Compliance | GHG Advisors

Proposed Changes to the CMS-HCC Risk Adjustment Model

Policy changes governing risk adjustment in plans for Medicare-Medicaid dual eligibles may soon be coming.

In response to concerns about the accuracy of the Centers for Medicare & Medicaid Services (CMS)-Hierarchical Condition Category (HCC) risk adjustment model for predicting costs of dual eligible beneficiaries, CMS recently released a Health Plan Management System (HPMS) memo stating it will evaluate how well the model performs for these beneficiaries based from concerns raised that "the model may disproportionately affect specific populations, particularly dual eligibles."

These proposed changes will not affect the clinical relevance CMS has already included in the existing model or on non-dual eligibles. However, this new approach is a clear "win" for plans having significant numbers of full dual eligibles, both Dual Eligible Special Needs Plans (D-SNPs) and otherwise. The under-payment in the current system is pretty severe, based on the statistics in the CMS memo, and this new approach will fix that.

"This is an interesting change and will definitely have downstream impacts," said a member of the Operational Performance team at Gorman Health Group (GHG). "There isn't a lot of reconciliation on the Medicaid status. Health plans have to go by the designation by the state of what type of dual eligible someone is as there is no independent way to validate that level of coverage. So there isn't any additional reconciliation which will occur. Health plans can no longer submit updates to Medicaid eligibility through the retro processer. That data is much cleaner now than in past years and is fixed quickly due to Low-Income Subsidy (LIS) status cost share implications for dual eligibles."

Further, SNPs determine the type of dual eligible they will cover during the application process. They validate the member is eligible, based on that status at time of enrollment, but there is no submission or correction of that status. They have to use the state's data to validate whether they are a full dual-eligible, Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Medicare Beneficiary (QMB), etc.

What may be a challenge is identifying more clearly who is in what status to allow for projections and reconciliation of risk adjustment status.

I cannot stress the dire need for your Risk Adjustment team to be in constant collaboration with the core operations leaders within your organization to be sure the necessary reconciliation is occurring and that you have a solid data management and analytics strategy in place.

Initial Highlights:

a. The Impact on Partial Dual Eligibles

Some SNPs have most likely been generating some of their profits by enrolling partial duals for which the current HCC model generates some over-payment. The new model will eliminate this, and SNPs with significant partial dual populations need to start planning now.

b. Member Eligibility and Reconciliation

Beneficiaries could have months in one or more of the six sub-populations. Tracking a member's status and the hierarchy of the status in the base year will be important as plans forecast and reconcile their risk adjusted payments. If CMS moves forward with reviewing predictive ratios for six segments as it states in the HPMS memo, it will be very important for plans to ensure they are updating a member's Medicaid eligibility (QMBs/SLMBs, etc.) in a timely manner, which is currently a requirement, and the accuracy will be even more critical for projections and reconciliation of risk adjustment status.

Takeaways:

a. New Opportunities to Manage Trend and Control Utilization Costs

With improved accuracy for predicting cost, comes an opportunity for plans to be more targeted and efficient with their efforts to manage trend and control the utilization of those beneficiaries that are seemingly very costly (or at least are predicted to be very costly).

Processes around moving patients to and from the community and back to institutional settings will need to be seamless, clinically appropriate, and efficient. Politics and system loopholes allow facilities and health systems to game the system, keeping people in beds or reserving space in order to receive the reimbursement associated with the patient's status. Controls will need to be put in place: Utilization Management and Compliance need to be involved to keep a close eye on patterns for both beneficiaries and providers.

Data has had a staggering increase of importance and remains an integral part of the healthcare industry. The need to have refined data management processes to ensure data integrity and quality analytics is at an all-time high. Achieving this should be at the forefront of health plans' minds, especially with impending policy changes.

This proposed model will improve payments a little for the least expensive non-dual members, while reducing payments a little for the most expensive. But the most expensive probably have the most unreported and under-reported diagnoses, so a good risk adjustment program could compensate for the small predicted impact of this new approach.

CMS is soliciting feedback on their approach to revising the CMS-HCC risk adjustment model to better predict costs for beneficiaries based on their dual status and aged/disabled status for Payment Year 2017. If you wish to submit comments, please submit them to RiskAdjustment@cms.hhs.gov , with the subject heading "Proposed Updates to the CMS-HCC Risk Adjustment Model," by November 25, 2015.

If you are unsure how this will affect your organization, or how to accurately communicate your ideas to CMS in two weeks, our integrated team of experts specializing in risk adjustment, analytics, compliance, pharmacy, and operations can work with your organization to ensure you have the right processes in place to ensure a timely submission to CMS. Contact us today >>

Resources

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>

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

by GHG Advisors

Is Your Customer Service Ready? Top 5 Lessons Learned in 2015 Rolling into 2016

It's only a few months until we ring in a new year. Time flies, but there is still enough time to ensure we put our best foot forward as we begin 2016. Here are the top 5 lessons learned in 2015 as we roll into 2016 to ensure Customer Service is ready for the New Year:

What were your member's pain points in 2015? Reviewing grievances and appeals and Complaints Tracking Module cases (CTMs) has many purposes. High on that list is to improve the impacted process, but of course it goes beyond that. Sometimes we forget to close the loop and review and educate Customer Service staff on managing the pain points and how to work through difficult topics with our members. Better prepared Customer Service means better educated and knowledgeable members.
Are all tools and support materials updated for 2016? There is a close-out for issues and claims from 2015, so for a period of time, Customer Service will heavily rely on two sets of information. A clear understanding of what is in place for 2016 and how to find the correct information is critical to preventing confusion for Customer Service and members.
Have you tested your compliance with the various required timeliness standards? Can all Customer Service staff secure a translator within 7 minutes? Do they all know to stay on the line with the member and the translator once the translator is secured? Have you tested your TTY lines to ensure they reach a live agent during all hours of operation, 8 am — 8 pm? We are all monitoring average speed to answer and disconnect rates, but translator and TTY availability is harder to monitor, and every year the Centers for Medicare & Medicaid Services (CMS) finds plans failing to adequately manage non-English language and TTY calls.
Can your Customer Service staff recognize complaints about coverage for drugs as coverage determinations? In a recent CMS enforcement notification, the first item called out in the health plan sanction letter was the plan improperly classified coverage requests as grievances or customer service inquiries. The coverage determination request process should begin at the time of the original call. It is critical Customer Service staff can recognize and correctly process these calls. Have you pulled your Customer Service call logs to see if these are being correctly identified and routed appropriately? That's what CMS will do in an auditâ€•don't let them discover it first.
Have you set up a process to ensure all letters and communications sent to members are also available to Customer Service? Everyone hates being blindsided by an issue or new information. At most plans, this is an everyday occurrence in Customer Service. Have you set up a common repository for all member material to be stored, and copies of the member materials placed there, before the information is mailed? An informed Customer Service Department shows cohesiveness and gives members confidence in your program.

Customer Service is the heart of a health plan. Ensuring your Customer Service staff is top-notch and has the tools to perform at the highest level for every call is critical to your plan's success. Gorman Health Group's experienced Operations team can work with you to set up knowledgeable, well-trained Customer Service and Operations departments. We've been in your shoes and know your struggles and how to solve them.

Before we ring in the New Year, let's double check that our members will have everything they need from your Customer Service Department to start the year right!

Resources

Our team assists dozens of health plans every year in scrubbing their member data and can 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 >>

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

by GHG Advisors

2015-2016 CMS Program Audit Protocols Update

It's Christmas in October (and Hanukkah, too) if you've been waiting for the revised 2015-2016 Program Audit process and protocols. Let's get right down to it!

You'll want to review all 20 documents (made up of the memo, data requests, supplemental questions, templates, and impact analysis layouts) for their significant enhancements and make necessary changes in your own oversight programs. What are some significant changes, and what do they mean for you?

Overall Process

If the Sponsor fails to provide "accurate and timely" universe submissions twice, it will be cited as an observation in an audit report. After the third failed attempt, the Centers for Medicare & Medicaid Services (CMS) will classify this as an Invalid Data Submission, or IDS. There is NO reason a universe should be submitted late. Some of our Sponsor partners have required additional time for certain submissions, and they requested that time from CMS and got it. Nothing should irk senior leadership more than a universe being submitted a few minutes late, especially considering data issues in program audits directly impact Star Ratings.
CMS Account Managers will be playing a greater role in the validation of pre-audit issue summaries, which are made up of disclosed and self-identified issues. CMS also clarifies if CMS identified an issue during the course of routine monitoring and brought it to the Sponsor's attention, it would be classified as a self-identified issue. There are specific timing issues CMS will consider in determining whether an issue is corrected or uncorrected. It is best practice for Compliance departments to incorporate a log similar to what CMS has provided in the management of disclosed and self-identified issues.

CPE

Reduction of employee interviews, with addition of interview(s) of those responsible for managing accountability for FDR oversight. Not a surprise seeing as this has been a consistent finding for CMS throughout 2015 and previous years. Sponsors should coordinate and start mock interviews now with those who are responsible. CMS is seeing gaps in FDR oversight compliance whether or not you have three FDRs or three dozen.
By the numbers:
1. Tracer templates narrowed down from 2 to 1;
2. Tracer samples increasing from 5 to 6, all to be conducted in week 2, so Compliance staff can participate in week 1 activities;
3. There are 3 options for providing supporting documentation for tracers: embed into your Tracer, upload via SFTP, or have it immediately available onsite.
CMS has incorporated a documentation request list to help them review the effectiveness of a compliance program. These documents will need to be submitted along with the 5 universes for this audit area. CMS has also provided a template for the Sponsor to demonstrate organizational structure and governance. This template includes a number of questions and data requests, and should help auditors compare apples to apples.

CDAG and ODAG

Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) universe time periods will be determined by the Sponsor's enrollment size. In addition to numerous data layout clarifications and updates, CMS also details which universes may be combined with others to determine effectuation and notification scores.
As previously announced in 2016, Part C and Part D grievances should be submitted based on date of resolution notification. They include a reminder not to include Complaints Tracking Module (CTM) cases in grievance universes. (Who is still including CTM cases in grievance universes? Please call us, whoever you are, and let us help!)

Formulary Administration (FA) and Special Needs Plan Model of Care (SNP-MOC)

Thankfully, there were no significant changes noted in the core processes for these audit areas. Plans will note CMS has added the Cardholder ID to the SNP Enrollees (SNPE) record layout, and, more importantly, they request separate record layouts be submitted for each unique MOC rather than per contract.

Pilot Protocols

CMS commits to releasing the pilot protocols for Medication Therapy Management (MTM) and Provider Network Adequacy later this year.

They describe one of their objectives for the MTM review to "initiate enforcement actions and/or identify possible performance measures for sponsors to implement." Technically, CMS can refer a Sponsor for enforcement action for any aspect of the audit. Why highlight it in MTM? Get busy making sure your program is in order.
No surprises in network adequacy — CMS has emphasized they will be evaluating networks for adequacy by also evaluating whether or not participating providers' practices are open to treat enrollees. Some of our partner clients have already started their own internal evaluations to ensure this important beneficiary protection is met.

This year's audit season was a whirlwind of many things. For Sponsors and auditors alike, it's fair to say the industry struggled with the earlier-published protocol. Now that this document set has been released for 2015 and 2016, this should allow some breathing room for all to start implementing changes in tools, reports, and monitoring efforts. Unfortunately, that breathing room overlaps the upcoming holiday season, so perseverance is key! There is truly no rest for the weary.

Resources

In addition to monitoring your operations and auditing the organization's performance, CMS also audits the compliance function. In recent years many CMS sanctions have been issued as the result of a Compliance Program that was determined to be ineffective. Let us help you create a culture of compliance. Contact us today to get started >>

If your organization is interested in a mock audit utilizing the latest protocols. We can help! The Online Monitoring Tool™ is our compliance software designed to help organizations operating in Medicare, Medicaid and the Health Insurance Marketplace track the compliance of their operations. Learn more >>

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

by GHG Advisors

Considering Network Expansion? The Role Network Adequacy, Risk Adjustment, and Star Ratings Play

The leaves are changing colors, pumpkins are out on every front stoop, and the brisk weather signifies fall is in full swing. It also means we are in the midst of application season for health plans wanting to expand their geographic footprint. The Centers for Medicare & Medicaid Services (CMS) has put provider networks front and center under the bright spotlight, and Medicare Advantage (MA) plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan's network adequacy and accessibility is a cornerstone of any new initiative.

In today's marketplace, it is no longer acceptable to meet the bare minimum health service delivery (HSD) requirements. Consumers, and CMS, are demanding plans be able to offer choices including quality and cost efficiency. With consumer-savvy, newly aged-in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentive and rewards programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.

Additionally, the belt is tightening with day-to-day network management, and plans must reach out to their providers on a monthly basis to confirm demographics and availability of their providers to ensure the information is updated in real-time with online directories and close the loop between the providers submitted on the HSD tables versus those in the directory. We will also delve into network adequacy becoming part of the overall audit protocol pilot for 2015.

In an upcoming white paper, Gorman Health Group's (GHG's) Senior Vice President, Regan Pennypacker, will provide compliance insight on the draft application. A key network component in the draft is that plans will be required to submit their HSD tables for their entire network, not just the counties the plan is proposing to enter with the service area expansion request. This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely.

Given that applications will be due in a few short months, GHG is here to help. We have a long history of providing direct contracting assistance for plans, the ability to run multiple network adequacy and availability scenarios, and prepare your plan's HSD tables for submission. We also have the bench strength to help you develop a true network strategy taking into consideration the quality, financial, Star Ratings, and risk adjustment goals you need to reach in the competitive landscape of healthcare. Let us know how we can work together and build strategic network operations to support your plan goals.

Important key dates for application submission:

Resources

GHG can assist your organization 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. Let's get started. Contact us today

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

by GHG Advisors

MA-VBID Request for Applications Released

The Centers for Medicare & Medicaid Services (CMS) has released the Request for Applications for the Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model, which is an opportunity for MA plans to offer supplemental benefits or reduced cost sharing to enrollees with CMS-specified chronic conditions, focused on the services that are of highest clinical value to them. Applications are due by January 8, 2016.

CMS will tentatively select plans by April 2016. The application document repeats most of the information CMS released in the original announcement and webinar. However, the application will be submitted via a web portal which will be released in the near future. The process is much like the MA contract application process. CMS does provide information about the questions which will appear in the template.

Applicants will be required to present narrative explanations about their proposed interventions. First, there is the general overview of the proposed interventions describing the overall approach and understanding. This section must convey specific enough information tracking to details about interventions in later sections of the template. It will act to set the stage of an application.

Next, applicants must describe each separate VBID intervention. This will include each combination of plan and enrollee group so every target population is described with repetitive plan information and interventions. CMS describes the target population according to the eight qualifying diseases/conditions listed in the VBID demonstration.

Applicants must list specific benefits for each target population. CMS lists the various combinations of benefits:

Reduction or Elimination of Cost Sharing (not conditional)
Reduction or Elimination of Cost Sharing for High Value Provider
Reduction or Elimination of Cost Sharing Conditioned on Participation
Supplemental Non-Covered Benefits

CMS asks for "clear descriptions" in each of the four options and provides a number of elements applicants must discuss in their narratives.

While applicants must upload actuarial and financial documentation in this template, there are no specifications about the types of information for which CMS will ask. Notably, there is a statement that such information may not be required.

Health plans must also discuss their compliance history extending to January 1, 2010. Finally, an official of the applicant must certify their applications, their understanding about the conditions including marketing limitations, and bid requirements.

Data analysis is the key first step to identifying target populations and subsequent benefits which will become the focus of the demonstration. A team of subject matter experts from Gorman Health Group will deliver actionable results, driven by data analysis of current capabilities and benefit designs, to achieve quality care for the target populations. Contact us to learn more >>

Resources

Download a copy of the recording from the October 5 webinar titled "Medicare Advantage Value-Based Insurance Design Model (MA-VBID)", hosted by John Gorman.

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

by GHG Advisors

The 2016 Star Ratings: Finding Calm in the Chaos

All great changes are preceded by chaos, and the Centers for Medicare & Medicaid Services (CMS) release last week of the 2016 Star Ratings certainly introduced a great deal of chaos for Star Ratings teams throughout the industry. With approximately 5% of additional reimbursement tied to â‰¥4-Star performance, health plan leaders are either taking a deep breath this week (if they earned â‰¥4 Stars and qualified for Quality Bonus Payments) or doing their best to quell the inevitable panic if the 4^th Star eluded them.

CMS continues to leverage Star Ratings to support improvements in member perceptions and longer-term, sustainable improvements in health plan performance and health outcomes. CMS continues to make rapid, continuous changes among measures, cut points, and program criteria. The speed and extent of change reinforces the need for a seasoned, dedicated Star Ratings leadership team which embraces and manages Star Ratings as a holistic, silo-busting program. It's vital for health plans to simultaneously excel not only in their clinical and pharmacy quality functions but also in every other health plan function. This includes everything from care coordination, network operations, member experience, risk adjustment, appeals and grievances, and compliance, to claims and encounter data and analytics, marketing, and every other department in the organization.

As we adapt to the first Star Ratings cycle with no predetermined thresholds, it's clear there is very little low-hanging fruit left in the Star Ratings program. It's time for us to climb the tree.

With budget season upon us, it is an ideal time to evaluate Star Ratings strategies and work plans to ensure 2017 investments are wisely made. Now that the 2016 Star Ratings are out, take an objective look at your Star Ratings programs to ask:

Are we investing adequately in the areas where we need the most Star Ratings lift?
Will our Star Ratings initiatives achieve our goals?
Are we conducting the right interventions, with the right members, at the right time?
Are we adequately integrating medication management and behavioral health into our Star Ratings programs?
Are we adequately coordinating provider and member engagement activities?
Are our provider contracts and pay-for-quality programs designed adequately to sustain success in the new Star Ratings environment?

If your plan achieved 4 Stars this year, this is no time to rest. The 178 plans at 3 or 3.5 Stars in 2016 are working hard to achieve 4 Stars this year, and with CMS' bell curve, this means some of the current 4-Star plans will drop in 2017. And don't forget — there are another 188 Medicare Advantage plans not rated in 2016. This huge group of plans will impact the bell curve as they receive their first ratings.

If your plan missed a 4-Star Rating this year, now is not the time to panic. There is still time to influence your 2017 Star Ratings, particularly since the Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) and Health Outcomes Survey (HOS) surveys will not be fielded until early 2017. But since time is definitely of the essence, it is important to invest time and resources wisely into the areas with the greatest opportunity for short-term improvements.

We can help. Gorman Health Group understands the complexities and nuances of the Star Ratings program and measures. We know how to design programs, initiatives, and tactics to improve Star Ratings performance. From evaluating organizational strategy to developing and optimizing tactical Star Ratings work plans, our team of experts has a long history of success helping health plans achieve Star Ratings success.

With time waning to influence the 2017 Star Ratings, find calm amidst the chaos and prepare for the great changes to come.

Resources

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

by GHG Advisors

2016 Star Ratings are Working, and the Bar is Rising

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Medicare Advantage (MA) Star Ratings early this year, on Thursday morning. The usual practice is to wait until Friday after the close. It was a shift designed to move markets, and the news was mixed. Overall, Star Ratings are working to improve quality in many areas of health plan performance, but insurers and their provider and pharmacy benefit partners are struggling on a similar number of metrics. What is clear is that Star Ratings are now the fulcrum of competition in government health programs — and man, this stuff is hard and getting tougher.

There are clear winners and losers in this release. There is a "Divine Dozen" of 5-Star-rated plans, including a couple of new arrivals to the 5-Star world. CIGNA traded its 5 Stars in FL (the legacy HealthSpring plan at the legendary Leon Clinic) for its Arizona plan. Sierra (9 states), Tufts (MA), Group Health of MN, and Essence (IL and MO) made it into the Pantheon. Repeat 5-Star rock stars include Kaiser in 8 states, Martin's Point (ME and NH and will soon own Medicare in Northern New England), and Gunderson in IA and WI.

The half-dozen "walking dead" — plans scoring below 3 Stars for 3 consecutive years —included Wellcare of LA, Sierra Health, Touchstone, Cuatro, Windsor, and GHS (owned by HCSC). Three will be terminated by CMS at the end of 2016.

Star Ratings are proving to be tremendously effective in moving markets and forcing industry investments in population health and the member experience and are driving big improvements in Medicare quality. Roughly half of MA plans (179 contracts) earned 4 Stars or higher for their 2016 overall rating, a nearly 9% increase in a year and the first time a majority scored over 4. On an enrollment-weighted basis, over 70% of MA enrollees are in contracts with 4+ Stars, a nearly 11% increase year over year.

But below the water line, at the metric level, the news was mixed and cautionary:

The good news: Average Star Ratings increased for 10 Part C measures and 5 Part D measures. We saw significant improvements in several challenging, longitudinal Health Outcomes Survey (HOS) measures: Improving/Maintaining Mental Health, Monitoring Physical Activity, Part D Appeals Autoforwards, and High Risk Medications. There were smaller improvements on many other measures, where removal of the 4-Star thresholds helped plans improve ratings.
The bad news: Average Star Ratings DROPPED for 16 Part C measures and 6 Part D measures. We saw significant decreases in several screening measures (colorectal cancer screening, diabetes kidney disease monitoring) and the HOS measure of improving/maintaining physical health. And there was a big drop on the Medicare Plan Finder (MPF) Price Accuracy measure, where the cut points have gotten so small that 97% accuracy only gets 3 Stars, 99% results in 4 Stars, and it literally takes a perfect 100% to earn 5 Stars.

We knew the removal of the 4-Star thresholds would produce a tremendous amount of fluctuation in the measure cut points, and that's exactly what happened. It's like playing "Pin the Tail on the Donkey" during an earthquake, making it really hard for health plan leaders to predict where their ratings will ultimately land while they still have time to influence them. For example:

The average rating on the Diabetic A1c Control measure increased from 3.3 in 2015 to 3.9 in 2016. But there was no change whatsoever in the average performance rate for this measure — in both 2015 and 2016, the average compliance rate was 76%. The improvement on this measure can be entirely attributed to CMS relaxing the cut points once the predetermined threshold was removed.
In contrast, the Controlling Blood Pressure measure rating dropped from 3.7 in 2015 to 3.4 in 2016. The compliance rate actually increased from 65% in 2015 to 71% in 2016. This is an example of where the removal of the predetermined thresholds tightened the pressure on this measure — in fact, the 4-Star threshold increased 12% upon removal of the predetermined thresholds.

The Star Ratings data for 2016 pretty much emasculated industry arguments for relaxing metrics for Special Needs Plans (SNPs). SNPs saw improvement in their quality scores roughly equal to that of HMOs and PPOs: MA plans operating SNPs averaged a 3.61 rating in 2016 (up from 3.47 in 2015), while plans with HMO/PPO-only contracts averaged 3.87 in 2016 (up from 3.79 in 2015).

Non-profit MA plans are pounding for-profits into the sidewalk on quality. About 70% of non-profit MA plans received 4+ Stars vs. 39% of the for-profits. Much of that discrepancy is due to culture. Non-profits tend to be far more focused on the all-important member experience measures and are more collaborative with their provider networks.

Methodological changes by CMS ensure the Star Ratings bar will continue to rise. 2016 is the first year plans with 500-999 members were rated. Only 369 Medicare Advantage Prescription Drug Plans (MA-PDs) were rated in 2016. 188 more plans weren't rated, but may be in 2017 — and this dilution will warp the bell curve plans are graded on, especially when considering most of those 188 are provider-sponsored, and strong performers will emerge. 4+-Star plans have the most to lose in this environment, and no one can afford to get comfortable.

Some takeaways:

Stars must be managed as a program and a corporate priority, not as a group of measures. The effort must be directed by dedicated executive leadership and support. No plan improves Star Ratings doing it off the side of their desks.
The removal of the remaining predetermined thresholds means there is no way for plans to "pick and choose" a subset of measures to focus on. It has to be improvement across the board.
The bar continues to rise fast among Part C Star Ratings measures. The "low hanging fruit" has been eaten. Part C Star Ratings success is no longer easily influenced by slick reports provided to physicians. Plans need to help providers execute on gaps in care plans and eliminate barriers to care for the vulnerable. There's a reason the 5-Star plans are mostly provider-sponsored, vertically integrated, collaborative, and member-centric by nature.
Star Ratings measures need to be woven into every department's work streams. This includes not only quality, care management, health services, and pharmacy, but also risk adjustment, network operations, and compliance.
Lagging SNPs need to work harder and smarter and assume no CMS help on the measures for the low-income and disabled. To the contrary, recent draft measures for dual eligibles from the National Quality Forum focus on mental and behavioral health and will prove an enormous challenge.

If you achieved 4+ Stars this year, congratulations, it's an increasingly impressive accomplishment. Now get back to work. There are 178 plans at 3-3.5 Stars who are close on your heels and feeling the urgency. Now add the 188 unrated plans who will smash the bell curve in 2017. A 4-Star plan's equal effort in 2016 only guarantees a score that starts with a 3 the next year. Keep. Moving. Forward.

If you missed your 4^th Star this year, panic a little, but then get it together. Fast. In a competitive market, you're circling the toilet bowl but aren't flushed yet. You still have time to influence your 2017 Star Ratings and must make improvement the focus of your benefit, formulary, and network designs in the months ahead. You have big decisions to make and must invest time and resources wisely and with a sense of urgency.

Once again, the 2016 Star Ratings prove the world's biggest experiment in performance-based payment is working and forcing insurer evolution. And evolution isn't about size, it's about continuous adaptation.

Resources

Whether your plan missed the overall 4-Star Rating necessary to earn Quality Bonus Payments, or whether the new 4-Star cut points have introduced new risks of maintaining your overall 4-Star rating, we can help. Our team of experts understands the Star Ratings program and knows how to influence performance. Contact us to learn more >>

Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register now >>

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

by GHG Advisors

Do More Than Survive AEP

How quickly another Annual Election Period (AEP) is upon us. This time of year is the perfect time to review your new member onboarding activities and AEP strategy. We all know the sale doesn't end when the application is turned in and membership begins. This is where the rubber hits the road.

These are the four questions to consider going into AEP:

Are all plan resource documents updated with the 2016 plan benefits? Picture this: A friend newly eligible for Medicare recently enrolled in a Medicare Advantage plan. He experienced a benefit problem that nearly ended in a sales allegation all because a representative was relying on outdated benefit information. This would have been avoided if everyone at the plan had the new benefit designs.
Does health plan staff see the big picture? It's easy for us to focus on our individual operational components. After all, the number of regulations and processes to manage a compliant Operations Department is significant and takes our full attention, but the big picture allows for cohesive programs and the ability to see what part we play. Does Enrollment know the top issues that Reconciliation experiences? Is there a feedback loop established to catch improvement opportunities early as we move into AEP? Has Sales shared the advertising schedule and advertisements with Customer Service? Customer Service can maintain that strategy and answer member questions about the campaigns for 2016.
Are operational oversight tools in place? Not only should all operational staff know the requirements governing their processes, they should know how to tell they are meeting those requirements. The ability to oversee our own processes and know we are in compliance is empowering. Not only can corrections occur immediately, but staff can be confident and efficient, focusing on the important actions supporting new and existing members.
Is everyone focused on the goal — ensuring a positive member experience? If applications are incomplete, is the Enrollment staff focused on sending a letter to get the application off their plate or focused on reaching out to the member to complete the member enrollment? Are welcome calls in place to answer any lingering questions and ensure new members feel confident and engaged in their plan choice?

AEP was quick to arriveâ€”it will be equally quick to come to an end. Make sure it's the AEP you designed rather than the AEP you survived.

Resources

In Operations, we naturally focus on our own internal processes and efficiencies, but now is the time to invest in making sure staff knows how their contributions impact members and the health plan. Gorman Health Group's experienced Operations team can work with you to set up strategic, efficient, and knowledgeable operations. We've been in your shoes and know how to navigate through AEP. Visit our website to learn more >>

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

by GHG Advisors

The CMS Fall Conference: 4 Ways to Solve the Preparedness Problem

The Centers for Medicare & Medicaid Services (CMS) held their Fall Conference and Webcast on September 10 in Baltimore. The presentations and videos from the event are found on the Compliance Training, Education & Outreach site here. CMS covered various aspects of the Medicare Advantage Prescription Drug (MA-PD) program, but here I've focused on four lessons I heard loud and clear: work with CMS, prepare ahead of time, seek continuous improvement, and don't wait until the last minute.

Linda Anders from CMS hosted two Aetna representatives who discussed lessons learned in beneficiary and pharmacy outreach stemming from strategic network changes taking place over 2014 to 2015. They had developed a communication strategy but soon understood a lack of clarity and misinformation caused significant beneficiary and pharmacy confusion. Ms. Anders stressed there is much to be learned from Aetna for any plan contemplating changes to their program. Aetna recognized their Part D network configuration was "generally consistent" with CMS requirements. It is recommended any plan contemplating program changes not tested in the industry work closely with CMS on these initiatives.

Gregory Woods gave valuable information regarding the Value-Based Insurance Design (VBID) Model Test. Things will move quickly for the VBID model. While they are beginning this test for 1/1/2017 effectives, the Request for Application (RFA) responses will be due sometime this November or December. This is new, so Compliance and Product teams, prepare yourself for a new onslaught of questions from Clinical and Actuarial, because they are coming.

As a lead-in to a presentation from MAXIMUS Federal Services, CMS confirmed they are working with a small number of plans on point of sale rejections. They hope to share more information about that in the 2017 call letter. Some helpful reminders were then provided regarding appeals going to MAXIMUS. Make sure your organization is referring to the most updated process manuals provided by MAXIMUS for Part C and Part D appeals. Additionally, there is a significant amount of appeals data dating back to 1997 showing your plan's percentage of upholds and overturns. Organizations can compare to other plans to benchmark or simply leverage to spark internal process improvements. Cathleen MacInnes, Project Director, also addressed the development of a submission portal for electronic upload of case info to MAXIMUS. If your organization is interested in participating, contact either her or her Part D counterpart. From an operational perspective, that should make sharing case info much easier, so long as it is secure, secure, secure.

The icing on this conference cake was the update from Jennifer Smith, Director, Division of Analysis, Policy and Strategy, Medicare Parts C and D Oversight and Enforcement Group, on 2015/2016 program audit protocol, processes, and activity. The changes she outlined are exciting — here are some, and since I've already written plenty, you can either watch the video or contact me for more details and my thoughts.

Edits to record layouts will include not only those outlined during June's Oversight and Enforcement conference but also additional edits based on plan and auditor feedback. Extraneous fields will be gone, headers will be added to record layouts, and more clear instruction will be incorporated as to what should be included and excluded.
Beneficiary Impact Analyses (BIAs) will not be requested at the time of the self-identified and self-disclosed issue reporting. Organizations should still anticipate a BIA request if an issue is found during an audit.
CMS is also revising their policy on the "three strikes" for universe submission.
The two anticipated pilot audit areas are being moved to 2016.
Compliance Program Effectiveness (CPE) will be conducted either onsite or virtually.

"It is also important to remember the audit protocols are more like a pop-quiz than a final exam," says Charro Knight-Lilly, Senior Vice President of Client Relations. Don't lose sight of the need to comply with all requirements and testing performance through monitoring, auditing, and annual risk assessment. Ms. Smith said something that resonated with me and likely others in the industry: Don't wait until the audit notice to practice universe pulls and activities. If you do, you are behind the 8-ball.

Resources

CMS outlined areas of poor performance within the release of the Outlier Notification in August. In addition to audits and Corrective Action Plans (CAPs), this notice also referenced Compliance Letters (C and D) and Star Ratings (C and D) as areas of concern and indicators of poor performance. Both of these areas require advance planning, preparation, and coordination in order to make an impact a minimum of one full year later. Don't exhale as we head in to the 2016 Annual Election Period (AEP) — now is the time to plan strategy for 2017. Contact us to learn more.

Join John Gorman, Founder and Executive Chairman at GHG, for our upcoming webinar on MA-VBID Model plan requirements, needed strategies for data analysis and benefit development, as well as what you need to be doing now to prepare for January 2017 on Tuesday, September 29, from 1-2 pm ET. Register here

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

by GHG Advisors

Government Sends Stark Reminders that Insurers' Biggest Customer is Still the Regulator

Since we opened our doors 19 years ago, we've preached to health insurers to think of the government as your business partner. This week, we got several reminders that insurers' biggest customers -- Medicare, Medicaid, and ObamaCare -- are still the regulator. As business conditions improve for health plans across these business lines, government expectations are rising, and scores are about to get settled, as they always are in the second term of a Democratic administration.

We see it in enforcement activity from the Centers for Medicare & Medicaid Services (CMS). We see it in a steadily-rising bar of Star Ratings and other performance measures for health plans for all three programs, the basis of looming contract terminations. And now the White House jumps in with an aggressive schedule of risk adjustment data audits, openly seeking repayments and dropping "f" bombs: fraud, that is.

They named a great film after a moment like this: "There Will Be Blood."

You can't argue with the numbers: 2015 remains the most punitive year in Medicare Advantage history. Look at the trend:

CMS is also being much more aggressive this year with data-driven oversight and enforcement. Communications to health plans who are "outliers" in various performance measures, especially in member communications and consumer protections, began recently. A pattern we are seeing play out is CMS chasing down all clients of noncompliant pharmacy benefit managers; where poor Part D performance is seen in one plan, the agency then begins auditing that vendor's other customers, assuming they'll get the same findings.

We know that Star Ratings and expanding reporting requirements in Medicare Advantage and Part D mean the bar is rising and establishes data-driven thresholds against which health plans can be penalized and terminated beginning in 2016. CMS announced sweeping new reporting requirements for both programs this week, which inevitably get picked up in Medicaid and ObamaCare rules in following years.

And now the White House is piling on. In Washington, we talk a lot about "setting the terms of debate." Our industry has lost the debate on risk adjustment coding and has allowed anti-managed care advocates to define payers' inaccurate diagnostic coding as fraud. A just-disclosed February 2015 letter from President Obama's Budget Director to Health Secretary Sylvia Matthews Burwell stated, "While some progress has been made on this front, we believe a more aggressive strategy can be implemented to reduce the level of improper payments we are currently seeing...we must continue to explore new and innovative ways to address the problem and attack this challenge with every tool at our disposal...the government estimate of $12.2 billion in these mistakes for fiscal year 2014 remains a concern." He extended his mandate beyond Medicare Advantage to over $3 billion in questionable payments from Medicaid. This means a spike in data validation audits for payers across both programs with the threat of improper payment clawbacks and even prosecution under the False Claims Act.

There has never been a more Golden Age of opportunity for health insurers in government programs. But the threats are escalating as well, and as my politics professor told me, "99% of political wounds are self-inflicted." Plans caught up in this dragnet will have gotten plenty of warnings.

Resources

The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. Click here to review the Part C highlights that merit your attention in a blog posted by Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG).

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

by GHG Advisors