Insights | GHG Advisors

Partners Needed

I calculated the total amount of civil monetary penalties (CMPs) levied by the Centers for Medicare & Medicaid Services (CMS) last year on Medicare Advantage and Part D plans, and it's a big number: $4,925,150. There were also five suspensions in 2014.

Now more than ever, plan sponsors need to assess their Pharmacy Benefit Manager (PBM) relationship to ensure that both parties are working in partnership to not only be successful as a business but to be CMS compliant. What is your PBM's priority? Is your account management team responsive? Is your issues log so long that you've given up even trying to get resolution on the old items? Are you utilizing all of their existing reporting to consistently oversee and monitor the delegated functions they perform on your behalf?

There is no perfect PBM just as there is no perfect health plan. In our experience, it is a much less onerous process to make your current PBM relationship work than to go through a Request for Proposal (RFP) and implementation project which sucks up about six months of plan resources. Finding a new PBM should be your course of action only if you have exhausted all efforts to work with your current PBM partner.
Assess this list of successful PBM partnership tenets:

Detailed and specific PBM contract with clear definitions of the services to be provided.
Service level agreements (SLAs) for delegated function compliance.
Detailed and exhaustive oversight and monitoring plan for all delegated functions.
Frequent and productive account management interactions.
Transparent and full disclosure of all PBM-identified deficiencies which affect the plan sponsor.
Quick resolution of identified issues or agreed-upon timelines for issue resolution.
No CMS outlier communications due to PBM operational deficiencies.

Now is the time of year when health plans are planning for formulary submissions and working on their bids. Make sure you have the right PBM partner for a successful 2016. We can help! Contact us for more information.

Resources

The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult â€” to say nothing of actually managing to them. 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. Contact us today to learn more >>

Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!

by GHG Advisors

The Model of Care: More than Just a Technical Requirement

The Model of Care (MOC) represents the backbone of a health plan's operational infrastructure and offers powerful potential through which to drive quality improvement, service excellence and improved health outcomes.

Though only required for plans operating a Special Needs Plan (SNP), the MOC is not just a legal or regulatory requirement. The MOC captures and documents deep insights regarding plan leaders' strategic vision by which to provide services to members, to work with providers, to manage and coordinate care, and to conduct operations. It also includes a thorough analysis of a plan's staffing model, provider network and the local demographics of its members.

Perhaps because the MOC is such a lengthy and technical document, or perhaps because it addresses the entire spectrum of a health plan's clinical and operational processes and systems, MOC's are often developed and updated by a small team of highly experienced subject matter experts within a health plan. Despite CMS' requirement that all health plan staff and providers receive annual training on the MOC, plans often miss the opportunity to leverage their MOC's not only to comply with CMS regulations, but also to more deeply entrench their Quality Improvement (QI) and operational service models throughout the organization.

Developing and/or updating a MOC requires health plans to make important strategic and tactical decisions about the way in which their team, in conjunction with their provider network, will work together to coordinate care for their members. As a result, the MOC serves as the strategic plan for your care management, member services, provider relations, risk adjustment, Stars/quality and marketing teams.

By leveraging the strategic and tactical discussions necessary to develop a successful MOC, plans can use the MOC development process as a vehicle through which to develop, review, and enhance Star Ratings, Risk Adjustment and Provider Engagement strategies.

Gorman Health Group's team of experienced clinicians has a deep understanding of how to leverage Models of Care to refine, document and hardwire your strategic vision for collaborations with your provider network to improve Star Ratings and optimize risk adjustment performance.

If your plan is preparing to develop or update your Model of Care, contact us today and let's work together to help your plan achieve your strategic vision.

Resources

Gorman Health Group is ready and available to execute a complete MOC evaluation that will provide the data and information needed to make smart decisions in refining your plan's strategy of managing your SNP population. Contact us today >>

Registration for the Gorman Health Group 2015 Forum is underway! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Room Rate expires on March 23. Register your team for The Gorman Health Group 2015 Forum today!

by GHG Advisors

Marry Data to Build Accurate Customer Profiles

Have you ever played "Pin the Tail on the Donkey" as a kid and found yourself laughing when you got completely turned around and totally missed the donkey? That's what it's like when blindly developing benefits, products, marketing, and sales strategies without understanding what your current and prospective customers look and think like — except there's not a lot of laughing going on.

Utilizing enrollment and benefit data to gain an understanding of your marketplace is a great beginning to understanding your market. Taking the deep dive into the data gives you a greater understanding of your competitors, their benefits, and how different benefit, product, and possible provider strategies have affected the enrollment trend. It also gives you the ability to look at your own benefits/products and enrollment trends to try and build hypotheses of what is driving enrollment/disenrollment trends and develop premium, benefit, and product strategies to either reinforce the direction you are heading or to get back on track.

When you have the ability to add additional dimensions such as demographics, geographic, and psychographic elements to your current members and prospects to develop member and prospect profiles, it helps to gain clarity about your benefits and possible product development strategies to get a full picture of your market. This sets you up for changes that may need to be made or products to be developed in the future.

Analyzing these dimensions will also allow you to build a better pathway to smarter marketing and sales strategies to succeed. In June, when marketing and sales strategies are finalized, you don't know what your competitive advantage/disadvantage will be in the marketplace. Understanding how your 2016 products/benefits match your current membership and the prospective market and how your marketing and sales strategies will attack the market during the Annual Election Period (AEP) and subsequent year will give you a solid game plan to help crystallize your strategic vision.

Resources

GHG's Sales, Marketing, and Strategy division has developed a detailed analysis of the 2015 Annual Election Period (AEP). This allows health plans to understand existing opportunities in their market as well as the potential for new market opportunities.

The Medicare Advantage marketplace is evolving — are you prepared? Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. Visit our website to learn how we can help you >>

Even as you are enrolling beneficiaries for the new plan year, your team should be working on your strategic positioning for the following year — reviewing the past year's performance, conducting feasibility analyses, testing assumptions — all to ensure future success. Contact us for more information >>

Time is running out to register for the Gorman Health Group 2015 Forum, April 7-9, at the Gaylord National Resort & Convention Center. Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team today >>

by GHG Advisors

Is the â€œNUNCMO" Nightmare Keeping You Up at Night?

The recent MAPD Help Desk Memo, dated 3/3/15, advises that on March 8, 2015, "The Centers for Medicare & Medicaid Services (CMS) will be performing a clean-up to process "73" transactions that contain NUNCMO (Number of Uncovered Months) value from the extraneous NUNCMO row that was removed in Phase 1 multi-phase NUNCMO data clean-up which occurred on March 23, 2014. The effective start date of this transaction will be the preceding Part D enrollment start date."

The memo goes on to say that Part D organizations should review the NUNCMO data for these beneficiaries for ALL time frames, even if the change is prior to 2012. Organizations should submit any changes that may be necessary if the data is inaccurate or incorrect!

Looks like this could be troubleâ€¦

If your organization has an automated processes in place to update "73" transactions in your system, and the information on the data file is incorrect, these files could end up being a "nightmare." Loading incorrect data in your systems can result in significant consequences, such as generation of bills, correspondence, and increased customer service call volume.

Best-case scenario?
Increased customer service call volume.

Worst-case scenario?
Complaint Tracking Module complaints (CTMs) or increased Independent Review Entity (IRE) reconsideration requests if late enrollment penalties are inaccurately retroactively imposed.

How should you respond to this data file once you receive it?
Gorman Health Group (GHG) has developed a roadmap solution to guide you through validating and processing this file.

Resources

When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. Visit our website to learn more >>

by GHG Advisors

Network Adequacy Test Submissions for Medicare-Medicaid Plans

In follow up to the October 2014 Health Plan Management System (HPMS) memo titled "MMP Network Adequacy Standards," the Centers for Medicare & Medicaid Services (CMS) announced dates in which Medicare-Medicaid Plans (MMPs) and Minnesota Senior Health Options Dual Eligible Special Needs Plans (D-SNPs) can check their network against the MMP standards in the HPMS Network Management Module (NMM). These standards were developed using the same methodology that is used to develop the network standards for Medicare Advantage but were adapted to reflect the population served under the demonstrations. Specifically:

Utilization Patterns and Minimum Number of Providers — Medicare Advantage network standards are based on analysis of service utilization patterns in fee-for-service Medicare. The new standards use the same analysis but based exclusively on utilization rates for dual eligible individuals.
Total Beneficiaries — In Medicare Advantage, network standards are set based on current market penetration in MA. In the new standards, we will use actual or projected enrollment based on the enrollment policies for each demonstration. This affects the minimum number of providers and acute inpatient hospital beds criteria.
Time and Distance — The Medicare Advantage standards require that 90% of beneficiaries are able to reach the minimum number required for a certain provider type within the time and distance standards established. These new network standards adjusted the time and distance for certain provider and facility types in certain counties.

To ensure your health plan's Medicare portion of the network adequately reflects and supports the beneficiaries served by this demonstration, Gorman Health Group (GHG) can analyze your existing provider file, assist in uploading the prepared files into NMM, and provide strategic planning should any deficiencies be found. The gates in the NMM will be open on the following dates:

March 31, 2015
May 26, 2015
August 4, 2015

GHG advises all MMPs to be proactive and take advantage of the pre-checks available. The annual network submission deadline is September 17, 2015, with an exception request period to follow. Let's work together to ensure your provider network not only meets CMS standards but is working to meet the strategic initiatives of your plan.

Contact us today to start a conversation >>

Resources

by GHG Advisors

The Annual Full Replacement COB Files Are on Their Way

It's that time of year again when Part D plans will receive full replacement Coordination of Benefits (COB) files from the Centers for Medicare & Medicaid Services (CMS). The Health Plan Management System (HPMS) memo dated 3/6/15 states that the 2015 Full Replacement COB files will be sent to organizations beginning March 19th. Plans will need to distinguish these files from daily COB notification files by the date of receipt and the file size. Easy enough? Not exactly.

Opportunity to Review and Correct Your Records

The full replacement COB files offer organizations a great opportunity to review their current records, make corrections, and re-sync with CMS. When a Medicare Part D enrollee has other prescription drug coverage, coordination of benefits allows the plans that provide coverage for this same beneficiary to determine each of their payment responsibilities. This process is necessary in order to avoid duplication of payment and to prevent Medicare from paying primary when it is the secondary payer. Unfortunately, many times plans will "just load" the data file when received. This is a very risky decision, as doing so will override information you have already validated with outdated information from CMS. File analytics is a necessary step in the process.

How we can help:

GHG can evaluate your file to determine actions needed, including verification letter mailing

Part D sponsors are required to notify each beneficiary of other prescription drug coverage information as reflected in the COB file from CMS. The beneficiary should review the information and report back any updates. It's important to analyze the file and not send out verification letters to members unnecessarily, especially if a letter was recently sent to a member or if the member is terminated. Plans that use the "send letters to all" approach will realize this just overloads your customer service call center.

GHG can assist with the Primary record validation and correction

Many times erroneous information is on the data file and gets loaded time and again. This can cause multiple problems such as bad COB flags at the Pharmacy Benefit Manager (PBM) or, worse, point-of-sale (POS) issues at the pharmacy which could lead to Complaint Tracking Module complaints (CTMs). It's important that information submitted to the Electronic Correspondence Referral System (ECRS) is valid, complete, and consistent. Transactions submitted that are incomplete or fail ECRS system edits will be submitted for development, which will place a freeze on the record for up to 100 days.

Unsure where to start? Contact me at ctobin@ghgadvisors.com, and let us help you maneuver through the COB file verification process.

Resources

by GHG Advisors

Key Changes to Star Ratings from 2016 Draft Call Letter

Now that the news from last month's 2016 Advance Notice (also known as "the Call Letter") from the Centers for Medicare & Medicaid Services (CMS) has had time to sink in, it's time for the real work to begin.

Perhaps even more noteworthy than the long-discussed removal of 4-Star thresholds is CMS' planned interim action to reduce the weights of six Part C measures (for Medicare Advantage Organizations), and one Part D measure (for Prescription Drug Plans) by half to provide immediate Stars relief to plans serving dual eligibles. With these changes looking likely, plans are working feverishly to predict whether they may be on the winning or losing end of these program changes.

While CMS continues to study the correlation between low-income status and lower quality scores, there is much work to be done by health plans to rapidly operationalize the six 0.5-weighted measures, the retirement of three measures, the temporary retirement of one measure, specification changes to more than a dozen measures, and CMS' return of several additional measures that had previously been removed from the program. The sheer volume of these changes almost overshadow the long-awaited, and much-anticipated, introduction of the new Comprehensive Medication Review (CMR) Completion Rate for beneficiaries eligible for Medication Therapy Management (MTM) programs measure.

As is always the case with Star Ratings, time is of the essence as we chase the moving target set forth by CMS. With CMS' renewed commitment (inclusive of a timeline) for termination of plans with less than 3 Stars for three years, plans whose ratings are trending downward will need to work swiftly and effectively to incorporate not only these changes but also proven Stars best practices into 2015 work plans.

With the many changes to Star measures announced in the 2016 Advance Notice, plans may be finding it increasingly difficult to design, implement, and manage Star Ratings programs. Has your 2015 Stars action plan adequately addressed:

Internal reporting, monitoring, and trending of measure-level performance?
Provider targeting, education, and pay-for-performance (P4P) program changes to capture these changes?
Evaluations of programs to determine those that are working (and those that are not)?
The reduced influence that Diabetes Disease Management programs will have on Star Ratings?
Changes to member interventions and wellness programs to address these program changes?
Any weaknesses identified in the 2015 Star Ratings?
Population health tools and strategies needed for Star Ratings success?

Gorman Health Group's team of experts can help your organization adapt to the new clinical areas emphasized in the Advance Notice, develop or enhance care coordination within your programs, or evaluate the effectiveness of your current Star Ratings program.

Resources

Gorman Health Group's Summary and Analysis of the 2016 Draft Call Letter and the Medicare Advantage (MA) Advance Notice is now available. Download it today >>

Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.

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. Visit our website to learn more >>

by GHG Advisors

Go-to-Market — No Department Left Behind

Although the next Annual Election Period (AEP) is a ways off, now is the time to start thinking about product development and overall strategy. In most organizations, the start of the "Go-to-Market" (GTM) strategy discussions begins with the C-Suite, Product Development, and Sales and Marketing. This keen group of professionals works sequestered and siloed for a period of time and then, voilÃ , they emerge with the lifeline of the health plan's benefits and strategy in their hands.

In order to launch a successful set of products (as well as strategies for selling these products), one of the most important and initial steps must be the creation of a fully integrated GTM governance structure to enable the organization to manage more effectively between strategy implementation, optimization, compliance requirements, and results tracking of an integrated marketing strategy. This will require the involvement of multiple functional areas, even those that aren't traditionally thought of (e.g., Medical Management, Pharmacy, Compliance, Member Services, Provider Relations, etc.), which means no department can be left behind.

"The failure to include Compliance as part of GTM initiatives is a prime reason for some of the regulatory pitfalls that arise and are discovered way too late," says Regan Pennypacker, Vice President, Compliance Solutions. "Whether your organization deals in Medicare, Medicaid, or a combination of these lines of business, the overall guiding principles will be the same. A culture of compliance starts at the top and is effectively integrated when each area of the organization takes ownership of compliance requirements and expectations respective to each functional area."

Execution and management of this initiative is no easy task. A successful GTM strategy brings Compliance and operational stakeholders to the table. Assigning the right accountable parties at the onset is critical to ensuring regulatory requirements are implemented and overall strategy is executed. For suggestions and solutions on how to build your GTM strategy and team, contact me directly, cknight-lilly@ghgadvisors.com.

Resources

Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>

by GHG Advisors

Money Grab: CMS to Rerun Risk Scores, Implement Plan for Overpayment Recovery

Do you know your level of exposure for overpayment recovery from CMS?

On March 3, 2015, Cheri Rice, CMS' Director of Medicare Plan Payment Group, released a memo notifying all Medicare Advantage Organizations, PACE Organizations, and certain Demonstrations of its intent to rerun risk scores during the calendar year 2015. If you read this memo and muttered, "uh oh" under your breath, you might be thinking that your plan/organization owes CMS some money, and soon. If you haven't read this memo, "uh oh" would be an understatement.

The memo was brief and a bit vague, but the impact to health plans and providers could not be clearer. CMS will be rerunning risk score data and the corresponding payments made to plans dating back to 2008 Dates of Service (DOS), payment year 2009. Additionally, the memo anticipates that plans will clean up their data by submitting deletes. This could raise the specter of false claims if a plan fails to submit deletes when they knew, or should have known, of unsubstantiated risk adjustment submissions. This could get ugly, and fast.

The table below was included in the memo and outlines the DOS and payment years that CMS intends to rerun, assess, and then start collecting:

Do you know if your plan is at risk for receiving a letter from CMS requesting "money back?"

Better yet, do you find yourself asking the following questions?

What is your level of exposure and how much money might you owe CMS depending on their findings?
Do you know how many risk-adjustable diagnoses will be swept away when CMS reruns the data, and do you have the ability and infrastructure to conduct that analysis?
What is the impact of the overpayment recovery effort on my provider contracts, relationships, and reimbursement?
How will this effort impact my medical management, quality, and affordability strategies?
Is this on my radar for our ICD-10 preparedness plan?

Gorman Health Group's team of experts can help your organization answer these questions and assess the impact to your plan, your providers, and your budget.

Unsure where to start? Contact me directly at dweinrieb@ghgadvisors.com.

Resources

Gorman Health Group's Summary and Analysis of the 2016 Draft Call Letter and the Medicare Advantage (MA) Advance Notice is now available. Download it today >>

Gorman Health Group provides expert insight into state and federal regulations surrounding risk adjustment, as well as enterprise-wide strategies to address quality, trend, and risk revenue across all product lines. Learn more >>

by GHG Advisors

Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight

There is no shortage of concern when it comes to awareness of first tier, downstream and related entity (FDR) oversight. In fact, during a recent webinar hosted by John Gorman, Executive Chairman at GHG, on "The Top 10 Things Killing Your Organization", we shared survey results showing the number one Compliance Program risk, from a health plan's perspective, is FDR oversight.

A number of compliance specialists recently asked us about a CMS condition that either they have received as part of a program audit, or have heard about others receiving. Specifically, the condition pertains to the failure to provide evidence that a Plan Sponsor's FDR employees received fraud, waste and abuse (FWA) training within 90 days of hiring or contracting and annually thereafter.

The citations previously referenced in this condition include 42 CFR § 422.503(b)(4)(vi)(C) and 42 CFR § 423.504(b)(4)(vi)(C), as well as the Compliance Program Guidelines, Section 50.3.2 (dated 1/1/2013). In summation, the CFR required MA organizations to establish and implement effective training and education, and the sub-regulatory guidance supported the regulation, also stating that:

Sponsors may choose to tailor the training;
Sponsors must provide the FWA training directly or provide FWA training materials to their FDRs; and
Sponsors may have FDRs access CMS' standardized FWA training and education module

It is important that all Plan Sponsors are aware of the regulation change made effective as part of the Final Rule released May 24, 2014. In summary, 42 CFR § 422.503(b)(4)(vi)(C)(3) now states as follows: "A MA organization must require all of its first tier, downstream, and related entities to take the CMS training and accept the certificate of completion of the CMS training as satisfaction of this requirement. MA organizations are prohibited from developing and implementing their own training or providing supplemental training materials to fulfill this requirement." The corresponding update was also made to Part 423 for Part D.

For some organizations, this is business as usual. However, for those organizations that were providing their own training and delivering to their FDRs, this is no longer permissible as of 1/1/2016.Therefore, it is recommended that organizations implement this new requirement now. Make sure that any policies and procedures documenting this process are updated, especially since the Compliance Program Guidelines require update. For reference, the Medicare Learning Network is here and the link to the web based training courses is near the end of the page.

Have Questions? Contact me directly at rpennypacker@ghgadvisors.com

Resources

Gorman Health Group's solution, the Online Monitoring Tool (OMT™), streamlines vital compliance activities, such as the implementation of new requirements and corrective actions. Read our recent White paper to learn more.

The external audit program process is fully customizable according to your organization's needs and can encompass both internal and delegated functions, CMS audit protocol, as well as the inclusion of other audit elements that are not part of the current protocol (e.g. enrollment, credentialing, member services). Don't let CMS be the first to tell you where your deficiencies are. Visit our website to learn more >>

Gorman Health Group's Summary and Analysis of the 2016 Draft Call Letter and the Medicare Advantage (MA) Advance Notice is now available. Download it today >>

by GHG Advisors