CMS' Recent Enforcement Actions Show Agency Means Business in 2017
As we predicted, the Centers for Medicare & Medicaid Services (CMS) is off to an aggressive start on the compliance front in the last year of this administration and shows no signs of slowing down with $832,250 worth of fines levied in the month of February alone. The list of enforcement actions released comes with even graver announcements of two immediate suspensions of enrollment and marketing for the year. These fines augment two huge penalties with which CMS closed out last year − $3.1 million and $1.3 million.
In recent news, CMS did announce it will revise its policy of automatically reducing the Star Rating of sanctioned contracts to 2.5 stars. Effective immediately, CMS will suspend this policy, and will re-examine its approach in the 2018 Call Letter. This is a bit of good news for plans currently suspended from marketing and enrollment activities.
From the Medicare Advantage (MA) Advance Notice and Call Letter, we glean further insight into CMS' agenda for 2016. CMS stressed its commitment to improving beneficiary protections for 2016. CMS stressed its plan to increase severity of compliance and enforcement actions in Parts C and D. Particularly, CMS pointed out their commitment to increase the severity of compliance and enforcement actions for Part D auto-forwarded cases, as they saw no significant reduction in the volume of Part D auto-forwarded coverage determinations and redeterminations in the past several years, despite continued warnings issued to organizations. CMS' warning also extends to audits and enforcement actions in network adequacy, provider directory adequacy, and medication therapy management programs.
Given this strong warning, it is no surprise most of the civil money penalties (CMPs) levied in February were due to audits of benefit administration in Part D which showed "inappropriate delays of Part D benefits and increased out-of-pocket costs." Several fines were also levied on Part C appeals and grievances and benefit administration.
Enhancing its theme of focusing on getting plans to tighten up their compliance programs, CMS will issue a memo of their interpretation of methodology for CMPs given the large amount of questions CMS receives related to CMP calculations, not so coincidentally, right before an audit.
CMS has also added a new avenue for enforcement actions — one-third financial audits. CMS is required to conduct these audits for 30% of MA plans each year and has announced they will move to include these in enforcement actions, including CMPs and sanctions, and not just corrective action plans.
If you think 2015 was bad with over $13 million in fines, 2016 is poised to be a record year for enforcement actions. If you're not ready yet, now is the time to cross your t's and dot your i's and get your compliance program in order and prepared for what is positioned to be a busy year.
Resources
GHG's renowned team of experts collaborated to provide the key features and implications of the 2017 Advance notice and Draft Call Letter for your organization in 2017 and beyond. Download our full summary and analysis >>
For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Provider Directory & Network Adequacy Highlights in the 2017 Draft Call Letter
The Centers for Medicare & Medicaid Services (CMS) has emphasized the wide-scale monitoring efforts underway with respect to network adequacy and provider directory monitoring and the direct impact it has on not only the plan's ability to provide timely and adequate access to care, but the impact it has on the decision-making ability of the beneficiary and/or their caregiver to select the plan that best meets their needs.
While the new release cycle will affect CMS' ability to have gathered enough feedback and information to finalize the 2017 Audit Protocols, the Provider Network Adequacy (PNA) pilot is still at the forefront for CMS according to the recent release of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter. Plans have a key opportunity to do a deep-dive into their provider networks and the policies and procedures governing their network, such as provider terminations, and prepare a monitoring protocol that will not only meet compliance but also take steps towards the future of network management that includes ensuring data integrity for the plan and its members.
It was previously anticipated the PNA would drive the sample of providers used to evaluate directory compliance. The 2017 Draft Call Letter indicates the opposite, noting specifically the data collected during the monitoring process could drive additional reviews of network adequacy as well as future monitoring and/or audit-based activities. CMS has given plans the ability to develop innovative pathways to ensure directory accuracy. Plans will need to close the loop and ensure interoperability between all systems, including those such as Health Services Delivery (HSD) tables and programs used to formulate both online and printed directories, to have a true impact on the data integrity presented to CMS and to their members.
Additionally, CMS continues to move in the direction of a uniform evaluation for both PNA and provider directories across all government-sponsored health plans. Given the fact Medicare Advantage (MA) plans currently have the fewest data elements required for provider directories and the least restrictive reporting requirements for network adequacy, plans should anticipate the need to augment the information they collect on providers, and, as with the requirement to submit your entire network during a service area expansion, gear up for more stringent network review requirements.
At Gorman Health Group, we have experts who have worked directly with managing provider networks and adequacy for over 20 years, including detailed analytics such as specialty code mapping and software, which is critical in building the infrastructure needed to fully support the quality and financial goals the network brings to your health plan.
If you have questions regarding the recent regulations proposed in the 2017 Draft Call Letter for MA and Part D around provider and network adequacy, please contact me directly at emartin@ghgadvisors.com.
Resources
GHG's renowned team of experts collaborated to provide the key features and implications of the 2017 Advance notice and Draft Call Letter for your organization in 2017 and beyond. Download our full summary and analysis >>
Listen to John Gorman's recent podcast on his top line observations from the 2017 Draft Call Letter.
For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
CMS gears up for major quality performance program overhaul for ACA program
The Centers for Medicare & Medicaid Services' (CMS') recent issuance of the 2017 Letter to Issuers in the Federally-facilitated Marketplaces and Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule affirms the agency's plans to elevate the importance and transparency of quality performance by Qualified Health Plans (QHPs). Despite the continued absence of financial incentives for high-quality QHP performance, CMS' approach to quality oversight for QHPs is looking much like the early years of the Star Ratings program within Medicare Advantage (MA).
Similar to the MA Star Ratings program, CMS will use a 5-star scale to assign a Quality Rating System (QRS) rating to each QHP based on validated clinical measurements and enrollee survey responses. This year marks the first year QHPs must display these quality ratings prominently to consumers on their websites during the open enrollment period. Public reporting of these clinical measurements and enrollee survey responses will not only offer both consumers and providers new insight into a QHP's clinical quality performance but will also spotlight the consumer's perception of the QHP's operations.
The Affordable Care Act requires QHPs to submit a Quality Improvement Strategy (QIS) for the 2017 plan year if they offered coverage through the Marketplace in 2014 and 2015 and meet certain additional criteria. CMS requirements for the QIS, which must be submitted during 2016 and implemented no later than January 2017, include implementation of:
- A payment structure that provides increased reimbursement or other incentives to providers or enrollees to improve quality and reduce costs by incentivizing high-value rather than volume-driven care, and
- At least one of the following:
- Activities for improving health outcomes;
- Activities to prevent hospital readmissions;
- Activities to improve patient safety and reduce medical errors;
- Wellness and health promotion activities; and/or
- Activities to reduce health and healthcare disparities.
Because strong quality performance is necessary for long-term viability, QHP leaders will likely set new quality-related performance goals and evaluate whether current operations may need to be adjusted to meet those goals. Achieving such goals amidst the ongoing industry evolution, within the competitive environment, and within budgetary constraints will require innovation and creativity. Fortunately, many QHPs can lean into their own organization's Star Ratings experiences, expertise, and successes to help with these efforts.
An increased focus on quality, enrollee experience, and outcomes within a QHP will likely require new, short-term resource investments. Investments may be needed in areas such as population health management tools and analytics; member outreach, support, and education; and provider education, support, and engagement. By collaborating with their MA colleagues, QHP leaders may be able to leverage and expand MA tools, tactics, and expertise to simultaneously avoid the "learning curve," minimize provider abrasion, and optimize outcomes through such investments. With careful planning and strategic deployment of resources, a QHP can leverage its short-term investments for long-term return on investment.
Whether your organization is developing a QIS for your QHP, seeking insight to help align your QIS with successful Star Ratings strategies and tactics, or needs help interpreting the quality data recently provided by CMS, we can help. For additional questions and inquiries about how Gorman Health Group can support your QHP quality programs, please contact me directly at msmith@ghgadvisors.com.
Resources
For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
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Star Ratings: Moving the Needle
Now more than ever before, plans must streamline their Star Ratings programs to meet member expectations while encompassing all aspects of care delivery and breaking down internal silos. This requires innovation amidst a backdrop of the ever-changing Centers for Medicare & Medicaid Services (CMS) landscape. CMS continues to treat Star Ratings as an ever-evolving, dynamic measurement program that is consistently expanding to include challenging new clinical areas, the impact of socio-economic status on Star Ratings, and operational evolution within the risk assessment processes.
As CMS continues to introduce more medication-related measures into Star Ratings, as both Part C and Part D ratings, and evolves Medication Therapy Management from its current status as a process measure to a more impactful outcomes measure, highly-rated plans will continue to set a high bar for seamless, integrated, and holistic care management and coordination. Earning 4 stars will become more difficult without fully breaking down organizational and data-related silos and effectively communicating and engaging with providers.
Join my colleague, Lisa Erwin, and me at our annual Gorman Health Group Forum next month as we share best practices around optimizing the relationship of medication management (either in-house or via Pharmacy Benefit Manager delegation) with the "medical side of the house" for a more holistic approach to achieving Star Ratings success.
Resources
For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Operations Mistakes Will Be Costly — Highlights of the 2017 Draft Call Letter
There was a time when operational areas were shooting for 98% accuracy as the "golden" number. In today's age of data and focused audits, even 99% may not be enough. The Call Letter doesn't have many surprising new risk areas for Operations. No new crazy regulations to ponder how we can possibly implement them. Instead, they have something worse: the addition of teeth to the new regulations. Why is this worse? Because the focus is on areas Operations and plans often struggle with and eventually accept status quo as good enough. How many times have you heard or possibly said, "What are our peers doing?" and used them as the measuring stick.
Some of the key focuses to keep operational eyes on are:
- One-Third Financial Audit Results — Don't skip this section thinking this is Finance and doesn't involve Operations. One-third financial audits are full of operational reviews with direct member impact. The Draft Call Letter is indicating, beginning with 2017, one-third financial audits for plan year 2015 will have potential enforcement action like civil money penalties (CMPs) assessed for findings with adverse beneficiary impact. The Centers for Medicare & Medicaid Services (CMS) specifically calls out increased or incorrect cost-sharing or copayments as items of concern. Reviewing your benefit setup and claims processing to ensure controls are in place for adequate application of copays is a fundamental process but one in which CMS is seeing discrepancies year after year. Plans should review their controls or Medicare Secondary Payer (MSP) processes, their provider fee schedule process, and their benefit setup processes to ensure beneficiaries are protected and benefit designs are operationalized each year as filed with CMS.
- Timely Processing of Coverage Determinations and Redeterminations — Your plan may delegate coverage determinations and possibly redeterminations, but whether delegated or processed in house, the plan is responsible. CMS is seeing a continued high volume of auto-forwards of coverage determinations and redeterminations to the Independent Review Entity (IRE) when these functions are not processed within required time frames. CMS is indicating they will be taking action against plans with high volumes—no waiting for an audit and a review of the results. CMS has the data to know there is a problem. Have you looked at your numbers? Do you know your auto-forward volumes? Better yet, do you know the root causes and mitigations to ensure there are no auto-forwards and no negative beneficiary impact?
- Data Integrity — Once again a misleading title that has big operational impacts. CMS is raising concerns CMS program audits are identifying issues that may impact Star Ratings data used for Star Ratings. CMS is indicating they are looking at tying audit findings to data submitted for Part C and Part D reporting and Star Ratings where the audit may have raised concerns. CMS is indicating finding issues within other reviews, such as program audits, may result in review of submitted data for Star Ratings. They are right—it is a holistic approach health plans should be using to get ahead of this curve. If during an internal audit at the health plan a finding occurred indicating grievances were under-reported, is there follow-through to reconcile that under-reporting and revise Part C and Part D grievance reports? In our often-siloed departments and processes, that type of follow through doesn't often occur.
We are all busy. Few of us in Operations have the luxury of focusing on one product or function. We are all trying to keep multiple balls in the air. But if we don't take time to evaluate, stabilize, and set up good controls, we won't survive unscathed. The last thing any of us want is an enforcement action that will take time and energy to resolve and will ultimately impact our members, resulting in most or all of the balls crashing down. Our multi-disciplinary team of consultants has been in your shoes—we have juggled the same balls and are ready to partner with you. Contact us to get started >>
Resources
For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Final Rule: The Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017
The anticipation is finally over — the "Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule" has arrived. This annual document provides health plan issuers the rules and requirements to develop plans and operational processes for the upcoming year. Since the Affordable Care Act (ACA) was enacted, health plans have been feeling the pressure regarding the premiums allocated to the Marketplace plans, coupled with staggering losses for this line of business with the elimination of the underwriting process, health plans have been receiving negative feedback from all angles. Now to layer onto that pressure, for 2017, two of the three stabilization programs — reinsurance and risk corridor — will no longer be included to provide health plans financial relief since the applicable timing for these programs has expired. To enhance the existing stabilization program, the risk adjustment model will be recalibrated using more recent data to reflect more closely with the commercial market risks experienced.
Some of the high-level changes reflected in the Final Rule are the following:
- Open Enrollment Period for 2017 and 2018 will continue to have the same dates as 2016, which is November 1 through January 31 of the following year. Starting in 2019, the open enrollment period will be shortened to start on November 1 and end on December 15 of the same year.
- Standardized plans have been introduced as an option for 2017. Issuers are not required at this point to utilize these standardized plans and are allowed to offer non-standardized plans if they choose, however, it is encouraged that issuers offer the standardized silver plans. Standardized plans are preferred by the Centers for Medicare & Medicaid Services (CMS) to allow the enrollee to have a better shopping experience on the Marketplace. It allows for a more apples-to-apples comparison of the plans offered. Therefore, because of the ease to enrollees, the Marketplace will arrange the plans to be found more easily. There are 6 standardized plans available to choose from. One for each metal level with the exclusion of platinum. The standard or "base" silver plan also has benefits aligned for each of the actuarial value (AV) plans that are utilized for the members that are eligible for the cost sharing subsidy. In total the silver plan ends up with 4 standardized plans and then 1 plan each for gold and bronze.
Each plan has a fixed deductible, fixed annual limitation on cost-sharing, and fixed copayment or coinsurance for the Essential Health Benefits (EHBs) that are a part of the actuarial value (AV) calculator, with the addition of urgent care. These benefits represent a large percentage of the total allowable costs for an average enrollee.
- Cost-sharing maximum out-of-pocket limit has increased from $6,500 to $7,150 for an individual and from $13,000 to $14,300 for a family.
- Network Adequacy proposed requirements were partially accepted in the final rule. Probably the biggest requirement that was not accepted was the time and distance standard.
- "Surprise Bills" are a concern of members, which has been addressed in this notice.
- Federally-Facilitated Marketplace (FFM) user fees will stay at 3.5% for issuers utilizing the (FFM). Issuers who are part of a State-Based Marketplace (SBM) that utilized the FFM platform will see some relief with a reduction in their user fee for 2017, from 3% to 1.5% of premium.
- Medical Loss Ratio (MLR) will not be allowed to include fraud prevention expenses as part of the numerator as proposed in the Notice of Proposed Rulemaking (NPRM).
A detailed analysis of the Final Rule including health plan impacts, will be provided in the coming week.
Resources
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
The Good, the Bad, and the Ugly!
Regarding the New Proposed Medicare Marketing Guidelines (MMG)
Taking a quick read of the proposed 2017 MMG, our marketing team had some initial thoughts about the proposed changes we would like to share.
The Good
- It's only February, and we have the proposed 2017 MMG. This is great for us "Marketers" since we can plan now and won't get sucker-punched at the last moment with changes we weren't expecting.
- The proposed MMG state you no longer have to put the disclaimer about "Availability of Non-English Translations" on print ads and postcards except in the language in which the ad is printed. With so little space to work with on ads and postcards, this change is very welcome.
- Although already released in previous guidance, CMS now includes the following key provider directory updates in the MMG:
- CMS includes more specific guidance on timely updating of directories. Hard copy directories are proposed to be updated monthly; using addendums for the updates is acceptable. Online directories are expected to be completed within 30 days of notification. Although updating directories monthly or within 30 days is very difficult, it is better than real time, which was stated last year.
- CMS states all providers and/or pharmacies represented in the directory have a current contract in effect to participate in a Plan's network. At a minimum, any provider and/or pharmacy listed in the hard copy or online directory for the upcoming plan year should have a contract in effect for the first full month of the plan year. This greatly helps those of us in Marketing and Sales as nothing derails a sale better than stating a provider is in the network only to find out later the provider is not in the network.
- Last year the MMG stated Plans needed to contact their providers on a monthly basis to update their information. CMS has updated the previous language to state the provider contact is required quarterly.
- CMS is clarifying when it is acceptable to use the term "free" in marketing materials. CMS states the term "free" may be used when describing mandatory supplemental benefits that are provided at $0 cost sharing for all enrollees.
The Bad
- Unfortunately, CMS has also proposed Plans cannot use the term "free" to describe $0 premium plans, Part B premium buy-downs, low-income subsidy, or dual-eligibility.
- CMS has clarified guidance from last year to state if an agent is conducting a one-on-one appointment telephonically, the agent must follow the Scope of Appointment guidance.
The Ugly
- CMS includes language stating it will no longer generate Summaries of Benefits (SBs), and Plans will be required to develop their SBs based on their bid data in the Health Plan Management System (HPMS) and required data elements provided in an SB guidance memo. First-year changes like this are always ugly since there are always interpretation issues, and timing on these documents is already tight. However, we fully expect CMS to provide additional guidance around the implementation of this change in the months to come.
Not a BIG deal but Worth Mentioning:
- There is a proposed fifth mailing statement to be utilized for the Annual Notice of Changes (ANOC) mailing only: "Important information about the changes to your Medicare drug and health plan."
- CMS has included what they stated in a memo last year: the ANOC/Evidence of Coverage (EOC), directories, formulary, Utilization Management documents, and Multi-Language Insert must be on the website by September 30, with some exceptions.
Changes to the MMG are never wanted, unless it makes our lives easier, but having a "heads up" related to potential changes in February is a great way to get started for the upcoming Annual Election Period―thank you, CMS!
Resources
Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>.
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
CMS Releases New Medicaid Rule, OMB in Final Review
Last week, the Centers for Medicare & Medicaid Services (CMS) finalized the new Medicaid rule — a 653-page proposal requiring Medicaid managed care organizations (MCOs) to enhance their network adequacy, establish quality ratings, set a medical loss ratio (MLR) threshold of 85%, and develop a robust managed long-term care program. The new Medicaid rule has now been sent to the Office of Management and Budget (OMB) for final review. This means the new Medicaid rule could be published by mid- to late May. There are 39 states and the District of Columbia that currently outsource their Medicaid programs and about 46 million lives that will be affected by this new change.
Some of the proposed changes that were up for consideration:
- Medical Loss Ratio — CMS proposed an MLR of 85% for Medicaid managed care plans, the industry standard for Medicare Advantage (MA) plans. CMS proposed to mostly use commercial rules in calculating and reporting MLR due to the "need for consistency" between plans in the Marketplace and in Medicaid.
- Appeals and Grievances — The proposed rule made a few updates to the appeals and grievances process to align with MA plans. For example, the rule seeks to shorten the time frame in which MCOs and Prepaid Inpatient Health Plans (PIHPs) have to make a decision about a standard appeal from 45 days to 30 days, the same as MA plans. The expedited appeal time frame would be shortened from 3 days to 72 hours, also the same as MA.
- Beneficiary Protections — Under current regulations, coordination and continuity of care focus on primary and acute medical care. The proposed rules aim to reduce coordination issues beneficiaries with chronic and complex conditions face. The proposed rule also seeks to align enrollment practices between Medicaid fee-for-service, Medicaid managed care, and Marketplace coverage.
- Create standards to evaluate network adequacy and ensure beneficiaries are receiving accurate network information.
- Medicaid Managed Care Quality Rating System — Align with existing MA and Marketplace rating systems. Standardize quality metrics among states and plans.
- Updates to rate development standards and actuarial soundness of capitation rates, with a focus on federal oversight and a more detailed process to ensure actuarial soundness.
- Calls on states to update quality strategies at least once every three years. Currently, some states are operating on strategies drafted more than five years ago. States are called on to develop a description of quality metrics and performance targets the state will use to assess Medicaid managed care quality.
Let the team of experts at Gorman Health Group (GHG) help you prepare for the upcoming changes that could impact your organization. GHG's risk adjustment experts can help analyze the financial impact, develop feasibility models to help with meeting the new MLR requirements, and provide guidance on streamlining operations. GHG's Compliance Solutions can assist in the development and monitoring of these new contract requirements, and our clinical team can assist with reviewing and developing integrated care models to provide quality initiatives that are effective and efficiently managed to get optimal results.
For more information, contact me directly at sjanicek@ghgadvisors.com.
Resources
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Noteworthy Evolution for Star Ratings in 2017 MA Draft Call Letter
Last week's release by the Centers for Medicare & Medicaid Services (CMS) of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter ended the mystery surrounding potential policy and payment changes on the horizon. As our Founder and Executive Chairman, John Gorman, recently noted: "There's a lot to like — and much to fear." Although CMS is proposing higher-than-expected rates for 2017 and has introduced both payment and Star Ratings relief for plans serving dual-eligible beneficiaries, this positive news was counterbalanced somewhat by a number of factors, including proposals to increase compliance scrutiny in challenging areas such as network adequacy, provider directory accuracy, and medication therapy management programs.
As anticipated from a Star Ratings perspective, there were few surprises but quite a bit of noteworthy evolution for MA this year. CMS' proposals include:
- Accounting for the Star Ratings Impact of Dual-Eligible and Disabled Beneficiaries:
After a lengthy research process and significant pressure from the industry, CMS proposes moving forward with an interim analytical solution to account for the Star Ratings impact of dual-eligible and disabled beneficiaries. Despite the fact only a handful of plans would likely gain or lose a full half-star in their rounded overall Star Rating, this is a huge methodological win for plans serving dual-eligible members and will be important to monitor closely. When combined with CMS' simultaneous proposal to adjust revenues based on beneficiaries' status as either full duals, partial duals, or non-duals, as well as for their status as both aged and/or disabled beneficiaries, my colleague, Dan Weinrieb, advises, "This will mean timely reconciliation and maintenance of clean enrollment data has never been more important for MA plans." This proposal, in combination with the proposed strategy to account for the lack of low-income subsidy (LIS) support to meet Puerto Rican beneficiary needs, reflects a noteworthy shift in CMS' willingness to adjust the Star Ratings program to account for scientifically-supported evidence of nuances within MA.
- In-Home Risk Assessments
CMS' decision to leave in-home risk assessments untouched is great news for the many MA plans who are leveraging these important visits not only for risk adjustment, but also to connect members with needed care (as measured by Healthcare Effectiveness Data and Information Set (HEDIS®) and Prescription Drug Event (PDE) Star Ratings measures), to coordinate care across the spectrum of providers (as measured by Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Star Ratings measures), and to help support member's social and lifestyle challenges (as measured by Health Outcomes Survey (HOS) Star Ratings measures). We interpret this to mean CMS now better understands the incredible value in-home care can bring to a patient's holistic healthcare experience. However, despite this welcome news, plans should certainly ensure their program adheres to the best-practice expectations previously set forth by CMS, and supported by encounter data, in order to drive payment.
- Termination of Contracts Below 3 Stars for 3 Years
CMS not only reaffirmed its previously-announced plans to terminate contracts earning 3 consecutive Part C or Part D Summary Ratings of less than 3 stars, but also set forth an annual calendar by which this practice will become standard. With CMS guidance indicating these termination decisions are non-negotiable, plans will likely expedite efforts to improve Star Ratings performance such that impactful work begins as soon as it looks possible their first Summary Rating below 3 stars may be on the horizon.
- Connecting Compliance and Star Ratings
From a compliance perspective, CMS proposes to continue strengthening its connections between compliance, data integrity, and Star Ratings. CMS reminds organizations of its policy to reduce a contract's measure rating to 1 star if it's determined biased or erroneous data was submitted. Our experience this year indicates CMS is leveraging this authority much more frequently than it has in past years, which means plans will want to pay particular attention to Medicare Plan Finder and PDE data requirements, Organization Determinations, Appeals, and Grievances (ODAG) and Coverage Determinations, Appeals, and Grievances (CDAG) processes, internal controls to prevent errors in operational areas directly impacting the data reported or processed for specific measures, and Part C and D reporting requirements data validation for specific measures. CMS points out, and we're hearing evidence to support, it continues to identify new vulnerabilities where inaccurate or biased data could exist, which could result in the reduction of a star measure to 1 star. As my colleague, Regan Pennypacker, details in her recent article, CMS' proposed changes will require plans to "implement creativity and do more with less while enhancing the beneficiary experience." Certainly this will be no easy task as we survive 2016 and plan for 2017 under a new administration.
- Measure Updates
CMS is not proposing to add any new measures to the 2017 Star Ratings, although several measure specification changes are proposed for use in the 2017 ratings. As previously proposed, CMS indicated both the Improving Bladder Control (Part C) and High Risk Medication (Part D) measures will be moved to the Display page for 2017.
CMS proposes the addition of two new measures to the 2018 ratings (based on 2016 services/operations): Medication Reconciliation Post-Discharge and Hospitalization for Potentially Preventable Conditions. Addition of previously-proposed statin therapy and asthma measures were pushed out at least another year, possibly as a show of support for the recently-released and newly-aligned quality measures, giving plans a bit of breathing room to work with providers in this new area.
As we look ahead with CMS' foreshadowing of future program updates, continued attention is being paid to Care Coordination measures (with the National Committee for Quality Assurance's (NCQA's) assistance) and Depression measures (with NCQA and Minnesota Community Measurement's support), and the Advance Notice highlights a number of potential measure specification changes, which may take effect for the 2018 ratings.
Whether your organization is working to improve performance on your entire Star Ratings program, or just a few Star Ratings measures, or needs assistance understanding how the proposals contained in the Advance Notice may impact your plan, we can help. For additional questions and inquiries about how Gorman Health Group (GHG) can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.
Resources
On Tuesday, March 1, from 2:30-3:30 pm ET, join John Gorman, GHG's Executive Chairman, and colleagues Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and your partners and the steps you can take to soften the impact. Register now >>
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>
Compliance Highlights of the CY 2017 Draft Call Letter
According to the Centers for Medicare & Medicaid Services (CMS), the Call Letter activities follow four major themes: improving bid review, decreasing costs, promoting creative benefit designs, and improving beneficiary protections. This means implementing creativity and doing more with less while enhancing the beneficiary experience. To borrow from one of the earliest reality shows, this is the time when CMS stops being nice and starts getting real. There are some of the key items of which your Compliance Department needs to be aware outlined below; however, it is not all inclusive and a thorough read of the document is required.
Something that is highly detrimental to an organization is CMS' reduction of a Star measure to 1 Star if any compliance-related issues are identified with a measure's data. We have seen that applied repeatedly this year to a variety of measures. This Data Integrity initiative is not new; unfortunately, CMS notes in the Call Letter that the agency continues to identify new vulnerabilities where inaccurate or biased data could exist. You will hear more from my colleague, Melissa Smith, on the proposed Star Ratings changes here in this blog.
Program Audit Protocols and Enforcement Actions
In an effort to allow sponsors more time to implement new protocols, CMS is proposing to release the following year's protocols by the end of July, starting this year. How does this change impact an organization?
- An earlier release means industry feedback received at certain times this year will most likely inform the 2018 protocol updates. Since the Medication Therapy Management and Provider Network Adequacy (PNA) pilots are scheduled to be released "a few months into" the pilot audit period, comments won't be received in time to inform 2017 protocol. Therefore, CMS proposes to extend the pilot into 2017.
- CMS notes the PNA protocol will not be administered during the same time as the program audits. This is not surprising for two reasons. First, the current program audit schedule is jam-packed. It's tough to envision adding another layer of operational audits to an already taxing schedule. Second, CMS reminds sponsors that this is only one piece of their larger scale efforts at reviewing adequacy. Consider the provider directory requirements memo released on November 13, 2015. CMS will actually be using the PNA pilot to validate corrections required as part of monitoring completed by the Medicare Drug and Health Plan Contract Administration Group (MCAG).
Some of these changes may mean more impact to your Compliance staff day to day. Gorman Health Group (GHG) notes our sponsor partners are quick to dive into published protocols to update tools and programming. Oftentimes they identify unclear items and immediately contact CMS for clarification, so this change should not create a significant impact to those who follow suit.
Since CMS is focusing on network, this should drive renewed focus and monitoring as part of a risk assessment and current oversight activities. GHG is aware of at least one consistently rated five star plan that has conducted full network assessments on a quarterly basis for quite some time now. In addition, CMS, in working with a contractor, has developed what they believe is a comprehensive process for monitoring provider directory accuracy. Interpret as such: your focus on this area pays off. Our Network team will dive deeper into this area here in the GHG blog.
CMS plans to release a memo describing their interpretation of applicable rules in the methodology for civil money penalties and will provide a comment period to the industry. Compliance should distribute this memo and collect comments as the calculation is often questioned on user calls and during enforcement discussions.
The agency is also seeing no significant reduction in the volume of Part D auto-forwarded coverage determinations and redeterminations. For this reason, they plan to increase the level of severity of compliance and enforcement actions. This is an area of the program with direct impact on a beneficiary's ability to access his or her Part D benefit. It is hoped that turning up the heat in this area may encourage plans to implement changes to reduce that volume and start meeting time frames more regularly.
CMS also proposes to consider the findings of noncompliance from the one-third financial audits for potential enforcement actions. In the past, sponsors were required to implement a corrective action plan, but they have had this authority under 422.752 and 423.752.
Sensing a theme here? CMS has reached a tipping point, and as our Founder and Executive Chairman, John Gorman, has recently noted, it appears 2016 is the year they drop the gloves. If you've ever played hockey, that's when it starts getting good. We hope to see you at our webinar on March 1!
Resources
Join John Gorman, GHG Executive Chairman, and colleagues, Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and its partners, and the steps you can take to soften the impact on Tuesday, March 1 from 2:30-3:30 pm ET. Register now >>
Register your team for the 2016 GHG Forum! For more details around the event and agenda, download the full conference brochure or visit our website. Register now >>
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