How to Partner with Key Health Systems in your Service Area to Optimize Benefit Plan Offerings
As we anticipate additional information this week on the Centers for Medicare & Medicaid Services (CMS) network adequacy (pilot) audit, we can't help but consider how CMS' rigorous access and availability standards hamper Medicare Advantage (MA) plans' ability to be on the cutting edge of innovative network design. The Affordable Care Act, in comparison, has allowed for Marketplace plans to offer narrow networks as long as the networks have sufficient numbers and types of providers to deliver services without "unreasonable delay," leaving states to define the meaning of "unreasonable." This difference in network adequacy standards has widened the gap in plan offerings.
MA plans, after meeting network adequacy standards, are able to offer tiered benefit plans to members ensuring members are still afforded access to the larger network if not all standards are met within the smaller subset. The tiered benefit designs leave MA plans with the question of which providers would be the best partners.
In evaluating provider partners for tiered benefit designs or co-branding opportunities, health plans need to determine the attractiveness of each prospective provider by asking questions such as: Does the potential provider system have a similar philosophy? Is the provider system large enough to meet network adequacy standards in a given market area on their own, or would fill-in providers be required? How would their participation or non-participation in our network affect our market strategy? Does the provider system do anything particularly well, do they have unique services, service area, or exclusive providers, and how can those services be packaged? Would these bundled services contribute to increased revenue and/or market share?
In turn, provider systems that may be contemplating offering their own provider-sponsored health plan could be asking themselves similar questions and determining if a payor partnership would be a good option. Providers should develop a plan/partner evaluation process concurrent with developing a marketing strategy in order to find the best available partnership.
As we see the Marketplace and Medicaid proposing similar network access and availability standards as MA plans, we easily foresee a change in how these two government-sponsored programs will need to re-evaluate their network design. By beginning to monitor their networks now, Medicaid and Marketplace plans will be able to identify some of the provider network challenges MA plans have faced. As CMS moves forward with decisions on network adequacy for all government-sponsored health plans, enhanced relationships between payors and providers will be key in developing the networks needed to support competitive benefit plans.
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Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to 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 >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Let's get started. Contact us today
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Government Sends Stark Reminders that Insurers' Biggest Customer is Still the Regulator
Since we opened our doors 19 years ago, we've preached to health insurers to think of the government as your business partner. This week, we got several reminders that insurers' biggest customers -- Medicare, Medicaid, and ObamaCare -- are still the regulator. As business conditions improve for health plans across these business lines, government expectations are rising, and scores are about to get settled, as they always are in the second term of a Democratic administration.
We see it in enforcement activity from the Centers for Medicare & Medicaid Services (CMS). We see it in a steadily-rising bar of Star Ratings and other performance measures for health plans for all three programs, the basis of looming contract terminations. And now the White House jumps in with an aggressive schedule of risk adjustment data audits, openly seeking repayments and dropping "f" bombs: fraud, that is.
They named a great film after a moment like this: "There Will Be Blood."
You can't argue with the numbers: 2015 remains the most punitive year in Medicare Advantage history. Look at the trend:
CMS is also being much more aggressive this year with data-driven oversight and enforcement. Communications to health plans who are "outliers" in various performance measures, especially in member communications and consumer protections, began recently. A pattern we are seeing play out is CMS chasing down all clients of noncompliant pharmacy benefit managers; where poor Part D performance is seen in one plan, the agency then begins auditing that vendor's other customers, assuming they'll get the same findings.
We know that Star Ratings and expanding reporting requirements in Medicare Advantage and Part D mean the bar is rising and establishes data-driven thresholds against which health plans can be penalized and terminated beginning in 2016. CMS announced sweeping new reporting requirements for both programs this week, which inevitably get picked up in Medicaid and ObamaCare rules in following years.
And now the White House is piling on. In Washington, we talk a lot about "setting the terms of debate." Our industry has lost the debate on risk adjustment coding and has allowed anti-managed care advocates to define payers' inaccurate diagnostic coding as fraud. A just-disclosed February 2015 letter from President Obama's Budget Director to Health Secretary Sylvia Matthews Burwell stated, "While some progress has been made on this front, we believe a more aggressive strategy can be implemented to reduce the level of improper payments we are currently seeing...we must continue to explore new and innovative ways to address the problem and attack this challenge with every tool at our disposal...the government estimate of $12.2 billion in these mistakes for fiscal year 2014 remains a concern." He extended his mandate beyond Medicare Advantage to over $3 billion in questionable payments from Medicaid. This means a spike in data validation audits for payers across both programs with the threat of improper payment clawbacks and even prosecution under the False Claims Act.
There has never been a more Golden Age of opportunity for health insurers in government programs. But the threats are escalating as well, and as my politics professor told me, "99% of political wounds are self-inflicted." Plans caught up in this dragnet will have gotten plenty of warnings.
Resources
The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. Click here to review the Part C highlights that merit your attention in a blog posted by Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG).
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Potential Changes in Part C Reporting
The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. To follow are Part C highlights that merit your attention.
Organization determinations/reconsiderations, Special Needs Plans care management, and enrollments/disenrollments, were updated to include additional data elements, and two new reporting sections were added: Rewards and Incentives Program and Mid-Year Network Changes.
For most data elements with a due date of February 28, the data due date was changed to a couple of different Mondays in February, and the due date for enrollment/disenrollment was changed to the last Monday in August and February. These timing changes are proposed so the reporting load would be more manageable in 2016 than it was in 2015 for the Centers for Medicare & Medicaid Services (CMS)/Health Plan Management System (HPMS), and hopefully it will be more manageable for Plan Sponsors as well.
Two new data elements for Section 6 include the reporting of dismissals for organization determinations and reconsiderations to be more aligned with Part D reporting requirements.
Special Needs Plans (SNPs) will now also report four new pieces of data:
- the enrollee initial health risk assessment (HRA) refusals,
- the annual reassessment refusals
- the HRAs where the SNP was unable to reach new enrollees, and
- the annual reassessments where the SNP was unable to reach enrollees.
Excluded from this reporting are the HRAs that were not done where no refusal is documented and the HRA simply did not happen.
A few new disenrollment data points will now be requested:
- The total number of involuntary disenrollments for failure to pay plan premium in the specified time period.
- Of the total reported in the above, the number of disenrolled individuals who submitted a timely request for reinstatement for good cause.
- Of the total reported in the above, the number of favorable good cause determinations.
- Of the total reported in the above, the number of individuals reinstated.
A new reporting section is proposed for rewards and incentives programs. Plan Sponsors who respond in the affirmative will be required to explain which health-related services and/or activities are included in the program, which rewards enrollees may earn for participation, and how the value of the reward is calculated. They will also need to describe how enrollee participation is tracked, how many enrollees are currently enrolled, and how many rewards have been awarded so far.
Not surprising, CMS' increased oversight over network adequacy is making its way into Part C reporting. The new reporting section, Mid-Year Network Changes, will provide CMS with visibility into how often Plan Sponsors undergo mid-year network changes and how many enrollees are affected by this type of change. CMS states, based on 60-day comments, CMS increased the data elements from 13 to 53. Fun! CMS also states, "Collecting this data will help to inform CMS in determining how broadly to use the new Network Management Module (NMM) in HPMS to verify that plans' networks meet CMS network adequacy standards." If you recall from CMS' 2015 Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast, presenters specifically addressed this module and said Medicare Advantage Organization (MAO)-initiated submissions will not be viewable or evaluated by CMS. However, the NMM also allows for CMS-initiated requests of Health Service Delivery (HSD) tables "in support of various processes," which certainly you can presume will be viewable and evaluated. I don't know about you, but if it is in HPMS, it's viewable to CMS.
For all Plan Sponsors who currently do not have mechanisms for capturing this information, we encourage you to nail down a process. Operational areas may want to get a head start on determining how this information is captured today. CMS is using data now more than ever to determine outliers and to identify candidates for program audits, both of which can lead to enforcement actions. Remember: what they are asking Plan Sponsors to report on are not new requirements — so we anticipate CMS to have little patience for those who demonstrate non-compliance with items agreed to upon initial application.
Resources
Compliance permeates every department, and must be supported by effective tools and rigorous oversight. Learn how we can help you create early warning systems to ensure that operational inefficiencies and threats to member satisfaction are identified immediately. Visit our website to learn more >>
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Changes for 2015 Part D Reporting Announced by CMS
The Centers for Medicare & Medicaid Services (CMS) recently released an updated version of the Contract Year 2015 Part D Reporting Requirements Technical Specifications.
Sponsors are required to undergo data validation to have some of their Part D data audited annually. Each Part D Sponsor is required to provide necessary data to CMS to support payment, program integrity, program management, and quality improvement activities. Additional reporting requirements are identified in separate guidance documents throughout the year.
REPORT DELETIONS
Long-Term Care (LTC) Utilization -
One notable change for 2015 reporting is the LTC Utilization section will be suspended effective immediately because similar information can be obtained using Prescription Drug Event (PDE) data. Similarly, CMS removed the LTC Utilization reporting section which reports information about the total number of beneficiaries in LTC facilities for whom Part D drugs have been provided because it is provided elsewhere in the Plan's CMS contract.
Prompt Payment -
CMS removed Prompt Payment to Part D Sponsors and Fraud, Waste, and Abuse (FWA) reporting sections and decreased hour estimates associated with these sections because CMS determined these data are no longer necessary for monitoring through these reporting requirements.
CMS has determined the reporting of these data is no longer necessary for monitoring through FWA reporting requirements. Other methods using data validation processes have replaced the need for this reporting element. Annual Data Validation Audits, informatic analysis of PDE data, and other elements reported elsewhere meet the FWA monitoring goals of CMS.
REPORTING CHANGES
Medication Therapy Management (MTM) -
The addition of a note, reporting of Line Q, "Date(s) of Comprehensive Medicare Reviews (CMRs) with written summary in CMS standardized format," has been reduced to two CMR dates, even if more have been completed. One CMR is required if the member meets eligibility requirements. After analyzing the data, CMS concluded only two dates are needed for monitoring purposes.
CMS provided clarification to Line S, "Qualified Provider who performed the initial CMR," (Physician; Registered Nurse; Licensed Practical Nurse; Nurse Practitioner; Physician's Assistant; Local Pharmacist; LTC Consultant Pharmacist; Plan Sponsor) to provide more descriptive choices.
The Technical Specifications for Part D Reporting document can be viewed in its entirety as posted on the Health Plan Management System (HPMS) Plan Reporting site and on the external CMS website by clicking this link.
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We can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Visit our website to learn more >>
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Teaming with Providers: Together, Everyone Achieves More
When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly, we have proven that adage true in healthcare, as can be seen with the success of integrated delivery systems, Independent Practice Associations (IPAs), and Accountable Care Organizations (ACOs).
As health plans continue adapting to the growing influence of clinical quality on its provider network operations, building an effective team with your providers has never been more important.
But, factor in the necessities of compensating members of the team for their role, of each team meeting its profit targets and the competing priorities faced by often short-staffed teams, it should come as no surprise many health plan staff and providers are left wondering how to make it happen. Below are our top five ways to engage your providers to influence your Star Ratings.
- Prioritization: Ensure Clinical, Risk Adjustment, Stars, Claims, and Network Operations are all collaborating and prioritizing their "asks" of the providers and working together to ensure the needs of the providers are met.
- Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
- Support ICD-10 readiness: If CMS predictions hold true, denial rates and outstanding receivables are likely to increase during the conversion. Despite testing and readiness efforts, it's entirely possible some providers may not be staffed or prepared to mitigate technology-related problems among its payers or to weather the longer-term reduced productivity of their coding staff. Before your providers can invest additional energy into our Quality priorities, they've got to keep the cash flowing.
- Focus on actionability: Health plans often provide catalogs of reports each month showing providers' numerous views of their panels and forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let the providers be providers.
- Continuous measurement, re-evaluation, and reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a "thank you" are often simple but overlooked motivators.
Questions to ask:
- Were there any surprises in your first Star Ratings Plan Preview rates?
- Are your providers effectively supporting your Star Ratings goals?
From identifying the health plan functions that require provider engagement, to interpreting Plan Preview rates and trends in order to build 4th quarter Star Ratings action plans and evaluating provider contracting strategies around a holistic approach, our team can help. Contact me directly at emartin@ghgadvisors.com .
Resources
CMS recently notified plans of the first preview period for the 2016 initial Star Ratings data. It is critical for plans to begin evaluating their Star Ratings now to pinpoint problem areas, implement tactical actions, and identify improvement opportunities to raise their current score. Need assistance with your action plan or preparing for plan year 2016? Contact us today >>
At Gorman Health Group, we can help you decide what payment models are appropriate to your unique circumstance and support your implementation efforts. Learn more >>
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The Impact of CMS Changes on MA & FFM 2016 Agent Readiness
Preparing for the 2016 selling season means implementing a strategy that mitigates compliance risks for your organization and empowers your sales force to meet your enrollment targets. In our recent webinar regarding the impact of the Centers for Medicare & Medicaid Services (CMS) changes on Medicare Advantage (MA) and Federally-Facilitated Marketplace (FFM) 2016 Agent Readiness, I outlined key takeaways your organization needs to enforce in order to protect your health plan from compliance risks while also positioning it for sales success in 2016 and beyond.
1. MA/Part D Compliance and FWA Training for FDRs:
Beginning on January 1, 2016, every organization will need to ensure Compliance and Fraud, Waste, and Abuse (FWA) training requirements for first-tier, downstream, and related entities (FDRs) are fulfilled ONLY through CMS courses found on the Medicare Learning Network (MLN). This includes contracted Field Marketing Organizations (FMOs) and agents/brokers. This means the organization may now require these individuals to take custom training and must have mechanisms in place to accept completion of the CMS training. CMS also explicitly states plans will need to provide accurate reporting of this information.
Ways to fulfill requirement:
Note this requirement does not exempt organizations from ensuring all employees and FDRs are informed on how to report instances of fraud, waste, or abuse and other relevant information as described in Compliance Program requirements.
2. New Features for Health Insurance Marketplace Training
CMS is implementing changes to its process where vendors will be offering training. CMS has approved three vendors as "conditionally approved" (not approved until go-live in late summer 2015). GHG is a conditionally-approved vendor for Health Insurance Marketplace training. The number one takeaway from this is agents still begin and end on the CMS website. They cannot come to any vendor website to take their training; they must go directly to CMS and choose the party they would like to utilize.
Important to note:
- Vendors may use CMS' training or vendor-developed training approved by CMS.
- New! Vendor pricing varies: GHG's pricing is $29 for Individual and/or Small Business Health Options Program (SHOP), while AHIP is $125 for Individual or SHOP and $150 for both.
- Vendors offer Continuing Education (CE) units in 5 or more states (pricing varies by vendor).
For information on the requirements and process for completing Health Insurance Marketplace agent and broker registration and training for plan year 2016, please visit here.
Learn more about GHG Health Insurance Marketplace training at exchangebrokertraining.com.
3. Plan Benefit Training Is Important (but doesn't have to be long!)
The point of plan benefit training is not to communicate every detail of your benefits but to provide key information, such as:
- basic company information,
- plan types,
- service areas,
- premiums and deductibles,
- any changes from benefits last year,
- network restrictions and/or changes,
- highlights of drug benefits,
- description of value-added benefits,
- anything that makes you stand out from competitors, and
- most importantly, how and where to get more detailed information
Remember, every interaction your sales agents have with prospective enrollees should be viewed as a golden opportunity to educate the public about your organization. Ensure your staff is effectively trained to make every member touch count.
4. Licensure
CMS does not specify how or how often the organization checks licensure − just that they ensure the agent is licensed. GHG recommends the organization use primary-source verification through the state Department of Insurance (DOI) or National Insurance Producer Registry (NIPR). At a minimum, the organization should check annually and upon any expiration date. Quarterly checks are slightly more robust, and monthly checks the most rigorous.
5. OIG/GSA (Exclusion) Checks
Like compliance and FWA training, this is a compliance requirement that applies to all delegates (and employees) — not just agents. Every agent representing your plan needs to be checked against the federal exclusion lists every month. Plans need to work with their Compliance Department to ensure this requirement is met.
Whether you operate strictly in the MA market or are participating in the Health Insurance Marketplace, thorough and streamlined agent/broker training positions your plan to make the most of every opportunity and minimize compliance risks. Focus on better agents, not just more agents, to best serve your plan and your beneficiaries.
Need help? GHG's fully-automated Sales Sentinel™ can take your agents from zero to ready-to-sell in as little as one week, ensuring agents are not only trained but contracted, licensed, and appointed per CMS requirements. Sales Sentinel™ can also assist your organization with administrative onboarding functions such as form collection and writing code assignment.
If you have questions, please contact me directly at afleming@ghgadvisors.com.
Resources
Gorman Health Group is one of three conditionally approved for exchange marketplace training, is accepted by all carriers in federal exchange states and provides CE credits available in most states. To learn more visit exchangebrokertraining.com >>
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The Affordability Review — “Reading the Tea Leaves"
The fall season is a good reality check — back to school, cooler weather, end of summer, and …. Budgeting/financial forecasting. Forecasting is like predicting the future — you have to know how to read the tea leaves and see the efficiencies and interdependencies of your current performance to have a better idea of future performance and challenges.
Regardless of lines of business and marketplaces, companies need to manage to an acceptable loss ratio. Government regulations use this metric across different products and populations. Medicare Advantage demands at least 85% medical loss ratio (MLR), and many Medicaid plans and special needs populations require at least 90% MLR. Administrative costs are constantly squeezed, and risk adjustment is an ongoing process that is sometimes hard to quantify relative to the amount and timing of the additional revenue.
So the process of going through an affordability review is like a readiness audit. It is better to be proactive and look for opportunities before it is too late. An affordability review consists of several steps. An initial onsite visit, including interviews with management across the key departments of medical management, networks, pharmacy, claims, finance, risk adjustment, and marketing, can set the foundation for an in-depth review of internal financial and operating reports. An objective review of claims trends, based on cost and utilization drivers across members, providers, and services, can result in improved financial and operational performance. With collaboration among subject matter experts, initiatives with financial targets and action plans can be developed and monitored.
Even with new products and demonstrations, reports and a monitoring process should be in place on day one. Many Centers for Medicare & Medicaid Services (CMS) demonstrations only last for three years, so waiting for claims data and trends minimizes your window for mitigation.
Resources
Gorman Health Group has subject matter experts in operations and analytics to provide assistance with this process and help cultivate a corporate awareness and discipline toward financial outcomes that deserve a spot with quality and compliance. It is everyone's responsibility. Contact us to learn more >>
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Best Practices and Common Conditions of Audit Preparation
As we wait for the 2014 Part C and Part D Program Annual Audit and Enforcement Report to be released, we contemplate the activity that our client partners have experienced during CMS audits, in remediation of identified conditions, and preparation for future activities.
This year started a new audit cycle. It has also been a year filled with plan sponsor confusion and frustration over published audit protocol that did not appear to be fully vetted before release to the industry. We received a number of clarifying questions regarding the protocol instructions and data layouts before CMS' summer Oversight and Enforcement conference, and we continue to advise clients — whether they are undergoing a CMS audit or not — to reach out to CMS for clarification in writing. Protocol aside, there is much you can do to perfect the things you have control over — when you can't change the data of the past. With that, and using CMS nomenclature, I bring you some best practices and common conditions of audit preparation that we have garnered over the years.
Best Practices
- Audit participants know their self-identified and disclosed data very well.
- All documentation is perfectly organized when presenting tracers in easily accessible folders, reachable by one click.
- Information Technology and Support staff tests telephone and web connectivity in every conference room. Contact names of multiple IT staff are posted in each webinar room, with one professional outside the conference door at all times.
- Debrief meetings occur every evening with the full plan audit team and CEO. CEO also kept well informed during the day throughout the audit.
- Audit participants are honest and forthcoming with reviewers.
Common Conditions
- Organization is not audit-ready in light of annual protocol release.
- Organization is not fully prepared in light of best practices/common conditions memos to demonstrate thorough evaluation of same.
- Tasks completed but documentation is not in place to substantiate it.
- Webinar participants designate drivers and speakers ahead of time, but do not designate note-takers, runners, or a master of the mute button.
- Organization does not leverage opportunities to outreach to Compliance or CMS for clarification of guidance.
If you have been holding your breath patiently waiting for an audit notice, don't worry, there's still time. The best practices above help your audit run smoothly, efficiently, and help demonstrate a connectedness of a well-oiled machine of a Compliance Department. These folks are generally the ones tasked with the housekeeping and logistics of planning, as well as documentation uploads, leadership summaries and let's not forget their day-to-day work.
Resources
The Centers for Medicare & Medicaid Services (CMS) audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more >>
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Medicare at 50: Past, Present & Future
Since its inception on July 30,1965, millions of elderly and disabled Americans have been able to obtain medical care through Medicare. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number has dropped to a staggering 2 percent.
The accomplishments for Medicare have been noteworthy.
These include increased access to health insurance coverage and healthcare, decreased disparities in access by race leading to desegregation of hospital staff and facilities, as well as payment and delivery system reforms such as prospective payment, capitation, and shared savings — all of which have been adopted by private payers. Karen Davis from Johns Hopkins and former President of the Commonwealth Fund noted the success of Medicare's insurance Marketplace which offers beneficiaries a choice of traditional Medicare and Medicare Advantage plans with a 4-5 Star program that is driving plans and enrollment to higher quality. Medicare spending per capita has grown more slowly than overall health spending per capita and is currently at historically low rates.
The challenges are many.
Disjointed coverage (Parts A, B, D) is confusing to beneficiaries and results in high administrative costs and overpayments. Out-of-pocket costs for premiums, cost-sharing, and uncovered services remain high, and Medicare has no out-of-pocket maximum. Medicare does not cover long-term care services or home- and community-based services. Provider payment still remains largely fee-for-service, resulting in incentives for volume and provider not patient-centered care.
The Future
The future involves many different directions. The first is moving from an acute care model to a program that can effectively care for beneficiaries with complex chronic conditions. Provider payment reform needs to move to value-based payment that rewards efficiency and quality. The focus needs to shift to patient-centered care rather than provider-centric care. Care coordination and team care needs to be a focus. Program fragmentation and high out-of-pocket costs, particularly for high service users, needs to be addressed.
As Charles Darwin pointed out, evolution isn't about being the biggest or the smartest, but the most adaptable. Government programs have become the biggest opportunity for payers. Rates will be positive especially in Medicare Advantage, but the compliance environment will be brutal throughout the rest of the Obama administration. Star Ratings and the member experience are now driving the market — 30 plus states are now using some form of Star Ratings for performance-based payment, many states have adopted quality ratings for Medicaid managed care plans, but there is no national standard….yet, and the Health Insurance Marketplace will begin publishing quality ratings in 2016.
What have we learned?
John Gorman, Founder and Executive Chairman at Gorman Health Group, recently provided lessons learned in the 19 years we have partnered with health plans operating in Medicare, Medicaid and now the Health Insurance Marketplaces. He discusses the current industry environment and what's important moving forward. Read more >>
About 81M will be enrolled in Medicare by 2030. Is your organization prepared?
Resources
Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to 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 >>
GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. Contact us to learn more >>
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2016 Marketing Guidelines: Evolve or Pay
There were several significant changes released in the 2016 Medicare Advantage & Part D Medicare Marketing Guidelines (MMGs), all of which communicate the same consistent message from the Centers for Medicare & Medicaid Services (CMS), the focus is on the beneficiary.
Possibly one of the more surprising trends was that with the focus on improving the beneficiary experience, CMS has actually also provided significant leeway in the way that Organizations are permitted to fulfill the requirements. However, with the leeway provided, CMS reminds us that "If CMS finds the Plan/Part D Sponsor failed to comply with applicable rules and guidance, CMS may take compliance action, including intermediate sanctions and civil money penalties." In other words, "Evolve or Pay".
In our recent webinar, Nilsa Lennig, GHG's Vice President of Sales & Marketing Services and I, discussed the new guidelines and what is required of plans to do moving forward.
Below are the top three revisions released in the 2016 MMGs that we believe will have the most significant impact on Organizations:
1. CMS revises current guidance to allow Organizations the option of providing the pharmacy/provider directory to new or renewing enrollees OR a separate notice to alert enrollees where they can find the pharmacy/provider directory online and how they can request a hard copy. In addition, in keeping with the information released in the 2016 Call Letter, CMS includes language requiring Organizations to contact providers monthly to obtain updates to provider information. Once updates from providers are received, Organizations must update the online provider directories in real time.
The operational implications that come along with the changes around network updates and provider directories are huge. While Organizations will have to work through the specifics of these new processes, the cost savings of not having to automatically send printed directories is a clear win for the industry.
2. CMS modifies current guidance to require submission of all agent/broker websites that mention specific products. While this change may be operationally burdensome, we actually view this as a positive. Clearly, this is a revision that has to do with risk areas that have been identified in the industry - anyone who has overseen or reviewed agent/broker websites can attest to that! With the CMS requirement in black and white, we believe that CMS has actually made it easier for Organizations to oversee agent/broker websites in order to ensure Compliance.
3. CMS now specifically states that submission and approval of mobile applications (app) for marketing to prospective enrollees is required. From our perspective, this revision indicates again that CMS has become aware of an area of industry risk. In order to implement this requirement it will be important that Organizations get ahead of this trend and a) ensure that agent/broker/FMO contract language is strong related to which delegates are permitted to develop an app to market plan products and b) ensure that there is a process in place around internal compliance review and submission to CMS of mobile applications.
Conclusions?
- CMS continues method of applying Compliance Actions, as well as Civil Money Penalties
- CMS Continues to have a laser focus on beneficiary protections
- CMS has provided significant flexibility to fulfill certain key requirements — take advantage!
If you have questions or need clarifications regarding any of the information listed above, contact us here and a team member will bee in contact with you shortly.
Resources
Read our recent case study regarding a mid-sized managed care health plan who struggled with appeals, grievances, and Complaint Tracking Module cases (CTMs) to see what their challenges were and how they overcame them. Download now >>
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