year’s activities and positively affect our members within the remaining five months of this plan year, especially in the rural areas of your plan’s service area. CMS released its first "rural health strategy" here:

Barriers to care/access and disparities for the rural service areas and their communities are routinely missed as a focus for a care management program objective, a quality improvement process, or independent study within population health management.

Here are a couple of tips to consider and questions to ask yourself as a plan that can truly be implemented within this plan year:

What do you know (or not know) about your rural populations specifically?

Age bands overlaid by claims data/GeoAccess: Oftentimes, populations in rural areas are older than those residing in urban areas. This means access or capability to access care is a potential issue right off the bat. Elderly populations who may be isolated by a rural geographic location due to distance to care can be compounded by other issues: daylight hours available to drive, their own vision, condition of their vehicle, if they have to care for others…you get the picture. Do we as an industry really take into account how to identify those who are isolated by being rural? I believe we can do better!

Plans could take their specific rural counties and break down by age bands the populations who live there; overlay the claims utilization to determine patterns of care AND potential barriers. For example, if you have vision as a supplemental benefit, and you know your elderly population in the rural service area cannot access the vision stores due to the fact they are all urban, how do you expect these members to access care SAFELY simply by having the vision benefit? What can you consider to support these folks? This is where telemedicine could become your new best friend to support the reach your network cannot. I believe plans could use the telemedicine option more than we see today. Many plans are not aware of the details, the codes, and what the benefits are, so please educate your network teams, provider networks, and update your care management program to include this option. If you are not sure what the rules are, look here:

Also, consider engaging a home visit vendor to support this population – you will want to make certain that networks can deliver in the rural areas and not face access to members’ issues.

If your plan does have rural hospitals that service your rural counties, please be certain to mine this facility’s utilization, emergency room, observation, and inpatient data. Frequently, rural hospitals serve communities with greater rates of diabetes and known associated hypertension and obesity, all of which speak to the rural community structure and lack of urban services.

Don’t forget the analysis of rural service area prescription drug claims. Drug claims alone often identify issues for and about plan members that may not otherwise be exposed.

Introduce “rural service area access” into your quality program as a quality improvement project. Because rural communities face provider shortages, especially primary care, as well as behavioral health, dental, and vision, consider enacting a rural clinical day, either through a Federally Qualified Health Center (FQHC) or other partner to draw members to a one-stop shop day of service. Sort of like a spa day but for health! If folks cannot get there, offer transportation, too!

Thinking outside the box to enhance our rural populations’ access, engagement, and health outcomes could only benefit everyone. If you need assistance to evaluate your plan’s populations, creative care model changes, please reach out to me at





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Population Health Management Tactics to Succeed in Medicare Advantage

Population health. Many of us in the industry speak those words often without truly thinking about what it really means to us as a health plan or as a provider group, and often times, what it means to our data collection and analysis processes.

For many Organizations today, success in the Medicare Advantage market space is critical to our existence. This success will require many Organizations, whether plans, provider groups, or even vendors, to examine their capability to collect data, the process by which they examine data, and then how they tailor interventions to manage the results of that data for sustained improved health outcomes. After all, isn’t that why we have chosen our careers and are in this industry or taking care of folks to make a difference and hopefully improve results? I believe that is the case for many of us.

Population data management is key for many organizations as we drive to value-based care agreements within our provider networks. Providers need to be able to track their assigned member populations, the population health outcomes, the data associated to the Healthcare Effectiveness Data and Information Set (HEDIS®) measures, and quality measures, all while managing assigned risk.

In this writing, let’s focus on a few points to consider in your population health management tactics:

The whole population: While many of us segment data to focus on certain diagnoses, utilization, or measures for a targeted population, we leave out many patients/members who still have needs or influence healthcare spend. Focusing on an entire population, similar to how a plan defines a target population to enter a Special Needs Plan market, allows a plan to manage an entire group of people, their conditions/disease states, and respond to the group’s needs rather than a small segment. Using registries that identify and track a population over time allows a plan to view the total overall care received and identify gaps/trends. Looking at an entire population will also allow you to track improvements for overall health outcome measures while comparing for demographics, provider groups, benefit structure, and access.

Evidence-Based Clinical Guidelines: Today, one of the most important tools used in managing populations is the electronic medical record (EMR). Many health plans adopt different types of evidence-based clinical guidelines, which they apply to the administration of benefits filed within their bids. Evidence-based clinical guidelines are often times the guiding point for population management and the path followed for treatment decisions within the delivery of care. Providers need to utilize this guidance in order to treat a clinical problem, however, it is not readily available at their fingertips within the EMRs to manage patients/populations as desired by a plan. Embedding these guidelines with applicable decision trees within an EMR can allow a provider to best apply treatment options and enables the provider to manage a population aligning with projected costs/outcomes, which results in effective care planning and treatment adherence.

Overlay the above two tactics with correct identification of at-risk patients through appropriately defined criteria, which includes behavioral health attributes and accounting for the variation in the care delivery models and the associated patterns of utilization, will enable better designed care planning across the care continuum.




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Integrated OTC Benefits: A Prescription for Customer Satisfaction

Most over-the-counter products and medications like pain relievers, allergy medications, heartburn drugs and topical antimicrobials were once available only by prescription. In OTC form, these drugs are FDA approved and often equally effective as prescription drugs at a fraction of the cost. Yet their OTC status has long meant these drugs are not covered under prescription drug plans for Medicare Advantage, Medicaid or commercial health plans. As a result, consumers with limited incomes may simply forgo needed medications while others may opt for more expensive prescription drugs that are covered by their health plans.

Adding an OTC benefit component to a health or drug plan may seem like one more administrative burden. After all, why add products and medicines to a formulary that subscribers are already buying anyway? Because an integrated OTC benefit can be a real cost-saver for health plans and subscribers alike, and OTC benefits boost customer satisfaction and retention.

The Consumer Healthcare Products Association Clinical/Medical Committee found that OTC medicines bridge treatment gaps, are convenient and reduce unnecessary use of health care services. The Center for Medicare and Medicaid Services allows OTC coverage in Medicare Part D drug plans in acknowledgement of OTCs’ utility as part of step-therapy algorithms and to improve cost-effective utilization management.

Each dollar spent on OTC medicines saves the US health care system $6 to $7, according to a 2012 study commissioned by the CHPA. The savings come not only from lower drug costs but also from fewer patient visits to health care providers and emergency departments.

The key to an effective OTC benefit is seamless integration of robust formulary management, benefit management and customer service. Various vendors offer an OTC benefit add-on in the form of prepaid cards, but the cards must be set up to cover only approved drugs. The result is frustrated customers who find out at the pharmacy cash register that their card doesn’t cover the medicines and health supplies in their shopping carts. That’s not good for customer retention.

What Carriers Should Look for in an OTC Benefit Partner

An effective OTC benefit partner relieves administrative burdens on the carrier by managing formularies, handling member interactions, processing eligibility files frequently and generating required reports accurately and promptly. Added features like developing and distributing online and print catalogs to subscribers and mail-service delivery of approved OTC medications and supplies further enhance customer satisfaction. Mail service also enables the inclusion of educational, program and informational inserts in OTC product shipments.

An OTC plan partner should also be experienced and well-versed in compliance with regulatory requirements and oversight for OTC benefits, and the partner must be able to assist with development of a formulary that meets the carrier’s goals. In addition, all technology used for OTC benefit administration must be able to demonstrate adherence to the latest security standards for robust cybersecurity and privacy protections.

A Turnkey Solution

A fully functional OTC program delivered with minimal effort from the carrier, full CMS compliance and quality assurance, and robust cybersecurity and privacy protections relieves the administrative burden on carriers. Packaged with exceptional member service and convenience, such a program constitutes a turnkey solution that contributes to plan STAR, HEDIS and NPS ratings, while delivering customer satisfaction, retention and market share.

Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans.  Convey provides member management solutions for the rapidly changing health care world.

First seen on SmartBrief.

Learn more about Convey’s OTC Benefit solution here.

For information on the other solutions Convey has to offer, please follow this link.


"Plans that offered an OTC benefit in 2018 won big during AEP," explained GHG leaders during a recent webinar. Download the recording now.

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe

HEDIS Deadlines Approaching

It’s HEDIS® time again! Health plans should have data collection and audit activities in full swing for Healthcare Effectiveness Data Information Set (HEDIS®) 2018. High-performing plans will have started the hybrid chart collection and medical record review.

January 31 is the National Committee for Quality Assurance (NCQA) deadline for the HEDIS® 2018 Roadmap. This document is used by HEDIS® auditors as the backbone for evaluating a plan’s systems and processes to ensure the plan’s HEDIS® results comply with NCQA standards for reporting.

February 16 is the due date for submitting the Healthcare Organization Questionnaire (HOQ) to NCQA. Populating the HOQ can be confusing for some plans, but it is important to get it right to prevent surprises when it is time to upload final data submissions in June.

HEDIS® results are a significant portion of CMS Star Ratings and NCQA accreditation scores, so it is critical for plans to understand all the moving parts and multiple deadlines of the HEDIS® process. Gorman Health Group has the expertise to help your plan implement a robust strategy and targeted actions for delivering measurable HEDIS® improvements.


(related link below)




Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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The Importance of Accurate Provider Data and Network Adequacy

For almost two years, 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 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. CMS released its first “Online Provider Directory Review Report” in January 2017 and followed up on January 17, 2017, with a CMS Memo on Provider Directory Policy Updates.

In addition to the regulatory compliance and existing provider directory requirements, CMS noted two additional guidance steps:

  1. For group practices, directories must only list individual provider at locations where they routinely see patients, as opposed to every location of the group practice.
  2. Organizations must make a reasonable attempt to ensure provider practice names are up to date and reflect the name stated when an enrollee calls to make an appointment.

CMS also noted plans should institute other steps to ensure the information included in their directories is accurate and useful to their members. One item suggested was that plans have a hotline for members to use when they encounter a directory issue, such as a provider no longer accepting new members. The plan should then use this information to investigate and correct the issue for the member. Moreover, CMS readdressed the issue that any issues found during a directory self-audit, CMS audit, or member or provider calls should also be updated and ensure accuracy in the Health Service Delivery (HSD) tables used to submit the provider network to CMS.

Overall, plan provider networks have never had the scrutiny of CMS or other spotlight and as such have tended to take a back seat to issues unless a particular grievance was filed. At Gorman Health Group, we keep a pulse on the various health plan areas on which our organization consults as we regularly have cross-functional projects. I asked a Compliance colleague how her Compliance meetings went at a plan, and she responded that every meeting expounded upon their fear of not meeting the network and directory regulatory guidance. I discussed the directory issues with an operational colleague, and her comment from a recent project on member calls was that “approximately 40% of member calls were due to directory issues.”

For this blog, I had a chance to ask another colleague, one of our subject matter experts on Stars, to give her perspective:

Accurate provider data is a mission-critical foundation for a strong Star Rating.  If provider data is inaccurate, members will likely struggle to access providers or may actually show up at the wrong location for an appointment.  These issues influence all Star Ratings measures; they directly impact clinical quality measures and indirectly impact member survey and administrative measures.  In addition, inaccurate provider data jeopardizes the success of numerous key health plan business functions and minimizes the return on investment of supplemental investments in Star Ratings, Risk Adjustment, and Quality Improvement (QI).

The nature and extent of inaccuracies within a health plan’s provider directory has, to date, often been a well-kept secret within health plans.  Though data hygiene of names, addresses, and phone numbers is undoubtedly a very basic administrative function, competing priorities inside of a plan often redirect administrative staff away from these time-consuming, mundane activities until a crisis occurs (such as a CMS audit of the data or “ride-along” conducted for Star Ratings, Risk Adjustment, or QI purposes).

Perhaps even more troubling is when a provider listed in the directory is not accepting new patients.  Although CMS recognizes this can be a “fluid item” in the directory, Medicare Advantage enrollees often select a plan specifically based on a provider’s participation in that plan’s network.  When these situations arise, the health plan’s credibility and brand loyalty are placed at risk, and the member’s healthcare experience and Star Ratings status are placed in jeopardy.

Part of the anxiety is easy to diagnose: it is a new requirement, and we need to find the best approach. However, if you dig deeper, you will find directory data is the tip of the iceberg. Provider network operations in some plans can have functionalities that reside in several difference departments such as Provider Relations reporting to Operations, Credentialing reporting to Medical Management, and Contracting reporting to Finance. Like many plans, the functions were done in silos.

In retrospect, the issues identified are not new. They do, however, expose a systemic issue with provider network operations and the downstream impact they will have.

Please join us at the Gorman Health Group 2017 Forum as we further discuss the Provider Directory Accuracy and Network Adequacy regulatory requirements as well as the downstream impact they have on our internal operations and our external vendor operations. 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 Gorman Health Group Forum can support your efforts to avoid risk and improve results.


GHG’s multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>

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Reflections on the Basics of Delegation Oversight

Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to understand complex language and reading concepts without the foundation or basics. It would be quite an overwhelming few months for anyone.

With any course of study, it is important to start from the beginning. Furthermore, if you want to master that course, teamwork and collaboration allows for practice and improvement towards fluency.

As we start wrapping up 2016 (and wrapping up holiday presents), it’s a good time to reflect on the basics. What does this have to do with delegation oversight? The basic premise of delegation is that you are entrusting someone to perform an activity on your behalf. If you are looking to delegate for success, we recommend the following key steps to take place at the very beginning:

  • Get to know your delegate partner via pre-delegation discussions, site visit, and audit.
  • Understand how your delegate will demonstrate effective, compliant activities on your behalf.
  • Agree upon monitoring and auditing activities ahead of time, leaving room for augmentation.

We have seen many examples of delegation oversight programs and activities over the course of the year, and some Compliance Officers and Operations leaders find themselves in the delegation oversight equivalent of enrolling in Advanced French. That is, they were not involved in pre-delegation activities and, therefore, did not have a chance to advocate for the sponsor's obligations towards an effective compliance program. Without the basic foundation, they find themselves in an uphill battle when they try to get data or ask for changes to monitoring frequency.

“Oversight of delegated entities can be an overwhelming task,” says Beth Matel, Senior Director of Compliance Solutions. “To help ensure a sponsor has the cooperation of the entity to which they have delegated responsibilities, they must start by including the pertinent contractual provisions outlined in Medicare Managed Care Manual, Chapter 11, Section 100.4 - Provider and Supplier Contract Requirements and 100.5 - Administrative Contracting Requirements.” Sponsors delegating Part D administrative or health care service functions will need to ensure the appropriate subcontractor contractual language is in place as well.

Our Compliance Solutions team is grateful for all the opportunities we have had this year to support our client partners and share best practices, from the basics to the advanced. As you reflect on your delegation oversight programs, give yourself a present if you:

  1. Have strategies in place to ensure shared data is sent and received correctly each time (especially membership data!).
  2. Conduct immediate root causes analysis in response to inquiries or grievances regarding something potentially amiss.
  3. Complete robust testing prior to new benefit implementation.
  4. Partner as a team (Compliance and Operations) to ensure success together.
  5. Maintain a dedicated unit focused on delegation oversight.
  6. Stay up to date on the Centers for Medicare & Medicaid Services requirements and changes as they affect your delegates and communicate them timely.

Bonne chance!



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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



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 >>

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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:
    1. Report a full 90-day or one-year period to maximize chances to qualify for a positive payment adjustment.
    2. 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.
    3. 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.
    4. Participate through an Advanced Alternative Payment Model (APM) and qualify for a 5% bonus incentive payment in 2019.
    5. 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:
    1. 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.
    2. 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.
    3. 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.
    4. 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.



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