Insights | GHG Advisors

2016 Readiness Review Smaller Size, Bigger Punch.

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Readiness Checklist on Monday, November 9, 2015. The 20-page checklist is full of items CMS is expecting plan sponsors to review and validate it will be compliant for the 2016 calendar year. While CMS won't have an official website for plan sponsors to attest to the readiness this year, they will use other methods to validate compliance. No matter the validation method, CMS' expectations are clear: Part C and Part D plan sponsors should review and validate compliance for each item.

In reviewing the 2016 Readiness Checklist, there are some new and modified requirements as well as other areas of CMS concern. Regardless of whether or not the items are new to the readiness checklist party, they should all be known to you. If they aren't familiar, you may want to check your Health Plan Management System (HPMS) and regulatory guidance distribution process. CMS indicates at the end of almost every requirement where the guidance for that item came fromâ€•what Medicare manual or HPMS memo provides the supporting information for that item. CMS makes it convenient to validate what you are asked to validate and attest.

If you have waited until now to implement or validate new guidance from 2015, it will be a stressful few weeks in what is already a very busy time of year. Several items are heavy-hitters and get into the nitty gritty of processes. As in past years, any items which won't be in compliance are to be reported to your CMS Account Manager. No one likes to be on that list.

Many sections of the Readiness Checklist are smaller but have more potential process changes. "By no means should plans see an abbreviated Compliance and Fraud, Waste, and Abuse (FWA) section and start resting on laurels," said Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). Regan went on to say, "In this year's checklist, CMS issues another reminder about the May 24, 2014, regulation change which requires mandates on Medicare Advantage (MA) organizations to require all of their first tier, downstream, and related entities (FDRs) to take the CMS training and accept the certificate of completion of the CMS training as satisfaction of this requirement."

Another change highlighted in the readiness assessment is plan sponsor's appropriate use of extensions for organization and coverage determinations and appeals. In audits, we often see plan sponsors who have failed samples due to extensions granted for contracted providers or when extensions are used early in the process and on a routine basis rather than as an exception. CMS is expecting plan sponsors to review their process for exceptions and ensure they are in compliance.

One change Regan called out is CMS included a recommendation that plan sponsors making pharmacy network changes provide both those pharmacies whose network status is changing and enrollees using those pharmacies with notices of changes specific to their situation. "This is almost certainly a result of CMS' close work with one plan sponsor on effective notification strategies as part of pharmacy network changes. While the plan sponsor had indeed sent letters to supplement the Annual Notice of Changes' (ANOC's) notification of changes, the recommendation is to move to a more personalized notification approach," indicated Regan. "This will allow beneficiaries to make a more informed decision and will also aid pharmacies in understanding their network status."

A senior consultant of Pharmacy & Clinical Solutions at GHG, stated, "The Readiness Checklist is always an excellent method of making sure you have the bases covered for new guidance which takes effect in the new plan year (2016)." Deb went on to indicate there are three items plan sponsors must pay particular attention to in the 2016 Readiness Checklist for Part D. They are as follows:

The long-delayed requirement "physicians and other eligible professionals who write prescriptions for Part D drugs are required to be enrolled in Medicare in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, unless the prescriber is an â€˜Other Authorized Prescriber'." This takes effect on June 1, 2016, and, therefore, plans must confirm their contracted providers, including dentists, are eligible to furnish Part D prescriptions.
Also, providers must have a valid prescriber National Provider Identifier (NPI) number for Part D claims to be valid. Specifically, "for plan year 2016 and thereafter, claims for covered Part D drugs must include a valid prescriber NPI. Part D sponsors must submit to CMS only prescription drug event (PDE) records containing an active and valid individual prescriber NPI."
Starting on January 1, 2016, it is CMS' expectation Medicare Advantage Prescription Drug (MA-PD) plan members will not leave a network pharmacy without their prescription for a medication(s) where coverage may available under either Part D, Part A, or Part B. Plan sponsors and/or their PBMs must have processes in place so the network pharmacist can exchange information with the plan sponsor or PBM about the member to make the determination about which arm of Medicare will pay.

Parting words from Regan, "CMS makes it clear these are key requirements, and the checklist is not an exhaustive list. Consider these items to be hot topics CMS will hang their hat on in the coming year." The key to successful MA and Part D programs is to know your business better than anyone, including CMS. The Readiness Checklist is one additional tool to do just that.

Resources

If you need assistance in assessing your organization against the Readiness Checklist or in strengthening your MA or Part D program, GHG's knowledgeable team is here to help you. We've been in your shoes and know the pain points and how to move through them. We can help you prevent that punch from being a knock out. Contact me directly at jbillman@ghgadvisors.com.

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

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

by GHG Advisors

Influencing Your 2017 Star Ratings: It's Not Too Late

We are officially in the throes of the unavoidable, and much dreaded, 4^th quarter Star Ratings "fire drill." While health plan leaders (again) promise their staff and providers this year will be the last a Star Ratings fire drill will be needed, the day-by-day countdown to year-end has officially begun. As even more evidence year-end is almost upon us, Star Ratings leaders throughout the nation are putting the finishing touches on their 2016 Star Ratings work plans and counting down the days until Star Ratings measure rates and denominators are reset and the annual cycle begins again.

Because providers and pharmacies can only provide Star Ratings-impactful services to members through the end of December, many health plans may mistakenly think their ability to impact the 2017 Star Ratings is also on the countdown clock. Luckily, this couldn't be farther from reality. Not only is this a great time to evaluate the adequacy of your 2016 Star Ratings work plans and budgets, but there are also plenty of opportunities for health plans to continue impacting their 2017 Star Ratings. Health Plans must continue to focus significant effort to ensure administrative processes capture all of the services provided to your members this year. Organizations still have several more months to influence members' responses to next spring's Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) survey and Health Outcomes Survey (HOS), and don't forget the Call Center — Foreign Language Interpreter and TTY Availability measurement period occurs entirely during the spring of 2016.

While it is certainly true Health Plans won't be able to provide additional clinical services after December 31^st to impact 2017 Star Ratings, there is plenty of opportunity to influence the 2017 Star Ratings over the next few months. The following are a few ways you can continue to impact your 2017 Star Ratings even after December draws to a close:

Review your Healthcare Effectiveness Data and Information Set (HEDIS^®) medical record review workflows, encounter data workflows, and claims/prescription drug event (PDE) reconciliation workflows to identify any gaps or opportunities for improvement.
Objectively review the effectiveness of your 2015 Star Ratings activities to determine what worked well, what didn't work as well as planned, and what areas can be improved or enhanced in support your Star Ratings vision.
Objectively evaluate the cohesiveness and coordination occurring among your internal teams and external partners and vendors to improve your members' experience.
Evaluate how effectively your teams are working with your high-volume providers and under-performing providers to improve Star Ratings and effectively administer risk adjustment programs.

Gorman Health Group's (GHG's) team of experts can help you leverage your infrastructure and workflows to improve your Star Ratings performance. Contact us today >>

Resources

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

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

by GHG Advisors

Is This Payment Real? CMS Launches Policy-based FFM payments Through the HIX 820 in 2016

If you think your organization has been working from a fire hose these past few years since the launch of the Health Insurance Marketplace, wait until the Centers for Medicare & Medicaid Services (CMS) rolls out policy-based payments to Federally-facilitated Marketplace (FFM) Issuers beginning in 2016. It's not as if the accuracy of member data wasn't significant before, but now with a direct payment from CMS to the Issuer, your enrollment discrepancy rate will be transparent in real dollars.

For the first time, Issuers will be able to quantify the financial impact of enrollment discrepancies simply because CMS will be making payments directly to Plans through Advanced Premium Tax Credits (APTCs), Cost Sharing Reductions (CSRs), and User Fee (UF) charges based on effectuated subscribers within the federal system, not the Issuer system. This ups the ante for synchronization of data between the Issuer and the Marketplace.

In January 2016, CMS will begin paying Issuers at a policy-based level through a transaction called the HIX 820 complimented by the Preliminary Payment Report, or PPR. Aside from the typical challenges and workarounds Issuers are confronted with during open enrollment season, the timing of policy-based payments creates somewhat of a twist or a renewed focus on the financial impact of enrollment data being out of synch with the government.

Issuers are anticipating more work ahead in 2016 with a long list of inherited issues and newfound challenges such as 2016 renewals, ongoing Health Insurance Case System (HICS) activity, continued FFM lags with system updates, and continued interim processes. Yet, one can view the implementation of the HIX 820 as a new opportunity to review and build upon your operations and reconciliation practices simply based on your Chief Financial Officer's (CFO's) perspective.

If your CFO hasn't asked you before, he/she will.

If we have an expected payment of $100 million based on effectuated members on our books, why is our payment $120 million this month?
Is this a real payment or an overpayment based on lags with the FFM applying member updates such as cancels and terminations?
Aside from timing and adjustment activity, what should the prospective payment for next month be? Let's review and find out why your estimate differs once the HIX 820 arrives.
What does this high volume of adjustment activity in May 2016 applied to January and February 2016 coverage months represent? How do we build an expected adjustment each payment cycle so there are no surprises?
How many monthly cycles will it take to be paid accurately for January 2016?

With the goal of measuring the overall financial impact of your enrollment and payment discrepancies, you will be able to build a strategy around successful reconciliation. Some key drivers are fundamental and important to highlight. Your organization can simply calculate your expected payment to your actual payment by comparing your PPR/820 monthly payment files to your plan data (RCNI) as a first step. At the end of the day, your CFO will not be interested in a partial picture — he/she will want to understand if the payment is real and whether it will change retroactively. Understanding the complete financial impact of all discrepancies should be your first step. The operations surrounding the resolution of discrepancies should be secondary, albeit a huge undertaking. So, how do you get there?

Recommendations for Issuer's HIX 820 Strategy:

Be audit ready.
- Understanding CMS will pay you based on the FFM system signifies your daily enrollment processing oversight and the audit of those processes in the form of reconciliation practices go hand in hand. In an audit, you never want CMS to identify you are being paid for non-members or not paid for members consuming the benefit and everything in between.
See the big picture.
- On a weekly or monthly basis, your organization needs to understand its discrepancy rate and the formula the rate represents. Is it 2%, 8%, 12%? Measure it, and work that rate downward.
- If you have a 5% FFM orphan discrepancy rate in January 2016, what is your January discrepancy rate in April 2016? Monitoring by coverage month each report month is critical to being paid accurately and other downstream issues impacting revenue.
Put your CFO hat on.
- Institute a monthly review of your organization's discrepancy rate with your CFO.
- Be able to tell a story on the difference between expected and actual payment along with your retroactivity predictions. Now that the 820 will be paying prospectively and retroactively back to 1/2016, Issuers will be able to measure the swings in payment activity.
- Track discrepancy drivers within your organization and look for process improvement opportunities you can operationalize along with aligning resources more effectively.
Track CMS-defined payment issues and submit timely through the Payment Dispute template. Remember, these are discrepancies sourced to an FFM system issue since your Issuer data matches the FFM data (Pre-Audit File).
Summarize, work, and measure success of the FFM Recon Outbound File (RCNO).
- Update your enrollment system or dispute Issuer action flags.
- Track and monitor the FFM action flags as well as ensure CMS is applying corrections to the FFM database in conjunction with Issuer corrections. This is a two-pronged approach.
Track orphan discrepancies (both Issuer and FFM) by coverage month through the FFM Pre-Audit file and resolve each subscriber case.
- Categorize the causal such as FFM BAR error, missing 834, Issuer processing error.
- When you know your data, you are able to answer every audit question that arises.
At a maximum, when monthly orphan identification is working well, move to weekly discrepancy tracking by comparing the authoritative Pre-Audit file to your Issuer data. This allows you to detect internal issues more timely before interfacing with the government.

While none of this is new for government programs as history always repeats itself, it is clear you can apply the same guiding principles. Positioning your organization to succeed in this new environment is directly tied to an optimal reconciliation approach so you can answer the question, "Is this payment real?"

To learn more about Gorman Health Group's reconciliation solution, Valencia™, and how it supports enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com or Diane Fischer at dfischer@ghgadvisors.com.

Resources

Gorman Health Grouop's Valencia™ creates the workflows organizations like yours need for critical operational functions. With Valencia™, you'll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments. Contact us today to set up a demo >>

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

by GHG Advisors

Proposed Changes to the CMS-HCC Risk Adjustment Model

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

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

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

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

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

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

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

Initial Highlights:

a. The Impact on Partial Dual Eligibles

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

b. Member Eligibility and Reconciliation

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

Takeaways:

a. New Opportunities to Manage Trend and Control Utilization Costs

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

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

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

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

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

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

Resources

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

by GHG Advisors

Mergers Pave Way for Good Opportunity to Enter Medicare Advantage Market

While the largest insurance companies await their fate at the hands of federal regulators, other plans and investors should pay close attention to the opportunity to acquire divested plans from the two deals.

With the shareholders overwhelmingly approving the merger between Aetna and Humana, all eyes are on what the Department of Justice (DOJ) and the Federal Trade Commission (FTC) will make of the proposal for the two largest health insurers to consolidate. Anthem and CIGNA also await federal scrutiny. The mild grilling of the healthcare executives on the hill has led many to believe these deals will receive federal approval. And while hospital associations warn of lack of competition in programs such as Medicare Advantage (MA), it is widely recognized these companies will face significant divestitures in markets which will become highly concentrated due to the mergers. Aetna already announced it took a conservative look at the amount of business it would need to divest in order to make this deal go through.

Humana and Aetna would need to divest their plans anywhere the two plans have too much of the market combined — financial analysts estimate this to be any county where the market share is over 40% to 50%. One example of such state is Kansas, where Humana and Aetna combined hold 90% of the MA business. Other major states include West Virginia, Iowa and Missouri, and Ohio, where the two insurers would control an overwhelming amount of MA business. While, according to the Kaiser Family Foundation, Aetna currently only controls 7% of the MA business nationwide, Humana has the largest enrollment in 11 states.

These divestures present a great opportunity for investors and existing plans to enter or increase their presence in the MA market. MA enrollment currently sees no end to the growth spurt it is experiencing. In fact, the National Committee for Quality Assurance (NCQA) recently praised MA plans for their success in increasing quality for seniors, for the first time ever outpacing commercial plans on some quality measures. These existing MA plans are also attractive because of their existing infrastructure already in place, as the investment in creating a new MA plan is very burdensome and can take a long time to reap the benefits.

With both deals expected to close mid to late 2016, investors should really consider looking at states and counties where divestitures will be particularly significant and entering the ever-growing MA market.

Interested in entering or increasing your presence in the MA market?

Gorman Health Group's integrated team of experts can provide strategic analysis in evaluating market conditions across the country to identify MA opportunities and high potential target areas for expansion. Contact us today >>

Resources

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

by GHG Advisors

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

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

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

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

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

Resources

Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>

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

by GHG Advisors

A New Report by Kaiser Family Foundation Found Part D Premiums Will Rise an Average of 13% in 2016

We blogged earlier this month about Medicare Advantage (MA) premiums showing slight decreases to no decreases across the board for 2016 based on the Centers for Medicare & Medicaid Services (CMS) estimates. But what does the landscape look like for Part D?

CMS stated in a September 2015 article, "Premiums in the Medicare Prescription Drug Program (Part D) will [also] be stable next year." Earlier this year, CMS announced the average basic Medicare prescription drug plan premium in 2016 is projected to remain stable at $32.50 per month.¹ CMS' Part D average premium estimates include both Medicare Advantage Prescription Drug plans (MA-PDs) and Prescription Drug Plans (PDPs). If we carve out PDPs from the Part D premium average reported by CMS in September, data shows, for most PDP enrollees, premiums are projected to be higher in 2016 than in 2015, and many will also see higher deductibles and more cost-sharing tiers with coinsurance.² As cited in a recent Kaiser Family Foundation study on Medicare Part D plan offerings for 2016, the average PDP premium is projected to increase by 13 percent from 2015 to 2016, from $36.68 to $41.46 per month. When looking at the $0 premium PDP options, low-income subsidy (LIS) enrollees will have fewer to choose from. This means either plan reassignment or beneficiary plan switches will occur for beneficiaries to continue without a premium.

What will this mean for MA plans offering Part D coverage in 2016? Increased 2016 PDP premiums may contribute to a potential shift in membership from PDPs to MA-PDs this Annual Election Period (AEP). Leveraging this opportunity will require time investment from MA-PDs, educating beneficiaries on how making plan changes could lead to beneficiary cost savings and still meet their Part D coverage needs.

"Premium" may be the first category beneficiaries are looking at, but it is not the only thing beneficiaries consider when comparing Part D options. The entire point of AEP is to offer Medicare beneficiaries the opportunity to evaluate their plan options and choose a plan which best meets their needs. This means, in addition to premiums, beneficiaries are looking at deductibles, cost-sharing, formularies, and network pharmacies.

In 2016, 84 percent of PDPs will use tiered pharmacy networks, with lower cost-sharing in selected network pharmacies and higher cost-sharing in other network pharmacies. Two-thirds of all PDPs will have deductibles, with a growing share of PDPs imposing the maximum deductible allowed by law, which increased from $320 in 2015 to $360 in 2016, the largest increase in the deductible since the start of the program.²

Now that the cards are on the table, your immediate strategy, as well as that for next AEP, should be examined. Are you at risk for losing members to competition due to pricing increases? Are your retention efforts aligned to address this issue? Have you identified opportunities to gain membership and benefit from your competitors' increases?

Have questions or need information? Contact me directly at nlennig@ghgadvisors.com or Charro Knight-Lilly, Senior Vice President of Client Services, at cknightlilly@ghgadvisors.com.

¹ CMS, "Medicare Prescription Drug Premiums Projected to Remain Stable" available at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releases-items/2015-07-29.html.

²Oct. 13, 2015 | Jack Hoadley, Juliette Cubanski, and Tricia Neuman, Medicare Part D: A First Look at Plan Offerings in 2016, http://files.kff.org/attachment/issue-brief-medicare-part-d-a-first-look-at-plan-offerings-in-2016

Resources

The Medicare Advantage marketplace is evolving — are you prepared? 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 >>

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

by GHG Advisors

The Transition From RAPS to EDS: New Offering Helps Your Plan Calculate & Define Risk Level

In 2016, the Centers for Medicare & Medicaid Services (CMS) will start to transition from utilizing Risk Adjustment Processing System (RAPS) files, to support the Medicare risk adjustment payment, to encounter files. The transition process is gradual, with a weighted percentage being taken for 2016: 10 percent based on the encounter files and 90 percent based on the RAPS files. With this transition, it is critical that health plans ensure that their RAPS files and Encounter files are in sync. Oh- and the vendors are on the hook for this too.

For some, the financial and operational impact of the transition from RAPS files to EDS files for risk adjustment is still a mystery. On October 23, CMS announced further guidance regarding RAPS and EDS Submissions.

There were three key elements:

1). The addition of diagnoses submitted after the risk adjustment deadline for payment year

2). The submission of HIPPS Codes for CAH's

3). The use of default NPIs for atypical providers.

Gorman Health Group (GHG) continues to stress the importance of accurate and timely submission of RAPS and EDS files to CMS. This memo clearly supports our rationale behind this emphasis, and it takes it one step further. Your organization not only needs controls on the front end, it needs quality oversight and standard operating procedures in place to manage the file return elements from CMS.

CMS states that it will not incorporate into the risk score for a payment year additional diagnoses submitted after the risk adjustment deadline. Specifically, after the final risk adjustment submission deadline for a payment year, only diagnoses deletes will be included in a rerun of risk scores for the payment year. Knowing this, there is no time like the present to reevaluate your RAPS and EDS processes. Our new capability will help your plan do this while calculating and defining its current level of risk.

This is a critical time and an imperfect process for health plans and risk baring provider groups, GHG is excited to introduce our new RAPS/EDS Variation Analysis capabilities. Our team of operations and data experts will assess your current processes and data, identifying gaps and discrepancies that need to be addressed in order to ensure compliance and secure accurate payment from CMS through Risk Adjustment operations.

Clients will receive the following critical items upon completion of the analysis:

Operational Assessment Report - Outline of the processes that the health plan currently has in place for RAPS/EDS file submissions, returns and error resolution, providing areas of opportunity for improvement.
Variation Analysis Review - Review of findings, outlining instances for potential inaccuracies and risks associated with the health plans current methodology and processes applied to the internal variation analysis.
Discrepancy Reports - Identifies opportunities to improve completeness and accuracy of each submission to CMS.
Encounter File Member Analysis - Provides detail around the member attributes utilized for risk score calculation to identify gaps when comparing to the RAPS file member analysis.
RAPS File Member Analysis - Provides detail around the member attributes utilized for risk score calculation to identify gaps when comparing to the encounter file member analysis.

With this information, a health plan can feel confident that they fully understand the revenue and operational impact of this transition and are able to put processes in place to ensure that there is no loss of revenue or instances of data inequities when transitioning to the Encounter file format.

For more information on our approach and the results, please contact me directly at dweinrieb@ghgadvisors.com.

Resources

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

by GHG Advisors

Relief for Plans Serving Dual Eligibles?

It seems as though the Centers for Medicare & Medicaid Services (CMS) may be taking a detour in their position on the effect of socio-economic characteristics of a plan's enrollees. Last week, CMS announced plans to release a proposal to change Star Ratings for plans with significant low socio-economic beneficiaries, in a forthcoming request for comment for updates to the program in 2017. CMS stated the agency will release this request for comment by early November.

Although the health industry has voiced their dissatisfaction for quite some time now with the current rating system being applied to dual eligibles, CMS warming to the idea is a bit surprising. Just last month, CMS announced its results from the study, stating that while "research to date has provided scientific evidence that there exists an LIS/Dual/Disability effect for a small subset of the Star Ratings measures, the size of the effect is small in most cases and not consistently negative." This month, the Medicare Payment Advisory Commission (MedPAC) also chose to postpone making recommendations until it saw what action CMS takes.

While this change in position is welcome, it is unclear whether CMS will actually implement a solution. CMS has previously proposed a temporary solution to reduce the weight of seven measures but, after negative feedback, chose not to implement the proposal. It is also unclear whether this change in position comes from new findings CMS has yet to release or whether it changed its position based on the analysis released from the study last month, where the disparities in measures were found to be "insignificant."

Until we see whether CMS changes its position on dual eligibles, plans falling below three stars for three years under the current rating system will still face termination, regardless of the number of dual eligible enrollees enrolled in the plan, if they cannot improve their performance to at least three stars.

Stay tuned.

Resources

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

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

by GHG Advisors

2015-2016 CMS Program Audit Protocols Update

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

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

Overall Process

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

CPE

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

CDAG and ODAG

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

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

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

Pilot Protocols

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

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

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

Resources

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

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

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

by GHG Advisors