Readiness Checklist Outlines Key Operational Requirements

The Centers for Medicare & Medicaid Services (CMS) published its annual Readiness Checklist via HPMS memo on 10/2/2018. As in prior years, the checklist provides a high-level overview of key operational requirements for the coming plan year. Plan Sponsors must communicate any at-risk requirements to their CMS Account Managers. Here we summarize important things to consider as the 2019 plan year approaches:

  • CMS is phasing out the Social Security and Health Insurance Claim Numbers and moving to a Medicare Beneficiary Identifier (MBI) by April 2019. Plans must ensure all systems are ready for the transition, including any “home-grown” data repositories (e.g., appeal and grievance databases).
  • CMS will be providing Medicare Advantage (MA) and Part D Sponsors access to a precluded providers list after eliminating the provider/prescriber enrollment requirement. Claims from those identified in the precluded provider list must be denied.
  • The reinstituted Open Enrollment Period (OEP) not only changes enrollment time frames, it also expands customer service extended hours for 7 days a week, 8:00 am to 8:00 pm, through March 31, starting in 2019.
  • Update systems, processes, and training to the new guidelines for Special Election Period (SEP) changes for dual-eligible (DE) and other low-income subsidy (LIS) eligible individuals. Beginning 1/1/2019, DE and LIS individuals will only be able to change plans one time per quarter for the first three quarters with no SEP in the fourth quarter. Many systems are automated to allow these elections to process when received, as through 2018, they are unlimited.
  • Health plans should be sure to include customer service, enrollment, and appeals and grievances in their drug utilization controls for opioid management. Staff will need to have scripts and processes in place when members are placed in drug management programs that may impact their access to medication and impact potential disenrollment restrictions.

Ensure your employees are familiar with new guidance from CMS, including the Call Letter; Final Rule and Medicare Communications and Marketing Guidelines. The Readiness Checklist does not convey all guidance changes, and understanding the new rules is critical for Plan Sponsor readiness and compliance.


Gorman Health Group conducts readiness assessments for its clients to help identify any areas of risk related to upcoming plan year preparedness. This is especially important for plans new to the market in 2019. Contact us today for additional information.



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Streamline Your Medicare Enrollment

Large Medicare Advantage carriers invested a median of $11.25 per member per month in marketing in 2015, and spent a median of $17.44 on account and membership administration, according to a Sherlock Company analysis. With that kind of spending, the last thing a carrier needs is for seniors to become confused and frustrated by the enrollment process, but that is exactly what happens when carriers rely on technology that is not up to the task.

Pain points in the enrollment process include intake, eligibility verification, enrollment acceptance and validation, and benefit activation and notification. Each is subject to federal regulations with which compliance is paramount, and at each step, consumers can run into problems, become frustrated and abandon the process.

Many MA enrollment platforms were initially designed for use by commercial health plans and retrofitted to Medicare, and these patchwork systems make for a disjointed, unfriendly consumer experience. Applicants are dropped or told they are ineligible, benefits are never activated, or the applicant is never notified of acceptance and activation. In the age of Amazon and Apple, this is unacceptable. The MA space is extremely competitive, and seniors who encounter enrollment problems with one carrier are likely to look elsewhere.

A single platform designed specifically for Medicare Advantage with capabilities to support the full enrollment lifecycle offers a better way to deliver return on your plan’s marketing investment.

A purpose-built system should guide the user with smart wizards that make it easy for customer service and sales teams. It should minimize the possibility that eligible applicants will be rejected and handle reinstatements with ease. It must accept enrollment applications in paper, electronic and telephonic formats, all of which remain important in this market. And it must capture all CMS-mandated information, regardless of the enrollment source.

Once an enrollment application is accepted into the carrier’s system, it must be transmitted to CMS for verification. An enrollment module that identifies eligibility verification errors and flags them for repair cuts down on the percentage of applications rejected by CMS – a serious problem with patchwork systems. Ideally, avoidable rejections should be reduced to a fraction of a percent, well below the CMS 1% threshold.

After an application is validated and accepted, beneficiaries must be notified within a CMS-mandated period. The right platform should be able to handle this task, too. It must reduce compliance and quality risk and keep track of ever-evolving Medicare regulations.

A purpose-built system offers the additional advantage of bridging integration and interoperability gaps between multiple systems and processes, improving efficiency and the member experience. Systems that include a module for tracking enrollment to the marketing or broker source allow plans to identify problems and further optimize marketing for future growth.

MA plans that rely on a patchwork of modules that have been tweaked and cobbled together shortchange the enrollment process, and they risk losing customers to competitors who understand the importance of a smooth, smart and efficient process. An intuitive, compliant, end-to-end system is the solution for a better consumer experience, improved market share and far fewer administrative headaches.

Convey Health Solutions focuses on building specific technologies and services that can uniquely meet the needs of government-sponsored health plans.  Convey provides member management solutions for the rapidly changing health care world. Learn more.


First seen on SmartBrief.

For information on the other solutions Convey has to offer, please follow this link.




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Lack of Staff: Biggest Hurdle to Success

Staffing continues to be a major hurdle in the healthcare industry. A recent poll conducted by Gorman Health Group showed that 38% of respondents believed the biggest hurdle to success in their organization was lack of knowledgeable staff or lack of staff.

regan blog_hurdle to success
What is the meaning of success? Is it reaching financial targets? Meeting and exceeding service level agreements? Achieving high marks in customer satisfaction? Being one of the best places to work? Having a great reputation in the community? I am not sure we have seen an organization that is meeting all of these factors. Then again, those are not the organizations that typically call John Gorman for help.

Most places have an ironed-out Human Resources process that includes job description drafting, salary grading, recruitment, and interview process, which may take weeks or sometimes months. However, regulatory agencies wait for no man in terms of expecting compliance metrics to be met. As I observed my colleague tell a group of client trainees, “Your contract is with the federal government.” I can think of no finer way to articulate the commitment made to offer Medicare Advantage and Part D.

Our industry experts currently hold interim staffing positions in all areas, including risk adjustment, compliance, strategy, operations, network management, and pharmacy. While organizations search for their full-time candidate, Gorman Health Group provides experts who have done the job, can manage the department, can report to their C-suite, and much more. Do not let a temporary lack of staff hinder your success. If lack of staff is preventing you from meeting requirements, we can tell you from experience that it by no means sways the Oversight and Enforcement Group from their obligations.


Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

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CMS Timeliness Monitoring Underway

The Centers for Medicare & Medicaid Services (CMS) timeliness monitoring is currently underway at organizations with active contracts in 2017 and 2018, with a few exclusions, such as Medicare-Medicaid Plans and organizations that underwent a program audit in 2017 and did not have any invalid data submissions in key audit areas. Is your organization excluded? See the Health Plan Management System memo dated December 12, 2017. If I had a nickel for every time someone referred to this activity as a timeliness audit, I’d have quite a pile of nickels. While it is not an audit, it sure feels like one as the validation activity is the same.

The first of three waves of letters is being issued this month. After upload, a data review will be conducted and a validation webinar scheduled. Once complete, timeliness rates will be calculated. To make sure this is an efficient process, here are some ways we have recently assisted clients:

  • Coach and guide delegates in the timeliness monitoring requirements
  • Evaluate universes for adherence to instructions
  • Review both timely and untimely case samples for data accuracy
  • Review systems to validate accurate population of fields

Data integrity continues to be a priority not only for informing Star Ratings and Independent Review Entity data accuracy but also for required Part C and Part D reporting and for the compliant operations of plan administration. Universe preparation steps are not one size fits all, as the methodologies for a small plan delegating very few activities and the steps a larger, more delegated model plan takes will vary. Not surprisingly, during the course of our review, our team often finds potential issues or concerns unrelated to timeliness. This gives our client partners the opportunity to conduct a deeper review to address and mitigate.

We currently provide guidance, suggestions, and best practices for universe development to address quality and identify potential risks. If your organization is not getting these data universes correct, you should ask yourself, what other reports might be flawed? Dashboard metrics? Board reporting? Identify and correct these issues before CMS and their contractors find them for you.




Registration is now open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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Highlights from 2017 CMS Audit and Enforcement Conference

The Centers for Medicare & Medicaid Services (CMS) hosted their annual Audit and Enforcement Conference on Thursday, May 11, and addressed the following topics:

  • 2017 Program Audits
  • Audit Protocol Updates: Compliance Program and Medicare Medicaid Plan
  • Medication Therapy Management (MTM) Panel
  • 2016 Program Audit and Enforcement Report
  • Timeliness Monitoring
  • Civil Money Penalty (CMP) Methodology

The presentations and recordings of the morning and afternoon sessions are posted here. All sessions merit a review by Compliance and operational teams at sponsors and delegated entities alike. Apart from the communicated clarifications and content provided on the slides, CMS allowed for numerous question and answer periods, both after each session as well as at the end of the day. Here I capture highlights of those Q&As.

Can an Independent Auditor (IA) follow the same CMS process of providing samples 1 hour before webinar sessions? In regards to the IA process, most sponsors do follow CMS protocol when doing validation, but it does not really matter to us how soon samples are delivered. It’s ok if you get them a little sooner. Most IAs do use the same protocol and timing, but it is not prescriptive, which is why there is not a lot of guidance around how IAs should audit.

If we had a CAR for CDAG clinical appropriateness, would the validation audit focus on that CAR, or would the validation audit need to be a full-scale CDAG audit? When it comes to that, the sponsor simply needs to validate the condition. A full CDAG audit is not required; just that particular condition.

To what extent are Invalid Data Submission (IDS) conditions a problem in 2016? They were not terribly problematic. Last year there may have been eight across seven sponsors, but CMS would like to see those at zero.

Now that you have covered 94% of enrollment with Cycle 2 audits, when do you plan to start a third cycle? CMS is not sure and is still looking at that.

Can or will CMS share overall observations in Timeliness Monitoring regarding performance? CMS believes they will be able to this summer.

How does CMS come up with the common conditions in calculating CMPs? CMS takes this from the annual audit report.

When are CMP notices posted on the CMP website? CMS posts CMPs as a result of program audits before end of February. For CMPs not related to audits, the agency posts those immediately after they are imposed.

In regards to call log universe, do we include calls placed to other vendors as a part of normal business (such as calls to transportation vendor) which do not pertain to main customer service? No, CMS wants only calls going to the main customer service line.

Is it appropriate to report date request received as AOR receipt date, or should sponsor report initial receipt date as request received? For ODAG tables with these two fields, sponsor should populate as each column specifies. CMS does consider both fields when doing timeliness calculations.

Will CMS release a revised Compliance Chapter 9/21 to reflect change in Elements from 7 to 3, or is this just a change in methodology? CMS is actively revising manual guidance. Compliance program requirements are still the same, but audit approach has changed. Do not confuse the three audit elements (Prevention Controls and Activities, Detection Controls and Activities, and Correction Controls and Activities) with the seven core elements outlined in chapter guidance.

Is there a timeline when CMS is expecting MTM audit activities to migrate from pilot to standard? At this point, it is not determined.

From a long-term perspective, considering validation is 150 days and MTM is a calendar year, how would this area be handled from a validation perspective? At this time, MTM not subject to validation. It is still to be determined if it will be subject to validation in the future.

How will appeals timeliness monitoring affect future audits? To the extent that the timeliness monitoring effort becomes annual, it would make absolutely no sense to review timeliness audit, but that change remains to be seen. However, there is a difference in that timeliness monitoring is a review of a snapshot of the year before. CMS may want to phase timeliness review out of program audits. CMS also answered the question from the perspective of the agency using results to target for audits. CMS noted they always like to compare data to audit scores and results to see if there is anything meaningful but confirmed there are no plans for that in the future.

"While CMS indicated they would not use results from the timeliness monitoring for referrals for audit, CMS did indicate they would study the results to see if there is a correlation to audit results," says a colleague on the Operational Performance team.  "Knowing what is in your data and using it for process improvement should be on every plan’s radar." Since CMS staff indicated that the timeliness monitoring could one day potentially replace the timeliness review on program audits, sponsors should get ahead of that curve by using their timeliness monitoring data for their own internal review.

As always, we love to hear your thoughts and perspectives on agency activities as well as your experiences in the government programs space. Keep an eye on this blog for more updates from my colleagues on this week's conferences.


The Gorman Health Group 2017 Forum concluded recently in New Orleans with over 200 of our closest clients and partners. John Gorman provides key takeaways from the event here. Make sure to join us next year!

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It’s Product, Benefit, and Premium Time for 2018

Whether you are just updating your current product benefits, are offering a new plan benefit package (PBP), new product, or service area, or are new to Medicare Advantage altogether, now is the time to start planning for the 2018 bid submission.

It is best practice in the bid process to utilize a working team approach, with one clear leader. The team should include representatives from the following areas to ensure the best product is brought to market, and, when it is offered, that the implementation of the product is seamlessly implemented.  Some of the members who should be included are:

  • Sales/Marketing
  • Finance/Actuary
  • Network
  • Pharmacy
  • Medical and Health Management
  • Operations
  • Compliance

GHG believes, at the beginning of the bid process, it is important to level-set the team on the marketplace. Some of the analyses we typically like to present include:

  • Service area demographics
  • Medicare penetration
  • Current membership analysis
  • Enrollment trend analysis
  • Results of the Annual Election Period (AEP): Who are the winners and losers this AEP, and why?
  • Product analysis
  • Benefit analysis
  • Competitive analysis

Strong planning is key in the bid process. You want to understand the goals upfront and make sure your product and benefits can deliver. We have found weekly meetings, a detailed project plan with strong leadership, and project management skills are critical if you want to limit the number of iterations and last-minute back and forth that brings along the increased risk of errors.

Having a strong operations component incorporated in the process helps identify the planning needed to seamlessly implement benefit changes and pinpoint impacts on customer service.  The Sales and Marketing team are key in characterizing product differentials and how the benefits will be sold, and not only how the sales team will sell, but if the Sales team can sell the benefits.

We could go on, but you get the importance of every department working together and pulling their weight. GHG has seen the success of plans who get the need for a deliberate process, as well as those plans in nail biting situations – hoping it all comes together at the end. Let me tell you, the first way is always preferable! So get your analysis started, put your project plan together, and start putting together your team if you haven’t already!



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The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year's event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

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Reflections on the Basics of Delegation Oversight

Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to understand complex language and reading concepts without the foundation or basics. It would be quite an overwhelming few months for anyone.

With any course of study, it is important to start from the beginning. Furthermore, if you want to master that course, teamwork and collaboration allows for practice and improvement towards fluency.

As we start wrapping up 2016 (and wrapping up holiday presents), it’s a good time to reflect on the basics. What does this have to do with delegation oversight? The basic premise of delegation is that you are entrusting someone to perform an activity on your behalf. If you are looking to delegate for success, we recommend the following key steps to take place at the very beginning:

  • Get to know your delegate partner via pre-delegation discussions, site visit, and audit.
  • Understand how your delegate will demonstrate effective, compliant activities on your behalf.
  • Agree upon monitoring and auditing activities ahead of time, leaving room for augmentation.

We have seen many examples of delegation oversight programs and activities over the course of the year, and some Compliance Officers and Operations leaders find themselves in the delegation oversight equivalent of enrolling in Advanced French. That is, they were not involved in pre-delegation activities and, therefore, did not have a chance to advocate for the sponsor's obligations towards an effective compliance program. Without the basic foundation, they find themselves in an uphill battle when they try to get data or ask for changes to monitoring frequency.

“Oversight of delegated entities can be an overwhelming task,” says Beth Matel, Senior Director of Compliance Solutions. “To help ensure a sponsor has the cooperation of the entity to which they have delegated responsibilities, they must start by including the pertinent contractual provisions outlined in Medicare Managed Care Manual, Chapter 11, Section 100.4 - Provider and Supplier Contract Requirements and 100.5 - Administrative Contracting Requirements.” Sponsors delegating Part D administrative or health care service functions will need to ensure the appropriate subcontractor contractual language is in place as well.

Our Compliance Solutions team is grateful for all the opportunities we have had this year to support our client partners and share best practices, from the basics to the advanced. As you reflect on your delegation oversight programs, give yourself a present if you:

  1. Have strategies in place to ensure shared data is sent and received correctly each time (especially membership data!).
  2. Conduct immediate root causes analysis in response to inquiries or grievances regarding something potentially amiss.
  3. Complete robust testing prior to new benefit implementation.
  4. Partner as a team (Compliance and Operations) to ensure success together.
  5. Maintain a dedicated unit focused on delegation oversight.
  6. Stay up to date on the Centers for Medicare & Medicaid Services requirements and changes as they affect your delegates and communicate them timely.

Bonne chance!



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CMS Releases New Guidance on Coverage Determinations & Redeterminations

On October 18, 2016, the Centers for Medicare & Medicaid Services (CMS) issued enhanced guidance on outreach attempts to support coverage decisions in its memo titled “Guidance on Outreach for Information to Support Coverage Decisions.” In recent years, CMS Program Audits have consistently identified the failure of plans to have documented sufficient outreach attempts when more information is needed to make a coverage decision. Guidance hasn’t been clear on what CMS expected, but it was obvious based on audit results most plans were not meeting the level of outreach CMS considered to be sufficient. The memo has many critical points every plan should be reviewing and implementing.

Here are four items your plan should look at today to determine system and process capabilities to support the new clarifications:

  1. Ability to Begin Outreach Quickly – How quickly does your plan open a coverage request or redetermination? Most plans process expedited cases quickly, but standard requests are often in a queue that may take days to open and review for completeness.  The new guidance requires the initial request for additional information for a standard Part C organization determination to be sent within two calendar days of receipt and a redetermination request to be sent within four calendar days. This means plans must not only be able to triage weekend requests for expedited versus standard requests but determine if standard requests need more information.
  1. Multiple Outreach Methods – CMS outlined several methods for requesting information. Those include telephone, fax, email, and standard or overnight certified mail. Many plans use one or maybe two methods. CMS indicated, upon review of cases, consideration will be given to the plan’s use of multiple means of communication.
  1. Documentation of Outreach Attempts – It is critical systems be able to both store and report on the methods and date/time of the communication. CMS noted for emails and faxes, the timestamp is the evidence. For mail, it is the date/time of the postmark, which is a change from the mail date often used in internal systems. For telephonic outreach, it is the date and time of the call. In addition to the date and time documentation, plans should document two other critical pieces of information for the outreach attempt: 1) the specific description of the required information being requested and 2) the name, phone number, fax number, email, or mailing address of the point of contact. In the case of a phone call, the plan should document with whom they spoke, what was discussed or requested, and what information was obtained.
  1. Ability to Enforce Response with Contracted Providers – CMS has often indicated there is a concern plans are unable to get timely responses from their contracted providers. In the new guidance clarification, CMS reinforces this requirement. CMS expects plans to set up contractual requirements to support contracted provider responses to requests for information. Additionally, CMS is looking to health plan physicians to outreach to contracted providers when more information is needed to make a determination and the provider did not respond to requests.

While the new requirements may be aggressive, they do provide additional clarity on what CMS is expecting health plans to complete in order to be compliant. The question is, what types of systems and process changes will be needed to store and report on these changes?

Gorman Health Group (GHG) subject matter experts have been a part of numerous CMS audits and have observed similar feedback from the auditors. We have worked on remediation projects to implement this type of enhancement as well as recommend this to our clients on operational assessment projects. We know the struggles these changes present and can assist you in working through them. Implementing these changes may be challenging, but the end results of higher compliance and consistent, fully reviewed decisions for members will be worth it.

If you have questions about implementing the changes outlined in this memo or whether your current processes are compliant, we can help. You can reach us through our website or by emailing me directly at



CMS conducts their audit and provides a list of risks and a short timeframe (ninety days) to correct the deficiencies. We can help. Visit our website to learn more about how we can help ensure the right actions have been taken to remediate the issues found >>

New Webinar: The 2017 Star Ratings are out! Join John Gorman, GHG's Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on October 27 at 1 pm ET for a cross-functional review of the 2017 Star Ratings ― from key program updates and 2017 Part D insights to emerging Pharmacy and Pharmacy Benefit Manager issues, new medication measures, and strengthening the connection between risk adjustment and Star Ratings. Register now >>

New Webinar: On November 1 at 2:30 pm ET, join GHG's John Gorman and Melissa Smith as well as Eric Letsinger, President of Quantified Ventures, a firm committed to supporting the progress of the social enterprise community, and his colleague Brendan O’Connor, an Impact Manager, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>

New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>

2017 Readiness Checklist – Valuable Tool or an Exercise in Redundancy?

Some people are list makers and wholeheartedly embrace the value of checklists. They utilize lists to manage tasks, stay focused, and ensure high-quality results. A publication by the Institute of Health’s Committee on Quality of Health Care in America, titled “To Err is Human: Building a Safer Health System,” lays out the value of checklists in improving patient safety. We should view the Centers for Medicare & Medicaid Services (CMS) Readiness Checklist in that same view: it is a tool to allow health plans to improve the quality and compliance of their health plan and safety of their members.

As with all checklists, the process can be a “check the box” experience or a valuable tool to make sure everything is in place and nothing was forgotten. We all know to expect a CMS Readiness Checklist on an annual basis, but do we use this amazing tool to its fullest?   Be sure you make this a serious exercise to evaluate your program and readiness for 2017.  Some sections may be redundant year after year, but health plans find broken processes year after year, sometimes through negative member experience―don’t let that be your plan.

Every item on the Readiness Checklist should be reviewed and validated. Some items are new and may take more time and effort to validate. Here are four new items on the 2017 Readiness Checklist where you may want to invest additional time:

  1. Medicare-Medicaid Dual Eligibles Non-Discrimination and Cost Share Protection – The 2017 Readiness Checklist has a new emphasis on protecting the rights of lower income members, particularly Medicare and Medicaid dual eligibles and others eligible for the Low Income Subsidy (LIS). CMS also highlighted this topic in their conference in September. Plans are required to ensure dual eligible beneficiaries are not balance billed for deductibles, coinsurance, or copayments for which they are not responsible. CMS is requiring plans to verify they have procedures in place to ensure their providers do not discriminate against beneficiaries due to their dual eligible status or balance bill those members who receive assistance with Medicare cost-sharing from a state Medicaid program. It is a health plan’s responsibility to manage their provider network to prevent this type of abuse of Medicare and Medicaid full dual eligible individuals.
  2. Best Available Evidence (BAE) – CMS included additional guidance for plans to review their BAE process. CMS expects plans to have processes in place to allow BAE to be accepted at the point of sale. If health plans do not have scripts in place to assist their member services and pharmacy help desk staff, then they must be developed and put in place to support members requesting assistance with BAE-type issues.
  3. Online Enrollment Center (OEC) Application Receipt Date – One policy change this year is the way the receipt date is calculated for OEC applications. Plans need to calculate the receipt date to 11 hours earlier than the time and date stamp provided on the CMS file.
  4. Non-Discrimination and Alternate Language Tagline Language – CMS also raises the new requirement for Non-Discrimination and Alternate Language Tagline translation language plans are now required to distribute to their members. CMS is requiring plans to verify they have processes in place to satisfy these new requirements.

This year’s release is earlier than previous years, allowing plans more time to validate and implement all actions. Similar to last year, CMS has changed the attestation process for the 2017 Readiness Checklist to a strategic conversation between plans and their CMS Account Managers. Without that formal attestation process, don’t devalue the Readiness Checklist and required actions – utilize the tool as the valuable resource it is which will ultimately make your health plan better and your members safer. To err is human, and for that reason, redundant validation is a critical step to make sure your program is ready for 2017.

Our consultants have implemented items from the 2017 Readiness Checklist for health plans just like yours. If you need assistance verifying you are ready for 2017 or have questions on your processes, we can help. You can reach us through our website or by emailing me directly at



New Webinar! Each year, billions of dollars are set aside by investment banks and pension managers to invest in measurable social good. Gorman Health Group (GHG) is offering a new capability to connect health plans and providers with social impact investors to obtain capital for clinical innovations of which many plans have only dreamed. Join us on Tuesday, November 1, from 2:30 to 3:30 p.m. ET, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>

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Double Your Value: Three Critical Ways CMS Audit Readiness and the Member Experience Program Intersect

What do the Centers for Medicare & Medicaid Services (CMS) program audits and member experience programs have in common? At their core, both activities are looking out for and protecting Medicare health plan members. CMS, in their oversight role, is responsible for ensuring Medicare Advantage (MA) and Prescription Drug Plan (PDP) members receive all the rights and benefits of original Medicare as well as the additional services agreed to in contracts with MA plans and PDPs. Operations has to own compliance with CMS as well as how operational functions touch and impact our members' experiences. "The cornerstone of an effective member experience is cross-functional alignment, placing the member at the center of the health plan's initiatives and core business functions" says Carrie Barker-Settles, Gorman Health Group's (GHG's) Director of Sales & Marketing Services. In days of shrinking payments, plans need to be even more efficient as they provide services to their Medicare members but without cutting corners that result in non-compliance or driving members away from our plans. We can each make a difference in the areas of compliance and member experience efficiently as the goals are so aligned.

Here are three critical ways you can increase your member experience program's operational components and drive audit readiness.

  1. Denials in Claims Payment and Appeals: One of the most negative things a member will experience with his or her insurance is having something be denied that he or she thought would be covered. This is reality with any health plan, but how a denial is handled can make things so much worse. Claims denials often include standard templated denial reason codes. Appeal upholds may be more customized, but not always. It is important to review member denial language in claims and appeals to make sure the language is clear and understandable to your members. Are they able to understand the next steps they should take if they disagree with the decision? This is a common audit finding and a big driver of dissatisfaction.
  2. Claims and Appeals Development: Another action that should occur prior to denial of services is to completely develop the claims and appeals prior to the decision. Many plans experience trouble obtaining additional information from their contracted providers. When this occurs, what is the process to escalate that lack of response? Establishing a systematic process to obtain needed information to correctly determine approval or denial of service is critical to appropriate management, member satisfaction, and compliance.
  3. Appeals and Grievances: Root cause analysis on your appeals and grievances and then taking action on what is identified is an important step to close out cases. Often only provider information is tracked and trended, or overall appeals and grievances reports are provided to the Quality Committee. Programs need to ask how complaint information is being used to improve the plan. A plan can enhance a member's experience through analysis of what happened and what can be done to prevent that from happening again.  CMS expects to see thorough and complete investigations and resolutions when complaints are received, as do we all when we submit a complaint. Root cause analysis and follow-through will not only benefit all your members but support your need to demonstrate quality complaint processing to CMS.

Just as compliance is everyone's job, so, too, is ensuring members have the most positive experience possible every time they interact with a plan. Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, says it best, "I'm often asked what is the cost of non-compliance, or how much is the fine if we don't do X-Y-Z? A final rule was released on September 6, 2016, which adjusts maximum civil monetary penalty (CMP) amounts allowed for all agencies within the Department of Health and Human Services (HHS). This, along with CMS' recent memo on the 2017 CMP methodology, should demonstrate to the industry that the agency is prioritizing this aspect of enforcement for good reason. Denials, appeals, and access to care should be under constant evaluation by Operations and Compliance in order to identify opportunities for improvement." She goes on to say, "Audit readiness aside, ask yourself if you are truly beneficiary ready."

When we in Operations expect CMS compliance to be managed by the Compliance area or member experience to be managed by the Sales & Marketing area, we do ourselves a disservice and lose out on some of our most valuable benefits to our health plan. Implementing these steps will change the dynamics of our department by making our teams more member centric, promoting ownership, and making a live CMS audit easier.

GHG's Operational Performance practice area consultants have been in your shoes. We have faced the multiple priorities and pressures to meet production goals and maintain team satisfaction at the same time. If you need assistance in setting up an audit-ready department or improving your support of member engagement, we can help.



At Gorman Health Group, we maintain the country's largest staff of senior operations consultants.  Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more about how we can help you >>

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