Three Compliance-Minded Steps to Take for 2018 Marketing and Sales

Is it me, or is time flying by? Applications are done, bids are in, new plans are in planning stages, and existing plans are getting ready for the launch of the next benefit year.

The 2018 model materials were released late last month, and any second now, we should see the release of the 2018 Medicare Marketing Guidelines (MMG). The industry is expecting additional Summary of Benefits guidance to be incorporated in the MMG by the Centers for Medicare & Medicaid Services (CMS) as my colleague Diane Hollie noted in her article on the CMS Spring Conference. We are also interested to see if any modifications are made to CMS’ draft MMG language on Additional Marketing Fees as discussed in this article. Time will tell!

What is the compliance professional to do to help sales and marketing professionals prepare while we are in this holding pattern for the finalized guidance? Three things:

  1. Evaluate what worked and what didn’t work well in the material review process last year. Did you conduct a lessons learned session at the end of the season? Any top performers that contributed to the success of last year’s material creation, review, and submission activities? If you did not have a chance to do a lessons learned session, take some time to reflect this week. This way, you can set expectations with your team and colleagues.
  2. Identify greatest risks and rewards in sales and marketing activities, and take proactive steps to correct. We all understand the obligation to conduct a risk assessment. As Carrie Barker-Settles told an engaged audience at this year’s Gorman Health Group Forum, it is important to understand both the risks and rewards of each sales channel. Did your organization have an upswing in marketing misrepresentation complaints? What sort of turnover did the prospective member call center experience over the past year? Ongoing review of potential risks of non-compliance and fraud, waste, and abuse is necessary to help drive continued customization to monitoring and auditing plans.
  3. Develop training tools and checklists. If these are not in place already at your organization, these resources are integral to helping marketing and sales stay in between the lines.

Does this quick hit list warrant additional discussion within your team? If you are doing the above already, fantastic! As a good friend so alliteratively once told me, proper prior planning prevents poor performance. That said, are you inundated with the day-to-day of CMS requests, six+ hours of meetings a day, and little time to catch up on what new guidance was released? Do you need temporary help during the material review season? At anytime of the year when things go wrong, we often see it become an “us vs. them” situation between Operations and Compliance; it’s demoralizing and unproductive, and we don’t like to see anyone in that situation.

Contact me directly at for more information on how we can help.


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Marketing Takeaways from CMS’ Spring Conference

Although the Centers for Medicare & Medicaid Services (CMS) Spring Conference is typically thought of as a “compliance” conference, there is always important information that comes from the conference which affects Marketing. It is important to understand the information coming today instead of waiting for a CMS memo or the Medicare Marketing Guidelines (MMG). It is also a great way to hear how CMS personnel are thinking about a subject instead of just trying to infer their thoughts from the MMG. The following are some takeaways that may affect you and your plan.

Summary of Benefits (SB)

CMS reviewed 191 SBs – one from each parent company. If you haven’t heard from CMS about your SB, congratulations, CMS did not find any issues with your document. CMS gathered the SBs from each plan’s website, so make sure your documents are uploaded timely and the correct document is utilized. Here are some of our notes from the conference on SBs.

  • CMS stated one of the biggest concerns they saw was plans not using the correct order of benefits. Plans are required to maintain the specified order. Monthly premium, deductible, and maximum out-of-pocket (MOOP) should be first, followed by drug benefits. Some plans were alphabetizing benefits, including other benefits, and this is not allowed. In addition, make sure you are using the correct version of the SB. CMS noticed some SBs had multiple fonts in one sentence, brackets were not removed, and track changes were in SBs. Furthermore, some plans had incorrect cost-sharing in their SBs.
  • New for 2018:
    • No more hard copy changes.
    • No annual memo will come out this year; 2017 requirements will continue for 2018 – a copy of the memo and any 2018 changes will be listed in the 2018 MMG.
    • Outpatient hospital coverage will be listed right after inpatient hospital coverage.
    • Extra premium for optional supplemental benefits can be included in the SB.
    • The document must be labeled “Summary of Benefits,” and the plan year should be visible on the cover.
  • If a benefit is not covered, such as transportation, you still need to list the benefit and state “Not covered.”
  • Plans can add other benefits not listed by CMS to the SB and should label the section “Additional Benefits.”
  • Although CMS will continue to allow plans to utilize “benefit highlights,” “Benefits at a Glance,” and other types of marketing documents to highlight their benefits, CMS would prefer plans not utilize these documents and have prospects and members read the SB instead.

Supporting Access to Information for Individuals with Disabilities

CMS explained plans should be very familiar with Sections 508 and 504 of the Rehabilitation Act. Section 508 explains the media/electronic needs, and Section 504 explains accessibility, regardless of technology utilized. CMS stated access extends beyond hearing and visual impairments. Plans need to understand what the requests are for their disabled members and meet those needs in a timely manner – as though it was a member without a disability. This requirement must also be provided by your downstream contractors, so if you utilize a call center or other vendors that handle and fulfill prospect or member requests, make sure you have policies and procedures to handle these types of requests.

“The agency expectation is that individuals with disabilities are provided equal opportunity to participate in your program, and you should want that, too,” says Regan Pennypacker, Senior Vice President of Compliance Solutions. “We know this is operationally tricky, but this is an opportunity for innovation. A plan must work with beneficiaries to identify how they would like to receive information and make sure the info is provided in a timely manner.” CMS stated they are very interested in working with plans and hearing about their challenges and also best practices and successes.

Provider Directories Review Update

Provider directories will continue to be a challenge for everyone, and although CMS acknowledges this is a difficult endeavor, plans are responsible for their data. CMS also stated, since the provider is contracted by the plan, it is the plan’s responsibility to make sure they get the proper information from the provider. Although we could spend a lot of time discussing what CMS said about directories, we have provided a few things you want to be aware of from a marketing standpoint:

  • Make sure what is on your website is the latest and most up to date! Understand how and when it gets updated.
  • These are common errors CMS wants addressed in provider directories (both paper and online):
    • Plans must include notation if provider is accepting new patients or not. Make sure meaning of notation is clear.
    • Do not assume specialists are accepting new patients.
    • If listing provider prior to effective date, include effective date in directory.
    • Identify when provider has significant limitation to the patients they see (e.g., only treats members of a Native American tribe).
    • Does provider practice all their specialties at all locations?
    • List facilities as facilities and providers as providers. For example, they sometimes see surgeons listed with facility address where surgeries are conducted, but it should be address of where the member can get an appointment.
    • The languages spoken at doctor offices.

This discussion will continue to be a hot topic for CMS. As a marketer, we need to understand the data we are getting to develop these documents and help ensure it is meeting the guidelines set forth by CMS.

These are just the highlights from a few of the topics. Reach out to your Compliance Department to understand what might affect you going forward!


CMS also recently held its 2017 Audit and Enforcement Conference. Our Senior Vice President of Compliance Solutions, Regan Pennypacker, provides a recap here >>


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Highlights from 2017 CMS Audit and Enforcement Conference

The Centers for Medicare & Medicaid Services (CMS) hosted their annual Audit and Enforcement Conference on Thursday, May 11, and addressed the following topics:

  • 2017 Program Audits
  • Audit Protocol Updates: Compliance Program and Medicare Medicaid Plan
  • Medication Therapy Management (MTM) Panel
  • 2016 Program Audit and Enforcement Report
  • Timeliness Monitoring
  • Civil Money Penalty (CMP) Methodology

The presentations and recordings of the morning and afternoon sessions are posted here. All sessions merit a review by Compliance and operational teams at sponsors and delegated entities alike. Apart from the communicated clarifications and content provided on the slides, CMS allowed for numerous question and answer periods, both after each session as well as at the end of the day. Here I capture highlights of those Q&As.

Can an Independent Auditor (IA) follow the same CMS process of providing samples 1 hour before webinar sessions? In regards to the IA process, most sponsors do follow CMS protocol when doing validation, but it does not really matter to us how soon samples are delivered. It’s ok if you get them a little sooner. Most IAs do use the same protocol and timing, but it is not prescriptive, which is why there is not a lot of guidance around how IAs should audit.

If we had a CAR for CDAG clinical appropriateness, would the validation audit focus on that CAR, or would the validation audit need to be a full-scale CDAG audit? When it comes to that, the sponsor simply needs to validate the condition. A full CDAG audit is not required; just that particular condition.

To what extent are Invalid Data Submission (IDS) conditions a problem in 2016? They were not terribly problematic. Last year there may have been eight across seven sponsors, but CMS would like to see those at zero.

Now that you have covered 94% of enrollment with Cycle 2 audits, when do you plan to start a third cycle? CMS is not sure and is still looking at that.

Can or will CMS share overall observations in Timeliness Monitoring regarding performance? CMS believes they will be able to this summer.

How does CMS come up with the common conditions in calculating CMPs? CMS takes this from the annual audit report.

When are CMP notices posted on the CMP website? CMS posts CMPs as a result of program audits before end of February. For CMPs not related to audits, the agency posts those immediately after they are imposed.

In regards to call log universe, do we include calls placed to other vendors as a part of normal business (such as calls to transportation vendor) which do not pertain to main customer service? No, CMS wants only calls going to the main customer service line.

Is it appropriate to report date request received as AOR receipt date, or should sponsor report initial receipt date as request received? For ODAG tables with these two fields, sponsor should populate as each column specifies. CMS does consider both fields when doing timeliness calculations.

Will CMS release a revised Compliance Chapter 9/21 to reflect change in Elements from 7 to 3, or is this just a change in methodology? CMS is actively revising manual guidance. Compliance program requirements are still the same, but audit approach has changed. Do not confuse the three audit elements (Prevention Controls and Activities, Detection Controls and Activities, and Correction Controls and Activities) with the seven core elements outlined in chapter guidance.

Is there a timeline when CMS is expecting MTM audit activities to migrate from pilot to standard? At this point, it is not determined.

From a long-term perspective, considering validation is 150 days and MTM is a calendar year, how would this area be handled from a validation perspective? At this time, MTM not subject to validation. It is still to be determined if it will be subject to validation in the future.

How will appeals timeliness monitoring affect future audits? To the extent that the timeliness monitoring effort becomes annual, it would make absolutely no sense to review timeliness audit, but that change remains to be seen. However, there is a difference in that timeliness monitoring is a review of a snapshot of the year before. CMS may want to phase timeliness review out of program audits. CMS also answered the question from the perspective of the agency using results to target for audits. CMS noted they always like to compare data to audit scores and results to see if there is anything meaningful but confirmed there are no plans for that in the future.

"While CMS indicated they would not use results from the timeliness monitoring for referrals for audit, CMS did indicate they would study the results to see if there is a correlation to audit results," says a colleague on the Operational Performance team.  "Knowing what is in your data and using it for process improvement should be on every plan’s radar." Since CMS staff indicated that the timeliness monitoring could one day potentially replace the timeliness review on program audits, sponsors should get ahead of that curve by using their timeliness monitoring data for their own internal review.

As always, we love to hear your thoughts and perspectives on agency activities as well as your experiences in the government programs space. Keep an eye on this blog for more updates from my colleagues on this week's conferences.


The Gorman Health Group 2017 Forum concluded recently in New Orleans with over 200 of our closest clients and partners. John Gorman provides key takeaways from the event here. Make sure to join us next year!

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CMS Puts Plans on Notice with Recent Enforcement Actions

The Centers for Medicare & Medicaid Services (CMS) Program Audit reviews a subset of contractual requirements every year, and each year, leadership wants to know how they fared compared to others, when they are due for an audit notice, and what some of the most pervasive conditions were identified. How many of you, dear compliance-minded readers, have been asked, "What will it cost us if we stay non-compliant?" By the numbers:

  • Just under $7.3 million in penalties were levied between October 2016 and February 24, 2017.
  • 37 sponsors were audited, with a combined total of 115 contracts.
  • The active contract with the smallest enrollment has 93 members (as of February 2017).
  • The largest audited contract has almost 2.9 million members (as of February 2017).
  • The 2016 average audit score was 1.22, a decrease from the 2015 average of 1.76.
  • There are over 11.5 million members currently enrolled in a plan levied a Civil Money Penalty (CMP) for Contract Administration. That’s the population of Ohio, or 11 Rhode Islands¹.

CMP data points tell us not to focus on the score, the plan’s enrollment size, or number of contracts – none of this will alone tell the outcome of CMPs. There were a number of sponsors audited in 2016 with similar violations yet not issued CMPs, including violations which appear on CMS’ ever-referenced common conditions.

CMP 2017

Do you delegate most key member-facing functions? Is there a palpable culture of a focus on other lines of business? Has your enrollment grown too quickly for operations to adjust? Are you in the midst of organizational changes? What have you done to prepare for your audit, or better yet, timeliness reviews? What do you plan on doing with this knowledge?

¹Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2016, US Census Bureau



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Gorman Health Group’s Summary and Analysis of the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter is now available. Download now >>

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Adjusting Star Ratings for Audits and Enforcement Actions

Within the Draft Calendar Year 2018 Call Letter, the Centers for Medicare & Medicaid Services (CMS) acknowledged the valuable comments received from the industry related to the use of audit findings and enforcement actions in the Star Ratings Program. As a result of those comments, CMS proposes a revision of the Beneficiary Access and Performance Problems (BAPP) measure.

First, what is the BAPP measure? You can find information on this Part C measure in the 2017 Star Ratings Technical Notes. As described, the agency checks each plan to see if there are problems with the plan, for example, whether members are having problems getting services and if plans are following all of Medicare’s rules. The current BAPP measure is based on CMS’ sanctions, civil monetary penalties (CMPs), and Compliance Activity Module (CAM) data. CAM data includes notices of non-compliance, warning letters, and ad hoc corrective action plans.

In the Draft Call Letter, CMS is proposing a number of revisions to the BAPP measure for the 2018 Star Ratings.

  • CMS is proposing to change the data time frame to the period from July of the measurement year to June of the following year. For example, the time frame for the 2018 Star Ratings would be July 2016 through June 2017. (Current data time frame for 2017 Star Ratings is January 1, 2015, to December 31, 2015.) This change would address feedback to use more recent data for the CMP portion of the measure.
  • In addition, CMS proposes to employ the first option outlined in the November 10, 2016, Request for Comments, that is, the agency would apply the same scaled CMP deduction to all contracts cited in the CMP notice based on a ratio of the unadjusted CMP amount to enrollment at the time of the enforcement action. So, let’s say a parent organization has five contracts cited in a CMP notice. CMS will calculate the BAPP deduction by dividing the CMP by the total enrollment of those five contracts. The resulting BAPP measure deduction would apply to all five contracts.
  • CMS also proposes the total deduction for a contract for CMPs be capped at 40 points instead of 40 points per CMP, which is what is in place today. Furthermore, CMS proposes retaining both the current BAPP measure score reduction for contracts under sanction and the current CAM deductions.

After all this work, CMS is also considering whether to implement proposed BAPP measure changes for 2018 or 2019. For more information on proposed changes to Star Ratings, refer to our expert commentary on this key aspect of the program.

It is recommended Compliance, Operations and Star Ratings professionals consider scenarios and how this would affect their Star Ratings. Ideally, a plan will keep CMPs and CAM data to a minimum, but the reality is with program audits, timeliness monitoring, an annual release of CMPs for Annual Notice of Changes/Evidence of Coverage issues, provider network accuracy reviews, and CMS’ revitalized focus on nondiscrimination and accessibility, it is expected there will be plenty of data for CMS to inform this measure.


Gorman Health Group’s Summary and Analysis of the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter is now available. Download now >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

Our Star Ratings subject matter expert discusses several key changes for Star Ratings in the 2018 MA Draft Call Letter. Read now >>

How to Maximize Your Medicare Advantage Website Strategy

How was your Annual Election Period (AEP)? Have you evaluated your performance? Do you need to enhance your sales and marketing strategies? Now is the time to recognize and appreciate your 2017 successes as well as confront your shortcomings.

There are several moving parts to a successful sales and marketing strategy, one being your Medicare Advantage (MA) website. The internet shopping trend is ever rising and this now applies to MA. Baby Boomers are aging into Medicare and with them come a new trend in internet shopping, enrolling and communicating with not only family and friends but with organizations they receive goods and services. In the 2016 Age-In Study by Deft Research, we learn, “Internet shopping rates have surpassed the rates of all other shopping activities.” The days of only direct mail are in the rear view. In fact, we also learn that your direct mail is actually motivating your website visits. Take advantage of these trends and take control of your website strategy.[1]

Here are the top 3 items to keep in mind when evaluating, developing and implementing your MA website strategy.

  1. Think Easy: Your website mantra shall be: “clear and easy to navigate.” Not only is this the top requirement given to us from the Centers for Medicare & Medicaid Services (CMS) – in fact, this is the first requirement listed in section 100 of the 2018 draft Medicare Marketing Guidelines (MMG) – but this approach will ensure your website is user friendly and an effective marketing tool. Shoppers want the facts about your plan offerings and most importantly, they want them now. And if they are ready to enroll – the online enrollment process should just as easy as the shopping.Helpful tip: Organize your website around 3 general focus areas:
    1. Prospective member information – Here are your sales and marketing web pages, including the online enrollment tool.
    2. Current member information – These web pages focus on required content that is mostly geared towards your current members.
    3. Member Experience –Enhance your website with tools and a member portal that help drive your retention efforts.
  1. Follow the Rules: Make your list and check it twice. Compliance is key and whether you are developing, revising or monitoring your website, it is critical that you and your team have an understanding of all the CMS requirements as they apply to your MA website.Helpful tip: GHG recommends creating a website checklist that includes all CMS requirements. Are you developing a new website? List these requirements out as they would impact each of your proposed web pages or section of the website (prospective, current, retention). This is your content development driver. Are you revising or monitoring your website? This checklist is your tool to ensure compliance and it documents where each requirement is met by URL tracking.
  1. Member Perspective: It’s all about that member portal. As the Deft study highlights, web is worth it. Ensure an easy transition from prospect to member by providing your membership with an online, password protected member portal. Here the possibilities are endless – think newsletters, healthcare/health service reminders, provider/pharmacy look-up, drug search, claims check.Helpful hint: Collaborate with Stars! The experience of your members directly impacts your Star Rating. Collaborate with your Stars and care management teams to develop a member portal that truly supports member needs while simultaneously moving the numerator of your Stars measures.

Finally – don’t forget about your third-party websites. You may not have much control over the look and feel of your third-party websites but you must ensure they are compliant. Take note that one of the major changes proposed by CMS in the 2018 draft MMG is the addition of section 100.7 on third-party websites. CMS expects plans to be monitoring these sites in addition to their own.

All in all, enhancing our sales and marketing strategies is found in understanding our successes and failures. Take advantage of the rise in internet shopping and develop or revise your MA websites to go beyond the compliance requirements but to sell your products and retain your members. We are here to help!

[1] Deft Research, LLC. (n.d.) Marketing to Medicare Age-Ins: Internet and Direct Mail Trends. Retrieved from



On Thursday, February 9, from 2-3 pm ET, join John Gorman and colleagues Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document, including CMS’ changes to risk adjustment and encounter data, Star Ratings, Benefit Parameters and Bid Requirements, Part D Utilization Review, and more. Register now >>

The Medicare Advantage marketplace is evolving – are you prepared? Gorman Health Group’s marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

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A Vendor's Oversight is Never Done

There are many industry voices adding their perspectives about the new administration and changes to come. However,  the Compliance Officers I know do not have the luxury of stopping and truly considering the potential impact as they are managing the continuous pressures of their daily directives. Today I address a group of very industrious Compliance professionals not often addressed, and those are the staff responsible for Compliance Programs at first tier, downstream and related entities, or “FDRs.” Under Medicare regulations, plan sponsors may enter into contracts with FDRs to provide administrative or healthcare service functions on their behalf.

Building the relationship between the sponsor and FDR, just like any marriage, is very important for the partnership to be fruitful.  In order to ensure a successful relationship, it is important for delegated entity Compliance staff to have a firm grasp on what the health plans face and to build a strong foundation to support those needs. So often we talk about the Centers for Medicare & Medicaid Services (CMS) Program Audit, so delegates supporting those services should already be in lock-step with their plan sponsor partners. However, that review methodology is a small subset of Medicare Advantage Prescription Drug (MA-PD) plan requirements.

One question we are often asked is: How are sponsors looking at FDRs? FDRs can be collaborative, cost-saving partners that bring significant value to an organization. However, we have also heard dozens of anecdotes of buyer’s remorse, some of which are in credit to the following:

  • The sponsor’s Compliance Officer was informed months later that a business area contracted with an FDR.
  • A key business owner did not ask the right probing questions during the sales presentation.
  • No pre-delegation site visit was conducted to validate processes, or the right attendees were not included in the visit.
  • The procurement process was not followed, and appropriate monetary penalties were not imposed for failure to perform.

As a Compliance professional at an FDR, what could you be doing to improve current relationships?

As a vendor, the sponsor is entrusting you to perform an activity on their behalf. If you are looking to partner for success, we recommend you take a look at current processes and evaluate if you are making the right impression from the beginning. You can be a proactive partner in supporting your sponsor, or you can be reactive, thereby weakening your product/service and increasing your and your sponsor's oversight. Whether you are thinking of contracting with a plan sponsor for the first time or you are already in the thick of it, ask yourself these questions:

  • Do you “speak” CMS? Can you and your business leaders hold a fruitful conversation about current industry issues, recent CMS releases, and agency focus?
  • What is the state of your Compliance Program? Is it in good shape? Have you tested mechanisms and safeguards lately? Do you have an independent audit of your Compliance Program Effectiveness on an annual basis?
  • Are your record-keeping tools equipped to handle the many sponsor requests received, such as attestation data, training information, and exclusion list checks documentation?
  • How does your organization demonstrate knowledge of CMS requirements, and, more critically, how do you demonstrate meeting or exceeding those requirements?
  • Are you restrictive in how often you allow plan sponsors to audit each year?

To be successful in fulfilling the daily rituals of a delegated entity Compliance Officer, it requires a very particular set of skills (thanks, Liam Neeson), as they are often communicating with multiple sponsor contacts at a time. They are not off the hook just because they are not CMS-facing. And as history has shown, when a potentially large-scale, pervasive problem occurs, CMS can and will contact a vendor directly. Think about the above questions and evaluate your current resources to ensure CMS never feels the need to do so.


Join Nilsa Lennig Rudisill, Gorman Health Group’s Vice President of Sales & Marketing Services, and colleague Diane Hollie, Senior Director of Sales & Marketing Services, on January 31, 2017, from 1:00 - 2:00 PM ET, as they outline how to analyze your market and the necessary steps to develop a successful growth strategy. Register Now >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

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It’s Product, Benefit, and Premium Time for 2018

Whether you are just updating your current product benefits, are offering a new plan benefit package (PBP), new product, or service area, or are new to Medicare Advantage altogether, now is the time to start planning for the 2018 bid submission.

It is best practice in the bid process to utilize a working team approach, with one clear leader. The team should include representatives from the following areas to ensure the best product is brought to market, and, when it is offered, that the implementation of the product is seamlessly implemented.  Some of the members who should be included are:

  • Sales/Marketing
  • Finance/Actuary
  • Network
  • Pharmacy
  • Medical and Health Management
  • Operations
  • Compliance

GHG believes, at the beginning of the bid process, it is important to level-set the team on the marketplace. Some of the analyses we typically like to present include:

  • Service area demographics
  • Medicare penetration
  • Current membership analysis
  • Enrollment trend analysis
  • Results of the Annual Election Period (AEP): Who are the winners and losers this AEP, and why?
  • Product analysis
  • Benefit analysis
  • Competitive analysis

Strong planning is key in the bid process. You want to understand the goals upfront and make sure your product and benefits can deliver. We have found weekly meetings, a detailed project plan with strong leadership, and project management skills are critical if you want to limit the number of iterations and last-minute back and forth that brings along the increased risk of errors.

Having a strong operations component incorporated in the process helps identify the planning needed to seamlessly implement benefit changes and pinpoint impacts on customer service.  The Sales and Marketing team are key in characterizing product differentials and how the benefits will be sold, and not only how the sales team will sell, but if the Sales team can sell the benefits.

We could go on, but you get the importance of every department working together and pulling their weight. GHG has seen the success of plans who get the need for a deliberate process, as well as those plans in nail biting situations – hoping it all comes together at the end. Let me tell you, the first way is always preferable! So get your analysis started, put your project plan together, and start putting together your team if you haven’t already!



Don’t miss our webinar on Tuesday, January 31, at 1:00 PM EST, where we will provide an informative session on how to conduct a feasibility study to develop a successful growth strategy for your organization. Register now >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year's event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

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

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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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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