Outbound Enrollment Verification (OEV) - To call or not to call?
With the release of the 2015 Marketing Guidelines, CMS made a few key updates to the Outbound Enrollment Verification (OEV) Process. One of the most significant updates is that CMS now allows organizations to complete the OEV process via direct mail or email (if the beneficiary opted-in for email). This change actually provides significant opportunity for organizations. The way we see it, organizations will now need to choose one of two paths. The first path is to continue using outbound telephone calls to fulfill the CMS requirement. If your organization has developed and implemented an effective OEV process, by all means continue with this process. However, if you're thinking "why would we continue the current process when our OEV process has been riddled with issues of non-compliance?" Well, we agree.
If your organization has seen significant and ongoing issues with the OEV process, this is your opportunity to change that by fulfilling the requirement via another mechanism. However, if you do choose this path, it is critical that your organization develop a top notch welcome call for those new members who would have previously received the OEV call. This first touch is key in terms of identifying any possible gaps in the member's understanding of plan benefits and rules, identifying any issues of sales misconduct, as well as ensuring that your member retention program gets off on the right foot. Remember, it is always better (and less expensive) to retain a member than to obtain a member!
Please note: In CMS' memo titled "Clarification of Medicare Marketing Guidelines and Additional Agent/Broker Compensation Guidance" that was released on August 13, 2014, CMS revises current guidance language to clarify that the OEV process applies exclusively to enrollments in which employed, captive or independent agents/brokers were involved.
Resources
On July 23, GHG leadership spoke about what provisions in the final guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes. Download the recording >>
On September 10, join John Gorman, GHG's Founder and Executive Chairman for an exploration of why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Register now >>
On September 12, join us for 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." Register today >>
Regulatory Oversight of Narrow Network Plans
The Alliance for Health Reform held a meeting that focused on "Network Adequacy: Balancing Cost, Access and Quality" on July 21. The meeting was very well attended for mid-summer, indicating substantial interest in the trend towards smaller networks particularly in qualified health plans offered through the ACA Exchange marketplaces. Several of the panelists mentioned a recent McKinsey study that found that 92 percent of consumers using ACA plans have access to narrow network plans while 90 percent of ACA plans offer broader networks.
The panel participants emphasized the value that smaller networks bring to consumers in offering substantially lower premiums. For example, a recent Milliman report for AHIP found that high value networks can reduce premiums by 5 — 20 percent. However, it is important that plans select the providers based on quality and performance and not just on price. Paul Ginsberg pointed out that smaller networks also can support integration of care and that these plans are moving in the same direction as payment reform e.g. making payment based on episodes of care or bundled payment. Katherine Arbuckle from Ascension Health noted that providers in smaller network plans can benefit from being connected to the same electronic health record system which further benefits clinically integrated care.
All of the panelists agreed that there needs to be adequate regulatory oversight of network access. Currently the NAIC is in the process of updating their Model Network Adequacy Act which has not been modified since 1996. The goal is to have an updated model by the end of the year. NAIC is focusing on new provisions on essential community providers, tiered networks, formularies, provider directories and updates, continuity of care and consumer protection from unanticipated bills and broadening the act to all types of managed care plans. NAIC wants to retain state flexibility to deal with local conditions, for example, provider access standards should be very different in Wyoming than Los Angeles. Paul Ginsburg noted that passing any willing provider laws is an overreach and will offset the advantages that smaller networks, carefully chosen, can bring to the marketplace.
NAIC does not have regulatory jurisdiction over Medicare Advantage plans. CMS is considering making changes to MA access standards to deal with mid-year network changes beginning in 2015, for example by allowing enrollees to switch plans if their doctor leaves the network mid-year without cause. Senator Sherrod Brown and Rep. Rosa DeLauro have introduced legislation to prohibit MA plans from dropping physicians mid-year without cause.
Resources
Find out what provisions in the final marketing guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes in a webinar next Wednesday, July 23.
American Action Network Promotes Government Subsidies
The American Action Network (AAN), a 501(c)(4) conservative think tank, has published a report that purports to show that Medicare Advantage (MA) payments will be about 13% less in 2015 than they would have been had the Affordable Care Act not interfered. To get the attention of members of Congress, the report shows the reductions by Congressional district.
The AAN analysis doesn't mention sequestration, which probably accounts for 2% of this 13%. Sequestration of course, has nothing to do with the ACA. Nor do they mention MedPAC's repeated recommendations to Congress to reduce the benchmarks that determine MA payments, so that they equal Medicare's average fee for service (FFS) costs. For example, see MedPAC reports in the period just prior to the passage of the ACA: http://www.medpac.gov/chapters/Jun09_Ch07.pdf and http://www.medpac.gov/documents/Mar10_EntireReport.pdf.
Reducing Medicare Advantage payments to parity with Medicare FFS, as recommended by MedPAC, is the reason for the cuts that the ACA imposes. As usual in Washington, the word "cuts" in this context doesn't mean an absolute reduction, just less than what would have been spent under the old law.
The AAN report does not describe how either the projected 2015 payments or the pre-ACA 2015 payments-that-would-have-been were calculated, so there's no way to comment on the validity of the 13% figure beyond the above observations. By my calculations, the ACA reductions amount to about 9% less than what the average benchmark would have been, before sequestration. With sequestration, I come up with a reduction of 11% relative to the trended pre-ACA benchmark, compared with the AAN's 13%. That figure doesn't take into account any changes in risk adjustment or quality bonuses, which the AAN report claims to include. One would expect risk adjustment to be a net positive, even after the increase in the amount deducted by the coding intensity adjustment, as plans have gotten better at coding. And quality bonuses are also a net positive, even with the end of the Stars demo in 2015. So adding these to the 9% reduction in the published benchmark should produce a smaller reduction, relative to the pre-ACA benchmarks trended forward. So I am skeptical of the 13% figure published by the AAN, without more information regarding how they calculated the 2015 pre and post ACA figures.
However, it is worth noting a couple of consequences of the pre-ACA figures. One is that these additional payments would have been funded, in part, by an increase in all Part B premiums, including those paid by non-MA members. Avoiding this increase is tantamount to a tax cut for Medicare beneficiaries. Yet the conservative AAN, whom I would expect to applaud anything that has the effect of a tax cut, is criticizing this reduction.
The other consequence is that the remainder of the additional payments would have been drawn from public funds. These funds would come either from the Part A trust fund, or from general revenues. The balance in the trust fund is being drawn down each year, since Medicare payroll tax receipts are less than trust fund obligations. Since the money in the trust fund is invested in treasury bonds, the fund gets the cash it needs by cashing in those bonds. To redeem the bonds, the treasury has to issue more debt.
And, since general revenues are less than expenses, the portion paid from general revenues would actually be paid from additional borrowing as well. So, by reducing the amount that would otherwise have been paid to MA plans, the ACA is reducing the net federal debt. The net debt would be the amount of real debt after excluding money the government owes itself (like the trust fund).
Taken together, I would expect a conservative think tank to argue in favor of reducing MA payments, to reduce the Part B premium and to reduce the net federal debt. The AAN position seems like a triumph of politics over policy, where an ostensibly conservative organization is promoting public subsidization of MA because a Democratic Congress took the conservative approach and cut the subsidies.
This report will probably be useful in ginning up some high dudgeon among conservative-leaning seniors whose conservative principles are somewhat plastic when it comes to getting government subsidies. Maybe it will help get out the vote in a few districts, if the target population remembers it come November. Otherwise, I'm not sure what the point of this is.
Resources
Find out what provisions in the final marketing guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes in a webinar next Wednesday, July 23.
It's silly season again, so let's sue the President
The Speaker of the United States House of Representatives, one of the most senior elected officials in the US government, has announced that the House is going to sue the President because he has delayed enforcement of a provision of the 2010 health care law; a provision that a majority of that same House has vociferously criticized as unfair to business and a "job killer." In 2014 Washington, this makes perfect sense.
President Obama has delayed enforcement of the mandate that requires most employers to offer health insurance to their employees, starting in 2014. The President has delayed enforcement until 2015 or 2016 (depending on the size of the employer). The Administration argues that the Internal Revenue Code allows for transitional relief in the implementation of new legislation (the mandate's fee would be collected by the IRS, and so this ostensibly falls under the authority of the Internal Revenue Code). The Speaker says not so much.
So here's the scenario. The employer mandate is set to take full effect by 2016, less than 18 months from now. The House's lawsuit will make its way through the federal court system, with appeals ultimately taking it to the Supreme Court. By then, the mandate will be in full effect, and the Supremes could decide that the case is moot and reject it. Or, even if they decide in favor of the House, there will be no immediate impact since the mandate will already be in effect.
So what's the point? My guess is that the Speaker is hoping to suck some energy from his back benchers who want to impeach the President. Impeachment would fill the newscasts with images of issue conservatives and libertarians competing to load up the articles of impeachment with every criticism of Mr. Obama that has been rendered from the Right since 2009. Having this public spectacle just as voters are going to the polls this November must be one of the Speaker's worst nightmares. So sue the guy. Anyway, it's one of the few things that the GOP majority in the House can accomplish without help from Democrats or concurrence of the Senate.
There is risk for the Speaker in this. He only has a 35 vote majority at present (with 2 vacancies). If half of them vote against the lawsuit, on the grounds it's too wimpy and only impeachment will do, he's going to suffer a major political embarrassment. That's a margin of 18 votes, and 15 members have already voiced support for impeachment.
Even with the Nats in first place in their division, Congress is still the best spectator sport in DC. So pull up your lawn chair, grab a brew, and try to forget for a while that these are the people to whom we have entrusted the governance of our homeland.
Resources
Find out what provisions in the final marketing guidelines will have the greatest impact on your organization and how plan sponsors can prepare for the upcoming changes in a webinar next Wednesday, July 23. Register now >>
High Performance Health Plan Networks
A Milliman report commissioned by AHIP finds that narrower, high value provider networks can help reduce premiums from 5 to 20 percent when compared to broad network plans. A high value network is one selected on the basis of not only fee schedules, but also overall efficiency and quality metrics. Health plans can make these judgments in ways individual consumers cannot.
It is ironic that ObamaCare has created the structure and incentives for a truly competitive health care market, something long sought by Republicans as an alternative to government regulation of prices and medical practice.
The Exchanges offer consumers an opportunity to compare plans on cost and (when the data are accurate and up to date) on networks. Now that insurance companies cannot manage costs by waiting periods and exclusions, they have more incentive to high performance networks as their main competitive advantage. This leaves excluded providers with the option to improve, and qualify for high performance networks, or lose business. Maybe, just maybe, we'll see some improvement in the mismatch between what we pay for health care and what we get.
Resources
On Wednesday, July 23, join GHG to discuss the 2015 Medicare Advantage Marketing guidelines and how to plan for the upcoming changes. Register now >>
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott, Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
Hobby Lobby and Corporate Person-hood
The Supreme Court ruled on Monday, in the Hobby Lobby case, that requiring family-owned corporations to pay for insurance coverage for contraception under the ACA violated a federal law protecting religious freedom. This essentially means that some corporations now have religious rights. Although the majority tried to make this ruling as narrow as possible, it does open the door to future suits claiming exemption from other laws that are deemed by the owners of closely held corporations to infringe on the free exercise of their religion. An initial concern for insurance issuers is whether religious exceptions will proliferate, requiring an increase in benefit design variation. More benefit options means increased operating costs, and more difficult premium calculations.
Beyond this, the logic that a family-owned corporation is indistinguishable from its owners when it comes to religious rights may poke holes in the corporate veil in other ways. Corporations are created by state governments to protect their owners from personal liability. They are fictitious persons, endowed by their creator (the state) with certain specific rights and privileges. The tendency of this Supreme Court to see corporations as extensions of their owners, or of their donors in the Citizens United case, seems to violate this notion of limited rights as well as limited liability, all as determined by state incorporation law. If corporations enjoy freedom of speech and protecting under the federal Religious Freedom Restoration Act, are they also people for purposes of voting and holding public office? Isn't this train of thought leading into some weird and nonsensical places?
Resources
On Wednesday, July 23, join GHG to discuss the 2015 Medicare Advantage Marketing guidelines and how to plan for the upcoming changes. Register now >>
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott, Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
Part D and Hospice Rules Mucking Up Beneficiaries' Last Days
Last week the Centers for Medicare and Medicaid Services (CMS) met with 30 hospice & healthcare organizations about suspending a new rule intended to avoid duplicate payments for hospice medications. This is a very big deal and the new rule is mucking up many beneficiaries' last days. The National Hospice and Palliative Care Organization described the meeting as "an important first step at righting the wrongs being faced by dying Medicare patients."
Previously, hospice (under Medicare Part A) paid only for the drugs that patients needed for palliation and management of the terminal illness and related conditions, and Medicare Part D covered drugs for hospice patients' unrelated conditions. Under the new rule, CMS requires a beneficiary level prior authorization process for all hospice and Part D providers to determine responsibility of drug coverage, and hospice must cover medications related only to the hospice diagnosis.
CMS' expectations are unrealistic. Putting prior authorizations on everything adversely impacts beneficiary access to drug therapies and causes agonizing delays at the point of service. Consider this: first, it has to be determined if the drug in question is covered under Part A or D. If Part A, then you have to figure out if it's even covered under the hospice formulary and beneficiary refuses to try formulary equivalent first or drug is not reasonable or necessary per the hospice provider if not and the beneficiary wants the drug, it will be self-pay. If it's neither Part A nor D, then the beneficiary must self-pay. If covered under Part D and the prescriber is not hospice affiliated, the sponsor has to jump through hoops, including what to do if the prescriber is unable or unwilling to coordinate with the hospice provider.Then, if the drug has prior authorization on Part D it would have to satisfy those requirements. Plans have to be able to accept and save proactive determinations from hospice. It's an administrative nightmare. For 2014 only, CMS is universally allowing Plans to treat hospice coverage determinations as exceptions. That in and of itself shows that they are not sure how best to handle this mess.
With end-stage patients (the only kind you get in hospice), it is often difficult to discern which drugs are used for symptom management and what drugs are really for chronic conditions that if in hospice should not be treated, such as diabetes or hypertension meds. The hospice industry has reported widespread confusion and disputes that have made it harder for patients to get their drugs.
Seventy senators signed onto a letter circulated by Sens. Jay Rockefeller (D-WV) and Pat Roberts (R-KS), calling for CMS to suspend the rule. "We ask that CMS immediately suspend the Guidance and begin a process to develop an alternative approach which will ensure both that the right individual or entity pays for the hospice patient's medications and that the patient get the medication that he or she requires without interruption," they write.
We agree and hope CMS goes back to the drawing board on this rule. Calm and freedom from pain should define a beneficiary's last days, not administrative hoops and preauthorizations.
Resources
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott , Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult — to say nothing of actually managing to them. Contact us today to learn how we can help >>
Further Evidence That PBMs are Failing on Government Programs
At CMS' oversight and enforcement conference last week Jonathan Blanar, the agency's Deputy Director of Compliance Enforcement, presented the following slide. In this slide, you will see actions CMS has imposed against Medicare health plans in the last two years, and for what reasons. It's further evidence that pharmacy benefit managers (PBMs) are failing Medicare beneficiaries and the plans enrolling them.
PBMs have a big hand in the first category, coverage determinations, though they're not entirely culpable. What's maddening about that tally is the fact that appeals and grievances rules in Medicare haven't changed much in the 17 years since they were first issued, and PBMs and plans are still screwing it up. To CMS, appeals are the most important consumer protection at the point of service, so they dish those findings out regularly.
It's the second category, formulary administration, that's most disturbing. The numbers speak for themselves. But Blanar added this color, the most frequent findings, which included the following and are a damning indictment of PBMs as the Keystone Kops of government programs:
- Unapproved quantity limits
- Unapproved utilization management practices
- Failure to properly administer the CMS transition policy
- Improperly effectuating a prior authorization or exception request
- Failure to provide a transition supply of a non-formulary medication
Resources
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott , Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult — to say nothing of actually managing to them. Contact us today to learn how we can help >>
4 Points to Ponder from CMS' Oversight and Enforcement Conference
On June 26, CMS hosted their MA-PD Oversight and Enforcement conference. Not one of the topics was less relevant to the audience than another — they prepared ahead of time to present current, critical information related to their data-driven approach to oversight, best practices and common findings, preparing for an audit and enforcement actions. I was glad to see CMS invite plan sponsor staff to share their experiences. They included Todd Meek of SilverScript Insurance Company; Margaret Drakeley of Kelsey Care Advantage; Shannon Trembley of Martin's Point Health Care; Marcella Jordan of Kaiser Permanente, and Jenny O'Brien of UnitedHealthCare. Their first-hand accounts are worth your full attention.
The webinars and materials are all available to the public and I encourage you to watch them and encourage your staff to watch. Of all of the things said, the following should be enough to kick your compliance efforts into high gear:
- Jerry Mulcahy shared that the improvement is not what CMS had hoped, and that organizations are still not testing effectively. That should warrant a hard look in the mirror to ensure your "trust but verify" methods are working. Put another set of eyes on your validation. Leverage staff with auditor experience. If the improvement is not what CMS has expected, especially after having shared their protocol and numerous best practice/common findings memos over the past few years, then consider this a red flag.
- Statutes and regulations expect nothing but 100% timeliness. Too often we are asked for the acceptable threshold for compliance of a measure. Unless otherwise published, the expectation is 100%. Kady Flannery stressed this while explaining the 2014 method for checking CDAG and ODAG universe timeliness.
- LCDR Lorelei Piantedosi communicated an additional best practice that didn't make the slides, and that's a 100% rejected Part D claims look-back. Seeing as how all five of the Formulary Administration common findings have been common findings published in the past, it is a wonder when an organization does not dedicate resources to this activity. (She also communicated a best practice near and dear to our hearts, but I'll leave that for another blogger.)
- "Be transparent!" Todd Meeks says he would often times get asked about how transparent to be. Based on the fact that he shared how collaborative CMS was in aiding his organization, at times providing easier, cleaner ways to correct something, then the answer should be simple.
Think about it this way: if you draw the short straw this year for a CMS Program Audit (and I use ‘short straw' in the most lovingly way possible, CMS), then everything you add to your Self-Assessment Questionnaire should already be known by your Account Manager. We can be broken-record about this, but a Medicare Compliance Officer should know what's going on well before CMS does — it's arguably just as important to your organization that your Account Manager knows about it before Central Office.
Resources
From a simple gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Learn more >>
Taking the time needed to regularly assess the risk exposure of operations can be both disruptive and costly — if not impossible. Let us augment your efforts by conducting your required annual risk assessment. Visit our website to learn more >>
PBMs are the Health Plan Industry's Achilles Heel
In this Golden Age of government programs, the health plan industry has never had more exposure to the generally poor performance of pharmacy benefit managers (PBMs). Performance metrics in Medicare, Medicaid and ObamaCare are directly tied to PBM execution, and the recent track record of these companies means they are the Achille's Heel of insurers.
PBMs historically made most of their money on commercial insurance and have lagged on government programs, a trend exacerbated by a brain-drain of talent following a wave of PBM consolidation. The danger has never been greater for health plans, and their choice of vendor has never been more important.
First, Medicare's Star Ratings system has several critical performance measures directly tied to PBM performance, notably those related to drug plan service, formulary administration, patient adherence to drug therapies for chronic diseases like hypertension, and readmission prevention (many hospital readmits are due to drug over/underdose post-discharge). The numbers don't lie: Medicare Part D Star ratings and formulary administration were the two leading reasons for CMS-mandated corrective action plans dropped on insurers in the last year. Of plans scoring less than 2 Stars by performance domain, Drug Plan Customer Service came up worst in CMS's last review cycle -- followed by Member Experience with the Drug Plan, and Member Complaints, Problems Getting Care, and Improvement in the Drug Plan's Performance. It's a dismal record and getting worse.
Then consider that the two critically-important health plan quality improvement measures -- C33 and D07 -- are now weighted 5, a first for CMS and a huge development. The concern here is that PBMs are often terrible at data management, and under these measures a plan can be reduced to 1 Star where mishandled data resulted in bias or error, or where appeals and grievances handling is in question. With that 5-weighting, this has come as a rating killer for several plans and a major vulnerability for the rest, as most don't keep good logs of non-compliance issues or audit results.
PBMs are generally good at managing the drug benefits of commercial members, but the complexity of seniors and the low-income and the previously uninsured continues to confound these companies. Gorman Health Group ran 15 solicitations for government program PBM services for its clients in the last 12 months, and we wouldn't wrap fish in one of the responses we received. All varying degrees of suck.
In this last round of contract and service area expansions for 2015 Medicare Advantage and Part D, in our 18 years we have never seen more rejections due to PBM failings like pharmacy and home infusion network adequacy -- literally dozens this cycle, due both to PBM sloppiness and a new resolve at CMS to directly address it.
As PBMs continue to consolidate, plans need to protect themselves from weak execution by bringing renewed focus on PBM-directed Star ratings measures and most importantly, inspecting what they expect. The delegation oversight plan for this vendor is the most important document in compliance right now. Payers are now literally at the whim of the government programs sophistication of their PBM account manager, and that is not a comfortable place to be with literally billions of dollars and millions of seniors and the vulnerable hanging in the balance.
PBMs need to awaken to the new reality of the primacy of government programs today, and make a serious commitment to catching up.
Resources
If you've just submitted your HEDIS data, now is the time to analyze that data for gaps and identify interventions for your health plans, providers and members. On July 17 join John Gorman, Executive Chairman at GHG, Jane Scott , Senior Vice President of Clinical Services and Anita McCreavy, Senior Consultant, for a webinar on HEDIS reporting, the new measures and what's next. Register now >>
The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult -- to say nothing of actually managing to them. Contact us today to learn how we can help >>