Gorman Health Group Client Forum Takeaways: Government Programs are Booming, Bar is Rising
We just wrapped our best-ever Gorman Health Group 2015 Client Forum at National Harbor with over 200 of our closest clients and partners. There was both great and tough news, so here's a few takeaways, including a couple stunners:
- For the first time, a prominent Wall Street analyst said he could see a path to 100% Medicare Advantage penetration. Barclay's eminent health care observer, Josh Raskin, stunned our audience with projections of over 29 million Medicare Advantage enrollees by 2023, a penetration rate of over 42%, with the potential to go all the way with Ryan Plan-like legislation now feasible this decade.
- 47 states now hold Section 1915(c) home and community-based services waivers for Medicaid, which will unleash a new flood of dual eligibles into health plans. Special Needs Plans (SNPs) for duals are now on a path to permanent reauthorization, and over 30 states now use D-SNPs to enroll over 1.6 million beneficiaries. That number will more than double in the next 2 years.
- While year 2 of open enrollment for ObamaCare was dramatically improved from its messy launch, problems persist, especially with membership reconciliation and issues related to the interim process to auto-enroll most members staying in their plans. Cleanup of membership discrepancies will likely take another year or even longer.
- Risk Adjustment Data Validation (RADV) audits will become the new normal in Medicare Advantage. 2015 will be the first time we see plans prosecuted under the False Claims Act and hundreds of millions clawed back by the Centers for Medicare and Medicaid Services for unsubstantiated codes submitted for higher payments.
- Maximizing data, strong provider partnerships, documentation and ICD-10 preparedness are keys to audit proofing your Risk Adjustment program.
- The Star Ratings system of performance-based payment is the new cornerstone of competition among health plans. Stars has expanded into more than a dozen state Medicaid programs, and to ObamaCare's issuers as well, and the bar is rising. Technical changes to several measures mandate much higher performance to stay ahead of the curve and avoid falling below 4 Stars, where bonus payments and bid rebates vanish. 2015 will be the first year where plans below 3 Stars are terminated.
- Medicare Advantage plans won several lobbying victories in this year's "Call Letter", the rate and policy announcement for 2016, including an average 1.25% benchmark increase from a cut in the February draft. This signals a new era of influence muscle for the industry, where CMS will increasingly fight out policy changes "below the waterline" in subregulatory guidance and enforcement, where politicians are less likely to intervene.
- Appeals and grievances and pharmacy benefit management vendor performance remain the #1, 2 and 3 regulatory infractions in Medicare Advantage, and integration of long-term care and supports and services the leading challenge facing Medicaid health plans.
- CMS is on pace for its most aggressive enforcement year ever, with over a dozen actions taken against plans this year already.
As we've said since the passage of the Affordable Care Act, we are now in the Golden Age of government-sponsored health programs, and the opportunities and challenges that come with this shift have never been greater. Our clients went home with a clear grasp of both, and we are thrilled so many joined us this year.
Resources:
Join John Gorman, GHG's Founder & Executive Chairman, as well as Bill MacBain, GHG's Senior Vice President of Strategy on April 14 as they provide a hard-hitting analysis of critical areas addressed and finalized in the document from 1-2pm ET. Register now >>
GHG's Senior Vice President, Healthcare Analytics & Risk Adjustment Solutions, Dan Weinrieb, recaps the Risk Adjustment rulings in the Final Call Letter and provides keys to success in an article on the GHG blog. Read more here >>
Private label health plans - a tool for increase market capture and improved patient outcomes
Private label health plans or co-branded health plans are joint efforts between like minded health plans and provider organizations interested in enhancing market share, achieving improved patient outcomes, minimizing duplication of services and achieving financial accountability. In its purest form, a private label health plan combines the strengths of the participating providers such as reputation, innovative practice patterns, trusted referral patterns and coordination of care techniques with those of the participating health plan such as benefit design, network design, contract administration and other insurance plan core competencies.
Most often, a private label enterprise has as its core characteristics, a value based limited network in which the participating providers agree to, and adhere to, mutually designed clinical and financial performance targets which are intended to optimize patient outcomes and financial performance targets ultimately leading to increased provider and health plan profitability. Benefit plans are customized to maximize in network access, member engagement and minimize out of network referrals. The insurance partner, in addition to providing the basic insurance administrative and medical management insurance functions, contributes by offering access to data and technology often unavailable to providers otherwise.
Private label health plans are a potentially attractive option for health plans that are already working with Accountable Care Organizations , (ACO's) and large Integrated Health Systems, (IDS) who control all, or a majority of, the resources necessary to achieve continuity of care ranging from primary care to end of life care.
Large self insured Employers that labor under legacy self insured insurance programs for their retiree populations are potential customers for private customized private label benefit plans and value based networks because they offer the Employer greater control over benefit offerings, defined employee or retiree contribution and medical cost.
At the Gorman Health Group we have a history of supporting Medicare and Medicaid Health Plans and Provider organizations on innovative approaches to network development, healthcare pricing and model of care development, as well as working with ACO's on achieving improved financial performance and member engagement.
Resources
Need our help? Interested in starting a dialogue on Private label plan development, value based network formation or optimization of ACO performance? Take the first step and call us at 202-364-8283 and ask for me directly or one of our senior subject matter experts or contact us via the GHG website. We are here to help.
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
Republican Congress to Use "Inside Baseball" and Courts to Maim ObamaCare
Blowing in like a flu outbreak as year-end approaches, ObamaCare Derangement Syndrome has enveloped the Capital. Republican leaders in Congress are plotting to use arcane parliamentary procedures and the courts to do further violence to ObamaCare, and by extension, to the millions who have gained insurance through it. While it's red meat for the conservative base, the strategy presents a huge political problem for the GOP: they have nothing to replace it with.
Since the midterms last month, Republican Congressional leaders have been locked in a furious, behind-closed-doors planning effort to gut ObamaCare once and for all. While the GOP has finally awakened to the fact that repealing the Affordable Care Act ain't gonna happen on Obama's watch, Republicans are licking their chops to use an obscure fast-track budget process called reconciliation to deal it a mortal wound with only a simple majority. It's a longshot with many difficult parliamentary steps, but if successful, could deal a fatal blow to the marketplace subsidies, the Medicaid expansion, and/or the individual mandate. But I've consistently underestimated the effects of ObamaCare Derangement Syndrome, so I'm making no bets this time around.
Barring that, plans are also being laid to craft a bipartisan bill that would strip out more minor provisions like the device tax, the Independent Payment Advisory Board (IPAB), and restoring a 40-hour workweek. That seems to have a better shot, assuming the reconciliation effort doesn't poison the already toxic well on the Hill.
The second prong of the Republican attack is through the courts, with a goal of "repeal by Justices." GOP leaders are convinced that where repeal may fail legislatively because the President won't kill his signature domestic achievement, the Supreme Court just might do the dirty work for them.
The first test, of course, is King v. Burwell, the challenge to the Federal marketplace subsidies the Court accepted in a surprise move last month. The case hinges on payment of Federal subsidies to people who enroll in insurance marketplaces run by CMS, and not by states. It was basically a drafting error that now threatens to put ObamaCare into a death spiral if the plaintiffs win.
The Court has acted to hear the case early in its session in March, but we won't know their ruling until June 2015. I put it at 50/50, because four Justices don't vote to hear a case unless they're confident they can get a fifth for a majority ruling. That fifth vote, of course, is Chief Justice John Roberts, and he's a total wild card. He has voted for both sides of the Court, and is very mindful of his legacy and the institution's legitimacy. He said recently that the partisanship shouldn't penetrate the walls of SCOTUS, and that's encouraging for ObamaCare supporters.
Most Constitutional scholars here in DC seem to think the merits of the case favor the Administration, but there's a whole lot of liberal hand-wringing going on here. A win for the plaintiffs and the end of Federal subsidies to 4.5-7 million Americans would of course be lethal to the marketplaces, and there's little activity underway at the state level for that contingency. It would effectively wipe ObamaCare off the map entirely in Red States with no exchange and no Medicaid expansion. If it fails and the ACA's subsidies are upheld, Republicans are lining up multiple other challenges to the Affordable Care Act, all with a goal of getting them to SCOTUS.
I think a win for Republicans in King creates a huge political problem: they will tear health insurance away from millions of Americans, with no alternative or replacement in sight. Not even Medicaid expansion. And that would take some "splainin'" to do in 2016, when Hillary gets her second act on health reform.
Resources
Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.
Don't miss GHG Founder & Executive Chairman, John Gorman, at the ICE 2014 Annual Conference, delivering the keynote address titled "Evolve or Die: A Darwinian Moment in Government-Sponsored Health Programs. To find out what other events GHG experts will be speaking at, visit our website >>
Medicare and Exchange Risk Adjustment: Data Quality Matters
Plans/Issuers participating in the Exchange may think they have dodged a bullet because HHS has stated payments will not be adjusted during the first two years of the program as a result of RADV audits. However, other remedies such as prosecution under the False Claims Act may still be applied to non-compliant issuers (health plans).
With CMS processing the results of the first Medicare RADV audit subject to extrapolation and with the inaugural audits for the Exchanges kicking off in just a few months, plans need to have a blueprint of how they are going to minimize their audit exposure through data analytics. Because of the different demographics of the Exchange population vs. the Medicare population, health plans in the Exchanges have a learning curve to overcome to address some of the more common coding issues associated with diagnoses for this younger population. The HHS-HCC model is more complex than Medicare and has 15 different payment models based on 5 metal levels and 3 different age bands: the adult model (ages 21+), the child model (ages 2-20) and the infant model (ages 0-1). Pregnancy, newborn and congenital coding rules need special focus in order to receive the appropriate reimbursement. Plans need to be proactive in their approach to data integrity in order to remain competitive and minimize government take-backs.
Whether you rely on multiple vendors, an internal team, or a combination of the two, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping stride with CMS and HHS expectations in both compliance and health care outcomes. Our services include:
- Risk Adjustment Strategies — Retrospective, Prospective and Concurrent Outreach strategies, evaluation of staffing structure and levels
- Quality Assurance Programs — Proactive programs to improve data accuracy
- Data Analytics — Identifying data gaps and appropriate gap closures
- End to End Process Review — Testing for dropped data and recommendations for best practices in data processing
- Provider and Coder Education/Coding - including ICD 10
- Risk Mitigation - Identifying unsubstantiated diagnosis codes
- Data Validation — Mock Audits
- Vendor Audits — Coding accuracy, data completeness
- Requests for Proposals (RFP) - Developing RFPs and/or the evaluation of RFP vendor responses
Resources
GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit out website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.
Don't miss GHG Founder & Executive Chairman, John Gorman, at the ICE 2014 Annual Conference, delivering the keynote address titled "Evolve or Die: A Darwinian Moment in Government-Sponsored Health Programs. To find out what other events GHG experts will be speaking at, visit our website >>
A Bad Couple Weeks for ObamaCare
It's been a bad couple weeks for ObamaCare. It started with a Republican gorilla-stomp in the midterms, a rout that included several Governors' mansions and state legislatures that essentially froze in place the Medicaid expansion map. Then, in a shocker, the Supreme Court decided to consider King v. Burwell, the case that could undo ObamaCare's marketplace subsidies and threaten the coverage of more than 4 million Americans. It's enough to give weekend bedspins.
Ice Age for Medicaid Expansion
In many states with rampant uninsurance, Republican candidates won critical Governors' races and in others the GOP solidified seats in their legislatures. The net effect: it's a new Ice Age for the Medicaid expansion map, with states taking the Affordable Care Act's (ACA) 100% Federal match for uninsured adults essentially now frozen in place. We may even see some backsliding.
Some 24 states have accepted the ACA deal and expanded their Medicaid programs in the wake of the last big SCOTUS ruling on ObamaCare. In fact, more Americans have gained coverage from Medicaid expansion than ObamaCare's subsidies in the new insurance marketplaces. But despite the fact that holdout states continue to pay their share for Medicaid expansion through Federal taxes, over two dozen mostly Red State governors continue to throw the middle finger at the guy in White House. Most notably, reelection of Rick Scott in Florida, Scott Walker in Wisconsin, Sam Brownback in Kansas, Nathan Deal in Georgia, and Rod LePage in Maine stuck a fork in coverage for the uninsured there.
Utah Gov. Gary Herbert will outline a formal Medicaid expansion plan this month. Republican governors in Tennessee, Wyoming, South Dakota and North Carolina have also flirted with Medicaid expansion plans in 2015. And a late recount win in Alaska for left-leaning Bill Walker may open prospects for coverage for 43,000 residents in 2015.
But we could see real retreat on Medicaid expansion in GOP states that were already moving forward. New Republican governors in Arizona, Arkansas, and Illinois have the power to threaten health coverage for hundreds of thousands who have enrolled in expanded Medicaid, and have done so during the campaign. Indiana Governor Mike Pence was negotiating a plan with the Obama administration pre-election, but now appears to have his own Presidential aspirations in mind and may put the plan on ice. Arkansas' controversial Medicaid expansion waiver to use Federal dollars to buy private coverage was already approved, but its new governor, former US Rep. Asa Hutchinson, is no fan of the plan, which requires annual approval by the legislature and is now very much in doubt.
It was a bad midterm election for the uninsured, especially childless adults. What remains to be seen is how hard a line the Obama Administration takes to force holdout Red States to take the money, using existing Medicaid funds as leverage. My guess is that hard line will be pretty limp. As George Burns said, "like shooting pool with a rope."
The SCOTUS Subsidy Surprise
The day after the election the Supreme Court made a surprise decision to hear arguments in King v. Burwell, what many thought to be a sideshow case in the lower courts around the Constitutionality of ObamaCare subsidies in the 36 states using the Federal exchange. It was basically a case challenging a drafting error in the law, which didn't make clear enough distinction between state-based and Federal marketplaces, and ACA opponents saw their opening.
Even being "strict constructionists" in their jurisprudence, one has to believe the conservative activist Court didn't take this case to rubber-stamp ObamaCare's subsidies. If the justices find for King, some 4-4.5 million Americans will see their martketplace subsidies at risk. Without subsidies, the vast majority of those insured will drop coverage like a hot rock, leaving only the sickest in the pool — what economists call a "death spiral" for insurers operating in the marketplaces. It would essentially lay a mushroom cloud on all private coverage options in those states, leaving ObamaCare a smoking wreck of mostly Blue State Medicaid expansions.
There's no ignoring this point: in Republican territory, the ACA and its marketplaces and Medicaid expansion are more vigorously opposed than in states that elect Democrats. If SCOTUS upholds King, then coverage and politics will truly converge in Red States. A win for King means Red States can effectively purge themselves of all vestiges of ObamaCare, by not expanding Medicaid and not establishing an exchange.
I think this would be a huge problem for Republicans, forcing them to come up with solutions that are politically palatable to them. All these new GOP Members of Congress, and Red State holdout governors, need to start thinking, now, about what to do if SCOTUS announces a decision in June 2015 denying tax credits to millions of their citizens, while they in turn continue to deny Medicaid coverage.
Resources
On Friday, November 21, join John Gorman, GHG's Executive Chairman, together with colleague, April Fleming, GHG's Senior Vice President of Products, as they discuss the challenges of non-compliance, and introduce the new Appeals & Grievances solution from 1-2 pm ET. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
12 Years in the Making - Rules Guiding Medicaid Managed Care are Getting a Makeover
At the Medicaid Health Plans of America (MHPA) meeting last week in Washington, DC, there was a lot of buzz surrounding the upcoming release of an updated Medicaid Managed Care regulation. Per CMS officials speaking at the conference, the last update was 12 years ago!
Discussions surrounding the update were focused on three main themes:
- Aligning Medicaid Managed Care with other public programs
- Payment and accountability
- Network adequacy
Aligning with other programs — This could take many different shapes and sizes. Certainly the well-established program guidelines of Medicare Advantage could become very prominent. In contrast, the newly evolving rules of the Exchange Marketplace could be drawn more into the spotlight. Being that Medicaid beneficiaries sometimes align with Medicare Advantage and sometimes with Exchanges, this is likely to draw a lot of comments from the industry when released in the coming months.
Regardless of how you think it should be done, the rationale to better align all of these programs makes good sense for both beneficiaries and the managed care plans that serve them. Beneficiaries can have common experiences; families with multiple program enrollments have an easier time navigating the system; and plans reduce unnecessary administrative burden to administer multiple programs.
Payment and accountability — Several hot button items are involved in this theme. All of these involve modernizing the regulation to the current day environment.
- Using data to think about issues related to rate setting and rate review
- Using program dollars wisely, as more is at stake as the program continues to evolve and grow
- Integration of long-term services and supports into the regulation
Network adequacy — The OIG recently released a report identifying significant variation between states as it relates to access to care, and how those standards are being checked on a regular basis. With the recent significant growth in Medicaid Managed Care enrollment, this becomes even more concerning. We can expect CMS to take a strong stance on access to care issues including network composition, availability of primary care and specialists, and provider directory issues. As a major beneficiary protection issue, we also expect this area to draw a lot of comments from the beneficiary community.
We are very anxious to see the draft regulation and the "give and take" it is going to provide to the industry. With 12 years worth of ideas baked into it, it should be a fun ride!
Resouces
Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
Gorman Health Group is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement. Visit our website to learn more about how we can help you with your Medicaid initiatives.
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Exchange 2014 Data Submission Due April 30,2015
As we wind down on our inaugural year with Health Insurance Exchanges (HIX), we have seen plans using a variety of approaches in their Risk Adjustment data reporting efforts. Some continue to use the same approaches used for their Medicare programs (chart reviews, provider outreach, in-home assessments, etc). Some have not even begun any retrospective, prospective or quality programs because they don't know where to begin. What is the right approach? Probably somewhere in the middle.
Qualified Health Plans need to be very targeted in their retrospective and prospective programs. They also need to have some type of quality assurance program in place. Although HHS has stated that "For 2014 and 2015, an initial and second validation audit will be conducted, but the findings will not be used to adjust payments." Plans still need to be cognizant of the quality of the data they are submitting and are still subject to the False Claims Act. CMS has also stated that when medical record reviews are performed, "the issuer must evaluate all diagnoses on the original claim and the issuer must delete any diagnoses not supported by the medical record." This is a new practice for many plans, but one that must be implemented.
Whether you rely on multiple vendors, an internal team, or a combination of the two, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping stride with HHS expectations in both compliance and health care outcomes. Our services include:
- Risk Adjustment Strategies — Retrospective, Prospective and Concurrent Outreach strategies, evaluation of staffing structure and levels
- Quality Assurance Programs — Proactive programs to improve data accuracy
- Data Analytics — Identifying data gaps and appropriate gap closures
- End to End Process Review — Testing for dropped data and recommendations for best practices in data processing
- Provider Education/Coding - including ICD 10
- Risk Mitigation - Identifying unsubstantiated diagnosis codes
- Data Validation — Mock Audits
- Vendor Audits — Coding accuracy, data completeness
- Requests for Proposals (RFP) - Developing RFPs and/or the evaluation of RFP vendor responses
Resources
In a webinar on Thursday, October 23, Janet Fina, GHG's Vice President of Risk Adjustment, together with colleague, Carol Olson, GHG's Director of Risk Adjustment, addressed areas for documentation improvement that will allow for accurate reimbursement and disease and case management opportunities. Become a member of the Point to access the recording >>
Gorman Health Group supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure that the procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete. Visit our website to learn more >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Marketplaces — Your Stars are coming
The Centers for Medicare & Medicaid Services (CMS) has been aggressively working in the background to establish the Star Ratings program for the Marketplaces, thus consumers will have their first quality information by 2017. Selecting a Marketplace health plan will no longer be based only on price or provider. As such, quality ratings will have a bearing on market share.
Notably, CMS is also creating future Stars for hospitals, dialysis centers, home health with nursing homes and physicians. However, it's different for the Marketplaces.
The CMS plan starts with a beta test in 2015 by collecting both clinical data defined by HEDIS and consumer rating data collected via CAHPS. Clearly, neither of these is untested. CMS has extensive experience using both HEDIS and CAHPS to build Stars in the Medicare Advantage program; a process that has evolved over the last six years. CMS has honed its methods for conducting statistical analysis of each measure into a dynamic process that annually adds and removes measures to refine information provided to consumers. Notably, CMS is also paying rewards to higher performing plans. Even more significant for 2015, CMS has suspended its regulatory authority to terminate low performing plans. CMS is seeing the focus of these plans on improving Stars when faced with termination.
With the wealth of experience in running Stars in Medicare Advantage, this beta test is merely an assessment of collecting the information from Marketplace plans and validating data and statistical analysis methods. There will not be a long ramp up similar to what Medicare Advantage plans experienced before CMS put in Marketplace rewards and penalties.
If you haven't already, now's the time to put your team in place. Not just to respond to CMS setup requirements and contract with your HEDIS and CAHPS vendors, but to also begin establishing the Stars team as an operational component in your organization. It will be important to create a focus to find and monitor operations that affect Stars performance. Building the proper team and charging them with the responsibility to track and develop a Stars framework is necessary for a long-term commitment to achieving five-Star performance.
Resources
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Reasonableness — The Last Chance
After four tries, some Marketplace health plan applicants have still failed to meet CMS reasonableness standards for 2015. Some of these applicants complained that they did everything they were told to do but were again rejected. Others are still asking for definition and written standards. Unfortunately, most understand that nothing in writing exists beyond the regulation.
In response, CMS encouraged them to call and discuss their issues next week when the subject matter expert is available. Their appeal is limited to a phone conversation with this lone CMS interpreter of reasonableness. These applicants need to have definitive data about available providers, population and time and distance to convince this reviewer. Demonstrating the use of a deliberative process may be the lesson for 2016 applicants but for 2015, time has run out.
Resources
We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Learn more about how GHG can help you tackle the application process >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Passing Marketplace Reasonableness — One More Chance
September 4th was final submission day for Marketplace plans but some worried health plans were asking "what ifs" about their last submission for network access. These plans have re-submitted network updates after two CMS rejections that required correction for failing reasonable access. They have three consecutive wrong guesses on whatever standards CMS believes they have not met. They want to know what happens if CMS doesn't approve their network access plan. Of course, they are still asking what standards need to be met.
Rest assured, CMS says they will have another bite to justify reasonable access. However, time periods shrink. The window opens on September 23 when CMS notifies health plans about needed corrections and responses are due on September 25.
CMS is well aware that failure to get a pass has unwanted consequences for everyone. Service areas will need to be reduced with compounding changes to plan packages that necessitate more CMS re-review and approval. So, everyone wants a good justification but CMS is not backing off given the potential for political backlash. Failure is an option. Health plans worried about their last re-submission can't count on CMS reviewer fatigue. Health plans asking these "what if " questions need to prepare a contingency narrative by either finding and fixing any weaknesses or documenting metrics that demonstrate access. Waiting to correct over a two-day window, is not sufficient time to prepare the last chance narrative justification for reasonable access.
Resources
Gorman Health Group's network evaluation service deploys an automated software solution that uses metrics based on population, provider ratios and time/distance standard. Learn more >>
Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>