At the Intersection of Exhausted and Impossible
Today, most employees and employers in all organizations struggle to do more with less…not just health plans.
Information flow and the necessity to respond quickly to change have totally transformed existing jobs in the last ten years. There is little opportunity to spend days considering the implications of data and information received. The necessity of implementing new programs to meet the Centers for Medicare & Medicaid Services (CMS) requirements strains the resources of health plan organizations and departments even further and may contribute to lapses in compliance and, therefore, regulatory risk. A daily to-do list for the Part D team routinely includes:
- Rejected claims review
- Formulary maintenance
- Adjudication issues resolution
- Intra-departmental calls to assist with resolution of grievances and Complaints Tracking Module cases (CTMs)
- Transition fill and notice monitoring
- B versus D medication resolutions
- Intra-departmental and other organization meetings
- Compliance communications and directives
- Personnel issue resolution
- Clinical pharmacy activities
- Part D Star Ratings monitoring and report reviews
- Case management activities
- CMS-required reporting
- Enrollment and eligibility issue resolution
- Prescription drug event (PDE) reconciliation
- AND the never diminishing email inbox
The list goes on and on. A thorough review of all department functions either utilizing internal human resource assistance or external experts can provide recommendations for the right size staffing, resource delineation, and recommendations for new products or tools for the Pharmacy/Part D Department. The review should include the following questions: What is the right mix of pharmacists, pharmacy technicians, and business analysts? How many hours or full-time employee (FTE) segments should be dedicated to the various tasks? Will additional training and refining of work processes help to alleviate some of the burden? Is there a software solution that will streamline some of the manual processes currently in place?
With the insufficient amount of true subject matter experts in the industry, we know recruiting is difficult and time consuming. If interim staffing is what you need, Gorman Health Group (GHG) can enhance your team with our own, providing knowledgeable, effective assistance and an eye for detail from processors and analysts with decades of experience. Our pharmacy consultants come fully trained and prepared to provide short-term or long-term support and create a business case for additional resources, training, and tools. We offer strategic and operational leadership experts when, and where you need it.
Interested in more information? Contact us today.
Resources
Our Part D services are designed with your staff in mind, ensuring that with a mix of counsel and DIY tools your staff will have access to actionable information — faster. Don't chase data points. Spend your time on the things that will impact your audit results when a CMS audit comes — and it always does. Visit our website to learn more >>
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CMS 2015 Oversight and Enforcement Conference - Compliance Edition
The pessimist complains about the wind. The optimist expects it to change. The realist adjusts the sail. -William A. Ward
Those who had the opportunity to view or attend the Centers for Medicare & Medicaid Services (CMS) annual Audit & Enforcement Conference & Webcast better start thinking about which group of folks you will be a part of: pessimists, optimists, or realists. In order to maximize your success, you best classify yourself in the realist bucket — quick.
One thing that did not change over last year is CMS' overall assessment of improvement. Mr. Mulcahy confirmed CMS has still not seen the improvement they had hoped to see after years of issuing best practices and common conditions information to the industry. Go back to last year's video archives, and you will find he said the same thing last year. According to CMS, sponsors are still surprised by audit activities and findings and unaware of their level of compliance.
Many best practices to combat this type of situation in your organization were discussed during the conference. For example, one organization pulls universes using CMS' data layouts on a monthly basis. Another organization stressed the need to not only focus on the short term in corrective action plans (CAPs) but also consider the long-term solutions required for long-term success—that includes a deep-dive into processes and continuous training. Once-a-year specialized training will no longer cut it, especially in the areas of Coverage Determinations, Appeals, and Grievances (CDAG) and Organization Determinations, Appeals, and Grievances (ODAG) where CMS notes sponsors, at times, seem unaware of their compliance.
Some things that are changing are the audit protocol instructions and data layouts currently on the Program Audits site. CMS confirmed there are a number of issues requiring clarification or correction in the protocol — we anticipated this. They hope to release updated protocols by the end of this month, but if a plan is subject to audit in the meantime, they will receive the updates. In terms of audit support, CMS' Jennifer Smith confirmed there is still a plan for CMS to release a chapter on audit activities. Once released, this should be a great help to plan sponsors. CMS also provided detail pertaining to the Medication Therapy Management (MTM) and Provider Network Adequacy audit pilots, scheduled to be released in late summer or early fall.
We are continuously making adjustments to processes to ensure alignment with CMS activity, and we hope our clients and all plan sponsors are doing the same. The Medicare Parts C and D Oversight and Enforcement Group (MOEG) confirmed that, if any sponsor receives a civil money penalty (CMP) or sanction, they will be expected to engage an independent auditor to validate corrections. CMS confirmed 93% of plans audited in 2013 received some sort of CMP, and at the recent GHG Forum in April, I shared the majority of enforcement actions since 2014 have indeed been related to CDAG and ODAG. Talk about a risk! It really is time to look inward, be a realist, captain your ship, and adjust those sails.
If you have questions pertaining to the audit protocol, CMS advises you to forward any questions to part_c_part_d_audit@cms.hhs.gov. If you have questions regarding the conference, or have questions on how we can assist, please feel free to contact me directly at rpennypacker@ghgadvisors.com.
Resources:
Register now for a new webinar on improving quality ratings and member retention efforts, as well as prominent compliance and service issues plaguing the industry on Friday, June 26 from 1-2 pm ET.
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Implementing a new PBM? What you need to know.
Now that the smoke has cleared and the ink is dry on the formulary/transition and bid submissions, it's okay for plans to breathe for a couple of weeks. Then—if you're implementing a new Pharmacy Benefit Manager (PBM)—it's time to roll up your sleeves and get started with conceptualizing and developing a road map for the next six months. It's important to start early and work steadily to make decisions, create processes, and complete training. During this time, you must continue to partner with your current PBM to process claims, make coverage determinations, and oversee and monitor all the delegated functions according to the plan you have in place. With the new PBM, you have the opportunity to tweak some processes that perhaps weren't working exactly as you had envisioned originally.
The new PBM should have a detailed work plan they utilize for implementations, and their team can be invaluable in assisting with timing needed for decisions and keeping the project on track. Don't cancel meetings or get behind on decisions that need to be made. You will need every bit of the time in November and December to get testing done on the new formulary and to reach out to members who will be disrupted by formulary changes. And, if you're implementing a new PBM because of dissatisfaction with your current PBM, begin as you mean to go on. In other words, think about the nature of the relationship that best serves your organization and staff and start developing it from the beginning. It IS just business, but you will be working with the PBM team members on a daily basis for the next few years. So start off on the right foot and build the foundation of a relationship that will benefit your members and your organization.
Resources
The GHG Pharmacy team can assist you with your PBM implementation by providing subject matter expertise on all the decisions that need to be made and the processes that need to be developed. And we have a state-of-the-art benefit administration testing plan to help you before go-live.
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CMS 2015 Spring Conference
Some important points came out of the Centers for Medicare & Medicaid Services' (CMS') Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast; the presentations and videos of the event can be found here in CMS' Event Archives. If you did not have a chance to attend or watch it live, please watch the videos for important changes pertaining to many aspects of the MA-PD program. Speakers addressed Part C and Part D call letter updates, policy and technical changes, Quality Improvement Project (QIP) and Chronic Care Improvement Program (CCIP) lessons learned and best practices, the new network management module, enrollment updates, and fraud, waste, and abuse (FWA).
From the Compliance perspective, we heard the following loud and clear:
- Enrollment in MA-PD is growing with the aging of baby boomers. CMS is taking a proactive stance to improve the program by stressing the need to work together with plans to provide care more efficiently and provide quality.
- Finalized program changes allow CMS to require MA organizations or Part D plan sponsors to hire an independent auditor to validate correction of CMS audit findings. The good news is − some of you are doing this today. Having another set of eyes on your correction efforts provides you with a level of assurance you may not be able to obtain by having internal staff performing validation. Ever hear that phrase, "There are three sides to every story: yours, mine, and the truth?" Getting an independent perspective is so important. While you might not agree with a reviewer's findings, the point is that it will hopefully bring you closer to the truth than validating yourself.
- CMS clarifies when it is appropriate for an MA plan to invoke an extension on organization determination and appeal requests. Based on what we see, most plan sponsors are invoking extension requests in rare circumstances and strive to meet the regulatory timeframes established without extension. Therefore, plan sponsors should be prepared to update procedures to ensure extensions are only taken when appropriate.
- Network adequacy — Not only is CMS requiring that provider directories be updated real time, they are adding network adequacy to program audit protocols (coming late summer or early fall, according to CMS). CMS is also implementing a way for plans to check their network adequacy by submitting their Health Service Delivery (HSD) tables in the Health Plan Management System (HPMS). Previously, this step was only available within HPMS when submitting an application for a new plan or a service area expansion (SAE). Plans could contract with a vendor or obtain software to check their own network adequacy. We anticipate that CMS' network adequacy protocol will require a plan to provide real-time data pertaining to whether or not their contracted providers have open panels. I'm aware of one 5-Star plan that has been doing ongoing network adequacy reviews for a while. Those plans that are used to pulling HSDs only at the time of application or (possibly) bid submission should plan now for the additional steps CMS may require of plans to tell the true story of adequacy. Keep your eyes on this blog for more information from my esteemed colleague, Ellie Martin, on network adequacy.
CMS' upcoming MA-PD Audit & Enforcement Conference & Webcast is taking place on June 16. Prioritize this event in your schedule, and attend either in person or via webinar.
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Gorman Health Group's Complaints Tracking Module (CTM), grievances, and appeals processes, provides a new way to ensure your cases come to a timely and compliant resolution. Created with CMS in mind, as it captures key information related to intake, processing, categorization, determinations and higher appeals or re-openings to process cases according to CMS' complex and detailed requirements. Contact us >>
You're Doing it Wrong in Care Management
An important paper recently released in the American Journal of Managed Care shattered the notion that care management can save money on high utilizers. The article reviewed recent studies of the effectiveness of health plan care management programs and found that, while many studies show significant savings, more rigorous studies concluded that savings were "limited or nonexistent." Mind. Blown.
We're all familiar with the "80/20 rule" of the commercial health insurance market: 20% of members account for 80% of expenditures. In government programs, Medicaid, Medicare, and now ObamaCare, it's the "5/60" rule: 5% of members account for 60% of spending. The AJMC article showed that across all payers in 2012, it's "5/50". 95% of the population accounted for just half of health spending, while the other half of spending was towards care for 5% of the population. The 5% of people needing to spend the most on health care spend an average of around $43,000 annually; people in the top 1% have average spending of almost $98,000. At the other end of the spectrum, the 50% of the population with the lowest spending accounted for less than 3% of all total health spending; the average spending for this group was $234.
The article then explored multiple studies on effectiveness of care management, concluding it's mostly pointless. It gave several reasons for why this might occur:
- Many high-utilizers only stay in this category for a short period of time. Conditions causing them to need intensive care may resolve quickly, reducing costs, but a study lacking a control group may inappropriately attribute this savings to the care management program.
- High utilizers suffer from a wide range of conditions and require a wide range of interventions, making it difficult for care management programs to tailor teams meeting each patient's needs.
- Providers working with a care management team may better identify conditions that were previously going untreated, leading to better outcomes, but also higher costs for additional services and therapies.
The author concluded that "for care management programs focusing on high-utilizing patients, it is crucial to select patients with long-term utilization patterns that are driven by the factors most conducive to change. Given the very limited direct evidence suggesting how to accomplish this, care management programs are best served by being kept small and focused on the highest-need patients, who may not necessarily be current high utilizers."
This finding calls for a rethinking across our industry about care management. For one thing, most health plans in our 19 years' experience are still doing 1990s-style managed care: preauthorizations, referrals, concurrent review -- what we refer to as "make work" medical management. It's look busy, high head-count work that does little to improve quality or reduce unnecessary spending.
Many GHG clients have been working with us to modernize this approach into data-driven care coordination "pods" providing a holistic model of care focused on high utilizers and those about to become them. This study means we need to recommit to data analytics identifying and directing the work of care managers toward those beneficiaries with long-term needs that can be impacted. This means greater emphasis on preventable episodes of care, and on end-of-life care preferences, advance directives and care plans. If you take the top 5% of the membership that is incurring the most cost and provide complex care management, including a higher level of home care, hospital diversion, medication therapy management, nutrition counseling, and wound care, plans and their provider organizations will see a reduction in avoidable medical expenses.
Savings can also be realized if that membership is appropriately placed in the right plan with the right network. Care Management might not be the answer but applicable coverage is a strategy. That's where plan and benefit design is so important. Innovative plans are working with specialists to design products that reflect risk and chronic conditions of their members. Our work with a prominent dialysis and kidney care provider is a perfect example: design a benefit and align a network that is tailored to patients with varying levels of chronic kidney disease, preventing disease progression and/or avoidable costs traditionally seen if CKD is not managed along the disease state continuum. Progressive conditions like CKD, Alzheimer's, and many cancers lend themselves well to "smart management" that spans clinical staff and benefit design alike.
The one thing you know about government beneficiaries is that if they're not sick today, they're gonna be. The game has always been finding the ones who need extraordinary care before they need it, and ensuring they get it in the right place, at the right time, from the right provider. That hasn't changed. This study underscores the point. "Make work" care management must give way to "make it work".
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Big Data is costly, distracting, overwhelming and paralyzing if not maximized. System and process interoperability and integration are keys to program alignment, oversight and evaluation . Systems and data should not just integrate; they need to align in order to yield superior, reportable outcomes. Visit our website to learn how GHG can help >>
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19 Lessons from 19 Years
Nineteen years ago this week, I left the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS) and the Office of Managed Care, to launch what would become Gorman Health Group. Time has flown, the company has grown, and my backside sewn with hard lessons about our industry and government health programs. Here are 19 lessons I've learned in those 19 years.
- What Medicare Advantage and Part D do, Medicaid and the commercial market, including the ObamaCare Exchanges, follow 3-5 years later.
- Every CMS staffer I've ever known is well-intentioned, many are downright brilliant, and all want to be good business partners to health plans. Their shortcoming is lack of business experience and how stuff works in the real world. There is a huge difference between policy/guidance and operations. That's where we come in.
- If government health programs were an easy business, we'd be out of business.
- Inspect what you expect. Or, as Reagan said, "Trust but verify."
- Star Ratings, like risk adjustment before it, is the biggest and most consistent experiment in performance-based payment on the planet, a total game-changer and the new fulcrum of competition. You don't excel at Stars by working on them off the side of your desk.
- Fish where the fishes is.
- Pick your vendors and partners like you pick your fruit.
- Capitation with performance-based payment is the only real hope for long-term viability of entitlement programs.
- Being a doctor is the worst job ever. Right after community hospital CEO and President of the United States.
- High-performing health plans are good at everything, especially those functions that are member- and/or provider-facing. It's about culture and execution.
- Health plans' days are numbered if they can't consistently provide value to CMS, their customer, and to providers, their partners. That value is about two things: making data actionable and moving money to contributors when quality and results improve.
- It's easier to increase revenue than it is to cut costs.
- Pharmacy benefit managers are a health plan's most important partner. They are also the ultimate B2B companies and most are struggling in the transition to B2C and true government accountability for results.
- Big data and high-tech is all the rage -- and all noise, unless it's actionable. What works is low-tech: clogs on the street; a house call; a medication consult.
- Doctors of the future are in multispecialty practice and leaders of a team of nurses, aides, social workers, and pharmacists. They are quarterbacks, not gods. They diagnose, and everybody else treats.
- So much of the future is about retail pharmacy. In short time, they will make more providing services than filling bottles.
- Ninety percent of the evil and waste in the system occurs at the tip of a doctor's pen.
- We are all going to retire thanks to government programs. Demographics is destiny.
- Five percent of members account for 60 percent of your spend. Put the love and focus on them, and you can pretty much leave everyone else alone.
It's been an incredible ride these last two decades, and especially the last five as health reform blossoms. We look forward to continuing the journey, older, wiser, and bigger. Stay tuned.
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Gorman Health Group Client Forum Takeaways: Government Programs are Booming, Bar is Rising
We just wrapped our best-ever Gorman Health Group 2015 Client Forum at National Harbor with over 200 of our closest clients and partners. There was both great and tough news, so here's a few takeaways, including a couple stunners:
- For the first time, a prominent Wall Street analyst said he could see a path to 100% Medicare Advantage penetration. Barclay's eminent health care observer, Josh Raskin, stunned our audience with projections of over 29 million Medicare Advantage enrollees by 2023, a penetration rate of over 42%, with the potential to go all the way with Ryan Plan-like legislation now feasible this decade.
- 47 states now hold Section 1915(c) home and community-based services waivers for Medicaid, which will unleash a new flood of dual eligibles into health plans. Special Needs Plans (SNPs) for duals are now on a path to permanent reauthorization, and over 30 states now use D-SNPs to enroll over 1.6 million beneficiaries. That number will more than double in the next 2 years.
- While year 2 of open enrollment for ObamaCare was dramatically improved from its messy launch, problems persist, especially with membership reconciliation and issues related to the interim process to auto-enroll most members staying in their plans. Cleanup of membership discrepancies will likely take another year or even longer.
- Risk Adjustment Data Validation (RADV) audits will become the new normal in Medicare Advantage. 2015 will be the first time we see plans prosecuted under the False Claims Act and hundreds of millions clawed back by the Centers for Medicare and Medicaid Services for unsubstantiated codes submitted for higher payments.
- Maximizing data, strong provider partnerships, documentation and ICD-10 preparedness are keys to audit proofing your Risk Adjustment program.
- The Star Ratings system of performance-based payment is the new cornerstone of competition among health plans. Stars has expanded into more than a dozen state Medicaid programs, and to ObamaCare's issuers as well, and the bar is rising. Technical changes to several measures mandate much higher performance to stay ahead of the curve and avoid falling below 4 Stars, where bonus payments and bid rebates vanish. 2015 will be the first year where plans below 3 Stars are terminated.
- Medicare Advantage plans won several lobbying victories in this year's "Call Letter", the rate and policy announcement for 2016, including an average 1.25% benchmark increase from a cut in the February draft. This signals a new era of influence muscle for the industry, where CMS will increasingly fight out policy changes "below the waterline" in subregulatory guidance and enforcement, where politicians are less likely to intervene.
- Appeals and grievances and pharmacy benefit management vendor performance remain the #1, 2 and 3 regulatory infractions in Medicare Advantage, and integration of long-term care and supports and services the leading challenge facing Medicaid health plans.
- CMS is on pace for its most aggressive enforcement year ever, with over a dozen actions taken against plans this year already.
As we've said since the passage of the Affordable Care Act, we are now in the Golden Age of government-sponsored health programs, and the opportunities and challenges that come with this shift have never been greater. Our clients went home with a clear grasp of both, and we are thrilled so many joined us this year.
Resources:
Join John Gorman, GHG's Founder & Executive Chairman, as well as Bill MacBain, GHG's Senior Vice President of Strategy on April 14 as they provide a hard-hitting analysis of critical areas addressed and finalized in the document from 1-2pm ET. Register now >>
GHG's Senior Vice President, Healthcare Analytics & Risk Adjustment Solutions, Dan Weinrieb, recaps the Risk Adjustment rulings in the Final Call Letter and provides keys to success in an article on the GHG blog. Read more here >>
The Risk in DIY: CMS Mandated Material
"Do It Yourself", or DIY, has been the rave for years now. From social media sites like Pinterest to television networks like HGTV, Americans have become fond of this philosophy. Now, I am a big believer in being self-sufficient and must say that I have been sucked into marathon viewings of DIY shows often (Nicole Curtis of Rehab Addict is no joke!). And, while I have seen my share of success stories, more often than not, I see DIY projects result in complete frustration from those attempting to DIY and very costly mistakes.
A prime example of this within the MA industry is the DIY approach to creating CMS mandated material. Year after year, I see organizations attempt to produce upcoming plan year material in-house with the intention of saving budget dollars, but ending up with a costly mess due to lack of subject matter expertise and lack of adequate resources. When you think about the overall importance that is placed on CMS mandated material and the level at which these materials are scrutinized by CMS, it begs the question, "Is the risk in DIY really worth it?"
Picture this: your organization decides to use existing staff to prepare mandated material for the upcoming plan year. Initially, the approach seems feasible and the cost savings looks attractive. Although the process is very time intensive, your organization completes the undertaking, or so you think. It turns out that the amount of time it took to review materials before HPMS submission could not be supported by your Medicare Compliance Department due to lack of resources. That results in functional areas being made accountable for not only the development of respective mandated material, but also the compliance review. With business-as-usual responsibilities not changing, the Enrollment department, which was tasked with creating ANOC/EOCs did not factor in a review for accuracy of information and compliance. Although your organization met the CMS distribution deadline, it is discovered that many of ANOC/EOCs contain cost-sharing errors and do not follow the CMS model templates and allowances. This discovery impacts about half of your membership and must be reported to CMS. CMS initially requires your organization to create errata for these documents, but when it is identified that the errors are so significant and high in volume, CMS requires your organization to recreate the affected ANOC/EOCs in their entirety and slaps on a civil monetary penalty. With a clear understanding of what led to inaccuracies in the first place, your organization seeks outside help from subject matter experts to limit the risk of non-compliance errors. It is later identified that an original version of an ANOC/EOC is still being sent to members upon request for a particular plan benefit package because a process for document version control was non-existent. In the end, this is a DIY project gone horribly wrong. The intention to save money by DIY resulted in something exponentially more expensive between CMPs and the exorbitant cost to reproduce materials. Most important of all, your beneficiaries were impacted by these inaccuracies.
I know we would all like to think that DIY is always a contending option, which it is, when you have the necessary resources and expertise to do so. But just as I will never claim to be an expert in building houses just because I've performed some wall patchwork here and there, organizations need to face the reality of the risks in DIY. Take the time to seriously consider how well-equipped your organization is to handle the development of CMS mandated materials as the season rapidly approaches. Is it time to bring in the experts?
Resources
For questions regarding consulting services for CMS mandated materials, contact me directly at rpennypacker@ghgadvisors.com
The Gorman Health Group 2015 Forum is April-7-9! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for the Gorman Health Group 2015 Forum today!
Partners Needed
I calculated the total amount of civil monetary penalties (CMPs) levied by the Centers for Medicare & Medicaid Services (CMS) last year on Medicare Advantage and Part D plans, and it's a big number: $4,925,150. There were also five suspensions in 2014.
Now more than ever, plan sponsors need to assess their Pharmacy Benefit Manager (PBM) relationship to ensure that both parties are working in partnership to not only be successful as a business but to be CMS compliant. What is your PBM's priority? Is your account management team responsive? Is your issues log so long that you've given up even trying to get resolution on the old items? Are you utilizing all of their existing reporting to consistently oversee and monitor the delegated functions they perform on your behalf?
There is no perfect PBM just as there is no perfect health plan. In our experience, it is a much less onerous process to make your current PBM relationship work than to go through a Request for Proposal (RFP) and implementation project which sucks up about six months of plan resources. Finding a new PBM should be your course of action only if you have exhausted all efforts to work with your current PBM partner.
Assess this list of successful PBM partnership tenets:
- Detailed and specific PBM contract with clear definitions of the services to be provided.
- Service level agreements (SLAs) for delegated function compliance.
- Detailed and exhaustive oversight and monitoring plan for all delegated functions.
- Frequent and productive account management interactions.
- Transparent and full disclosure of all PBM-identified deficiencies which affect the plan sponsor.
- Quick resolution of identified issues or agreed-upon timelines for issue resolution.
- No CMS outlier communications due to PBM operational deficiencies.
Now is the time of year when health plans are planning for formulary submissions and working on their bids. Make sure you have the right PBM partner for a successful 2016. We can help! Contact us for more information.
Resources
The rapid changes to Part D regulations make the tracking and implementation of these CMS requirements exceptionally difficult — to say nothing of actually managing to them. Our Part D services are designed with your staff in mind, ensuring that with a mix of counsel and DIY tools your staff will have access to actionable information — faster. Contact us today to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Is the “NUNCMO" Nightmare Keeping You Up at Night?
The recent MAPD Help Desk Memo, dated 3/3/15, advises that on March 8, 2015, "The Centers for Medicare & Medicaid Services (CMS) will be performing a clean-up to process "73" transactions that contain NUNCMO (Number of Uncovered Months) value from the extraneous NUNCMO row that was removed in Phase 1 multi-phase NUNCMO data clean-up which occurred on March 23, 2014. The effective start date of this transaction will be the preceding Part D enrollment start date."
The memo goes on to say that Part D organizations should review the NUNCMO data for these beneficiaries for ALL time frames, even if the change is prior to 2012. Organizations should submit any changes that may be necessary if the data is inaccurate or incorrect!
Looks like this could be trouble…
If your organization has an automated processes in place to update "73" transactions in your system, and the information on the data file is incorrect, these files could end up being a "nightmare." Loading incorrect data in your systems can result in significant consequences, such as generation of bills, correspondence, and increased customer service call volume.
Best-case scenario?
Increased customer service call volume.
Worst-case scenario?
Complaint Tracking Module complaints (CTMs) or increased Independent Review Entity (IRE) reconsideration requests if late enrollment penalties are inaccurately retroactively imposed.
How should you respond to this data file once you receive it?
Gorman Health Group (GHG) has developed a roadmap solution to guide you through validating and processing this file.
Contact us today to get started!
Resources
When it comes to financial reconciliation and overall membership data management, you must protect against leakage. Need help staying ahead of the CMS reconciliation process? GHG will access your member premium revenue, accounts receivable and CMS revenue reconciliation. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is underway! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Room Rate expires on March 23. Register your team for The Gorman Health Group 2015 Forum today!