Best Practices in Medicaid Claims Administration and Oversight
Every Medicaid operation needs high-performing claims administration. With strict medical loss ratios as required by healthcare reform, ongoing regulatory changes, timeliness, and payment accuracy relevant to provider pricing and benefit administration, covering operating costs poses significant challenges. Claims adjudication must be efficient and cost effective.
Claims adjudication is the process of paying or denying claims after a series of comparisons (automated system logic or manually by claims staff) against a comprehensive set of requirements. These requirements are as follows:
- Eligibility verification
- Benefit administration (deducible, coinsurance, copayment, accumulators and Maximum Out of Pocket (MOOP))
- Authorization criteria
- Provider verification
- Financial data and reimbursement guidelines (contracted or non-contracted)
- Claim edits
- Encounter edits
- Correct coding edits (based on line of business and state or federal guidelines)
- Medical review
- Coordination of benefits
Best practices of efficient Medicaid claims operations are as follows:
- Develop a strategy in enhancing claims quality control and oversight activities
- Implement quality control auditing through pre-payment auditing reviews
- Create a comprehensive oversight and monitoring reporting system
- Ensure that processes starts ticking when the claim reaches the organization, not necessarily when it reaches the claims department
- Increase auto-adjudication by complete set-up of pre-processing and routing logic. This results in higher first-pass rates and reduction in manual handling, which provide significant savings in operating costs
- Continue to redefine procedures, as well as provide a mechanism to understand all terms and conditions of the State contractual agreement relating to overall operations, claims and encounter processing
- Define and design configuration build at the product level by delineating lines of business (i.e., Medicare rules vs. Medicaid rules) which results in compliance with applicable regulations
- Continue to define or redefine claims adjudication policies and procedures, and data management, including consistency within each product
- Implement processes that monitor end-to-end claims adjudication
Execution of these best practices, and automating each procedural step of the claims cycle, results in quicker claim resolution. Monitoring operational performance helps track, adjudicate and measure claims as they flow through claims administration operations. As operational performance improves, auto-adjudication rates rise and the total cost per claim falls.
Gorman Health Group includes some of our industry's most experienced and proficient claims administration subject matter experts. Our consultants can help your organization implement best practices in claims administration. Please contact us at ghg@ghgadvisors.com to get started.
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GHG will help you by providing creative solutions to maximize cost effectiveness while building a solid framework to deliver results from eligibility to provider contract management to claims. Visit our website to learn more >>
Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
Exchanges - Risk Adjustment - Ladies and Gentlemen, Start Your Engines
Seriously, the first question is, "what do you have under the hood for risk adjustment in your health plan?" If you're running a stock claims engine that merely matches up with your enrollment file for CMS Edge Server processing, and you don't have a risk adjustment operation, you may be breathing fumes from your competitors. Now, for health plans accustomed to competing against each other, we have a new type of competition. Further, it's not just plans on the Exchanges, it's all health plans on or off the Exchanges. Up to now, health plans have been competing for market share on the basis of premiums, benefits or brand; but with Exchange risk adjustment, competition takes on new meaning. You can gain or lose dollars. Some plans will transfer dollars to competitors on the market share they painstakingly managed to enroll. Ouch!
The process is very much underway at CMS with Edge Server testing. Plans are calibrating their systems. This means passing CMS testing for submission of test files, as well as understanding processing for acceptance and rejection of individual claims. Health plans must submit their first production by December 5, 2014. Beginning in mid-December, CMS will provide the first estimate reports to health plans for their review and feedback. After that, CMS will process files monthly until the final processing that occurs in May 2015, when risk scores are finalized for 2014. By July 2015, CMS expects to notify plans of any payments due when their risk scores indicate lower risk. For those receiving dollars, getting risk score payments will be no accident. So, while appeals can be filed, the process is upon us and, it will be too quick for any plan giving up dollars.
Right now, most plans' IT staffs are clarifying processing details. However, it is clear that some IT staffs are struggling with the basics, indicating few supports and a lack of horsepower in their risk adjustment engines. Most likely, these are plans that are not offering products on the exchange, and have limited familiarity with CMS requirements. To say they are back of the pack in this new form of competition, and have failed to understand this threat, is an understatement. Being caught unaware of their unknown risk score values relative to competitors' scores should be significantly unnerving to their leadership.
These leaders need to gauge their understanding and determine how quickly and sophisticated they can get. This includes ensuring that leaders develop the processes needed to identify proper risk scores, develop coding necessary to support diagnoses, and initiate analytics needed to identify gaps that require further investigation. So, the right time is now to lift the hood. Getting a risk adjustment engine to run over the next six months will be crucial to getting the most optimal risk score that properly reflects the health status of the members they have enrolled.
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Gorman Health Group supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure that the procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete. Visit our website to learn more >>
Listen as Janet Fina, GHG's Vice President of Risk Adjustment, together with colleague, Carol Olson, GHG's Director of Risk Adjustment, addressed areas for documentation improvement that will allow for accurate reimbursement and disease and case management opportunities. Become a member of the Point to access the recording >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
A Bad Couple Weeks for ObamaCare
It's been a bad couple weeks for ObamaCare. It started with a Republican gorilla-stomp in the midterms, a rout that included several Governors' mansions and state legislatures that essentially froze in place the Medicaid expansion map. Then, in a shocker, the Supreme Court decided to consider King v. Burwell, the case that could undo ObamaCare's marketplace subsidies and threaten the coverage of more than 4 million Americans. It's enough to give weekend bedspins.
Ice Age for Medicaid Expansion
In many states with rampant uninsurance, Republican candidates won critical Governors' races and in others the GOP solidified seats in their legislatures. The net effect: it's a new Ice Age for the Medicaid expansion map, with states taking the Affordable Care Act's (ACA) 100% Federal match for uninsured adults essentially now frozen in place. We may even see some backsliding.
Some 24 states have accepted the ACA deal and expanded their Medicaid programs in the wake of the last big SCOTUS ruling on ObamaCare. In fact, more Americans have gained coverage from Medicaid expansion than ObamaCare's subsidies in the new insurance marketplaces. But despite the fact that holdout states continue to pay their share for Medicaid expansion through Federal taxes, over two dozen mostly Red State governors continue to throw the middle finger at the guy in White House. Most notably, reelection of Rick Scott in Florida, Scott Walker in Wisconsin, Sam Brownback in Kansas, Nathan Deal in Georgia, and Rod LePage in Maine stuck a fork in coverage for the uninsured there.
Utah Gov. Gary Herbert will outline a formal Medicaid expansion plan this month. Republican governors in Tennessee, Wyoming, South Dakota and North Carolina have also flirted with Medicaid expansion plans in 2015. And a late recount win in Alaska for left-leaning Bill Walker may open prospects for coverage for 43,000 residents in 2015.
But we could see real retreat on Medicaid expansion in GOP states that were already moving forward. New Republican governors in Arizona, Arkansas, and Illinois have the power to threaten health coverage for hundreds of thousands who have enrolled in expanded Medicaid, and have done so during the campaign. Indiana Governor Mike Pence was negotiating a plan with the Obama administration pre-election, but now appears to have his own Presidential aspirations in mind and may put the plan on ice. Arkansas' controversial Medicaid expansion waiver to use Federal dollars to buy private coverage was already approved, but its new governor, former US Rep. Asa Hutchinson, is no fan of the plan, which requires annual approval by the legislature and is now very much in doubt.
It was a bad midterm election for the uninsured, especially childless adults. What remains to be seen is how hard a line the Obama Administration takes to force holdout Red States to take the money, using existing Medicaid funds as leverage. My guess is that hard line will be pretty limp. As George Burns said, "like shooting pool with a rope."
The SCOTUS Subsidy Surprise
The day after the election the Supreme Court made a surprise decision to hear arguments in King v. Burwell, what many thought to be a sideshow case in the lower courts around the Constitutionality of ObamaCare subsidies in the 36 states using the Federal exchange. It was basically a case challenging a drafting error in the law, which didn't make clear enough distinction between state-based and Federal marketplaces, and ACA opponents saw their opening.
Even being "strict constructionists" in their jurisprudence, one has to believe the conservative activist Court didn't take this case to rubber-stamp ObamaCare's subsidies. If the justices find for King, some 4-4.5 million Americans will see their martketplace subsidies at risk. Without subsidies, the vast majority of those insured will drop coverage like a hot rock, leaving only the sickest in the pool — what economists call a "death spiral" for insurers operating in the marketplaces. It would essentially lay a mushroom cloud on all private coverage options in those states, leaving ObamaCare a smoking wreck of mostly Blue State Medicaid expansions.
There's no ignoring this point: in Republican territory, the ACA and its marketplaces and Medicaid expansion are more vigorously opposed than in states that elect Democrats. If SCOTUS upholds King, then coverage and politics will truly converge in Red States. A win for King means Red States can effectively purge themselves of all vestiges of ObamaCare, by not expanding Medicaid and not establishing an exchange.
I think this would be a huge problem for Republicans, forcing them to come up with solutions that are politically palatable to them. All these new GOP Members of Congress, and Red State holdout governors, need to start thinking, now, about what to do if SCOTUS announces a decision in June 2015 denying tax credits to millions of their citizens, while they in turn continue to deny Medicaid coverage.
Resources
On Friday, November 21, join John Gorman, GHG's Executive Chairman, together with colleague, April Fleming, GHG's Senior Vice President of Products, as they discuss the challenges of non-compliance, and introduce the new Appeals & Grievances solution from 1-2 pm ET. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
The Importance of a Proactive Call Center
During the AEP we know how critical a role our Member Services team plays. During this time, they are integral to helping prospective enrollees understand the benefits of your Plans, and play an important part in the retention of your current members. Having a strong proactive Member Call Center is crucial in today's environment. Test your call center — see if they pass the test. A proactive Member Service Call Center Department should at a minimum, do all of the following:
- Highly trained call center representatives develop "one on one" member relationships
- Becomes a one stop resource for seniors (meal on wheels, etc.)
- Track and trend Members' problems and resolutions (problem solving)
- Reduce members voluntary disenrollment with focus on first-time call resolution of Member's problems
- Take the time to educate members (benefits, Providers, and Claims)
- Look for opportunities to engage the member in Care Management services
- Provide outreach reminders to members (Member Newsletters, appointment reminder postcards, etc.)
- Proactively, through outbound calls, identify first level problems and implement resolutions
- Provide new members orientation (an educated member is a happy member)
- Provide consistent training to help reduce the number of members' appeals and grievances
- Have Quality Improvement initiatives consistently in play to help improve the Star measures
- Support members in accessing care, even making appointments for them if necessary
If you can answer yes to all the bullets above regarding your current Member Service/Customer Service Department, then you are on the right road to increased retention. If not, then leveraging member's satisfaction is an important retention tool that should be looked at going forward. Now is the time for forward thinking initiatives!
Stats: 30% of Medicare beneficiaries are enrolled into a Medicare Advantage Plan (MA/MAPD). And over 15% of Medicare Advantage Companies Fail to meet the government standards for customer service through a call center for 2014. (Source: https://www.healthpocket.com/healthcare-research/infostat/medicare-advantage-customer-service-ranking.)
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John Gorman, GHG's Founder and Executive Chairman discussed why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Become a member of the Point to access the webinar recording >>
Gorman Health Group can 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 >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
CMS Validation Process: The Silver Lining
We've seen quite a few changes over the past few years in the way that the Centers for Medicare & Medicaid Services (CMS) is approaching the program audit and audit validation process. The most notable trend this year is continued push back of responsibility onto the Organization. In recent sanction reports, CMS states that it will require the Organization "to hire an independent auditor to conduct validation in all operation areas cited in this notice and to provide a validation report to CMS." In addition, CMS presenters at the CMS Fall Conference, which took place on September 11, 2014, stated that "The onus of correction overall is on the sponsor. Therefore, CMS this year will not request universes to conduct sample testing unless the sponsor is unable to demonstrate through its presentation and from the responses to CMS questions, that it has not corrected the findings."
CMS is sending a clear message here. They expect the Organization, and not CMS, to do the work in the validation process. So, is there a silver lining? Why of course there is.
While it's clear that CMS is tightening the reins, they are also providing an opportunity - the opportunity to get it right the first time, and not go through the full CMS validation audit process. If you don't know the best way to proceed, in order to avoid a validation re-audit, we have the roadmap. Contact us today to get started.
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While it may be difficult (too much so, for our tastes) for many compliance officers to effectuate the necessary change in the business units, it is not impossible. Let us help you create a culture of compliance. Visit our website to learn more >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
CMS Initiates New Program to Support Care Coordination Among ACOs
Many of you are aware of the recently published Centers for Medicare & Medicaid Services (CMS) Affordable Care Act (ACA) initiative to support care coordination nationwide.
CMS announced the availability of a new initiative for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. The initiative is designed to encourage ACOs to realize quality improvement and care coordination through the use of health information technology; thereby helping to move the health care system to one that values quality over quantity, and preventative care over treating people after they get sick. The new ACO Investment Model is designed to bring these efforts of better coordinated care to rural and underserved areas by providing up to $114 million in upfront investments to up to 75 ACOs across the country.
"The ACO Investment Model will give Medicare Accountable Care Organizations more flexibility in setting quality and financial goals, while giving them greater accountability for delivering quality care efficiently," said CMS Administrator Marilyn Tavenner. "We are working with these organizations to make necessary investments that encourage doctors, hospitals and other health care providers to work together to better coordinate care and keep people healthy."
Through the CMS Innovation Center, this initiative will provide up front investments in infrastructure and redesigned care process to help eligible ACOs continue to provide higher quality care. This will help increase the number of beneficiaries — regardless of geographic location — that can benefit from lower costs and improved health care through Medicare ACOs. CMS will recover these payments through an offset of an ACO's earned shared savings. Eligibility is targeted to ACOs who joined the Shared Savings Program in 2012, 2013, 2014, and to new ACOs joining the Shared Savings Program in 2016. The application deadline for organizations that started in the Shared Savings Program in 2012 or 2013 will be December 1, 2014. Applications will be available in the Summer of 2015 for ACOs that started in the Shared Savings Program in 2014 or will start in 2016.
Gorman Health Group has assisted numerous organizations for the past three years in achieving Pioneer and Shared Savings ACO status. Additionally, GHG has assisted operating ACO's in analyzing operating and medical spend performance. If you, as an ACO, are wondering why shared savings expectations are not being realized, or how to improve on your internal analytical and decision support competencies -- we can meet your needs. Contact us today.
Resources
On Friday, September 26, John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, discussed the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Join the Point today to access this webinar recording.
Don't let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation - we can help design and implement these arrangements. Find out how GHG can help >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
12 Years in the Making - Rules Guiding Medicaid Managed Care are Getting a Makeover
At the Medicaid Health Plans of America (MHPA) meeting last week in Washington, DC, there was a lot of buzz surrounding the upcoming release of an updated Medicaid Managed Care regulation. Per CMS officials speaking at the conference, the last update was 12 years ago!
Discussions surrounding the update were focused on three main themes:
- Aligning Medicaid Managed Care with other public programs
- Payment and accountability
- Network adequacy
Aligning with other programs — This could take many different shapes and sizes. Certainly the well-established program guidelines of Medicare Advantage could become very prominent. In contrast, the newly evolving rules of the Exchange Marketplace could be drawn more into the spotlight. Being that Medicaid beneficiaries sometimes align with Medicare Advantage and sometimes with Exchanges, this is likely to draw a lot of comments from the industry when released in the coming months.
Regardless of how you think it should be done, the rationale to better align all of these programs makes good sense for both beneficiaries and the managed care plans that serve them. Beneficiaries can have common experiences; families with multiple program enrollments have an easier time navigating the system; and plans reduce unnecessary administrative burden to administer multiple programs.
Payment and accountability — Several hot button items are involved in this theme. All of these involve modernizing the regulation to the current day environment.
- Using data to think about issues related to rate setting and rate review
- Using program dollars wisely, as more is at stake as the program continues to evolve and grow
- Integration of long-term services and supports into the regulation
Network adequacy — The OIG recently released a report identifying significant variation between states as it relates to access to care, and how those standards are being checked on a regular basis. With the recent significant growth in Medicaid Managed Care enrollment, this becomes even more concerning. We can expect CMS to take a strong stance on access to care issues including network composition, availability of primary care and specialists, and provider directory issues. As a major beneficiary protection issue, we also expect this area to draw a lot of comments from the beneficiary community.
We are very anxious to see the draft regulation and the "give and take" it is going to provide to the industry. With 12 years worth of ideas baked into it, it should be a fun ride!
Resouces
Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
Gorman Health Group is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement. Visit our website to learn more about how we can help you with your Medicaid initiatives.
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Little Reason for Optimism in Red State Medicaid Expansion
For months several Wall Street analysts and others have predicted near-total adoption of the Affordable Care Act's Medicaid expansion by the states. To date, only 27 have, and I see little optimism for more than a handful to do so anytime soon.
Red State governors are WAY more entrenched than anyone anticipated, and they're getting too much political mileage out of throwing a middle finger at the guy in the White House to stop. Even if Democratic candidates leading in states like Florida win next week, the barrier is often their state legislatures. Virginia is a great example of a pro-expansion Democrat thwarted by his state lawmakers -- one that will be repeated many times in 2015.
Last week we heard mixed news on Medicaid expansion: it appeared likely that Utah governor Mike Herbert would accept an Arkansas-style expansion in a rare compromise with the Obama Administration, and also pretty certain that Indiana governor and 2016 GOP Presidential possible Mike Pence would reject one. Even if Herbert takes the deal, Utah may be another example like Virginia, with a supportive governor blocked from expanding by his state house.
At least six states could adopt Medicaid expansion, including Florida, Georgia, Kansas, Maine, Wisconsin and Alaska, if -- and it's a huge if given the political headwinds -- Democrats and one independent candidate win their gubernatorial races. The obstacle is getting state lawmakers on board in Florida, Georgia, Wisconsin and Kansas, where Republicans control the legislature.
So maybe it's really just Maine and Alaska that have any real shot at expansion? Maine lawmakers are poised to expand Medicaid if Tea Party wingnut Governor Paul LePage is defeated next week. LePage has vetoed several bills to expand the program after they were passed by the Democrat-controlled Maine legislature, and he is trailing in the latest polls. Alaska isn't nearly as far along.
A handful of new Republican governors could move for expansion, albeit after the midterm elections. Tennessee GOP Governor Bill Haslam said he plans to submit a plan later this year, although state Republican leaders warn it will be difficult to win approval. Wyoming Governor Matt Mead, also a Republican, said he will present an expansion plan to his legislature early next year, but prospects also seem slim there.
In many of the remaining Red States, where uninsurance is most epidemic and the ACA is needed most, there seems to be little hope of elected officials actually doing their jobs and meeting the needs of their constituents:
- In Mississippi, expansion doesn't have a snowball's chance in Hell. GOP Governor Gary Bryant made it clear Mississippi would not participate, leaving 138,000 residents, the majority of whom are black, with no insurance options at all after infighting killed the state's embryonic health insurance exchange.
- In South Carolina, where expanding Medicaid could reduce the number of people without health insurance by one-third, the state's health plan association doesn't expect any movement until at least 2017. Even its state medical association won't back expansion, apparently preferring bad debt and fewer customers to Medicaid payment.
- In Louisiana, payers aren't hostile to expansion, they just don't see any point in pushing it. The state health plan association chief said "it's a state where both the House and the Senate, and the governor, are pretty much on the same page of not being interested in moving toward expansion this year or next year."
- In Alabama, even the state's health plan association is openly opposed to expansion. "I agree, and I think my members agree, that [Governor Robert] Bentley is doing the right thing" by saying no, the association CEO said. In its current form, "expanding Medicaid makes zero sense for Alabama."
- In Texas, which has more uninsured people than Colorado has people? Um, no.
With Republicans poised to retake the US Senate next week and expand their dominance in the House, all this hopeful chatter about Medicaid expansion seems more like liberal dreaming than reality. Maybe 2-3 more states in the next two years, if we're lucky.
Resources
Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
GHG is dedicated to assisting managed care organizations, as well as states with developing models of care, maximize member engagement. Visit our website to learn more >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
The Good, the Bad and the Ugly in Medicare Advantage
In the last two weeks there's been good, bad and ugly news for Medicare Advantage (MA) plans. On one hand, the program has never been stronger and quality metrics are surging in the right direction; on the other, the industry is sucking it up on following the rules of its biggest customer, the Centers for Medicare and Medicaid Services (CMS).
First, the good: CMS did its annual data dump on Medicare Advantage and Part D bids and showed the program continuing its robust growth, with higher-than-ever enrollment approaching 17 million, and plans holding premiums and benefits steady during the worst rate environment in decades. Then, CMS released the MA Star Ratings database for 2015, showing MA quality continues to improve. The enrollment-weighted Average Star Rating for the industry stands at 3.91 out of 5. 40% of MA contracts were awarded 4+ Stars for 2015, but 60% of enrollees are members of those plans, showing a 30% increase since 2012 and demonstrating the competitive advantage high-performing plans now enjoy. The 2015 ratings show stable or improved performance in almost 70% of the 46 Part C & D Star measures, 7 of which improved by more than one-half star from 2014 to 2015, and 13 of which earned average ratings above 4 stars in 2015. There was even an 85% decline in plans receiving the low-quality performance badge of shame.
But then the bad: it's clear plans have eaten low-hanging Star fruit and are starting to struggle on more complex and outcomes measures, such as managing chronic conditions, managing mental health to improve outcomes, or increasing physical activity and reducing fall risk. The longitudinal Health of Seniors survey scores are below 3 Stars, and 135 plans remain on the Quality Bonus Payment bubble at 3.5 stars in 2015, meaning almost half of MA plans are circling the financial toilet bowl. Not good.
And then the ugly: last week's blistering New York Times story on rampant noncompliance among MA plans. The Times combed through months of compliance action reports and found widespread failures by plans in administering the program, including some common and potentially life-threatening stumbles:
- In more than half of all audits, "beneficiaries and providers did not receive an adequate or accurate rationale for the denial" of coverage when insurers refused to provide or pay for care.
- When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.
- In 61% of audits, insurers "inappropriately rejected claims" for prescription drugs. Insurers enforced "unapproved quantity limits" and required patients to get permission before filling prescriptions when such "prior authorization" was not allowed.
- MA plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.
CMS officials expressed frustration that they were seeing the same deficiencies year after year. That these boneheaded infractions are often being repeated makes the news all the more depressing. It's important to remember if an MA plan with a Star Rating over 3.5 gets sanctioned by CMS for noncompliance, it automatically knocks its rating down to 2.5. That's a kiss of death for an otherwise quality company.
What the Stars and compliance data show us is that the plans are doing great on strategy, pricing their benefit designs, selling to Baby Boomers, and managing straightforward quality process measures. But looking closer, it also shows our industry has a serious execution problem. We are lagging on performance measures with multiple clinical moving parts, and embarrassing ourselves and endangering our companies and beneficiaries with "101-level" compliance errors.
With both Federal and state governments increasingly relying on MA plans to manage the most complex and expensive patients in the US health system, we can and must do better.
Resources
Listen as John Gorman provides several takeaways from our first review of the terabytes of CMS data and understand why he believes this data shows the triumph of government-sponsored programs. Access the podcast here >>
Gorman Health Group 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 >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
NY Times article reiterates compliance trends in Medicare Advantage
As many of you have already read, the NY Times ran a scathing article on October 12th titled "U.S. Finds Many Errors in Medicare Health Plans" shining a light on serious Compliance issues we've all been aware of over the past several years. Is the continued lack of non-compliance really news to anyone in the industry? Most certainly not — we have all been tracking the continued issues of non-compliance, increased CMS Compliance actions, and have read the audit reports posted on the CMS website. What the NY Times article did was remind us that the compliance trends in Medicare Advantage are a serious matter which should not be taken lightly.
The fact is, Medicare beneficiaries have not had access to their care; both Medical care and Prescription drugs.This is simply not acceptable — period. That being said, I have personally worked on the Plan side, on the consulting side, and as a CMS sub-contractor, and I know, firsthand, the challenges we face in the implementation of the thousands of Compliance requirements. This is no easy task, and anyone who thinks it is, simply doesn't understand plan operations. By and large, what we find is that Organizations want to be compliant; but they don't have the tools or resources to implement and manage this highly regulated program. So, what do you do next? Here is what we recommend:
- If you haven't done so already, go through the exercise of a Mock CMS audit - find your deficiencies now, both for the sake of the beneficiary, and for the sake of your CMS contract.
- Focus first on those issues that have the most beneficiary impact — ensure that your members have access to care as your number one priority.
- Document your remediation efforts and measure outcomes — issues aren't resolved overnight, but ensuring that your remediation plan is working is the key to success.
If you're not sure where to start, we can help. Please find here a description of our Mock CMS Audit Service, or contact us directly.
Resources
On Friday, Sept, 12 a GHG team member provided GHG's perspective on trends relating to CMPs, the CMS audit findings and oversight activities that have taken place in the last six to 12 months, as well as tips on how to avoid and remediate CMS findings. Become a member of the Point to access the webinar recording >>
All Medicare Advantage and Prescription Drug Plans must ensure that they are audit-ready all the time so that each CMS audit is routine. Save the fire drills for fires, and receive standing ovations for the organization's final performance. Visit our website to learn more >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>