Exchange 2014 Data Submission Due April 30,2015
As we wind down on our inaugural year with Health Insurance Exchanges (HIX), we have seen plans using a variety of approaches in their Risk Adjustment data reporting efforts. Some continue to use the same approaches used for their Medicare programs (chart reviews, provider outreach, in-home assessments, etc). Some have not even begun any retrospective, prospective or quality programs because they don't know where to begin. What is the right approach? Probably somewhere in the middle.
Qualified Health Plans need to be very targeted in their retrospective and prospective programs. They also need to have some type of quality assurance program in place. Although HHS has stated that "For 2014 and 2015, an initial and second validation audit will be conducted, but the findings will not be used to adjust payments." Plans still need to be cognizant of the quality of the data they are submitting and are still subject to the False Claims Act. CMS has also stated that when medical record reviews are performed, "the issuer must evaluate all diagnoses on the original claim and the issuer must delete any diagnoses not supported by the medical record." This is a new practice for many plans, but one that must be implemented.
Whether you rely on multiple vendors, an internal team, or a combination of the two, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping stride with HHS expectations in both compliance and health care outcomes. Our services include:
- Risk Adjustment Strategies — Retrospective, Prospective and Concurrent Outreach strategies, evaluation of staffing structure and levels
- Quality Assurance Programs — Proactive programs to improve data accuracy
- Data Analytics — Identifying data gaps and appropriate gap closures
- End to End Process Review — Testing for dropped data and recommendations for best practices in data processing
- Provider Education/Coding - including ICD 10
- Risk Mitigation - Identifying unsubstantiated diagnosis codes
- Data Validation — Mock Audits
- Vendor Audits — Coding accuracy, data completeness
- Requests for Proposals (RFP) - Developing RFPs and/or the evaluation of RFP vendor responses
Resources
In a webinar on Thursday, October 23, 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 >>
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 >>
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 >>
Noteworthy declines in Star Measures: Ensure a 4-Star Performance
With 5% of revenue contingent on achieving at least 4 Stars, the stakes have never been higher for Medicare Advantage plans. Within the 40% of plans earning at least 4 Stars in 2015, plan leaders are celebrating their return on investment from quality improvement initiatives and other Stars-impactful activities. But for the 135 plans on the Stars bubble at 3.5 Stars, and the 102 plans earning 3 or fewer Stars in 2015, the race is on.
Although performance continued to improve on most screening measures and on measures within the plans' control in 2015, ratings declined on 15 of the 46 Star measures in 2015. The most noteworthy declines occurred on the following measures, all of which require significant coordination across provider , and pharmacy networks, plan personnel and members:
- Three of five diabetes care management measures (with two measures dropping by more than one-quarter star each, and declines on both of the triple-weighted Part C intermediate outcomes measures associated with diabetes),
- All three triple-weighted medication adherence measures and the high risk medication measure,
- Care coordination and customer service measures.
In addition, four additional measures, which are heavily dependent on effective care coordination as well as member education, continue to perform under 3 Stars:
- Improving or maintaining mental health,
- Special needs plan care management,
- Improving bladder control,
- Osteoporosis management in women who have had a fracture.
Since enrollment in high performing plans continues to grow, and dramatic improvements have occurred in low-performing plans, CMS is likely to continue driving quality and accountability of physicians, hospitals, and other providers through the ever-evolving Medicare Advantage Star Ratings program.
As plans race into the unavoidable 4th quarter ‘Stars crunch,' now is an ideal time to ensure that adequate workplans, budgets and resources are available to enable 4 Star performance. If your plan is striving to achieve 4 Stars, Gorman Health Group is ready to help! From evaluating organizational strategy to developing and optimizing tactical Star ratings workplans, our team of experts has a long history of success helping health plans achieve Star ratings success.
Resources
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. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. 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 >>
Reversing the Trend: Improving Care Coordination
The good news from the 2015 Star Ratings is clear: Medicare Advantage plans held steady or improved in almost 70% of the 46 Part C & D Star measures. But the more subtle message hidden underneath the 15 measures where performance declined in 2015 is similarly clear: health plans have not yet mastered population management and care coordination in a way that improves health outcomes. By linking the Quality Bonus Payments to 4 Star performance, the Centers for Medicare & Medicaid Services (CMS) is conveying their message: health plans must effectively coordinate the diagnosis to the healthcare activities for their members in order to drive improved health outcomes and satisfy members.
Gorman Health Group is often asked how plans can achieve Star Ratings success. As 2015 draws to a close, the following are a few key near-term suggestions on which to focus in order to achieve Star Ratings success in 2016:
- Create (or review) 2016 Stars work plan(s), evaluate customer service and medical/case management work streams, and processes to identify areas for improved care coordination.
- Evaluate provider and pharmacy network strategy to ensure that infrastructure supports Stars goals.
- Evaluate Stars performance among provider and pharmacy networks and develop targeted activities with under-performers.
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.
Resources
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. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. 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 >>
They Still Don't Like It
In the October 8, 2014 memo entitled "Contract Year 2014 Part D Formulary Administration Analysis (FAA)", CMS reiterates their concern with the accuracy of formulary coding. For the April 2013 analysis, 9 out of 88 (10.2 %) plan sponsors were found to have failed FAA, meaning that greater than 20% of the sampled rejects were determined to be inappropriate. The parameters for the 2014 FAA are:
- Sponsors will be required to submit all point-of-sale (POS) rejected claims relating to the following 4 categories: 1) non-formulary status; 2) Prior Authorization (PA); 3) Step Therapy (ST); and 4) Quantity Limits (QL).
- Larger plans (≥ 20,000 enrollees) should submit rejected claims data for service dates of June 1, 2014 through June 14, 2014 and smaller plans (< 20,000 enrollees) should submit rejected claims data for service dates of June 1, 2014 through June 30, 2014.
If you were one of the plans selected for the FAA, you were required to upload files to the Acumen site between October 16 and October 22. CMS will then select a sampling of the rejected claims for review. Those plan sponsors who meet or exceed the failure threshold will receive a notice of non-compliance and depending on how badly the plan sponsor exceeds the failure threshold, additional sampling and compliance actions may result.
Not to beat a dead horse, but this should again remind us of the importance of formulary benefit administration testing---rigorous and extensive at the beginning of the plan year and at every point during the plan year when formulary changes are made. You can't afford NOT to.
Resources
Beneficiaries should be able to receive the Part D drugs they are entitled to, consistent with CMS guidance, from January 1st through December 31st of the plan year.
We can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Contact us 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 2015 Ratings are In: Have the Stars Aligned?
The Centers for Medicare & Medicaid Services (CMS) has released the 2015 Medicare Advantage Star Ratings, and the Stars seem to be aligning with CMS' goals of the Star Ratings program. For the 40% of Medicare Advantage plans earning at least 4 Stars this year, and thus qualifying for Quality Bonus Payments, these newly-released Star Ratings illustrate the value of health plans' investments in clinical innovation and quality improvement within Medicare Advantage product offerings.
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. Improved health plan quality is illustrated by strong performance on preventive screening and testing measures across all domains, health plan performance measures, and measures of member complaints. During 2015, almost 60% of beneficiaries will be enrolled in one of the 158 Medicare Advantage plans which have earned at least a 4 Star Rating.
Despite these areas of strength and improvement, the Stars are not entirely aligned in the 2015 Ratings. The 2015 Ratings spotlight the ongoing challenges plans continue to face in the following areas:
- Managing chronic conditions
- Managing mental health to improve mental health outcomes
- Increasing physical activity and reducing fall risk
CMS continues to compel health plans to hardwire quality improvement and operational excellence by announcing adjustments to Star measures upon release of the ratings. With the 2015 ratings, CMS has again made Star ratings history by re-weighting the Improvement measures to 5x and announcing the following changes:
- SNP Care Management measure added with single weight
- Breast Cancer Screening and Beneficiary Access/Performance Problems measures removed from ratings and reclassified as Display Measures
- Glaucoma Testing and Call Center Foreign Language Interpreter and TTY Availability measures removed from ratings
- Adjustments made to methodology on Annual Flu Vaccine, High Risk Medication and Medication Adherence measures
With the overall national average for HOS measures below 3 stars in 2015, combined with the changes to 2016 Star measures announced in the 2015 Call Letter, the time is right to acknowledge the potential return on investment from activities aimed at improving performance across all aspects of health plan performance.
The 2015 Star Ratings continue to show opportunities for health plans to break through long-standing silos within our organizations and throughout the industry. Health plans can maximize Star Ratings by leveraging existing infrastructure, teams and processes to improve integration with providers and members. Through innovative tactical adjustments to existing processes and work streams, health plans can better integrate Part C activities with Part D activities, physical health care plans with mental health care plans, and internally-staffed work streams with delegated work streams.
Despite the approximate 85% decline in plans receiving the low performing icon (LPI), 135 plans remain on the Quality Bonus Payment bubble at 3.5 stars in 2015. Whether your plan's 2015 Star Rating is on the bubble or solidly above 4 stars, this is an excellent time to re-evaluate your 2015 strategies, work plans and tactics to best ensure that your Stars remain aligned.
Resources:
The Centers for Medicare & Medicaid Services (CMS) has been aggressively working in the background to establish the Star Ratings program for the Health Insurance Marketplaces. See what you can expect >>
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 >>
Part D Rejected Claims Continue to be Important Monitoring for CMS
Rejected claim analysis is a year-round activity with special emphasis that should begin before January. Are you confident in your current process to review and identify non-compliant rejected claims?
As a Plan Sponsor, whether you delegate all or part of your Part D Drug Benefit set-up to your Pharmacy Benefit Manager (PBM), The Centers for Medicare & Medicaid Services (CMS) expects plans to demonstrate effective management of the CMS-approved formulary to ensure timely beneficiary access to clinically appropriate medications.
CMS expects Sponsors to understand regulatory requirements and to oversee the PBM to ensure the PBM is compliant with claim adjudication. Beneficiaries should be able to receive the Part D drugs they are entitled to, consistent with CMS guidance, from January 1st through December 31st of the plan year.
To accomplish this, it is essential to perform comprehensive testing of formulary file and system edits prior to going "live" in the adjudication system. In addition, it is required to perform a regular review of rejected point of sale (POS) pharmacy claims as well as to perform regular oversight of other delegated PBM functions.
You can reduce your compliance risk of transition non-compliance by testing transition fill look-back logic which must accurately identify transition eligible beneficiaries and drugs eligible for transition fills; maintaining formulary consistency for beneficiaries across years and during the year; ensuring formulary edits are effectively tested for accuracy prior to implementation; and by ensuring that the PBM does not administer the Part D benefit based on either Medicaid or commercial program requirements.
In a Formulary Administration Audit and Coverage Determination Audit, CMS seeks to determine how the Plan properly administers the CMS transition policy and its approved formulary by avoiding unapproved utilization management practices, prior authorizations, quantity limits, rejecting formulary medications as non-formulary, and maintaining beneficiary access to protected class drugs during transition and throughout the year. Failure to properly us approved formularies creates high audit risk, a possible civil monetary penalty, or even plan sanction.
Performing a comprehensive review of the formulary and utilization management system edits prior to going "live" in the adjudication system requires a robust, systematic process for comparing the CMS approved formulary benefit to a comprehensive claims universe in order to ensure that all covered drugs, tiering, and UM edits are consistently and accurately adjudicated.
Our Pharmacy experts can create and conduct an in-depth benefit administration test plan for your organization to validate that everything is working precisely as it should before the new plan year begins as well as on an ongoing basis throughout the year. We can ensure your PBM is processing claims consistent with your CMS-Approved Prescription Drug Benefit.
Resources:
We can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Contact us 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 >>
Marketplaces — Your Stars are coming
The Centers for Medicare & Medicaid Services (CMS) has been aggressively working in the background to establish the Star Ratings program for the Marketplaces, thus consumers will have their first quality information by 2017. Selecting a Marketplace health plan will no longer be based only on price or provider. As such, quality ratings will have a bearing on market share.
Notably, CMS is also creating future Stars for hospitals, dialysis centers, home health with nursing homes and physicians. However, it's different for the Marketplaces.
The CMS plan starts with a beta test in 2015 by collecting both clinical data defined by HEDIS and consumer rating data collected via CAHPS. Clearly, neither of these is untested. CMS has extensive experience using both HEDIS and CAHPS to build Stars in the Medicare Advantage program; a process that has evolved over the last six years. CMS has honed its methods for conducting statistical analysis of each measure into a dynamic process that annually adds and removes measures to refine information provided to consumers. Notably, CMS is also paying rewards to higher performing plans. Even more significant for 2015, CMS has suspended its regulatory authority to terminate low performing plans. CMS is seeing the focus of these plans on improving Stars when faced with termination.
With the wealth of experience in running Stars in Medicare Advantage, this beta test is merely an assessment of collecting the information from Marketplace plans and validating data and statistical analysis methods. There will not be a long ramp up similar to what Medicare Advantage plans experienced before CMS put in Marketplace rewards and penalties.
If you haven't already, now's the time to put your team in place. Not just to respond to CMS setup requirements and contract with your HEDIS and CAHPS vendors, but to also begin establishing the Stars team as an operational component in your organization. It will be important to create a focus to find and monitor operations that affect Stars performance. Building the proper team and charging them with the responsibility to track and develop a Stars framework is necessary for a long-term commitment to achieving five-Star performance.
Resources
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 >>
High Value Network: Generation 4.0
When it comes to healthcare, two truism's are that medical costs are going up along with demand for healthcare services. And when it comes to organic growth of healthcare volume and expenses, government programs represent a major driver, particularly when considering that on a daily basis thousands of baby boomers age into Medicare. During the last several years CMS has published a number of demonstration programs which are intended to improve the quality of Medicare patient outcomes while promoting financial efficiency on a unity cost or per procedure basis.
Commonalities among the various demonstration programs include: providing financial incentives when providers and plans (through STAR ratings) achieve specific quality and financial metrics, that when properly implemented, result in improved patient outcomes at a reduced cost. Not surprisingly, the discussion among many health plans has started to focus on how to manipulate the size and inherent "quality" of provider networks to achieve performance gains.
The concept is not new, in that payer efforts at developing "Centers of excellence", proprietary physician networks, private label networks, etc., have been around for at least two decades. These efforts were driven by market considerations, provider availability and consolidation, expectations around consumer demand and use of services. Many times high cost hospitals were screened out and networks were defined by the plan offering, e.g.. PPO, HMO POS and the like. Provider price concessions were expected in return for volume. Provider performance, at least as defined by improved patient outcomes, was not a major consideration in the design of these networks.
At least not until now. Given the current climate of healthcare reform, shrinking payer margins, provider flight from Medicare, percentage declines in medical school enrollment and CMS initiatives to constrain medical expense through improved coordination of care and elimination of unnecessary procedures, Medicare Advantage, Medicaid, and commercial health plans are exploring how the design of networks, around performance, can lead to better patient outcomes and better managed financial costs. Thus, the approach to network design is shifting way from preferred pricing in exchange for volume to a network design strategy focused on horizontal and vertical integration, superior treatment outcomes, more efficient use of resources as well as a willingness to share in financial risk. Population management strategies, establishment of consensus clinical protocols and reimbursement strategies tied to CMS STAR ratings, as well as additional quality and financial metrics, dictate network performance and thus health plan sustainability.
Tracking the measurement and reporting on agreed to metrics require a level of analytical sophistication that was not apparent in the early days of network design. The development of high value networks suggests that payers and providers must share a common vision for network design and consensus agreement on expectations around network performance. In addition network design efforts will require unwavering leadership commitment to ensure long term sustainability.
In the final analysis high value network design is a partnership enterprise between the health plan, the provider and the patient. Contributing components include health services/medical management, provider contracting, actuarial services, finance, analytics/ decision support and management.
As a diversified health services consulting company the Gorman Health Group is well positioned to become a partner in this effort from start to finish including the development of the most appropriate network design strategy to development of performance payment models to the implementation of the final network including assurances that the final network meets CMS network adequacy requirements. When you are ready, give us a call.
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. Access the recording here >>
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. 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 >>
Reasonableness — The Last Chance
After four tries, some Marketplace health plan applicants have still failed to meet CMS reasonableness standards for 2015. Some of these applicants complained that they did everything they were told to do but were again rejected. Others are still asking for definition and written standards. Unfortunately, most understand that nothing in writing exists beyond the regulation.
In response, CMS encouraged them to call and discuss their issues next week when the subject matter expert is available. Their appeal is limited to a phone conversation with this lone CMS interpreter of reasonableness. These applicants need to have definitive data about available providers, population and time and distance to convince this reviewer. Demonstrating the use of a deliberative process may be the lesson for 2016 applicants but for 2015, time has run out.
Resources
We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Learn more about how GHG can help you tackle the application process >>
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 >>
It's a Marathon - Not a Sprint
Plans will shortly be receiving the Readiness Checklist from CMS. At first glance it looks like just a bunch of boxes to check off and answering yes and no questions. Here's the rub:
Starting to figure out whether or not you have 30 boxes of non-readiness to report to your Account Manager is not a good way to roll into 2015. The previous year's readiness checklist should inform your priorities for the year's operations. Your relevant questions are: Who and what department owns this? Do we have policies and procedures, business processes and reports for this? Have we had any CMS outlier notifications about this? Did we audit this? Anything that you answer as "not ready" is automatically a priority.
You can't start being ready when the checklist arrives. Plans should be preparing to "be ready" all year long. For instance, here's what has to be done for Coordination of Benefits readiness:
CMS expects health plans to establish/maintain systems and procedures for at least weekly COB data report/file processing by not only receiving COB information from various sources, but also applying the COB information to claim payment system(s). Health plans may not understand how to interpret the CMS COB file and use internal sources, such as enrollment forms, claims, provider services, and member services to identify other health information for COB. Health plans need to be able to clearly categorize the various types of records and perform distinct validation, outreach and processing for group coverage, non-group coverage, third party liability, federal/state programs, as well as charities.
The important step of validating the other health information from CMS and other internal sources is often overlooked and a critical step to maintaining COB information in CMS systems. Without this step, information is outdated causing incorrect claim processing, member abrasion and escalated issues. CMS expects that organizations utilize the Electronic Correspondence Referral System (ECRS) to send COB updates to CMS timely and accurately, but health plans often fail to work the ECRS response file rejections and update internal claim system COB flags or other coverage information. Readiness planning should include the final, most often overlooked, yet most vital step: Reconciliation. An effective reconciliation process will work all COB related reports including TrOOP Balance Transfer exception reports, COB error reports, reconcile enrollment, claim and pharmacy systems, as well as monitor claim payment accuracy and recovery of other liabilities.
Resources
The biggest risk health plans face in government programs is managing membership and financial data. With Gorman Health Group's Valencia, you'll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments.. Learn more about how Valencia can help you >>
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 >>