Medicare Secondary Payer — A Simple Process with a Big Impact
We've heard many organizations say, "We do MSP" or "MSP, it's easy, we've got it covered". MSP processing may not be rocket science but it's a regulated process with steps that need to be executed correctly. The MSP transactions that your organization submits directly affect the monthly payment to your Plan and impact your financial reports. Your organization needs to have a confidence level that is equipped with the proper tools to be efficient and compliant, and most importantly feel confident that the financials related to MSP are accurate.
If you‘re uncertain about your end to end process, then you may be missing something and that something could relate to millions of dollars.
Take a moment to review your current process with our MSP Quick Assessment Checklist:
- Tracking Tool: A comprehensive tracking tool is essential for a complete picture of your MSP population and should be:
- User friendly, efficient and compliant
- Provide inventory totals of open and closed cases
- Provide potential A/R of outstanding cases
- Show case responses (accepted and rejected)
- Types of outreach performed and number of attempts
- Dash board reports that provide up to the minute status of cases and financials
- Flexibility to create customized reports
- Audit Trail
- An easy way to be CMS compliant is to have an audit trail for each MSP case. Each step of the process, including outreach attempts, follow ups, responses and letters should be documented with a date and time stamp.
- Prioritize your MSP cases for efficiency
- Group your MSP cases by premium impact or carrier in order to increase efficiency and obtain the best results.
- Persistence
- One of the most difficult tasks in the MSP process is outreach. Many cases require multiple outreach attempts to carriers or employer groups to obtain validation. Ensure staff is provided proper training and sufficient time to perform outreach and the follow up that's necessary to resolve cases. Practice due diligence — do not submit cases for "development" as doing so could delay potential recovery for up to 100 days.
- Responses & Rejections
- Many times organizations fail to review ECRS responses or rejected records. Each rejection code should be reviewed and resubmitted if necessary. Always check your initial submission for keying errors. Don't miss out on money because you're failing in this area.
- Communication
- As a result of an enhancement to ECRS and Part D (4/2012) terminations or delete requests to an MSP occurrence will automatically be applied to a linked drug occurrence record. For example, if a CWF Assistance request is submitted to add a termination date (TD) to an MSP occurrence, the termination date will automatically be applied to the linked drug occurrence. There is no need to submit a separate Prescription Drug Assistance Request. Partner your Part C and Part D areas within your organization to streamline processes, share information and look for efficiencies.
GHG has tools and experienced consultants that can assess your MSP process and provide analytics on your current state process to look for gaps or processes that may be negatively impacting MSP. We can work to create Business Process Redesign plans for a more complete and compliant process.GHG can also provide MSP Analysts to work remotely or onsite for large scale reviews, backlogs, or current work support.
If you're currently tracking your MSP cases on Excel spreadsheets, then it may be time to set up a demo of GHG's Valencia— MSP Module. Valencia is the software solution we use when we work with organizations to recover revenue and clean up data.
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Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.
The Good, the Bad and the Ugly in Medicare Advantage
In the last two weeks there's been good, bad and ugly news for Medicare Advantage (MA) plans. On one hand, the program has never been stronger and quality metrics are surging in the right direction; on the other, the industry is sucking it up on following the rules of its biggest customer, the Centers for Medicare and Medicaid Services (CMS).
First, the good: CMS did its annual data dump on Medicare Advantage and Part D bids and showed the program continuing its robust growth, with higher-than-ever enrollment approaching 17 million, and plans holding premiums and benefits steady during the worst rate environment in decades. Then, CMS released the MA Star Ratings database for 2015, showing MA quality continues to improve. The enrollment-weighted Average Star Rating for the industry stands at 3.91 out of 5. 40% of MA contracts were awarded 4+ Stars for 2015, but 60% of enrollees are members of those plans, showing a 30% increase since 2012 and demonstrating the competitive advantage high-performing plans now enjoy. The 2015 ratings show stable or improved performance in almost 70% of the 46 Part C & D Star measures, 7 of which improved by more than one-half star from 2014 to 2015, and 13 of which earned average ratings above 4 stars in 2015. There was even an 85% decline in plans receiving the low-quality performance badge of shame.
But then the bad: it's clear plans have eaten low-hanging Star fruit and are starting to struggle on more complex and outcomes measures, such as managing chronic conditions, managing mental health to improve outcomes, or increasing physical activity and reducing fall risk. The longitudinal Health of Seniors survey scores are below 3 Stars, and 135 plans remain on the Quality Bonus Payment bubble at 3.5 stars in 2015, meaning almost half of MA plans are circling the financial toilet bowl. Not good.
And then the ugly: last week's blistering New York Times story on rampant noncompliance among MA plans. The Times combed through months of compliance action reports and found widespread failures by plans in administering the program, including some common and potentially life-threatening stumbles:
- In more than half of all audits, "beneficiaries and providers did not receive an adequate or accurate rationale for the denial" of coverage when insurers refused to provide or pay for care.
- When making decisions, insurers often failed to consider clinical information provided by doctors and failed to inform patients of their appeal rights.
- In 61% of audits, insurers "inappropriately rejected claims" for prescription drugs. Insurers enforced "unapproved quantity limits" and required patients to get permission before filling prescriptions when such "prior authorization" was not allowed.
- MA plans frequently missed deadlines for making decisions about coverage of medical care, drugs and devices requested by doctors and patients.
CMS officials expressed frustration that they were seeing the same deficiencies year after year. That these boneheaded infractions are often being repeated makes the news all the more depressing. It's important to remember if an MA plan with a Star Rating over 3.5 gets sanctioned by CMS for noncompliance, it automatically knocks its rating down to 2.5. That's a kiss of death for an otherwise quality company.
What the Stars and compliance data show us is that the plans are doing great on strategy, pricing their benefit designs, selling to Baby Boomers, and managing straightforward quality process measures. But looking closer, it also shows our industry has a serious execution problem. We are lagging on performance measures with multiple clinical moving parts, and embarrassing ourselves and endangering our companies and beneficiaries with "101-level" compliance errors.
With both Federal and state governments increasingly relying on MA plans to manage the most complex and expensive patients in the US health system, we can and must do better.
Resources
Listen as John Gorman provides several takeaways from our first review of the terabytes of CMS data and understand why he believes this data shows the triumph of government-sponsored programs. Access the podcast here >>
Gorman Health Group can evaluate your Star Ratings approach and identify tactics you can begin implementing immediately to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. Visit our website to learn more >>
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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.
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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 >>
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.
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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 >>
Another Flood of Good News for Medicare Advantage
Last week the Centers for Medicare and Medicaid Services (CMS) did its annual data dump for the 2015 Medicare Advantage (MA) and Prescription Drug Plan (PDP) bids. Even with MA plans sailing into the worst rate environment in over 15 years, the data offered another flood of good news for the industry.
Several takeaways from our first review of the terabytes of CMS data:
- 2015 will look a lot like 2014, with slightly fewer plan options. The average MA premium will rise $2.94/month, or $1.30/month on an enrollment-weighted basis, and 61% of MA enrollees will see no premium increase. Having said that, zero-premium options are down 18% in 2015, following a 14% decline this year as previously-free plans institute modest monthly fees to offset payment rate cuts in the Affordable Care Act (ACA). It speaks to how well the market is working as plans compete intensely for share.
- The number of MA plan bids were down 4.3%, but most of the reduction was attributable to non-renewing Private Fee-for-Service plans, and good riddance -- PFFS remains the worst policy fart in Medicare. PFFS products are down 31% next year following a 61% year-over-year decline in 2014. Network-based plans like HMOs and PPOs were only down 0.9%, showing tremendous commitment to this line of business across the country as MA membership surges past one-third of all Medicare enrollment.
- PDP bids were down around 7%, mostly attributable to consolidation among Pharmacy Benefit Management companies. Humana remains the cheapest PDP in 33 out of 34 regions. Aetna will get auto-assignment of low-income beneficiaries in 10 new regions, while WellCare lost auto-assigns in 10 regions.
- CMS implied MA membership in 2015 at 16.9 million, or growth of just 2.7%. That's very conservative -- we expect 5-8% growth in 2015, following 10% growth in 2014. CMS suggested that MA enrollment is up 42% over 2010 levels -- stunning growth that defies the funeral dirge played for the private Medicare option the year the ACA passed.
- Most of the major publicly-traded MA sponsors are keeping or expanding their service areas in 2015. Eminent analyst Josh Raskin of Barclay's points out that publicly-traded companies' enrollment growth in 2014 is up 9% year-to-date, while all others are at 8%.
- Humana continues to account for 25% of all MA/Special Needs Plan offerings nationally.
"Since the Affordable Care Act was enacted, enrollment in Medicare Advantage plans is now at an all-time high, and premiums have fallen," said CMS Administrator Marilyn Tavenner. "Seniors and people with disabilities are benefiting from a transparent and competitive marketplace for Medicare health and drug plans."
The good news didn't end there. MA quality continues to improve as the Star Ratings performance-based payment system continues to punch WAY above its weight. 40% of MA contracts were awarded 4+ Stars for 2015, but 60% of enrollees are members of those plans, showing a 30% increase since 2012 and demonstrating the competitive advantage high-performing plans now enjoy. Beneficiaries are now choosing higher-quality plan options in far greater numbers, and ALL of the roughly 200 plans we work with have made Stars their top priority for focus and investment. Stars has proven to be a game-changer in MA and a model all other government-sponsored programs from Medicaid to ObamaCare's marketplaces are beginning to follow. NCQA's 2015 health plan rankings show California-based Kaiser once again leading the pack among Medicare plans.
To me, the CMS data shows the triumph of government-sponsored, highly-regulated insurance markets. Medicare Advantage is one of the few examples of government getting it mostly right in partnering with private-sector companies to accomplish a tremendous public good, and continues to be a beacon of hope as ObamaCare enters what promises to be an even tougher second season.
For more updates, follow me on twitter @JohnGorman18
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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 >>
Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register today >>
Bombshells from MedPAC on Medicare Advantage Retention
The Medicare Payment Advisory Commission (MedPAC ), the nonpartisan blue-chip Congressional uber-nerds on our favorite entitlement program, met this week and the staff report presented a couple bombshells on retention rates in Medicare Advantage (MA).
In the aggregate, the commission noted that in 2012 the voluntary disenrollment rate from plans was slightly below 10%. The vast majority of individuals who disenrolled -- 80% -- switched to another MA plan, with the remaining 20% going back to traditional Medicare. Bombshell #1: we're seeing an overall MA retention rate of roughly 98%, and speaks to the tremendous popularity of the program vs. "old school" coverage.
The commission also noted:
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When beneficiaries changed plans, a large majority picked another plan with a lower premium.
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Beneficiaries who elected to switch back to traditional Medicare from MA had higher average cost per beneficiary vs. those who stayed in MA. Does this indicate that sicker beneficiaries feel they'll get less hassles and/or better care in unmanaged fee-for-service Medicare? I doubt it. More likely: once back in unmanaged Medicare they go on a wild utilization binge. Why? Because...
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Older MA enrollees are less likely to disenroll than younger ones. This is puzzling, given the finding above and the direct correlation between income, age and health status in the elderly. Older beneficiaries are, on average, poorer and sicker than younger ones.
On a plan-specific basis, Star ratings also correlate positively with member retention. Bombshell #2: MA plans with 2 or less Stars experienced a 17% disenrollment rate, while plans with 4 Stars or higher had a disenrollment rate of 4.9%. That's an incredible statistic, showing the rapid effectiveness of Stars impacting the member experience at the plan level in just a couple years. Stars has truly become a game-changing indicator of quality across health plan functions.
All of this speaks to the fundamental triumph of Medicare Advantage: for those who know, it's the far superior option for senior care. And once they're in, they don't leave.
Resources
Join GHG for an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy. Register now >>
To succeed in Medicare Advantage, plans must achieve higher quality and Star Ratings, surmount CMS and medical loss ratio (MLR) requirements, and develop member onboarding and retention capabilities, all while operating in a highly competitive market. Learn how GHG can help ensure your MA plan is positioned to make the most of the program's opportunity.
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
CMS's Star Ratings Firing Squad Gets Squirt Guns
Last week, in a surprise move, the Centers for Medicare and Medicaid Services (CMS) reversed its threat to terminate all Medicare Advantage and Part D health plans with 3 or fewer Stars for more than 3 consecutive years. Roughly a dozen health plans were lined up in front of the firing squad as an example to the industry for months -- and then CMS issued squirt guns to the executioners.
It's a one-year stay of execution, with the one year of course being an election year. Importantly, CMS said it will terminate contracts if plans do not achieve at least a 3-star rating by 2016. Our favorite agency maintains the authority to deny applications submitted by poor performers, and to deny an application if it has terminated an MA or PDP contract within the past 38 months. There is a 14 month "grace period" for new plans to comply.
CMS Medicare Chief Sean Cavanaugh made the surprise announcement (beginning at 20:30 on the YouTube video) Thursday along with a September 8 policy letter that went to a handful of media outlets, but strangely isn't posted on the CMS website or communicated to Medicare plans via the Health Plan Management System. The memo noted:
"In delaying the terminations of these low performing contracts, CMS expects all contracts that have for at least three years received...a Rating of less than 3 stars to concentrate on improving the quality of care provided to their enrollees. These contracts must focus on the overall health care needs of their individual enrollees, including improving enrollee experiences and ensuring that their enrollees receive needed clinical care. These efforts should improve CAHPS, HEDIS, HOS, patient safety, and adherence scores. Organizations and sponsors should focus on all areas where the contract has received less than 3 stars. Organizations and sponsors must take into account their enrollee populations and target any interventions to improve quality to the specific needs of their enrollees. In many cases, a one-size-fits-all approach for interventions will not work.
"CMS may be following up with contracts designated as having a low performing icon (LPI) to discuss their performance and will determine whether enforcement or compliance measures other than contract termination pursuant to §§ 422.510(a)(4)(xi) and 423.509(a)(4)(x) should be utilized to ensure that the contract comes into compliance with CMS' requirements."
Barclay's eminent analyst Josh Raskin pointed out that "WellCare is the biggest beneficiary of this change with 9.5% of its total Medicare Advantage members enrolled in plans with consistently (i.e., three consecutive years) less than 3-stars." Raskin looked at how publicly-traded Medicare Advantage plans' 2.5 and 2.0 star enrollment trended over the past two years. He concluded over 200,000 Medicare Advantage lives are at risk when the stay of execution is over next year. "Among the companies with the greatest risk, Centene is most exposed, with roughly 19% of its membership in plans below three stars, followed by Universal American with 16% and WellCare with roughly 12% of its membership in plans below three stars," he said.
On the positive side, Raskin noted Humana continues to makes strides with the company's "at risk" enrollment declining from roughly 550K lives in 2011 to 25K last year, and that Molina has also made progress, improving the rating of its sole 2.5-star plan above the 3.0-star threshold last year. All of UnitedHealth's sub 3-star plans increased to a 3-star plan last year, leaving the company with very little "high risk" enrollment.
So, we'll have to wait another year for a public hanging in Star Ratings Square. But all of this serves as further evidence of what a game-changer Star Ratings have become in government programs, from the crappy consumer information tool they were just 4 years ago.
Resources
Join John Gorman, GHG's Executive Chairman together with colleagues, Glenn Ellerbe, Executive Vice President, Dr. Paul Alexander, Senior Clinical Consultant, and Mae Regalado, Senior Director, for an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy." Register now >>
Now is the time to analyze your HEDIS data for gaps and identify interventions for your health plans, providers and members. On July 17 GHG experts spoke about HEDIS reporting, the new measures and what's next. Access the recording here >>
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Hospice Guidance Turns 180 Degrees
After 70 Senators signed a protest bill and the hue and cry from hospice providers, patients and prescribers got too loud, CMS rescinded its' previous regs for hospice patients and published new guidance on 7-18-14. Previous guidance required health plans to place prior authorization edits on all medications after a member was identified as being a hospice patient. So, all the medications that the member was previously receiving under their Part D benefit were denied at point of sale. This caused a significant hardship to hospice providers who many times had to pay for the hospice member's medications. The philosophical and medical issue continues to be what medications should be continued and which medications should be discontinued when members are in their hospice benefit. Should antihypertensive, antihyperlipidemic, diabetes and other chronic medications be continued for hospice patients? Rational and substantive arguments exist for the continuation of some chemotherapy medications which keep tumor growth in check and are considered to be palliative for some patients.
The new guidelines require plan sponsors to place beneficiary level prior authorization requirements on four categories of prescription drugs:
- Analgesics
- Antinauseants (antiemetics)
- Laxatives
- Antianxiety drugs (anxiolytics)
These categories are assumed to be "related to the terminal illness and/or related conditions". Hospice providers will provide these medications. Plan sponsors are expected to continue to provide other medications which may have CMS approved utilization management edits including quantity limits, step therapy and prior authorization. Retrospective review is expected to determine whether other medications were "unrelated to the hospice beneficiary's terminal illness".
Resources
We can help your MA-PD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Visit our website to learn more >>
The Online Monitoring Tool™ (OMT™) is a complete compliance toolkit designed to help organizations track the compliance of their operations. Modules developed specifically for MA and Part D sponsors address distinct operational and compliance needs. Learn more about OMT™ here >>
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 >>