DOJ’s Increased Focus on Risk Adjustment and Compliance

As the Department of Justice (DOJ) continues its efforts to investigate the diagnosis capture and reporting practices of Medicare Advantage Organizations (MAOs), MAO executives must start to ask, “How can we most effectively report all conditions contributing to a member’s health outcomes while upholding rigorous compliance standards, when official guidance on what is considered ‘compliant’ is unclear?” 

Risk Adjustment Litigation to Date

CMS rules are clear that MAOs must submit data for risk adjustment that is both accurate and complete to give CMS a true representation of a member’s disease burden. For many MAOs, this means submitting supplemental data from chart reviews or assessment programs to add unreported member conditions. Other MAOs have taken this one step further and have initiated programs to delete member conditions that were previously submitted to CMS when they have clear evidence that the condition is not supported after a review of the physician documentation.

Most of the recent activity has been targeted at large health plans for potentially overstating the disease burden of their membership via a common practice of retrospective chart review. This practice involves reporting additional diagnosis codes to CMS abstracted from reviewing members’ medical records after the member/physician visit has already occurred. These codes were not originally submitted to the health plan by the provider. In doing so, MA plans improve accuracy of member risk scores by providing a fuller picture of the member’s health status. 

What has come into question, however, is whether plans are, or should be, “looking both ways”. Not only are diagnoses omitted from claims submission by providers, but incorrect diagnosis codes are submitted, overstating the current illness of the membership, largely by reporting ailments that have resolved or were incorrectly coded. CMS has made a strong stance that the health plan is responsible for the “accuracy, completeness, and truthfulness of the submitted data”, and submitting these codes, or turning a blind eye is in violation of the False Claims Act.

Cigna Lawsuit

The most recent lawsuit against Cigna, however, has a different focus by centering on risk adjustment programs that are more prospective in nature. The lawsuit alleges that questionable conditions were reported during special assessments called “360 assessments”. The conditions were recorded on pre-populated forms. However, they were not always verified through medical testing, were often confirmed anecdotally from patient descriptions, and were reported by providers who were not familiar with the patient’s history. 

The 360 assessments were implemented as an enhancement to the standard Medicare Annual Wellness Visit (AWV), to allow physicians to focus on assessing all chronic member conditions. The program was first deployed at Primary Care Physicians (PCPs), with incentives for completing member visits ($150 per encounter). Additional incentives were given for attending training sessions ($1,000 per training) on how to effectively perform the visit. Due to low adoption, Cigna pivoted to having external vendors perform these encounters, often in the patient’s home with a Nurse Practitioner.

The 360 assessment form utilized by Cigna is similar to other prospective member-specific assessment tools used today as part of a comprehensive risk adjustment program. These assessment tools are currently being used by either PCPs during the in-office encounter or during in-home assessments using external clinical staff. These are typically long documents covering all body systems, which allows the provider to check for positive or negative findings, along with sections to add notes. The 360 assessment form also included a section called the Health Management Report (HMR), which summarizes all of the conditions previously submitted to CMS, but without providing insight into who reported the conditions, or when.

Per the DOJ, these vendors would submit these 360 assessments to another department for diagnoses coding abstraction. The results were sent to Cigna with disclaimers instructing the intent of providing information back to the PCP for diagnosis verification. The lawsuit alleges that Cigna submitted the diagnoses from the forms to CMS to be included in risk adjustment calculations regardless of PCP verification. In fact, included in the lawsuit is documentation of a PCP rejecting a diagnosis established during a 360 encounter, and it subsequently being removed from the form.

Incentives for provider performance are outlined in the document, indicating that benchmarks for condition reconfirmation performance were set (80-85%), and volumes of encounters were shifted towards providers that met or exceeded the benchmark.


This recent suit goes beyond questioning accurate data submission from health plans by questioning motives of providing actionable data, compensation for program participation, and at a high-level, the need for appropriate guardrails around pay-for-performance.

The Cigna lawsuit centers on the use of prospective assessments to capture and submit risk adjustment diagnoses data. While this differs from the other DOJ investigations that focused mainly on the use of retrospective chart reviews, the alleged violation of the False Claims Act is the underlying constant in all cases. The Cigna lawsuit adds to the growing body of investigations conducted by the DOJ, which focuses on the submission of risk adjustment diagnoses data to CMS and whether these submissions are a true reflection of a member’s disease burden. 

It is becoming clear that MAOs who participate in Medicare Advantage should begin to evaluate their own risk adjustment programs and whether they are not only utilizing programs to add diagnoses to a member’s risk profile, but also whether they are doing enough to delete diagnoses from CMS which may have been submitted in error.

Where Do We Go from Here?

Here are the top 3 questions MAOs executives should start to ask their risk adjustment teams:

  1. Are my risk adjustment programs designed to collect only additional member diagnoses for submission to CMS?
  2. Do I have a risk adjustment mitigation program in place to survey diagnoses submitted on claims to determine if there is documentation risk (i.e., no documentation support for the diagnoses)?
  3. Has an independent review of the risk adjustment program been completed to assess for compliance risk?

GHG's subject matter experts can help with the development or remediation of your risk adjustment strategy. Reach out to GHG's SVP of Healthcare Analytics and Risk Adjustment Solutions, Jeff De Los Reyes, at or Patrick Petty, Senior Consultant Risk Adjustment, at to start the conversation.

On October 8th, GHG’s SVP of Healthcare Analytics and Risk Adjustment Solutions, Jeff De Los Reyes, moderated a webinar with Austin Bostock of Pareto Intelligence and Meleah Bridgeford of Episource to discuss the future of the regulatory environment, as well as steps you can take to ensure that your data is ready in advance of the submission deadline. 

Our speakers shared their unique perspectives on the best strategies to deploy to ensure that your upstream encounter data is accurate, complete, compliant, and ready for submission. 

If you did not get a chance to attend the webinar, click here to view the recording.

2021 Chapter 2 Enrollment Changes

With the Centers for Medicare and Medicaid Services' (CMS) recent release of the 2021 chapter 2 enrollment changes, Medicare Advantage (MA) plans now have insight into the many proposals made earlier this year. GHG's Vice President of Sales, Marketing & Strategy, Diane Hollie, summarizes the key changes.

Medicare Advantage Plan Options for End-Stage Renal Disease (ESRD) Beneficiaries

Effective January 1, 2021, ESRD Medicare beneficiaries will now be able to enroll in MA Plans. Previously, ESRD patients could only enroll in a Medicare Supplement plan, MA Prescription Drug plan, or Medicare only.  This upcoming Annual Enrollment Period (AEP) is the first time ESRD beneficiaries can enroll in an MA Plan, even after diagnosis. Although this is a major change, plans have known about this for several years.  

Special Election Periods (SEPs) for Exceptional Conditions

In addition to codifying SEPs previously adopted and implemented, CMS established two new SEPs for exceptional circumstances:

  • SEP for Individuals Enrolled in a Plan Placed in Receivership. 
    • CMS established new SEPs for members enrolled in plans that are experiencing financial difficulties to such an extent that a state or territorial regulatory authority has placed the organization in receivership. 
    • The SEP begins the month the receivership is effective and continues until it is no longer in effect, or until the enrollee makes an election. The MA plan must notify its members, in the form and manner directed by CMS, of the enrollees’ eligibility for this SEP and how to use the SEP.
  • SEP for Individuals Enrolled in a Plan that has been identified by CMS as a Consistent Poor Performer. 
    • CMS established new SEPs, for individuals who are enrolled in plans identified with the low performing icon (LPI). This SEP exists while the individual is enrolled in the low performing MA plan.

Medicare Advantage and Prescription Drug Plan Model Enrollment Forms

CMS revised and improved the standard model form used for MA and Prescription Drug Plan (PDP) enrollment into a new streamlined form. The new model enrollment form requires a minimal amount of information in order to process the enrollment, and other limited information that the MA Plan is required or chooses to provide to the prospective member.

The new model form consists of the following parts:

  • Cover Page - The cover page includes information for the prospective member on Medicare enrollment and instructions to complete the enrollment form.
  • Model Enrollment Request Form - The model enrollment form includes two sections. Section 1 includes data elements required to process the beneficiary’s enrollment. Section 2 includes mandatory data elements that the plan is required to include on the application and optional data elements, which the plan is not required to include. All data elements in Section 2 are optional for the beneficiary to complete. Plan enrollment will not be affected if the beneficiary does not complete this additional information.

The new enrollment form is considered a “model” for purposes of CMS review and approval of plan marketing materials, and plans can choose to customize the form as needed.

Additional Updates

  • Model Notice Update – CMS removed information from Chapter 2 Exhibit 22 regarding the option to use an SEP to disenroll from the plan due to the loss of optional supplemental benefits because of nonpayment of optional supplemental premiums. An individual would be able to disenroll only if s/he is eligible for one of the existing SEPs.
  • Electronic Signatures - As part of the Electronic Enrollment process, CMS added language that allows plan sponsors to obtain an electronic signature as an alternative to the “Enroll Now” or “I Agree” button or tool used in completing an Electronic Enrollment request. This change only applies to the Electronic Enrollment mechanism. The affirmation requirements for the Telephonic and Paper Enrollment mechanisms remain the same.
    • An electronic signature is considered to have the same legal effect and validity as a pen-and-ink signature. An organization utilizing electronic signatures must at a minimum, comply with the CMS security policies.

Where Do We Go from Here?

GHG has been assisting our clients with both development and review of required materials for over a decade. We have a long, successful history of supporting these efforts. Our team undergoes re-training every year prior to deployment of any engagement, and we have a standardized process in place that is adaptable to any of your particular needs.

If you need assistance navigating these new changes or developing sales and marketing materials for the PY2021, contact Diane Hollie today to start the conversation.

For more information on the enrollment changes, you can view the full 2021 Medicare Advantage Enrollment and Disenrollment Manual here.

How Will Utilization Change After COVID-19?

Over the past several weeks, one question in particular has been top of mind for many healthcare systems: how will utilization change in a post-COVID world?

By now, we know that we will continue to live with this virus for years to come. As such, we will surely endure periods of shut down, as well as the need to limit face-to-face visits to help protect vulnerable populations. Change is continually happening and, unfortunately, we won’t be able to stay in a holding pattern as we wait for a vaccine. 

The Continued Decline of Face-to-Face Interactions

For healthcare systems that operate in a fee-for-service model, drops in utilization have resulted in significant financial strain. Emergency departments (ED) have been hit especially hard, and the sustained loss of utilization has had a significantly negative impact on their bottom line.

Many patients, out of fear of being exposed to the virus, have elected to stay at home and many will continue to do so. It’s well known that a significant number of emergency department encounters are avoidable, and the virus proved that point. 

However, there have no doubt been many instances in which patients should not have stayed home and should have sought medical attention. A patient who works as a cashier in a grocery store and doesn’t have stable housing or an established primary care doctor may avoid the ED with a headache today, but without some type of intervention, she may not be able to avoid a diabetes-related hospital stay in the months or years to come. Healthcare systems will almost assuredly have tens of thousands of patients just like this. 

Current Obstacles for Health Systems

It is unlikely that utilization rates will rebound back to pre-COVID numbers while the number of virus-related deaths continues to climb. So, what can healthcare systems do to stay financially viable? How do they ensure that patients are cared for when emergency departments were how they primarily accessed care? How can healthcare systems plan for future events that are being shaped now? 

Healthcare systems, already struggling, will not be able to operate long term in these volatile conditions. As we know, EDs can’t be turned off and on like a light switch. They are able to manage ebbs and flows; but maintaining the staff and infrastructure for a persistently empty ED on a fee-for-service basis is simply not sustainable. A healthcare system needs reliable revenue in order to care for patients – and patients want and need care. Regardless of the appetite for change, the emergency department and other parts of the system as we know it may not look the same in the future.   

For years, healthcare systems, health plans, and providers have developed and deployed clinical programs, strategies, and interventions to curb avoidable ED or inpatient utilization. From a population health perspective, even modest success is a double-edged sword for a healthcare system. On one hand, the system wants to decrease avoidable utilization or shift care to more appropriate settings; but on the other hand, they need to meet revenue targets, which are negatively impacted when patterns of utilization change and there isn’t an alternative payment model (APM) in place.

Value-Based Care as an APM

As COVID continues to transform the entire healthcare industry, healthcare systems now need to figure out how to care for patients outside of a traditional model and find alternative revenue streams while continuing to care for their communities who are affected by the pandemic. That is a tall order. This is one of the many reasons it can be difficult to meaningfully shift to a value-based care model.

Prior to the pandemic, the majority of providers and healthcare organizations wanted to and were moving toward value-based care. Most have contracts that tie their revenue to performance measures; but the proportion of those was limited. To take it to the next level, operating in a near complete value-based model requires significant operational capabilities (e.g., clinical, financial, etc.). It also requires the ability to manage at the provider level in order to manage cost and quality. This may sound easy enough, but it is still an area that in which healthcare systems commonly struggle.

While the pandemic forced the industry to immediately re-think the mechanism by which most care was delivered (e.g., face-to-face, telehealth, etc.), it doesn’t solve the problems that have plagued the healthcare system for years – inappropriate utilization, poor outcomes, disjointed care, etc. Telehealth is an incredible tool, but it isn’t a silver bullet. It needs to be part of a healthcare provider’s broader population health strategy.

Where Do We Go from Here?

Significant decreases in utilization of traditional service lines, such as the emergency department, may accelerate the move to alternative delivery and payment models accelerating an organization’s move to value-based care. Healthcare systems, already stretched thin, will need to revisit their population health strategy to prioritize efforts and plan for our “new normal”.

As the pandemic continues to change the way in which care must be provided, GHG’s subject matter experts stand ready to assist you in developing your population health strategy. To start the conversation, contact Kate Rollins, Senior Vice President of Population Health and Clinical Innovations at GHG.

Healthcare worker helping elderly man out of bed.

The Value in Shifting to a Value-Based Care Model

The pandemic has shown us that the fee-for-service model was just as fragile as we thought it was. Overnight, providers who had traditionally been reimbursed for the quantity of services provided (rather than better outcomes) found themselves in a devastating situation. 

The severe and sudden drop in office visits, without another strong source of revenue, has resulted in the temporary closure of practices or layoffs in order to stay afloat. Primary care physicians, in particular, have felt the greatest impact. It’s estimated that primary care practices will lose upwards of $15 billion in fee-for-service revenue in 2020 – a figure that does not yet account for the looming second wave of COVID-19. 

Primary Care Providers 

Despite research showing that the care they provide is associated with improved outcomes and lower costs, primary care physicians are among the most poorly compensated physicians. Although they serve as the backbone of the healthcare system, their most important role – to keep us healthy – is sorely overlooked and undervalued.

Primary care providers have known, more than anyone, just how untenable the fee-for-service model is. They have been working within and against a system that is firmly built upon a foundation that doesn’t align with value-based services, and instead rewards productivity with little to no concern for the outcome. 

The signs and symptoms clearly indicate just how sick our healthcare system has been for many years. All too common are the stories of providers who rise early in the morning to diligently complete loads of documentation, continue to work after dinner to return patient calls, and go to bed exhausted knowing that their work still isn’t finished. 

Shifting to Value-Based Care 

Before the pandemic, making the shift to value-based care was viewed, at best, as a “north star”, or, at worst, as a supplemental revenue stream. Many provider groups, health plans, and healthcare organizations have dipped a toe into the value-based world, but have struggled to dive in.

This is not necessarily due to a lack of desire to pursue a value-based model; but because navigating from fee-for-service revenue to an alternative payment model (APM) requires significant investment of time and resources. This investment is further exacerbated in that the transition process also tends to be messy and risky. 

At the end of the day, and after all of that work, the revenue will most likely continue to be tied to fee-for-service activities. For providers in particular, living with one foot in value-based care and one foot in the fee-for-service world still means living by productivity measures, which doesn’t get you very far from a value perspective, and can feel more like someone is piling on additional work. 

Anyone who has been on the frontlines of a practice or clinic understands that there is barely time to break for lunch, let alone time to address quality measures for an entire population or brainstorm on practice transformation. 

A Future with Value-Based Care

Value-based care should no longer be viewed as an unreachable north star, but rather as a way to navigate out of the mess we currently find ourselves in. The pandemic has created a tremendous sense of urgency to change the way care is provided. 

Primary care providers took a giant step by embracing and leveraging telehealth without skipping a beat, which has demonstrated that care delivered remotely is not only efficient, effective, and convenient, but is also remarkably well-received by those participating in it. 

There are many other things that can be made possible by our current situation to keep us moving on our journey toward “whole” value-based care, and they don’t have to be as seismic as telehealth. 

Consider these questions:

  • Has your practice seen any efficiencies gained by delivering care by phone or through remote video conference? 
  • Can that time (even as little as 30 minutes) be leveraged to identify what is most important to your practice? 
  • Can it be used to identify the pain points with your electronic medical records (EMRs)? 

You may be scratching your head and asking how simple things like this can push your practice closer to value-based care. The answer is simple—because these activities are value-based care. 


As the pandemic continues to change the way in which care must be provided, GHG’s subject matter experts stand ready to assist you in developing a value-based care strategy. Contact us to learn more.

Elderly woman and man sitting on couch with computer.

Why the OEP is So Important This Year

With the overwhelming uncertainty due to a global pandemic and a Presidential election year, the entire industry is looking for a crystal ball to shed some light on this year’s Annual Enrollment Period (AEP). Despite this uncertainty, there are a few things we do know for certain:

  • There will be NO large gatherings for member town halls in the fall to review 2021 benefits.
  • With town halls, seminars, and one-on-one meetings transitioning to virtual, health plans and agents will face a learning curve this AEP.
  • This AEP could mark a real change in how business is conducted within the Medicare market going forward.
  • The consensus is that this year's AEP will be challenging, but that there will also be huge opportunity during the Open Enrollment Period (OEP) for enrollment gains or, conversely, more losses.

Large Field Marketing Organizations (FMOs) and National Marketing Offices (NMOs) are learning how to skirt the Medicare Communication and Marketing Guidelines (MCMGs) by generically advertising Medicare all year long – but especially during the AEP and OEP. The sheer prevalence of ads featuring Joe Namath during the last OEP is evidence enough of plans' desire to find creative ways to advertise.

Why the Open Enrollment Period is Critical for 2021

This year, health plans should be prepared with an intentional OEP strategy that specifically focuses on gaining membership. If you aren’t prepared, you may be the only Medicare Advantage (MA) plan not advertising. So, how can plans advertise while staying compliant? There are several strategies that your team can incorporate:

  • Utilize your New-to-Medicare Programs to actively market during this time, and apply other tactics not currently in play.
  • Rely on your brand advertising to gain awareness.
  • If you have Medicare Supplement, use that advertising to gather leads and see how many prospects actually need an MA plan.
  • Research the current NMOs/FMOs and see if it is worthwhile to be a part of their programs.
  • Talk to your best agents and brokers to find out what they are doing for you—or what you can do for them.

In addition, remember member retention! Of course, it is important to gain new members, but it is equally as important to hold onto existing members. Ensuring that your new members understand their benefits, and how to utilize them, is critical for member retention. Make sure your plan's existing members know what is happening to their 2021 benefits—and don’t surprise them. Overcommunication is key, and there are specific actions your plan can take to ensure your members are receiving proper communication.


These are just a small handful of ideas to help you build your OEP strategy. If you have questions, or want more information about how you can improve performance this year's OEP, contact Diane Hollie today. It is not too late to get this done before 2021!

CMS Network Adequacy Changes & the Impact to Medicare Advantage Plans

The Centers for Medicare and Medicaid Services (CMS) has afforded Medicare Advantage (MA) plans flexibility in terms of meeting provider network adequacy. These changes lower the percentage of beneficiaries needed to meet adequacy in CEAC, Rural and Micro counties, offer credit towards states with Certificate of Need (CON) laws, and provide the ability for plans to achieve adequacy by expanding telehealth in twelve specialties. The updated adequacy changes will open doors for plans to provide services in counties that would have otherwise proven difficult to meet the network adequacy standards.

As we begin a series of discussions over the next few months, Gorman Health Group (GHG) will explore the impact that the lessening adequacy changes will have on MA plan strategy (including product and benefit design strategy), provide a review of the new requirements, offer an exclusive opportunity to have GHG review your network to determine how the changes could affect your MA footprint, and finally, circle back to a deeper dive into telehealth and how the changes impact a plan’s network operations, clinical operations, and the impact to risk adjustment and Stars. Today, we start with the importance of aligning your network and product strategy.

Network Development & Product Strategy Alignment

As more health systems and provider organizations successfully manage the shift from volume-based patient care to value-based population health management, health plan strategic planning should blend network strategy with product strategy as a key factor in the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay-for-performance and upside risk arrangements, and as providers have seen margins narrow and plateau, they are more willing to step out into more advanced risk-sharing deals. Plans have had to adapt and move beyond simply incentivizing for behavior change. Systems that have ventured into managing downside risk and percent of premium arrangements with measured success have an appetite for more.

Certainly, moving up the food chain from a provider to a payer has been a topic of conversation among Chief Executive Officers of large integrated delivery systems. They have worked hard to align referral networks and build physician trust, develop relationships with diverse community support organizations, forge strong brand recognition in their local communities, and negotiate contracts with health plans that have met and exceeded care and cost containment goals.

Historically, health plans have based a large majority of decisions regarding expansion areas on the financial feasibility of the markets. Understanding the desire and direction of health systems in general, coupled with the alliances plans have worked hard to develop in their current markets, has encouraged the trend of including a network assessment as part of the new market feasibility. Many factors can play a significant part in determining a new or expansion market as well as its success or failure:

  • Local players and their appetite for risk
  • Hospital alliances formed
  • Accountable Care Organizations (ACOs) in the market
  • Local demographics such as city and road expansions
  • Development of retirement communities and the effect they have on patterns of care and plan expansion
  • Modeling the potential partners against the updated CMS network adequacy standards

As we have met and strategized with provider systems from their baby steps into pay-for-performance incentives to negotiating their first risk deal, there has been, and still is, a strong reliance on health plans to set clinical pathways and benchmarks. From the provider perspective, the reporting, transparency, and willingness to share in the financial successes with the plan partners are key considerations when deciding with whom to collaborate.

Systems are starting to explore the administrative support organizations available and realizing stepping out to become their own health plan doesn’t seem as scary as it may have been five years ago. From the plan perspective, the need to partner with providers and health systems with a depth of understanding in risk adjustment, Stars, the clinical skill set, and non-clinical support services to truly provide a holistic approach to patient care has never been more critical to success. The directive of new network adequacy requirements and more telehealth options will allow room for plans to become even more innovative with their benefits. Thus, the ability to blend network strategy and product strategy will likely be evident of how successful plans are.


As we delve further into the adequacy changes and the potential impacts, GHG product and network strategy subject matter experts stand ready to assist you in developing a customized strategy to place your MA plan in front of the curve. Contact us to learn more.

CMS' Proposed Addendum to Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

On July 7, 2020, the Centers for Medicare and Medicaid Services (CMS) distributed a draft addendum to address changes to Unified Appeal and Grievance processing for Integrated D-SNPs in the Parts C and D Enrollee Grievances, Organization/Coverage, Determinations, and Appeals Guidance. CMS notes that rules implementing unified grievances and appeals apply only to fully integrated dual eligible special needs plans (FIDE SNPs) and highly integrated dual eligible special needs plans (HIDE SNPs) referred to as "applicable integrated plans." CMS included a list of states that may meet these requirements, but plans should contact CMS if they believe they may meet the integration criteria in the regulations. CMS requested comments on the proposed changes by August 7, 2020.

The addendum is a supplement to the current MA and Part D Appeal and Grievance guidance, and each addendum section aligns to the same section in the chapter. Noteworthy changes are summarized below. 

Section 10.1.a-10.6.a Introduction 

CMS added terms, applicable integrated plans, integrated organization determination and integrated reconsideration, and guidance that Medicaid requirements must be considered before finding a request invalid for dismissals. Also added were plan responsibilities for providing the enrollee the opportunity to present evidence and ensuring that no punitive action is taken against providers requesting or supporting integrated organization determination and integrated reconsideration. Finally, CMS added requirements to ensure that all comments, documents, and records are considered before making a determination and that applicable integrated plans must review Medicaid information as part of its monitoring procedures and updates to state Quality strategy. 

Section 30.a-30.3.1a Integrated Grievances 

CMS added that these must be reviewed by someone with appropriate clinical expertise if reviewing a denial of expedited resolution of integrated appeals or reviewing grievances regarding clinical issues. In addition, CMS clarified plan responsibilities for non-Part D and excluded drugs that may be available under Medicaid coverage. They added that integrated grievances can be filed at any time, so there are no timely filing limits. Plans must still meet the requirements for QIO and IRE reviews of termination of services from providers and hospital discharges, as well as for Medicaid-covered benefits. Plans must also comply with any state Medicaid quality of care requirements. 

Section 40.1a-40.12a Part C Integrated Organization Determinations 

CMS clarified who may request an initial determination, which includes providers that have not waived the ability to seek payment from the enrollee or are providing treatment to the enrollee. CMS stated that the provider may, after notifying the enrollee, request a standard or expedited pre-service request. Integrated organization determinations must be reviewed by a physician or other appropriate healthcare professional with knowledge of Medicare and Medicaid coverage criteria before the applicable integrated plan issues the integrated organization determination. 

Payment requests may be expedited and are not to be treated differently than non-payment requests for expedited integrated determinations. Plans should apply the same process to assess a request to expedite a payment as they to do assess requests to expedite non-payment cases. In addition, CMS included instructions on notification requirements for payment denials where there is no member liability, indicating that plans must send the enrollee a notice of the denial that includes that there is no member liability. 

Section 50.1a-50.10.a Level 1 Integrated Appeal 

If the provider requests that the benefits continue while the integrated appeal is pending, the provider must obtain the written consent of the enrollee to request the integrated appeal. In addition, plans must accept verbal requests for expedited and standard appeals and upon request, and integrated plans must provide the enrollee's complete case file free of charge and in advance of making the integrated reconsideration decision. Expedited Extensions may only occur if the enrollee requests the extension, or the extension is justified and in the enrollee’s interest, and there is need for additional information and a “reasonable likelihood that receipt of such information would lead to approval of the request, if received.” For denials of expedited appeals, the enrollee must be notified within 2 days of the denial.  They may be notified verbally, but written notice must be provided within 2 days of the verbal notice. Denial Notices must be sent and include language that the case was forwarded to the Part C IRE. 

Other Key Updates 

CMS also added in a new section 50.13 Continuing Benefits While an Integrated Reconsideration Is Pending, which applies to cases where an enrollee, their representative, or their provider is appealing an applicable integrated plan’s decision to reduce, terminate, or suspend previously authorized Medicare Part C or Medicaid covered services or items. This section should be carefully reviewed as it includes information on the timeframe for making these requests and the requirements to note when a plan must continue to provide service and when they are not financially responsible for services. 

Section 90.a Effectuation includes information about timelines for reversal effectuation and requires that the disputed services are authorized or provided promptly and as expeditiously as the enrollee’s health condition requires but no later than 72 hours from the date it receives notice reversing the determination. 


Plans should carefully review the addendum and provide comments to CMS by the deadline of August 7th, while making changes to plan policy as needed. 

Still feeling unsure about the potential updates? GHG assists plans in implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information. 

Building a Successful Social Determinants of Health Strategy

For those who have worked on the healthcare frontlines—in hospitals, provider offices, and even patients’ homes—the challenges of social determinants of health (SDOH) have been less of an emerging trend or buzzword and more of a longstanding problem that desperately needs to be addressed.

Health plans have also grappled with this issue on a massive population scale, oftentimes crossing large swaths of states, regions, and the country. Historically, health plans have been limited in their ability to intervene due to rules and regulations from the Centers for Medicare and Medicaid Services (CMS) and/or state Medicaid programs.

But that is changing.

The emergence of a viral pandemic and social movements such as “Black Lives Matter” have further defined and exacerbated the disparities that prevent people from participating in the basic activities required to successfully address health problems, such as getting to an appointment, filling prescriptions, and consistently sticking to medications, treatments, and care plans.

The State of SDOH Today

The CHRONIC (Creating High-Quality Results and Outcomes Necessary to Improve Chronic) Care Act provided health plans with the much-needed flexibility to cover services for persons living with complex care needs. This coverage comes with the need to evaluate and ensure quality and value. At a member level, such services make an immediate difference and can be qualitatively evaluated and justified, which is often reflected in “member success stories” or anecdotal accounts from a provider or case manager. Health plans also quantitatively define success by citing numbers of referrals to community agencies, rides to and from the provider, meals delivered, etc.

This is incredibly important for demonstrating the operational success and scale of SDOH activities, but alone, these metrics will fall short of defining the relationship and significance between the intervention and outcome of interest, which is needed to calculate return on investment (ROI). Scaling SDOH efforts without truly understanding what works or doesn’t work (on many levels) can torpedo efforts, and most importantly, impact population outcomes.

Figuring Out Where to Start

Knowing how to begin or continue SDOH efforts can be overwhelming. It is a highly complex systemic issue that is woven into every aspect of our communities. The solutions aren’t always straight forward and determining the return or value of an investment in SDOH is difficult.

Fortunately, it’s not necessary to start from scratch or limit ourselves to what other health plans have done. There are many population-level SDOH success stories from which we can learn.

For example, the Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS Program and grantees have thirty years of experience in this field, and their success could be leveraged by a health plan. The Ryan White CARE Act, enacted in 1990 to improve availability and access to care for low-income, uninsured, and underinsured persons living with HIV/AIDS and their families, recognized early on the importance of addressing SDOH. Adherence to appointments and medications, as well as partnering with community-based organizations to access resources, was directly linked to critical outcomes such as decreasing viral load, improving CD4 counts, avoiding unnecessary Emergency Department (ED) visits and hospitalizations, and improved management of common behavioral health issues such as depression and anxiety. This approach was fundamental to decreasing transmission and making HIV the manageable chronic disease it is today.

Leveraging effective evidence-based population approaches and interventions can speed up SDOH outcome achievement, translating to the ROI needed to sustain efforts over time.

Requirements for a Successful SDOH Strategy

Given the current state of SDOH, and drawing from extensive experience in this category, we know that the key to health plan SDOH strategic success lies in the following:

  • In-depth, local understanding of what the members want and need to improve access, adherence, safety, and other factors that contribute to SDOH challenges (for example, the avoidance of an ED visit or hospital stay).
  • The use of analytics to proactively identify hot spots, rather than reliance on incoming member calls, screenings, or blast communications.
  • Developing programs in concert with a rigorous evaluation methodology to determine ROI.
  • Identification of key performance indicators to continuously monitor what works and what doesn’t.
  • Meaningful linkages, including value-based models, with community-based organizations to ensure access to high quality, sustainable, and scalable interventions.
  • Compliance with CMS guidelines and audit readiness.

Final Thoughts on SDOH Strategy

Keep in mind that SDOH strategy shouldn’t stand alone, simply consist of delegated vendor activities, or try to address multiple issues at once. The overarching strategy should be led and championed at the highest levels of the organization through a mandate to align and integrate activities systemically with important areas such as member/health plan services, utilization management, network, quality, compliance, and analytics, among others.

SDOH strategizing is specialized and requires expertise in SDOH program design, implementation, operations, and rigorous program evaluation with underserved, vulnerable, and hard-to-reach populations in rural and urban communities; but it also requires expert knowledge of how health plans and the healthcare delivery system work. If you need help harnessing SDOH data, developing a strategy to address SDOH, or measuring the success of your SDOH initiatives, contact Kate Rollins at

6 Tactics for Better Agent/Broker Management During COVID-19

On May 29, 2020, the Centers for Medicare and Medicaid Services (CMS) released the Contract Year 2021 Agent and Broker Compensation Rate, Referral/Finder’s Fees, Submissions, and Training and Testing Requirements. While the compensation rate increases are a welcome update for agents/brokers, it is important to explore these changes in the context of COVID-19 and how the standard Medicare selling practices will not be sufficient for the 2021 Annual Enrollment Period (AEP). 

How can Agents/Brokers Navigate Medicare Sales During COVID-19?

Here are 6 tactics organizations and sales teams should consider to adjust strategies for COVID-19.

  1. Know and follow your state and local government requirements around stay-at-home orders and mask wearing. As healthcare leaders, organizations have the unique opportunity to position themselves as the go-to resource on the latest state and local mandates for the community, beneficiaries, and sales teams (internal and external). Partnerships with key network provider groups can emphasize this position.
  1. Invest in systems that allow for virtual meetings; conduct appropriate training and education well in advance of the start of AEP. Training and education don’t stop with sales teams. Organizations should make sure that beneficiaries understand the intricacies of a virtual sales meeting and provide support throughout the entire process to keep technology frustrations at bay. In addition, organizations must remember to establish compliant expectations for recorded virtual meetings and submission and/or record retention as needed for sales oversight programs to remain effective.
  1. Modify seminar strategies to limit participation and allow for safe social distancing. Does your organization and/or sales team rely on vigorous seminar strategies? GHG recommends evaluating seminar locations now to understand if the space will allow for a minimum 6 feet of distance between attendees. Providing this assurance demonstrates that beneficiary protection is top of mind. Organizations may also want to schedule multiple seminar sessions throughout the day to allow for the potential need to cap attendees per seminar because of limited space.
  1. Be prepared to move seminars to a virtual setting. The threat of a COVID-19 second wave in the fall is real and may lead to another round of economic shutdowns. If your “plan A” includes group seminars, make sure your “plan B” can move these seminars to a virtual setting.
  1. Arm field sales representatives and agents/brokers with face masks and hand sanitizer to distribute at one-on-one meetings and seminars. Bonus if the face masks and hand sanitizers include your branding or logo.
  1. Agents/brokers should be staying in contact with their clients. Organizations should provide tools to their sales force for discussing COVID-19, such as a COVID-19 Quick Reference Guide. Resources like this help to position the agent/broker, and ultimately your organization, as their trusted resource and support system in not only navigating Medicare but also the pandemic as well.

What This Means for Health Plans

The commissions may be higher this year, but the work is anything but “business as usual.” Both organizations and agents/brokers alike need to adjust their strategies to ensure an effective and safe AEP season. If you don’t have a game plan for adjusting to the new normal this AEP, now is the time to develop your Plan A, B, and C.

If you have any questions about the information above, or need assistance transitioning to a digital-first AEP sales strategy, GHG can help. Contact us today to get in touch with an expert.

As the Bid Submission Timeline Approaches, So Does the Release of PY2021 Model Documents

It’s that time again… the frantic whirl of both bid submission and material development in anticipation of the upcoming plan year and sales/enrollment activities.

If you are a health plan with multiple contracts and/or plan benefit packages (PBPs), you know how daunting material development and review can be.

If not delayed, the Centers for Medicare and Medicaid Services (CMS) will publish the plan year (PY) 2021 model materials by the end of May. Major changes to the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) are not anticipated, since they have been approved by the Office of Management and Budget (OMB) through December 2021. Regardless, ensuring accuracy of materials is critical as errors can lead to enforcement actions by CMS. Things to consider when developing PY2021 materials:

  • CMS model use
  • Following instructions found both in models and separate Health Plan Management System (HPMS) memo(s)
  • Applying the correct benefits to all of the documents
  • Submission and distribution timelines
  • Including fulfillment activities
  • Technology requirements (website changes)

How We Can Help

GHG has been assisting our clients with both development and review of required materials for over a decade. We have a long, successful history of supporting these efforts. Our team undergoes re-training every year prior to deployment of any engagement, and we have a standardized process in place that is adaptable to any of your particular needs. In addition, we have HPMS access and can submit materials on your behalf. Contact us today to discuss how we can best support you.