Teaming with Providers: Incentives to Achieve Results
When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs).
As health plans continue adapting to the growing influence of clinical quality on their provider network operations, building an effective team with your providers has never been more important.
But, factor in the necessities of compensating members of the team for their role, of each side meeting its profit targets, and the competing priorities faced by often short-staffed offices, it should come as no surprise many health plan staff members and providers are left wondering how to make it happen.
How do we as a health plan balance the range of providers in our network? How can we ensure the employed doctor with a large integrated delivery system has his/her needs met while at the same time engaging the single-office practitioner and ensuring his/her goals are met?
Meeting the needs for each of these scenarios and others starts with how well defined our provider incentive programs are. Do they adequately support the clinical and financial goals of the plan and the provider? Have we built an incentive program that has achievable and actionable benchmarks?
Whether your providers are still fee-for-service (FFS) or at full percentage of premium risk, a few building blocks will ensure success:
- Healthcare Is Local: Have we done our benchmarking for incentive programs at the local/regional level to ensure we are measuring apples to apples and taken into account the local practice of medicine?
- Prioritization: Ensure Clinical, Risk Adjustment, Star Ratings, Claims, and Network Operations are all collaborating and prioritizing their "asks" of the providers and working together to ensure the needs of the providers are met.
- Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
- Support ICD-10 Effective Implementation: If the Centers for Medicare & Medicaid Services (CMS) predictions hold true, denial rates and outstanding receivables are likely to increase during the conversion. Despite testing and readiness efforts, it's entirely possible some providers may not be staffed or prepared to mitigate technology-related problems among their payers or to weather the longer-term reduced productivity of their coding staff. Before your providers can invest additional energy into documentation for chronic conditions and quality priorities, they've got to keep the cash flowing
- Data Validation Reviews: Data integrity starts with collecting and configuring the provider data at the start of the contracting and credentialing process and becomes critical for downstream health plan operations. For example, the inclusion of an incentive program for achieving data accuracy, timeliness, and integrity is a critical element in your risk adjustment work plan. Offering incentives for providers to achieve and maintain 95% coding accuracy on all diagnoses, meaning 95% of the diagnoses submitted by the provider that can be substantiated in the medical record, subject to a random validation review, can often become a path to shifting providers to more risk-based contracting. However, if your provider data is not correct or complete, the plan or its vendor can spend more time trying to find a provider than validate results.
- Focus on Actionability: Health plans often provide catalogs of reports each month showing providers numerous views of their panels and forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let the providers be providers.
- Continuous Measurement, Re-Evaluation and Reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a "thank you" are often simple but overlooked motivators.
In summary, there is no one straight line to navigate the path from FFS to pay for performance to risk for the plan or the provider, but there is one way to ensure success on that path — collaboration between the plan and the providers. By breaking down the silos and barriers, being transparent in our actions, and reporting, we can build the trust needed to ensure we are not "checking the boxes" on the incentive plan but rather seeing the success in better patient outcomes and lower expenditures.
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Retail Healthcare - An opportunity for success
Are you providing your members and potential members the opportunity to speak with you in person?
In the age of technology, we are forgetting how to serve our customers without them having to pick up the phone or log into a website. For some, this way of doing business fits the population they serve. It's fast and convenient, but in the Medicare world, we still have customers who want to speak with us in person, who need help navigating the complexity of healthcare, and sometimes it just can't be solved by pushing a button on a phone or computer.
So how do health plans continue to evolve in the technology world and still provide a personal touch while remaining profitable?
If providing quality healthcare and outstanding customer service is the objective of a health plan, and members and potential members want services on their time, in their neighborhood, then a brick and mortar location can solve for both.
Brick and mortar locations — or storefronts — can be used as a multi-purpose space for health plan staff, agents/brokers, and the surrounding community. These stores can be strategically designed for year-round activity or be used as a pop-up location during open enrollment and provide numerous advantages that online cannot:
Year-Round Opportunity:
- Utilizing a variety of healthcare professionals such as medical groups and providers, senior associations, and ancillary community interaction at the store location.
- Provide informational seminars for both educational and sales purposes, health and wellness information, engagement with the local community, age-in seminars, and Medicaid eligibility clinics to help the low-income population apply for Medicaid/Low Income Subsidy (LIS).
Seasonal Opportunity:
- Facilitate sales seminars, lead agent appointments, walk-ins, and seasonal health fairs to drive Annual Election Period (AEP) awareness and educational seminars to bring awareness to the products and services offered by your health plan.
Achieving a measurable return on valuable marketing dollars goes a long way toward meeting growth objectives and improves profitability. With marketing budgets challenged by today's economic conditions, and the added pressure of Medicare Advantage rate reductions on health plan's cost structure and a shortened AEP, finding ways to maximize enrollment and spend less gets tougher and more challenging.
So whether your health plan is considering a year-round opportunity or seasonal location, this can bring your members and potential members a comfortable setting to gather, a place for the community to learn more about Medicare/Medicaid services, answer member questions, and troubleshoot issues pertaining to enrollment right in the heart of community — no dialing, no waiting — just fast and convenient.
Potential success with storefronts can be what your market needs, but careful design of a robust strategy is required to maximize your return on investment. Don't delay — Gorman Health Group can help you navigate the complexities and provide you with a plan that will surely satisfy your members, potential members, and your stakeholders.
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At Gorman Health Group, we want to change the perception that member experience is the responsibility of Sales and Customer Service, instead showing organizations that member experience is a comprehensive approach with full transparency and cross-functional leadership. Visit our website to learn more >>
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Meeting CMS Halfway: The 2016 Audit and Enforcement Conference
On June 16, the Centers for Medicare & Medicaid Services (CMS) held their third annual Medicare Advantage & Prescription Drug Audit and Enforcement Conference and Webcast. At the heart of this conference is the CMS Program Audit. Agency experts as well as Sponsor participants presented to an in-person and webcast audience on expectations, process enhancements, upcoming developments, and more.
While the agency has not given everyone the keys to the kingdom, the transparency of process improvements and changes can be likened to someone meeting you halfway. If you expect CMS to meet you where you are, you'll be waiting a long time. Sponsors need to do the rest: digest the free information provided, distribute to all affected parties, and implement. Practice until each step of an audit runs like a well-oiled machine. Sound cliché? It should. The core focus of this audit model has not changed in years. You may argue that you've had staff turnover or have switched delegates for a certain function. None of it matters. The requirements are still the same, and they are in line with many items your organization attested to upon application.
My summary and analysis of the conference can be downloaded here, however, it is no replacement for watching the webcast recordings on your own and making necessary changes to your program.
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Risky Business. Are You Ready for MACRA?
It turns out Uncle Sam has a plan. He tried mightily to bend that stiff cost curve. He threw everything he had at it — fixed prices, automatic reductions, sophisticated relative value schemes. He could not do it. Turns out the pen (or mouse) is mightier than the sword because almost all of the Medicare benefit spend flows with the ink (or electrons) that is released by the physician's hand. The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a game changer like prospective payment system (PPS).
Humans are inherently risk-averse. Doctors are humans. This new Part B payment scheme is going to make them uncomfortable. The Medicare Merit-Based Incentive Payment System (MIPS) puts a percentage of Part B reimbursement at risk — a modest 43% initially, but it climbs quickly. The Centers for Medicare & Medicaid Services (CMS) estimates 88% of eligible practitioners will be feeling that in 2019. This year more than 200,000 doctors (roughly two in five) were penalized for failure to achieve meaningful use of electronic health records in performance year 2014. Many have decided to just accept the reductions like the person who collects parking tickets because it's just too much trouble to park in a lot.
Changes in the law can have unintended consequences. Prospective payment led to premature discharges from hospitals. The introduction of the physician fee schedule and sustainable growth rate targets led to an increase in the volume and intensity of services (or claims maybe). What will the consequences of MACRA be? Will the money at risk motivate physicians to be more efficient? Or will it lead them to shun traditional Medicare patients?
Yesterday, during a U.S. Senate Committee on Finance hearing on MACRA, CMS seemed to acknowledge the challenges of releasing the final rule for MACRA in November 2016, then measuring physicians immediately after that in January 2017 for 2019 payment basis. Clients and prospective clients should be aware that the potential delay recently discussed by the CMS Acting Administrator is not a delay of MACRA implementation. He referred to possibly delaying the start of the 'performance year' that will be used to adjust payments in 2019. The need to prepare for value based Part B payment is pressing, and those that prepare soonest can turn MACRA into an opportunity.
We have been talking to clients and friends around the industry. We are seeing a lot of interest in the alternatives to MIPS, that is the Alternative Payment Model (APM) approach. Those programs like Pioneer Accountable Care Organizations (ACOs) that take meaningful downside risk clearly have the potential for growth and profit, but they are not for the faint of heart. We believe for group practices and hospitals that bill for physician services, the middle road shows great promise. That alternative is to develop a Medicare Shared Savings Program (MSSP) ACO that avoids downside risk initially. This is a "Track One" ACO — it lets providers have less exposure to complex MIPS reporting and the opportunity to get ready for a potential launch into a higher risk approach later.
On July 7, 2016, CMS further solidified their commitment to MACRA (alternatively the Quality Payment Program (QPP) with the announcement of the proposed rule updating payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) starting January 1, 2017. CMS is proposing modifications to the MSSP to update the quality measures set to align with the proposed measures for the QPP, changes to take beneficiary preferences for ACO assignment into consideration, and changes that would improve beneficiary protections when ACOs are approved to use the skilled nursing facility (SNF) three-day waiver rule. The writing is on the wall — CMS will continue to move towards standardization of government-sponsored health plans via clinical and financial policy to ensure dollars spent meet the goals of improved beneficiary health, better population health management, and a trend of cost containment.
Every organization in the healthcare industry will be impacted by MACRA; some will be directly impacted, others impacted indirectly, and some will be affected by unintended downstream consequences of the legislation. Regardless of whether you are a health plan, a provider organization or a vendor that supports providers or health plans, we can help.
Our experts can review operations to identify risks and opportunities, increase integration within clinical and pharmacy programs, design well-coordinated activities across multiple healthcare programs, and ensure that your organization's infrastructure and tools are prepared for MACRA's impact on the industry. From in-depth analytics and tactical support to thought leadership and strategic planning, we can help. Contact our team today >>
Resources:
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Navigating the path to value. Elena Martin, GHG's Senior Director of Provider Innovations, outlines the MACRA quality payment program. Read now >>
Star Ratings: 10 Years, 10 Lessons
The Star Ratings program celebrates its 10th birthday this year. In honor of the first decade of quality ratings systems within managed care, and to celebrate the many lessons we've learned during these formative years of the Star Ratings program, here are 10 of our top lessons from the first 10 years of the program.
- Success is not easy. Not only are Star Ratings constantly evolving, but the ever-changing regulations and Centers for Medicare & Medicaid Services (CMS) guidelines surrounding Medicare Advantage and Part D prescription drug benefit plans and the increasingly competitive Star Ratings environment make Star Ratings success a continuous, often challenging battle. Evolution is difficult, and every detail matters.
- One size does not fit all. Every health plan has a unique culture, strategic plan, and relationship with its members and providers. And every health plan has a unique combination of vendors, analytical tools, systems, and business decisions that support its culture and strategic vision. As a result, every Star Ratings work plan is similarly unique. Customization, personalization, and tailoring is vital for success.
- All healthcare is local. Every provider network is unique and has a unique combination of systems, tools, programs, priorities, and business decisions through which it provides clinical services to your members. And every group of members presents its own unique prevalence of conditions, expectations of local physicians, and social and lifestyle patterns. As a result, every Star Ratings work plan is unique.
- Social determinants of health are a lynchpin to achieving and sustaining high quality ratings. Critical gaps between clinical care and community services exist in the current healthcare delivery system. CMS Innovation Model tests are underway to systematically identify and address the health-related social needs of beneficiaries while evaluating their impact on total healthcare costs, improved health, and quality of care. Star Ratings success on challenging triple-weighted measures is far easier accomplished when plans simultaneously support the clinical, social, and lifestyle needs of their members.
- Easy, understandable, and contextually-appropriate requests (of members and providers) are most successful. Systems work best if they are kept simple rather than made complicated; Star Ratings is no different. Whether we are asking our members or our providers to take action, simplicity should be a key goal and external-facing, unnecessary complexity should be avoided.
- Converting "big data" into "actionable intelligence" is key. Include carefully selected clinical, pharmacy, and Health Risk Assessment data elements for efficient, holistic success.
- Member and provider interactions and programs are most successful with carefully targeted investments. This requires data-driven strategic planning, close alignment of routine operations with Star Ratings measure needs, and consistent execution of well-planned processes.
- Manual workarounds and tactics likely won't sustain success over the long term. When data and reports are manually built or Star Ratings-impactful activities occur outside of system-driven workflows, Star Ratings success isn't easily scalable. As the principles and foundation built during the first 10 years of Star Ratings expands into the Health Insurance Marketplace, Medicare Fee-for-Service, and managed Medicaid, this is an excellent time to reengineer any manual activities into sustainable workflows.
- The physician-patient relationship is the foundation for high-quality healthcare. Support members' physician relationships wherever possible and augment where/how needed by developing personal relationships between carefully-selected members and a care coordinator.
- "Best Practices" are often claimed as "best" before they have been carefully evaluated for wide-scale adoption. And don't forget — a best practice is only a best practice until it becomes standard practice.
For questions or inquiries about how Gorman Health Group can support your organization's Star Ratings efforts, please contact me directly at msmith@ghgadvisors.com.
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Technology and Vendor Implementations
As with all program and technology initiatives, the short- and long-term successes realized as a result of the investments made rely on the critical stages of vendor transitions, data and system readiness, and project management - A well-oiled Vendor and Program Implementation Initiative. Quite often, our health plan and provider clients have multiple projects running in parallel, making for an environment of competing priorities and scarce resources.
In order to optimize the investments made in technology, as well as the supporting member and provider interventions, the organization will need to commit and align subject matter experts (SMEs) in the areas of Risk Adjustment and Quality with SMEs in Information Technology (IT). Given the financial brevity of Risk Adjustment and Quality bonus programs, Gorman Health Group (GHG) encourages our clients to invest in program management and implementation staff. This staff must be solely dedicated to achieving both a seamless transition from legacy vendors to the new vendor partners. Additionally, the implementation team must be committed to ensuring the implementation of the solutions is on time, within budget, and managed to the highest degree of quality assurance.
If the implementation is delayed, the downstream impact on these critical programs could set the stage for years of inaccurate payments and missed opportunities.
GHG understands the challenges of implementing Risk Adjustment and Quality modules on an accelerated timeline in order to meet financial goals. Applicably, our team of industry experts has each been involved in over 40 unique vendor implementations during our tenure as health plan executives and GHG consultants.
Timing is critical. GHG's implementation team employs the Agile project management methodology, working with clients and vendor partners to run initiatives in parallel rather than sequentially, creating efficiencies, ensuring alignment of tasks, and coordinating an environment driven by thoughtful multi-tasking to help meet the deadlines for implementation.
Whether you are off-boarding or on-boarding vendors to support your Risk Adjustment and Quality programs, our experienced team of consultants can provide a wide range of support to your company. For more information on our process and our team, please contact me at dweinrieb@ghgadvisors.com.
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The much-anticipated "Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2015 Benefit Year" has been released by the Centers for Medicare & Medicaid Services (CMS). Read the full article >>
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2015 Risk Adjustment/Reinsurance Payments Published
Risk adjustment was designed as part of Obamacare to offset the impact of the underwriting process being eliminated to allow those individuals with pre-existing conditions to obtain health insurance. Now a health plan's risk is assessed after the member is enrolled. Health plans need to ensure the risk of their organization is reflected completely and accurately in the data submissions to the EDGE server since this is the information utilized for the risk adjustment calculation. Affordable Care Act (ACA) risk adjustment is a zero-sum game, so a health plan's overall risk will be measured against state averages and competitor results. Last week, the "Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2015 Benefit Year" was released by the Department of Health and Human Services (HHS). The report shows the risk adjustment payment transfers and reinsurance payments by state for each health plan that had an ACA plan in 2015.
The controversy around the ACA risk adjustment program is a hot topic and will continue to be the highlight of many discussions to come. With any new regulation or process, there comes a learning curve. Unfortunately, we are still in the early stages of a painful learning curve for a lot of health plans and co-ops. Slowly but surely, health plans are starting to realize the ACA risk adjustment program leaves no room for error. The complex nature of risk adjustment is not just the calculations or the interventions―it's the strategy and forethought behind the scenes to know how changes within the organization will impact the risk adjustment processes. Health plans can't just conduct some chart reviews, talk to providers, and send data to the EDGE server and expect to be successful within the ACA market. At that point, it's just going through the motions of what most individuals know as the core operations of risk adjustment without understanding what really makes the program tick. It's like a game of chess―you can't make the same moves in the same order every time you play and expect to win. You need to adjust your next move dependent upon the move of your opponent. That is exactly how risk adjustment needs to be approached.
It's a not so surprising reality that the co-ops are struggling with staying solvent given the magnitude of payments they are required to make for risk adjustment. Unbeknownst to individuals outside of a risk adjustment department, the strategy and operational structure to a fully-functioning successful risk adjustment program is extremely complex. When implementing Obamacare in preparation for the effective plan dates in 2014, co-ops, like most other health plans, did not put a lot of focus on developing a risk adjustment strategy and supporting operations. Some health plans simply did nothing, which was the worst of all scenarios. Risk adjustment was one of the "new processes" that came to be in the commercial market because of the ACA. Those individuals who had never worked with a Medicare Advantage plan before probably never even heard of risk adjustment. These things all played a role in the importance of risk adjustment being under-estimated during the development phase of the ACA for health plans. Now that everyone in the country is aware of the importance of risk adjustment and the magnitude of financial impact it carries, it's an uphill battle for the co-ops having to face making large transfer payments, some are upwards of $30 million.
So how did your health plan do? Was all of the effort and hard work done by your organization realized in the payment transfer outcome?
Being able to answer those two simple questions is a lot harder than you would think. Most health plans measure the success of a risk adjustment program by the magnitude of the payment transfer. By doing this, you will be missing the root cause of operational changes that need to be made to establish a long-term efficient risk adjustment program. Before you can realistically answer these questions, you need to understand where your health plan started and measure success at each step of the way. Then you will be able to see if the events that unfolded were in line with what you intended to happen. If not, then adjust accordingly. If health plans don't start looking at their internal operations relative impact to risk adjustment, then it's only a matter of time before you will become the next sinking ship in the calculation of the payment transfer.
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Now that the FFM is paying Issuers directly from the FFM system, Issuers need to shift gears and begin thinking about how they can impact a timely and accurate payment of Advanced Premium Tax Credit, Cost Sharing Reduction, and User Fee charges. Are you thinking about your overall payment strategy? Read the full article >>
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Advancement in Analytics
It's all about the numbers! As the Centers for Medicare & Medicaid Services (CMS) tries to quantify more and more aspects of government-sponsored healthcare, metrics are a critical component.
Metrics are needed to measure quality programs, returns on investment in patient care, redistribution of staffing and financial resources, as well as benchmarking.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is a perfect example of how CMS is pushing this financial focus. The past few years of shared savings models for Fee-for-Service members have evolved into very strict timelines and formulas that will directly impact the financial performance of providers in addition to the intended impact on improving member experience and quality of care.
As providers and health plans now have to walk this tightrope of real and projected results with multiple stakeholders (regulators, health plans, providers, members, and third parties), the necessity of analytics and good internal reporting are now of utmost importance.
The best tool to manage these priorities and resources is to have a solid reporting mechanism. Whether you are a start-up or an existing organization, the need for an integrated data repository cannot be ignored. Multiple vendors can help with specialized needs like population health or customized provider scorecards, but the sources have to be integrated. For a provider, this means to coordinate efforts with vendors and multiple health plans or payers. For a health plan, this means to coordinate efforts with vendors and payers as well as from within the health plan organization. Once the data is normalized and complete, reports and dashboards can be built, but keeping an eye on the whole organization is critical to recognize trends as they occur. The "whack a mole" analogy is appropriate — if you focus on one area, you might see improvement, but another area could suffer. You have to look at all areas.
We understand systems must be integrated to help identify actionable strategies. A gap analysis might be needed to assess organizational issues, procedures for reviewing the data to identify problems and their solutions, as well as timing — once a year budget variance reports will not be sufficient. Deep dives into specific problem areas are also critical — making sure you are looking for outliers (regardless of overall performance). Even if the organization does not change, the providers and members and regulations will change. This is a constant effort.
Recognizing the industry will spend nearly $600 billion on healthcare technology by 2020, we have built external, strategic partnerships, facilitated the development of internal solutions, and staffed a team of industry leaders to address this market trend in analytics. Our niche division cannot only connect Gorman Health Group clients with the solutions that are the best fit for their organization, the Healthcare Analytics team can ensure the governance of exiting systems and the investments in new technology are both implemented and optimized.
Let us help you keep your eye on the numbers and find solutions that will bring a return to satisfy all stakeholders.
Resources
On June 7, 2016, Daniel Weinrieb, Gorman Health Group's (GHG's) Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions and colleagues, David Sayen, Senior Vice President of Client Relations and Melissa Smith, Senior Consultant, recapped the details of the MACRA proposal and how these changes will affect providers, health plans, the care delivery system, and patients. Download the webinar recording here >>
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Is Your Sales Distribution Strategy Up for the Challenge?
It's already July, and time is ticking! Do you have your sales distribution strategy completed and management staff in place? With the Annual Election Period (AEP) just a few months away, finalizing your distribution channel, creating sales training, developing telemarketing scripts, and hiring management to oversee all these tasks must be completed now. In addition, making sure you have compliant marketing materials and a compliant website is more important than ever.
Make sure you have done the following:
- Develop sales recruitment strategies that align with your sales and retention goals
- Identify Field Marketing Organizations that fit your culture and believe in your value proposition
- Identify obstacles or gaps within your Sales team
- Develop sales goals that promote year-over-year growth
- Confirm the proper number of agents are in place to meet sales goals
- Verify you have a sales oversight program that will hold up to the Centers for Medicare & Medicaid Services (CMS) standards
- Create trainings that help your sales staff:
- Sell against the competition
- Develop key alliances in the community
- Navigate the dos and don'ts of marketing
- Conduct community meetings
- Self-generate leads and community outreach
- Telemarketing implementation plan — whether internal or external resources are being utilized
- Sales scripts for Telemarketing team that are ready to be submitted to CMS' Health Plan Management System for review
• Have strong call center staff development scheduled
• Update policies and procedures for Sales and Member Services based upon internal goals and 2017 Medicare Marketing Guidelines (MMG)
• Review marketing materials and your website to make sure they are compliant
If you feel overwhelmed by this list, don't worry — our Sales and Marketing subject matter experts can help you maneuver through the overwhelming task of hiring, training, and implementing strategies while navigating your Sales management staff through the newly released 2017 MMG. We can even provide you with proven interim staff to get you on track for the 2017 AEP.
Our goal is to help you succeed and achieve your 2017 AEP sales goals. Let us weather the storm for you while you watch your membership grow. Don't let time run out — contact us today!
My favorite quote:
"Sometimes I wish I could just fast forward the time just to see if in the end it's all WORTH IT!"
— Author Unknown
Resources
Impact of the 2017 Medicare Marketing Guidelines. On June 10, CMS announced the release of the 2017 Medicare Marketing Guidelines (MMG) for Medicare Advantage Organizations (MAOs) and Part D Sponsors. In a new article, our teams of Compliance and Sales & Marketing experts outline the top changes to the guidelines that we believe will have an impact on your organization. Read now >>
Gorman Health Group's Sales Sentinel™ is a flexible, module-based software solution with the ability to onboard agents, provide training, manage ongoing oversight activities and pay commissions. Created by GHG, Sales Sentinel™ was designed to address the specific needs of government managed care organizations. Request a demo today >>
Why Is Conducting a Part D Operational Assessment so Important?
Medicare Part D is a complex program that is continually in motion. The Centers for Medicare & Medicaid Services (CMS), in an attempt to provide clarity to stakeholders, actively publishes updated guidance to sponsors to assist in process improvement and encourage optimal beneficiary outcomes and experience. Keeping up with Health Plan Management System (HPMS) memos, best practices, yearly call letters, and webinar information is challenging. Dynamic and ever-changing guidelines inevitably bring uncertainty and risk. Understanding these guidelines and operationalizing a compliant program is key to a successful program and financial sustainability.
For an organization to succeed in this fluid environment, it must achieve higher quality and Star Ratings, improve beneficiary satisfaction and retention, while staying on top of compliance and operational efficiency. CMS expects all plan sponsors to carefully and regularly evaluate risks to their organization. Emphasis is placed on compliance, identification and prevention of fraud, waste, and abuse (FWA), and oversight of first-tier, downstream, and related (FDR) entities. Additionally, in recent years, there has been increased focus on coverage determinations, appeals, and grievances. All of these areas can have an impact on a plan's Star Ratings and financial outlook.
Conducting a comprehensive operational assessment is an excellent strategy to identify a plan's strengths and weaknesses and evaluate the adequacy and reliability of operations. Information is gathered and evaluated from multiple sources such as current policies and procedures, oversight activities, reports, and operational processes. Comprehensive evaluation of this information will proactively identify areas of risk, allowing plans to strategically adapt to the changing environment to reduce identified risks. Gorman Health Group, with our team of industry experts, can provide an assessment of areas of greatest risk exposure along with solutions based on best practices, ensuring the organization is well positioned for future success.
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Our broad array of services can assist you in post-audit remediation, implementation of best practices, PBM contracting and implementation, interim staffing, clinical process re-engineering, Star Ratings improvement, and claims and PDE assessment and adjustments. Visit our website to learn more about our Part D services >>
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