CMS 2015 Oversight and Enforcement Conference - Compliance Edition
The pessimist complains about the wind. The optimist expects it to change. The realist adjusts the sail. -William A. Ward
Those who had the opportunity to view or attend the Centers for Medicare & Medicaid Services (CMS) annual Audit & Enforcement Conference & Webcast better start thinking about which group of folks you will be a part of: pessimists, optimists, or realists. In order to maximize your success, you best classify yourself in the realist bucket — quick.
One thing that did not change over last year is CMS' overall assessment of improvement. Mr. Mulcahy confirmed CMS has still not seen the improvement they had hoped to see after years of issuing best practices and common conditions information to the industry. Go back to last year's video archives, and you will find he said the same thing last year. According to CMS, sponsors are still surprised by audit activities and findings and unaware of their level of compliance.
Many best practices to combat this type of situation in your organization were discussed during the conference. For example, one organization pulls universes using CMS' data layouts on a monthly basis. Another organization stressed the need to not only focus on the short term in corrective action plans (CAPs) but also consider the long-term solutions required for long-term success—that includes a deep-dive into processes and continuous training. Once-a-year specialized training will no longer cut it, especially in the areas of Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) where CMS notes sponsors, at times, seem unaware of their compliance.
Some things that are changing are the audit protocol instructions and data layouts currently on the Program Audits site. CMS confirmed there are a number of issues requiring clarification or correction in the protocol — we anticipated this. They hope to release updated protocols by the end of this month, but if a plan is subject to audit in the meantime, they will receive the updates. In terms of audit support, CMS' Jennifer Smith confirmed there is still a plan for CMS to release a chapter on audit activities. Once released, this should be a great help to plan sponsors. CMS also provided detail pertaining to the Medication Therapy Management (MTM) and Provider Network Adequacy audit pilots, scheduled to be released in late summer or early fall.
We are continuously making adjustments to processes to ensure alignment with CMS activity, and we hope our clients and all plan sponsors are doing the same. The Medicare Parts C and D Oversight and Enforcement Group (MOEG) confirmed that, if any sponsor receives a civil money penalty (CMP) or sanction, they will be expected to engage an independent auditor to validate corrections. CMS confirmed 93% of plans audited in 2013 received some sort of CMP, and at the recent GHG Forum in April, I shared the majority of enforcement actions since 2014 have indeed been related to CDAG and ODAG. Talk about a risk! It really is time to look inward, be a realist, captain your ship, and adjust those sails.
If you have questions pertaining to the audit protocol, CMS advises you to forward any questions to part_c_part_d_audit@cms.hhs.gov. If you have questions regarding the conference, or have questions on how we can assist, please feel free to contact me directly at rpennypacker@ghgadvisors.com.
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Takeaways from Accountable Physician Groups' Annual Summit
Twice a year I get the honor of speaking to the California Association of Physician Groups' (CAPG) annual summit and DC policy meeting. CAPG represents accountable, capitated physician groups, and now has members in 39 states. They're always among my favorite speeches given how sophisticated the audiences are. Here's a few takeaways from my talk last week on "The Future of Government Programs":
- Forevermore, physician group revenues and earnings will be dominated by Medicare Advantage, Medicaid and dual eligible health plans, and the ObamaCare plans, most likely in that order.
- Everything that Medicare Advantage (MA) does, the Medicaid, ObamaCare, and commercial markets follow 3-5 years later. Nobody knows this better than the CAPG members from CA, which the rest of the nation lags. Want to still be attending CAPG meetings in 2020? Master Star Ratings and risk adjustment. They'll apply to all lines of business if they don't already, and they are the keys to survival already in MA.
- Value-based contracting is in its infancy but will soon define all health plan contracts with physician groups. Fee-for-service is dead. Performance-based capitation is the only future. To master it a physician group needs a range of capabilities, including eligibility verification, interoperability, actionable clinical intelligence in real time, standardized care processes, and chronic care management, across all business lines.
- Most Accountable Care Organizations (ACOs), especially the 424 in Medicare, will not see a return on their investment. They will have spent millions to participate in these experiments and around 80% won't see a payoff. 2016 and 2017, when Medicare Advantage benchmark rates turn into a tailwind, present the perfect opportunity for ACOs to "move up the food chain" to become health plans.
- Dual eligibles are the biggest opportunity of our lifetimes, and there is no question that Special Needs Plans designed to serve them can be profitable. SNPs are a principal mechanism for states to shift long-term care risk into the private sector, and will be a central product for ACOs converting into Medicare Advantage. But they require a range of capabilities most physician groups lack today, such as enabling and social services that duals must have from their insurer.
- In all government programs, the "5/60 Rule" governs. 5% of members often account for 60% of costs. Any physician group that aspires to bear risk must be able to identify and intervene with their 5 percenters or they won't be risk-bearing for long.
- The biggest vulnerabilities for MA plans are consumer protections like appeals and grievances and complaint management, and who they have selected as their pharmacy benefit manager (PBM). Most PBMs are frankly terrible at Medicare Part D administration, and Star Ratings now count far more in Part D than in Medicare Advantage to a health plan's overall score. Physician groups typically have little or no experience with either PBMs or consumer protections.
- Retail pharmacies and the home are the most underutilized sources of care to government programs beneficiaries. Any successful physician group evolution will involve better integration of both sites for the chronically ill.
- Most at-risk physician groups are directly involved in coding and reporting for risk adjustment. Federal agencies are paying unprecedented attention to upcoding in Medicare Advantage with an eye to hundreds of millions of dollars in clawbacks and recoveries. The emphasis at physician groups involved in risk adjustment must move from chart reviews and claims extracts to more holistic member evaluations, and from a culture of "what can we get?" to "how do we stay out of trouble?"
Evolution is a messy business. Nowhere is that more the case than in physician groups evolving from fee-for-service to value-based contracting and becoming insurance companies. If it was an easy business, we'd be out of business.
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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 now >>
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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CVS Health is Serious About Growing its Clinic Business
CVS Health is serious about growing its clinic business. On Monday, USA TODAY reported that CVS Health plans to acquire Target's pharmacy and clinic business for $1.9 billion.
Healthcare reform is producing a surge in newly insured people seeking care, and hospitals are under severe pressure to keep pace.
"This long-term strategic relationship will certainly benefit the patients, the employees and the shareholders of both companies," CVS Health CEO Larry Merlo said in a conference call.
In addition, a primary care provider shortage is predicted to limit access to care. This is where CVS Health's new acquisition will come into play with more than 1,660 Target pharmacies offering accessible care in 47 states.
Demographic change exacerbates the challenge, with a steep rise in the ratio of elderly to young, adding yet more demand. Retail health clinics may be the "release valve" to the strained healthcare system and the future of care.
CVS Health has been the leader in the retail clinic industry to date, but other retailers like Walmart and Walgreens are poised for growth. The move to acquire Target's pharmacy and clinic business allows CVS Health to solidify its lead in the clinic business.
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Gorman Health Group continues to provide strategic, operational, financial, and clinical services to the healthcare industry, across a full spectrum of business needs. Our software solutions place efficient and compliant operations within reach. Learn more: https://www.ghgadvisors.com/about/.
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Implementing a new PBM? What you need to know.
Now that the smoke has cleared and the ink is dry on the formulary/transition and bid submissions, it's okay for plans to breathe for a couple of weeks. Then—if you're implementing a new Pharmacy Benefit Manager (PBM)—it's time to roll up your sleeves and get started with conceptualizing and developing a road map for the next six months. It's important to start early and work steadily to make decisions, create processes, and complete training. During this time, you must continue to partner with your current PBM to process claims, make coverage determinations, and oversee and monitor all the delegated functions according to the plan you have in place. With the new PBM, you have the opportunity to tweak some processes that perhaps weren't working exactly as you had envisioned originally.
The new PBM should have a detailed work plan they utilize for implementations, and their team can be invaluable in assisting with timing needed for decisions and keeping the project on track. Don't cancel meetings or get behind on decisions that need to be made. You will need every bit of the time in November and December to get testing done on the new formulary and to reach out to members who will be disrupted by formulary changes. And, if you're implementing a new PBM because of dissatisfaction with your current PBM, begin as you mean to go on. In other words, think about the nature of the relationship that best serves your organization and staff and start developing it from the beginning. It IS just business, but you will be working with the PBM team members on a daily basis for the next few years. So start off on the right foot and build the foundation of a relationship that will benefit your members and your organization.
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The GHG Pharmacy team can assist you with your PBM implementation by providing subject matter expertise on all the decisions that need to be made and the processes that need to be developed. And we have a state-of-the-art benefit administration testing plan to help you before go-live.
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HRADV: What you don't know could cost you millions
Now that the 2014 EDGE server submission is complete, it will soon be time to audit a large sample of the data. Are you ready?
HRADV is the Commercial Risk Adjustment Data Validation that will be conducted annually on the data submitted to the EDGE server. This audit is similar in nature to the Medicare Risk Adjustment Data Validation (RADV) with a few exceptions. You do not get selected for the HRADV; rather, it is an annual requirement that the auditing process is conducted on at least 200 members. An error percentage will be assigned for health status and demographic information that does not have appropriate supporting documentation. This error percentage amount will be deducted from the prospective years' risk adjustment payment, or a payable will be due to The Department of Health and Human Services (HHS).
I have heard many health plans say, "There are no financial implications to the 2014 and 2015 HRADV errors" and "These are the learning curve years." While both statements are true, the fact of the matter is, these years DO count. You could be leaving millions of dollars behind for these years, not only for risk adjustment but for reinsurance as well. You are also at risk of being fined a significant error penalty after the "learning curve" years. Now is the time to ensure you have all of the necessary processes in place. Here are a few questions to ask yourself about the risk adjustment operations at your company:
- Are your providers familiar with the tremendous impact the transition from ICD-9 to ICD-10 has on risk adjustment, reinsurance, Stars, and the Healthcare Effectiveness Data and Information Set (HEDIS®)?
- Do you have the right staffing in place to support end-to-end risk adjustment successfully?
- Did you successfully submit complete and accurate 2014 data to the EDGE server?
There are many areas inside and outside of the company where membership and claims data may be compromised. This information is being sent through many different systems which increases the probability for information to unknowingly be altered. Here are some tips to prevent submitting incorrect or incomplete data to the EDGE server:
- Ensure you have a solid provider contract and education program in place.
- Align a risk adjustment staffing model appropriate for your organization.
- Develop ongoing data review and reconciliations with various departments throughout the company to create data integrity.
- Be prepared for the HRADV and appeals process.
HRADV and appeals is the final step in the risk adjustment process. More information will be released from HHS regarding the specifics around the audit for 2014. Be prepared and ensure you have selected your Initial Validation Auditor (IVA).
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MLR: Don't Miss Your Target
As the ink dries on 2016 bids for Medicare Advantage (MA) plans, one important question remains…What to do with summer vacation? Drinks by the pool or a family trip to Disney?
Reality check!
The long hours spent on the bid submission included many spreadsheets with financial projections of loss ratios, per member per month (PMPM) trends, along with cost and utilization drivers. These projections required endless discussions on how to improve contracting and cost strategies as well as benefit designs and medical management programs. Executive assumptions were made to create a rosy picture that would result in an acceptable bid and optimistic market share!
However, the real agenda this summer is to take a hard look at those assumptions based on current trends for membership and utilization. An in-depth financial assessment of your medical and pharmacy claims over the most recent 24 months is an important step toward achieving financial success in the Medicare world.
Waiting two years for the Centers for Medicare & Medicaid Services (CMS) to respond to risk adjustment strategies and quality measures may be too late to ensure financial performance. Let Gorman Health Group (GHG) review your medical and pharmacy drivers across the operations. Our financial and subject matter expertise can help you determine long- and short-term strategies to maintain the required medical loss ratio (MLR) of 85% and build the operational infrastructure to support the bid proactively.
While CMS audits are time-consuming and threaten fines and lost productivity, the threat of missing your MLR target is just as real. If you underpriced your bid to get market share, the excess claims will bleed your bottom line. The MLR regulations require MA and Part D Plan Sponsors to spend at least 85% of combined Medicare contract revenue on clinical services, prescription drugs, quality improvement activities, and direct benefits to beneficiaries in the form of reduced Part B premiums. Plan Sponsors who fail to meet the 85% threshold must remit payment to CMS for the product of:
- The total revenue under the contract for the contract year, and
- The difference between 0.85 and the contract's MLR.
So an MLR including medical, pharmacy, and quality costs of 83% means returning 2% of the revenue back to CMS. It also means justifying the quality improvement activities.
The margins are thin as is the tolerance by CMS to balance quality and financial performance. If organizations are unable to meet the minimum MLR for three consecutive years, they will also be subject to enrollment sanctions and, for failure over five consecutive years, contract termination.
An assessment now will pay back in performance and visibility across the operations.
Unsure where to start? Contact us here.
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MLR requirements pose new challenges for payers. Gorman Health Group can help your organization interpret the drivers of MLR, and the tactical and strategic decisions a health plan should consider in managing to an MLR that is "just right." Contact us today >>
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Re-Evaluating Your Plan's QI Evaluation and the Process Behind It.
This is the time of year when most plans have either completed, or are in the process of completing, their annual evaluation of their Quality Improvement (QI) Program Description and Work Plan for operating year 2014. In the 12+ years I have worked for Gorman Health Group (GHG), I have seen a range of evaluations — from great evaluations to those that are just a couple of pages without content. Let's examine some mistakes and discuss some industry happenings that are often missed in the overall QI world. Before we go on to discuss, let's remind ourselves what the Centers for Medicare & Medicaid Services (CMS) is looking for in a QI Program Description, which is based upon the regulation 42 CFR § 422.152:
For each plan, a Medicare Advantage Organization must:
- Develop and implement a chronic care improvement program (CCIP) 42 CFR §422.152(c);
- Develop and implement a quality improvement project (QIP) 42 CFR §422.152(d);
- Develop and maintain a health information system (42 CFR §422.152(f)(1));
- Encourage providers to participate in CMS and HHS QI initiatives (42 CFR §422.152(a)(3));
- Implement a program review process for formal evaluation of the impact and effectiveness of the QI Program at least annually (42 CFR §422.152(f)(2));
- Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms (42 CFR §422.152(f)(3));
- Contract with an approved Medicare Consumer Assessment of Health Providers and Systems (CAHPS®) vendor to conduct the Medicare CAHPS® satisfaction survey of Medicare enrollees (42 CFR §422.152(b)(5)); and,
- Measure performance under the plan using standard measures required by CMS and report its performance to CMS (42 CFR §422.152(e)(i)).
- Develop, compile, evaluate, and report certain measures and other information to CMS, its enrollees, and the general public. Responsible for safeguarding the confidentiality of the doctor-patient relationship and report to CMS in the manner required cost of operations, patterns of utilizations of services, and availability, accessibility, and acceptability of Medicare-approved and covered services (42 CFR §422.516(a)).
Mistakes often seen:
Develop and maintain a health information system: Many plans have multiple platforms that make reporting — the validity and accuracy of — a nightmare! When a plan implements a new care management system, for example, the overall analysis of its performance is often not reported in the QI Work Plan or at the plan's QI Committee. Yet, this is a vital piece to overall operational and quality success. Ask yourselves: Did your plan implement a new system or module upgrade in plan year 2014, and do we know if it has improved our overall reporting and impacted any quality measures or our providers?
Recommendation: As part of a system upgrade or new system implementation project plan, include overall success reporting to the QI Committee. This can include major milestones success or failure during implementation as well as a narrative summary of changes the plan and/or providers will experience upon completion of the project. Will there be new requirements for claims submission? A new clearinghouse? A new provider portal sign-in process? Don't forget all of your external and internal customers and the impact they may experience.
Plan goals for HEDIS: I often see goals set for middle-of-the-road success at or below the 50th percentile. While I am not encouraging setting unrealistic goals, many plans miss aligning their HEDIS goals with a 4 or 5 Star Rating corridor. Now that CMS will be eliminating pre-determined benchmarks for plan year 2016, it will be even more important for HEDIS goals to be realigned with your plan's Star strategy. I also see many plans not include an improvement process or overall data analytics in their QI Work Plan showing how HEDIS measures actually improve overall population outcomes. We really don't want providers just checking a box that a test was completed — we want to understand if and how the HEDIS measures have possibly improved the overall health of our membership, and, if the outcomes are positive, how did this occur? Health plans often share data with providers regarding gaps in care but miss sharing any overall improved health outcomes so providers can see the successes of their efforts.
Recommendation: Consider adding true outcomes measures to specific HEDIS measures, especially those measures that affect your Medicare Advantage Prescription Drug (MA-PD) Plan or Special Needs Plan (SNP) population as a whole. The goal of the evaluation is to effect improvement changes both in plan operations as well as clinical outcomes.
Correct all problems that come to its attention through internal surveillance, complaints, or other mechanisms: Many plans recognize they have multiple issues or problems which may come to their attention through internal monitoring and auditing, inter-rater reliability processes, or dashboard reporting. These problems/issues, however, often do not make it to the QI process cycle.
Recommendation: Remember, when your plan discovers a risk area through internal monitoring or a high volume of complaints/Complaints Tracking Module complaints (CTMs) for a defined reason/category, it is the plan's responsibility to institute a process which identifies a root cause, implements a corrective action, and measures the success of the corrective action. Clinical and non-clinical activities are part of the overall QI process.
Lastly, let's discuss the pay for performance or provider incentive plan process. Many plans have instituted an incentive program designed to improve health outcomes, prevent acute readmissions, improve medication adherence, or improve preventive health services measures which reward physicians financially when goals are achieved. Yet, many of the goals within a provider incentive program do not align with the goals for Star Ratings, goals within a Model of Care (MOC) for SNPs, nor do these payments align with improved overall outcomes for a population.
Recommendation: Overlay the benchmarks from your current provider incentive program to be sure they align with desired goals defined within your QI Work Plan and your Star Rating strategy. Also evaluate your population health outcomes to determine if your incentive program is driving the results your plan desires.
If your plan is still an outlier in the completion of your program's annual evaluation, GHG is ready to assist!
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Medicaid Rule Imposes New Standards for Beneficiary Access
Per the announcement by CMS on Tuesday, the proposed Medicaid rule would require plans to implement an 85% medical loss ratio (MLR). Implementing an MLR for Medicaid would bring the programs in line with the private health insurance market and Medicare Advantage. However, as mentioned by GHG's Sunmi Janicek, it would not be without challenges. The compliance costs for Medicaid plans with the increase in diligence needed in identifying & documenting costs incurrent to improve quality could be high. Additionally, the CMS proposed rule would impose new standards for beneficiary access and availability to the MCOs provider network.
As with our Medicare Advantage clients, GHG can assist plans by doing a deep dive into their MLR cost drivers, such as poor-performing providers within their participating network, while balancing the requirements for a robust, accessible provider network for beneficiaries. Once we have identified the key cost drivers, we can work with plans to do the following:
- Develop forward looking budget assumptions for benefit premiums, project clinical utilization and provider reimbursement budgets
- Develop clinical & financial performance metrics designed to bring performance in line with expectations
- Develop strategies around how to best impact provider practice patterns, access, treatments, referrals and coordination of care
- Design network modifications based on clinical & financial performance
- Develop performance based payments for provider reimbursements benchmarked to clinical & financial outcomes metrics
Reaching these goals will require the formation of great partnerships between the plan and providers. Plans will want to reach out to provider partners that share their same goals and incentives and secure strong leadership and physician champions to lead the charge. We know the transformation will not be easy. The shift from fee-for-service to value based reimbursement, facing the social services, behavioral health needs of the population, and developing the analytical capabilities to support these changes are challenges that Medicaid managed care plans will face under the proposed rule.
GHG is here to help navigate you through the steps.
Please reach out if we can assist you with any of the following:
- MLR Analysis
- Provider Integration strategies
- Reimbursement strategies
- Risk Assumption strategies
- Network Adequacy compliance
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Gorman Health Group is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement.As states begin to increase oversight activities and implement more robust compliance and fraud waste and abuse practices, our expertise in compliance program development will be an asset to any organization. Contact us today >>
CMS Spotlight on Provider Directories & Network Adequacy
As we learned from the 2016 Call Letter, the Centers for Medicare & Medicaid Services (CMS) is placing a renewed focus on Medicare Advantage (MA) plans' provider network, with emphasis on both online provider directories and network adequacy.
CMS plans to monitor compliance of plans' adherence through direct monitoring with additional contract funds and through the development of a new network adequacy audit protocol to be tested in 2015 that will determine whether the provider network meets published CMS adequacy standards. The compliance and enforcement of the new protocols will include civil money penalties (CMPs) and enrollment closures.
Recent beneficiary complaints have brought into focus the accuracy, or lack thereof, with Medicare Advantage Organizations' (MAOs') online provider directories. Beneficiaries, and sometimes referring providers, have shown frustration in attempting to make an appointment, only to find the provider is no longer accepting new patients, has moved, or is no longer participating with the plan. CMS has supplemented their current guidance on provider directories and expects plans to:
- Establish and maintain a proactive and structured process by which to verify the availability of its contracted providers. This process will include outreach, on a monthly basis, to verify there has been no change in a provider's address, phone number, and office hours, and determine if the provider's panel is open or closed to new patients,
- Establish a policy to review and address beneficiary complaints when they are denied access to a provider(s), and
- Include a provision for real-time updates to the online directory.
Additionally, the Call Letter announced a new network adequacy protocol to be tested in 2015. During his presentation at the CMS Medicare Advantage Prescription Drug Plan (MA-PD) Spring Conference & Webcast, Greg Buglio provided insight concerning the upcoming audit protocol.
Mr. Buglio shared that the Network Management Module (NMM) is a standalone module, a version of which currently resides within the Health Plan Management System (HPMS), which may be utilized by MA plans to submit Health Services Delivery (HSD) provider and facility tables for evaluation against CMS HSD criteria.
CMS notes a robust version of the NMM will be released at the end of July 2015. According to CMS, the new version will be highly flexible and support a variety of reasons for HSD submission. The updated NMM will support CMS-initiated requests for submission of HSD tables and exception requests for various processes. Once released in late summer/early fall, the NMM will contain user guides, help screens, and templates for HSD submission.
The NMM will also permit plan-initiated submissions. It was noted plan-initiated submissions will not be viewable or evaluated by CMS. The goal is that plans will be encouraged to continuously self-evaluate their own network adequacy against CMS' criteria. Presently, CMS only reviews network adequacy with initial and service area expansion applications. We anticipate the self-evaluation will work similar to the network pre-checks available during the application process. It was noted the templates within the NMM would not be the same template used during the application process. The two templates will not be interchangeable.
We anticipate further guidance surrounding the network adequacy protocol to be presented during CMS' upcoming MA-PD Audit & Enforcement Conference & Webcast taking place on June 16. Prioritize this event, and attend either in person or via webinar.
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