MLTSS: Key to Caring for Duals
We all want to do it: Provide the best healthcare services for our members. For our vulnerable population, this can be complicated, if not near impossible to achieve, given the current healthcare issues at hand.
About 9.6 million people in the United States are covered by both Medicare and Medicaid, including low-income seniors and younger people with disabilities, according to the Kaiser Family Foundation (kff.org). Kindred Healthcare's "Making Sense of Healthcare Reform: Dual Eligible" points out, as baby-boomers reach their 65th birthdays, an estimated 10,000 individuals become eligible for Medicare-covered services each day. Couple this fact with the expansion of Medicaid eligibility in many states, the result is a much larger dual-eligible population in the near future. These dual-eligible beneficiaries are almost, by definition, a high-needs population often demonstrating to be the poorest and sickest beneficiaries of both programs. Consequently, they account for a disproportionate share of spending in both programs and, according to the Medicare Payment Advisory Commission (MedPAC), dual-eligible beneficiaries cost Medicare about 60 percent more than non-dual eligibles.
Medicare and Medicaid were never operationally designed to work as a single health plan (and it shows). Kindred Healthcare explains further in their article there are coverage and payment policies offered by 50 separate and unique Medicaid policies. Simplified, Medicaid pays for almost all long-term care (LTC) services, while Medicare covers more acute care such as emergency department visits. Dual eligibles are constantly bouncing back and forth between the two government-funded programs; Medicare pays for an operation and Medicaid for long-term recovery.
It's complex, inflexible, and silo-infested.
Health plans need to identify ways to better manage escalating costs and make payment reform a fundamental requirement in both improving quality and containing costs. The answer is multi-faceted.
Move from Volume to Value: According to an article in governing.gov, the volume-driven Fee-for-Service (FFS) payment system for the Managed Long Term Services and Supports (MLTSS) of the aging and disabled LTC populations is focused on volume. The volume-driven FFS payment system can be replaced with pay-for-performance and care management initiatives including performance-based contracting, shared risk, and capitated payments to providers and managed care organizations (MCOs). Success of these initiatives is dependent on the plan's ability to track and analyze the outcomes. Focusing on outcomes can transition staff perspective, actions, and care plan goals to be more person-centered.
Improve Access to Home- and Community- Based Care: Tennessee implemented a pilot based on a decade-long study published in Health Affairs in 2009 which found states with established home- and community-based programs were able to reduce their overall Medicaid LTC spending by nearly 8 percent. Acting on the results of this study, Tennessee lawmakers introduced a new program called CHOICES in 2010, which was a way to help seniors on Medicaid receive home- and community-based care instead of living in nursing homes. Programs like CHOICES are estimated by the Bowles-Simpson presidential commission of fiscal reform to possibly produce savings up to $12 billion by 2020. Nursing homes, as a default option for aging and disabled beneficiaries, will quickly prove unaffordable in the long run not to mention negatively impact satisfaction ratings. After all, AARP conducted a study of individuals over the age of 50 and found more than 80 percent prefer aging in their own home than in an institution.
Provide Feedback to CMS: September 14, 2015, is the deadline to provide the Centers for Medicare & Medicaid Services (CMS) comments regarding their newly released rule, Reform of Requirements for Long-Term Care (LTC) Facilities. This proposed rule would revise the requirements LTC facilities must meet to participate in the Medicare and Medicaid programs. An emphasis has been made on theory and practice of service delivery and safety in order to achieve broad-based improvements both in the quality of healthcare furnished through federal programs, and in patient safety, while at the same time reducing procedural responsibilities on providers. New sections address facility responsibilities for protecting resident rights and enhancing quality of life; requirements for comprehensive person-centered care planning; changes relating to behavioral health service and laboratory, radiology, and other diagnostic services; requirements for Quality Assurance and Performance Improvement (QAPI) and Compliance and Ethics Programs; and staff training requirements. CMS estimates costs to comply per facility over a span of two years will be about $40,685.
Care Coordinate Effectively: In John Gorman's blog, "You're Doing it Wrong in Care Management" issued May 18, 2015, he explained how modernizing your approach in care management into data-driven care coordination "pods" can help you better manage your high utilizers and those about to become them. By "doing it right in case management," you can both contain costs and improve quality.
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GHG can help your transform a total change in the delivery, payment, and care coordination efforts necessary to provide positive outcomes for a very challenging patient population. We can help you learn what works best in coordinating quality-driven care for dual-eligible beneficiaries — and what approaches would be unsustainable. Contact us to get started today>>
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EHR Incentive Programs: Improving Access to Care
The 2014 Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs were developed to provide financial incentives to eligible professionals, eligible hospitals, and Critical Access Hospitals (CAHs) to achieve meaningful use of certified EHR technology with the goal of improving patient care. The programs worked to prompt healthcare providers to adopt, implement, upgrade, or demonstrate meaningful use of certified EHR technology. In her May 18, 2015, article in RevCycleIntelligence, Jacqueline DiChiara reported by the end of 2014, EHR incentive payments reached over $28 billion with eligible hospitals receiving more than $17 billion, Medicare and Medicaid-eligible professionals collectively receiving nearly $10 billion. However, there are some changes with the EHR Technology Incentive Program that may affect your revenue—and not in a good way.
In the amended American Recovery and Reinvestment Act of 2009 (ARRA), Congress included provisions in the Medicare and Medicaid EHR Technology Incentive Program for CAHs, as well as eligible professionals and hospitals, who did not successfully demonstrate meaningful use of Certified EHR Technology to experience a negative payment adjustment to their reimbursement. Effective January 1, 2016, payment adjustments will be applied for those Medicare-eligible professionals not meeting the criteria for meaningful use in the Medicare EHR Incentive Program. For eligible hospitals, payment adjustments were applied as of October 1, 2014. Interestingly, DiChiara notes over 28,000 eligible professionals reported a 2% decrease in their 2015 Medicare payments for not meeting the standards related to Electronic Prescribing (eRx) and the Medicare EHR Incentive Program. CAHs unable to demonstrate meaningful use for the applicable reporting period of fiscal year (FY) 2015 will have a decrease in their reimbursement, from 101% of its reasonable costs to 100.66%, according to CMS.gov. For 2016, the percent of reasonable costs reimbursement decreases to 100.33% and then down again to 100% for 2017 and for each year thereafter, well into years 2020 and beyond.
CAHs were created to preserve access to primary and emergency care services in isolated rural areas by improving the financial conditions of CAHs and, subsequently, preventing some closures. Choices Magazine article, "Performance of the Critical Access Hospital Program: Lessons Learned for Future Rural Hospital Effectiveness in a Changing Health Policy Landscape," highlighted the CAH program grew rapidly from 41 hospitals in 1999 to 1,055 hospitals in 2005 and to 1,327 CAHs in 2011 because of the 1983 Medicare switch from cost-based reimbursement to the Prospective Payment System (PPS). CAHs now face possible Medicare cuts. Hopefully, the following information from CMS.gov can help CAHs effectively avoid EHR Incentive Program payment adjustments and ensure their financial longevity as Medicare and Medicaid providers.
- Hardship: A CAH may, on a case-by-case basis, be exempted from this adjustment if the CAH can demonstrate, on an annual basis, becoming a meaningful user of EHR technology would result in a significant hardship. However, in no case will a CAH be granted an exemption for more than five years.
- July 1, 2015: 2016 Eligible Professional (EP) Medicare EHR Incentive Program Hardship Exception Application Deadline
- CAHs can apply for hardship exceptions in the following categories:
- Infrastructure — CAHs must demonstrate they are in an area without sufficient internet access or face insurmountable barriers to obtaining infrastructure (e.g., lack of broadband).
- New CAHs — CAHs with new Centers for Medicare & Medicaid Services (CMS) Certification Numbers (CCNs) not having had time to become meaningful users can apply for a limited exception to payment adjustments. The hardship exception is limited to one full year after the CAH accepts its first patient.
- Unforeseen Circumstances — Examples may include a natural disaster or other unforeseeable barrier.
- Meaningful Use: In order to avoid the payment adjustments, CAHs must demonstrate meaningful use within the full federal fiscal year that is the same as the payment adjustment year. The adjustment would then apply based upon the cost reporting period beginning in the payment adjustment year (that is, FY 2015 and thereafter). Thus, if a CAH is not a meaningful user for FY 2015 and thereafter, the adjustment would then be applied to the CAH's reasonable costs incurred in a cost reporting period beginning in that affected fiscal year.
- An eligible hospital or CAH demonstrates meaningful use by successfully attesting through either the CMS Medicare EHR Incentive Programs Attestation System (https://ehrincentives.cms.gov/) or through its state's attestation system.
- CAHs are required to submit their attestations for meaningful use by November 30th of the following fiscal year. For example, if a CAH is attesting it was a meaningful EHR user for FY 2015, the attestation must be submitted no later than November 30, 2015, in order to avoid payment adjustments.
- Eligible hospitals and CAHs participating in meaningful use for the first time this year may attest to a 90-day reporting period for FY 2015. CMS is allowing eligible hospitals and CAHs participating in meaningful use for the first time the ability to attest. The hospitals must first register in the CMS Registration and Attestation System at: https://ehrincentives.cms.gov/hitech/login.action. Once the registration is active, the hospital should contact Elizabeth Holland at elizabeth.holland@cms.hhs.gov and provide the hospital name, CCN, and contact person information.
- Call CMS Information Center: Ask questions, get more information. Dial 888-734-6433 then dial 1 for the EHR Information Center.
At the Intersection of Exhausted and Impossible
Today, most employees and employers in all organizations struggle to do more with less…not just health plans.
Information flow and the necessity to respond quickly to change have totally transformed existing jobs in the last ten years. There is little opportunity to spend days considering the implications of data and information received. The necessity of implementing new programs to meet the Centers for Medicare & Medicaid Services (CMS) requirements strains the resources of health plan organizations and departments even further and may contribute to lapses in compliance and, therefore, regulatory risk. A daily to-do list for the Part D team routinely includes:
- Rejected claims review
- Formulary maintenance
- Adjudication issues resolution
- Intra-departmental calls to assist with resolution of grievances and Complaints Tracking Module cases (CTMs)
- Transition fill and notice monitoring
- B versus D medication resolutions
- Intra-departmental and other organization meetings
- Compliance communications and directives
- Personnel issue resolution
- Clinical pharmacy activities
- Part D Star Ratings monitoring and report reviews
- Case management activities
- CMS-required reporting
- Enrollment and eligibility issue resolution
- Prescription drug event (PDE) reconciliation
- AND the never diminishing email inbox
The list goes on and on. A thorough review of all department functions either utilizing internal human resource assistance or external experts can provide recommendations for the right size staffing, resource delineation, and recommendations for new products or tools for the Pharmacy/Part D Department. The review should include the following questions: What is the right mix of pharmacists, pharmacy technicians, and business analysts? How many hours or full-time employee (FTE) segments should be dedicated to the various tasks? Will additional training and refining of work processes help to alleviate some of the burden? Is there a software solution that will streamline some of the manual processes currently in place?
With the insufficient amount of true subject matter experts in the industry, we know recruiting is difficult and time consuming. If interim staffing is what you need, Gorman Health Group (GHG) can enhance your team with our own, providing knowledgeable, effective assistance and an eye for detail from processors and analysts with decades of experience. Our pharmacy consultants come fully trained and prepared to provide short-term or long-term support and create a business case for additional resources, training, and tools. We offer strategic and operational leadership experts when, and where you need it.
Interested in more information? Contact us today.
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Our Part D services are designed with your staff in mind, ensuring that with a mix of counsel and DIY tools your staff will have access to actionable information — faster. Don't chase data points. Spend your time on the things that will impact your audit results when a CMS audit comes — and it always does. Visit our website to learn more >>
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Quality Ratings: No National Standard for MCOs…Yet
A recent article noted five major changes in new Medicaid Managed Care rules, one pertaining to a quality ratings system. Many states have quality ratings for managed care plans, but currently there is no national standard. Medicare has a five-star system evaluating private plans, and private plans offered through the Affordable Care Act's (ACA's) Health Insurance Marketplace will begin publishing quality ratings in 2016. Ratings for Medicaid managed care plans would look similar to the Marketplace plan ratings.
"CMS' rationale was to more closely align the ratings system for managed care plans with [exchange plans], because a lot of those plans in the Marketplace are also Medicaid managed care providers," said Lisa Shugarman, a consultant at Health Management Associates.
The Marketplace plans will begin testing a ratings system this year including three broad categories (clinical quality, patient satisfaction, and plan management/affordability) that would also be a part of the managed care ratings. The Marketplace plans' ratings system will also have dozens of sub-categories — the specifics of which will be determined by state officials and health experts. It has taken about three to five years for the Marketplace plans to have their ratings system up and running and would likely be the same time frame for managed care, according to Matt Roan, another consultant at Health Management Associates.
States would have the option to include additional measures, but the process for doing that isn't clear yet, and many managed care organizations (MCOs) are wary of too much variation between state quality reporting systems. They will be pushing CMS to ensure a high level of standardization to ease compliance.
Non-profit Medicaid plans support quality ratings, but they also think the rule should apply to traditional, state-run Medicaid and other arrangements, such as Accountable Care Organizations (ACOs).
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Gorman Health Group can help your organization implement successful quality initiatives, from both the quality and operations perspectives, to improve scoring and control costs while continuing to serve the rapidly expanding Medicaid and dual-eligible populations. Visit our website to learn more >>
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Obamacare Reinsurance and Risk Adjustment, Year One.
The much-anticipated "Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2014 Benefit Year" has been released by the Centers for Medicare & Medicaid Services (CMS). A staggering 99.7% of Issuers were able to successfully submit data. The remaining 0.3% either did not set up an EDGE server or submitted data CMS could not use for risk adjustment calculations. Considering the aggressive timeline Issuers were given, this completion percentage is quite remarkable. Those who failed to submit compliant risk adjustment data were slapped with a non-compliance fee, which was distributed to other Issuers in the state.
CMS also announced plans would receive full payment under the reinsurance program. The reinsurance coinsurance rate has been increased from the provisionally announced 80% to 100% since the funds collected by CMS exceeded the requests for reinsurance payments. The information provided in this report further confirms risk adjustment will be an integral part of an Issuer's financial standing. It demonstrates risk adjustment payment transfers equate to anywhere between 2% of the total premium for merged plans to 21% of the total premium for catastrophic plans. So overall, from the highest view point, the processes for risk adjustment and reinsurance have shown to be a success. That perspective does not necessarily stand true when looking at the Issuers at a more granular level.
Yes, 99.7% of Issuers were able to successfully meet the submission requirements and get their data onto the server. That does not mean the data were complete and accurate to truly reflect the risk of the company. It just means, out of the 758 issuers eligible to participate in the risk adjustment payment transfer, 99.7% of them were able to send some sort of data to the server in the format CMS required and, therefore, were able to avoid receiving the default non-compliance charge. Issuers' completion percentages increased with each submission that got closer and closer to the April 30, 2015, deadline. The increase may not have been because Issuers were correcting errors; rather, it was CMS relaxing edits, allowing more data to be accepted onto the EDGE server. It would not have been beneficial for neither the Issuers nor CMS to have low completion percentages.
The commercial risk adjustment model is a zero-sum approach, meaning it collects funds from lower-risk Issuers then redistributes those funds to higher-risk Issuers. In order to determine how one company compares against another, state averages are calculated. An average is calculated for the monthly premium, risk score, rating area, and actuarial value for each risk pool category. These averages are then used in combination with the Issuers' actual calculations to determine the amount an Issuer is required to pay or will be receiving for risk adjustment. In looking at the Issuer-specific information, you're able to see the "winners" and "losers" for each state.
When evaluating how your company compared against internal projections and against your competitors in the market, here are a few things to consider:
- Approximately 20%-30% of your commercial individual and small group population will have a diagnosis correlating to a Hierarchical Condition Category (HCC) risk adjustment category. A missing diagnosis code for commercial risk adjustment could be the difference between receiving a payment or making a payment. What is your company's end-to-end reconciliation process for member and claims EDGE server data submission?
- There were unique claims circumstances CMS wanted handled a specific way, such as bundled claims and interim claims. These types of claims typically carry a lot of diagnosis information and claim cost. Were these claims handled appropriately to ensure demographic and diagnosis information was fully captured?
- Commercial risk adjustment is not just a process but rather a company strategy needing to be embedded throughout various departments in the organization. Is the strategy for your organization clear and understood by the areas involved in knowing how they impact risk adjustment?
It seems like it has taken forever for the 2014 risk adjustment payment transfer and reinsurance payment information to be released. Whether your results were stellar or not, don't get too hung up on the actual payments. What's done is done. Spend the time evaluating the full 2014 end-to-end process. What went well? What needs to improve? Act quickly and set your plan in place to impact your 2015 results—April 30, 2016, will be here before you know it. And invest wisely in people and systems to avoid subsidizing your competition due to inadequate or incomplete diagnosis data.
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The Reality of the 2014 Commercial Risk Adjustment Payment Transfer: Forecasted vs. Actual
The signing of the Affordable Care Act (ACA) into law threw health insurers into a whirlwind of changes. The guaranteed issue law made it so no enrollee in the individual or small group commercial market would be denied coverage due to their health status. In addition, the rate for all members now had to stay the same for all enrollees, with fluctuations only allowed for a few factors such as tobacco status. That key process, known as underwriting, could no longer serve as the method to evaluate risk and either deny coverage or set the enrollee's premium accordingly. With that shift came the introduction of risk adjustment, reinsurance, and risk corridor ("3 Rs") into the commercial market.
When the implementation of the ACA regulations were in process, a lot of plans took the "here and now" approach―meaning, they primarily focused on what the immediate pressing issue was, not contemplating what the downstream impact could possibly be. Project dollars were being spent on over-engineering enrollment processes and developing automated tools that, in the end, were not as useful as anticipated. It's human nature to want to tackle obstacles right in front of you, but when implementing ACA changes and introducing a new sales channel, like the Marketplace, a holistic approach needs to be taken. Developing a solid risk adjustment strategy was not part of the upfront planning for a lot of health insurers―it was a new process with a lot of grey area and unknown requirements.
So here we are now in the final stages of the first full year operating under the ACA. All health insurers are fully aware of the immense amount of work it takes to submit data to the EDGE server. With this data, CMS can calculate reinsurance dollars owed to health plans and calculate risk scores to support the risk adjustment process. They are also learning just because you can submit data to the EDGE server does not mean the overall risk for the company is reflected accurately. As each day passes, more information is becoming known about the transfer of risk adjustment payments. A limited number of health plans are being assigned a default risk score and are not eligible to receive reinsurance dollars due to not submitting adequate data to the EDGE server. In speaking with plans across the country throughout the evolution of the commercial risk adjustment operational process, the majority of health insurers were very optimistic they would be receiving risk adjustment transfer dollars, many of which will soon face the harsh reality that the forecasted risk adjustment receivable anticipated has turned into a payable.
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HRADV: What you don't know could cost you millions. Read the full article >>
Quick Hits for September Sweeps
Unfortunately, Risk Adjustment does not have the luxury of taking the summer off. As CMS continues to stress the criticality of submitting complete, timely and accurate data to support plan payments related to Risk Adjustment, health plans must have year-round processes in place to ensure compliance as well as accurate payment from the government.
As premiums continue to be reduced, health plans and capitated medical groups must have strategies in place to ensure an accurate Risk Adjustment Factor (RAF) score, meaning you must not only recapture your members' persistent conditions, but find new clinical conditions as they appear. Sounds easy? Not quite. As we've seen the processes, programs and requirements are daunting and difficult to juggle. Our advice: leverage existing analytics and data to drive efforts for Risk Adjustment and the looming September deadline.
Items to focus on:
- Specialists/Providers- What is your strategy to engage specialists? Collaborative partnerships between health plans and providers will ensure optimum performance outcomes for revenue, medical management, and quality. Assess the root cause and go right to the source. By following the initial diagnosis, you will be able to prioritize your outreach by disease prevalence.
- Pharmacy- Mine your pharmacy data. If this data reveals prescriptions for medications specifically prescribed to treat risk adjustable diagnoses and the patients are consistently filling medication — yet there hasn't been a diagnosis submitted through a claim- a new variable for prioritizing provider or member outreach has been created. Try looking at your patients that meet the criteria for Medication Therapy Management (MTM). Not only is MTM a strong tool for managing costs, improving outcomes, and positively impacting your Star Ratings, the program can support your efforts to prioritize initiatives for Risk Adjustment.
- Clinical Quality and HEDIS- Partner and coordinate with your Healthcare Effectiveness and Data Information Set (HEDIS) teams. Leverage the information and clinical data retrieved and reported for HEDIS measures to identify members with risk adjustable diagnoses. If your plan uses a HEDIS vendor, make sure that you are reviewing their most recent audited HEDIS reports. If a claim or claims do not exist, but patients have been pulled into HEDIS measures through chart reviews, create a chase list to reconcile that data and then assign the most appropriate patient and provider intervention.
- Manpower — Are you lacking the technology to aggregate and create your target and suspecting lists? If interim staffing is what you need, Gorman Health Group (GHG) can enhance your team with our own, providing knowledgeable, effective assistance and an eye for detail from processors and analysts with decades of experience.
- In- Home Assessments — Adopt a core set of components and best practices for In-Home Assessments, prioritization and timing of these assessments is key. Track subsequently provided care: In CY 2015, The Centers for Medicare & Medicaid Services (CMS) will track and analyze care provision following in-home visits. If you are mining your data and notice a beneficiary has not been to the doctor in some time, take initiative and facilitate an in-home assessment. These encounters can also be leveraged to close HEDIS gaps and close the care coordination loop, avoiding ER visits or unnecessary trips to Urgent Care facilities.
- Vendors - Convene with your vendor partners to coordinate strategies. Include the Case Management team, Utilization Management team, and Provider Network team in your strategy discussions. All departments need to be working together to understand what visits are coming up in your provider network and why — who better than the teams who are on the front lines? Whether you rely on multiple vendors or a largely internal team, we can help you streamline the execution of your risk adjustment approach, and maximize your analytic strategy to ensure you're keeping pace with CMS expectations in both compliance and healthcare outcomes.
It's all about prioritizing. Mining the data to leverage the analytics you already have is a good way to start.
Get it right the first time. Managing the operations of your risk adjustment function is no easy task. The integrity of your data impacts virtually every other department in your organization - especially Finance, Quality, and Care Management. It's important to examine the data and submit it correctly the first time to guard against data inaccuracies, errors as well as to allow for appropriate reimbursement.
GHG supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure the procedures for capturing, processing, and submitting risk adjustment data to CMS are accurate, timely, and complete.
Whatever your organization decides to do, your strategy should be targeted, prioritized, and have a clear call to action. You have time and options. Contact us today to discuss them.
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Gorman Health Group (GHG) announced its new vision for maximizing healthcare analytics and optimizing risk adjustment programs. Read the full press release >>
CMS to Monitor Access to Care, Defines Provider Network Adequacy Pilot Program
During the Centers for Medicare & Medicaid Services (CMS) Audit & Enforcement Conference & Webinar held on June 16, 2015, CMS provided a glimpse as to how the Provider Network Adequacy (PNA) Pilot Program would begin to monitor beneficiary access to care.
The two-pronged approach will evaluate both provider network adequacy and the plan's provider directory. As we have seen over the past several months, from the Call Letter to the proposed Medicaid rule, there is a renewed focus on provider network access across all government-sponsored health plans. The focus is on not only the beneficiary's ability to access care in a timely manner but to ensure the member and referring providers have up-to-date demographic information on providers, including open/closed panel status.
Historically speaking, Medicare Advantage (MA) plans have submitted their provider and facility networks via Health Service Delivery (HSD) tables during their initial application or during a service area expansion (SAE). The HSD tables have been the source of truth for the MA plan to validate 90% of their enrollees had access to the full spectrum of providers and facilities within a given time and distance metric. Unless requested during the bid submission process, plans may not have validated their network against CMS standards from the original date of inception. We have found from year to year, even with no changes to the provider network, it is possible for adequacy to change due to the beneficiary population files updated by CMS. Additionally, we may have kept the same providers in the network but may not have captured changes, such as closing their panel to new patients, in our directories. Fueled by increasing beneficiary complaints, plans will now be required to diligently monitor their providers and the provider office information.
As a result, CMS is supplementing the current guidance on provider directories and network access and availability reporting. CMS expects plans to establish and maintain a proactive, structured process to assess the availability of contracted providers on a monthly basis and monitor more closely member access to their provider network. CMS will monitor compliance via direct monitoring and the new PNA Pilot Program.
The new PNA Pilot Program will evaluate the two functional areas, network adequacy and provider directory, by requiring submission of HSD tables and by CMS calling a sub-set of providers from the HSD tables to monitor accuracy of information. The process, while still under development by CMS, is designed to promote continual self-evaluation by health plans. During the Audit & Enforcement Conference & Webcast, CMS outlined the process for the PNA requests.
- CMS will issue a Pre-Audit Issue Summary (PAIS)
- Plans will have the ability to disclose network adequacy issues in two ways: sponsor-disclosed, meaning the issue was discovered by the plan and disclosed to CMS prior to the audit, or self-identified, meaning the issue was discovered by the plan after the start of the audit and self-reported to CMS.
- In response to the network adequacy findings, plans will be asked to provide a Beneficiary Impact Analysis to disclose areas where beneficiaries will be affected by network issues. The impact analysis should be a three-month look-back at all beneficiaries who received care by the identified provider(s).
- Plan will also be asked to provide their provider directory to CMS.
A Sample PNA Audit Timeline:
- Within 5 business days of the engagement letter:
- PAIS will be issued
- Impact Analysis for PAIS
- Provider Directory
- Within 10 business days of the engagement letter:
- HSD tables uploaded to Network Management Module (NMM)
- NMM will provide plan with a report identifying all network deficiencies
- Within 14 days of receipt of the deficiency notice:
- Submit exception requests
The aggressive audit timeline will require plans to incorporate a robust network adequacy monitoring policy into its workflow processes. When we look at the types of exception requests that will potentially be included in the final CMS policy, plans will not only need to be well-versed on their network but also the total number of providers/facilities available in their service area. Plans must be able to identify patterns of care for their network and non-network providers, alternative providers that could provide the services, such as ENTs providing allergy clinics, and be able to pull the information together in a relatively short time.
The second portion of the audit process will be to ensure the provider directory is current for provider demographic information and open/closed panel status. Per CMS, they will review a select representative sample of providers from the HSD tables and verify the directory information, by calling each provider office, to ensure the information available to the beneficiary is correct. The Call Letter indicated plans should incorporate a robust policy to outreach to providers on a monthly basis to validate the provider's network status and ensure any changes, both provider or plan initiated, are updated on a real-time basis. CMS intends to further define the new policies and procedures governing the PNA Pilot Program and issue the guidance late summer/early fall via the Health Plan Management System (HPMS).
As CMS increases the scrutiny on provider network access and availability, we can only wait to see the impact it will have on a plan's ability to move towards building a network based upon quality indicators and the value-based contracting and reimbursement models needed to shift providers into a population health and outcomes-oriented mindset.
Gorman Health Group can assist your organization navigate the network adequacy pilot and provide the infrastructure support solutions needed to build a smarter provider network. Contact me directly at emartin@ghgadvisors.com for more information.
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Game Changer: Key Reforms Proposed in CMS Medicaid Rule
You've got your nose to the grind stone working to meet all the waves of operational changes and requirements related to Medicare, Medicaid, Obamacare, and Health Care Reform - you literally don't even have time to glance upward to the skies. Understandable. But it can cost you.
July 27th is the CMS deadline for all to submit their comments about the recent Medicaid Rule, which according to Andy Slavitt, Acting Administrator of the Centers for Medicare & Medicaid Services (CMS) is intended to "…better align regulations and best practices to other health insurance programs, …to strengthen federal and state efforts at providing quality, coordinated care to millions of Americans with Medicaid or CHIP insurance coverage." What does this have to do with me TODAY?
Now is the time to strategize, innovate and transform your plan and benefit design so that your operational platforms can grow as the rule will require you to. Here are two examples from Gorman Health Group's (GHG's) Medicaid webinar that took place on Wednesday, June 24, hosted by my colleague, Sunmi Janicek, Vice President of Medicaid and myself.
According to John Gorman's blog, "You're Doing it Wrong in Care Management" issued May 18, 2015, you are going to need to modernize your approach in care management into data-driven care coordination "pods" providing a holistic model of care focused on high utilizers and those about to become them. This means you need to recommit to data analytics identifying and directing the work of care managers toward those beneficiaries with long-term needs that can be impacted. Further, you need to place a greater emphasis on preventable episodes of care, and on end-of-life care preferences, advance directives and care plans. If you take the top 5% of the membership that is incurring the most cost and provide complex care management, including a higher level of home care, hospital diversion, medication therapy management, nutrition counseling, and wound care, plans and their provider organizations will see a reduction in avoidable medical expenses. Those reductions in avoidable medical expenses translate to better managed Medical Loss Ratios (MLRs), which directly impact your bottom line. How so?
The proposed implementation of the new rate setting will require managed care organizations to meet a MLR minimum of an 85% threshold. This is to ensure adequate funds are being spent on coverage for Medicaid members appropriately as states seek to move more and more Medicaid beneficiaries into managed care on a mandatory basis. CMS has charged states to develop new rates that will promote program goals that include benchmarks for quality of care, community integration of enrollees, and cost containment. Further, CMS wants to ensure enrollees are receiving quality of care and access in a timely manner, so they have asked the states to propose set standards for time/distance for specific provider types.
MLR thresholds are currently being used by the private health insurance plans, as well as, Medicare Advantage plans for projections of future medical costs and covered services. By including Medicaid in this imitative, it's evident CMS is trying to find a way to align standards among the different offerings across the board, but how will it affect your MCO?
While Medicaid MCOs don't have the high sales and marketing costs of individual commercial plans, since sales are handled by the states, compliance costs could be high, making the 85% figure a cause for concern. Medicaid MCOs will have to be diligent in identifying and documenting costs incurred to improve quality; essentially determining spend that could be considered medical versus administrative; to drive up their MLRs. Plans need to be able to fine-tune care coordination and quality, which are the hallmarks of managed care, and a federal MLR regulation could inhibit this. Do you have the right processes in place to ensure this happens?
With all these new changes, we can't stress enough that there will be a huge impact on implementation initiatives and sustainability that affect not only the finance department, but all departments. Once sustainability is achieved, it needs to be maintained as it will be addressed in future compliance reviews.
We are currently working with organizations in your area to identify gaps in operations while improving the ways they respond to clients, and developing care management models for the Long-Term Services and Supports (LTSS) population that make sense and will impact MLR. We share the same goal as you: to implement high quality, accessible, and cost-effective health care to our nation's most vulnerable population.
As soaring enrollment issues with varying populations of people persist, and new programs continue to be introduced, tough challenges are ahead. We can help make the transition smooth. Contact us today to get started >>
Resources
To download the recording of the June 24, 2015 webinar mentioned above, please click here >>
GHG understands the complexities of the Medicaid population, and the numerous shifting variables that affect plan financial performance, such as state specific requirements for risk adjustment. GHG can assist with identifying the current and future costs of doing business, while building in anticipated adjustments that make sense for each population served. Visit our website to learn more >>
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Financial Impacts of Unscrubbed Data
We have written many articles on the importance of maintaining accurate, reliable data. Data is everywhere and in many versions. Health plans need to be very careful to input only that information coming from a reliable source of truth. In government programs, that reliable source of truth is prescribed to be information contained within the government's systems. "Scrubbing" data means reconciling against that reliable source of truth. For health plans, this means reconciling with information within the government's systems, regardless of whether that information is right or wrong. Correcting the government's erroneous information requires adherence to prescribed processes.
The most effective way to process transactions with government programs is using the government's own data. This is most effective because it greatly lends itself to automation. A clear example of how this works is in Enrollment processing using what we call an "Intelligent Front-End." The objective of an Intelligent Front-End is to import the government's data and then utilize that same data in transactions back to the government. This Intelligent Front-End also receives data files from the government and then utilizes that same data to trigger required actions within the health plans' systems. This tactic ensures reconciliation, compliance, efficiency, and manageability.
Another example of utilizing "scrubbed" data is in validating health care providers' information. This is critical for provider credentialing, contracting, medical claims processing, pharmacy claims processing, risk adjustment, and encounter data submissions. The monthly National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) downloadable files and weekly incremental NPI files provide an abundance of information. Combining the Medicare Exclusion Database (MED) and Office of Inspector General List of Excluded Individuals and Entities (LEIE) helps to build a national universe of health care providers' information. Automating reconciliation with this comprehensive database can tremendously expedite provider set-up for processing claims from non-contracted providers. This helps to avoid interest payments for untimely processed claims.
It is imperative for health plans to keep current on updates to payment codes. This includes:
- International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM);
- International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM);
- International Classification of Diseases, Tenth Edition, Procedure Coding System (ICD-10-PCS);
- Current Procedural Terminology (CPT);
- Healthcare Common Procedure Coding System (HCPCS);
- Modifiers;
- Revenue Codes;
- Place of Service;
- Bill Types;
- Condition Codes;
- Occurrence Codes;
- National Drug Codes (NDCs).
Finally, it is absolutely necessary for health plans to keep current on updates to fee schedules and prospective payment pricers. Provider payment disputes are on the rise. Ironically, so are overpayments to providers. Ensure payment accuracy by utilizing up-to-date fee schedules and pricers.
Resources
Gorman Health Group (GHG) includes some of our industries most experienced and proficient health plan subject matter experts. Our consultants can help your organization with developing or improving your Intelligent Front-End, scrubbed health care provider information and national provider database, and assess whether your claims adjudication codes and payment systems are current and used appropriately. Contact us today to get started. >>
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Don't miss Gorman Health Group's Chief Consulting Officer, with colleagues Jane Scott, Senior Vice President of Clinical Innovations and Regan Pennypacker, Vice President of Compliance Solutions, as they discuss your member experience and the factors that influence success and failure, as well as prominent compliance and service issues plaguing the industry. Register today >>