2016 Readiness Review Smaller Size, Bigger Punch.

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Readiness Checklist on Monday, November 9, 2015. The 20-page checklist is full of items CMS is expecting plan sponsors to review and validate it will be compliant for the 2016 calendar year. While CMS won't have an official website for plan sponsors to attest to the readiness this year, they will use other methods to validate compliance. No matter the validation method, CMS' expectations are clear: Part C and Part D plan sponsors should review and validate compliance for each item.

In reviewing the 2016 Readiness Checklist, there are some new and modified requirements as well as other areas of CMS concern.  Regardless of whether or not the items are new to the readiness checklist party, they should all be known to you. If they aren't familiar, you may want to check your Health Plan Management System (HPMS) and regulatory guidance distribution process. CMS indicates at the end of almost every requirement where the guidance for that item came from―what Medicare manual or HPMS memo provides the supporting information for that item. CMS makes it convenient to validate what you are asked to validate and attest.

If you have waited until now to implement or validate new guidance from 2015, it will be a stressful few weeks in what is already a very busy time of year. Several items are heavy-hitters and get into the nitty gritty of processes. As in past years, any items which won't be in compliance are to be reported to your CMS Account Manager. No one likes to be on that list.

Many sections of the Readiness Checklist are smaller but have more potential process changes. "By no means should plans see an abbreviated Compliance and Fraud, Waste, and Abuse (FWA) section and start resting on laurels," said Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG). Regan went on to say, "In this year's checklist, CMS issues another reminder about the May 24, 2014, regulation change which requires mandates on Medicare Advantage (MA) organizations to require all of their first tier, downstream, and related entities (FDRs) to take the CMS training and accept the certificate of completion of the CMS training as satisfaction of this requirement."

Another change highlighted in the readiness assessment is plan sponsor's appropriate use of extensions for organization and coverage determinations and appeals. In audits, we often see plan sponsors who have failed samples due to extensions granted for contracted providers or when extensions are used early in the process and on a routine basis rather than as an exception. CMS is expecting plan sponsors to review their process for exceptions and ensure they are in compliance.

One change Regan called out is CMS included a recommendation that plan sponsors making pharmacy network changes provide both those pharmacies whose network status is changing and enrollees using those pharmacies with notices of changes specific to their situation. "This is almost certainly a result of CMS' close work with one plan sponsor on effective notification strategies as part of pharmacy network changes. While the plan sponsor had indeed sent letters to supplement the Annual Notice of Changes' (ANOC's) notification of changes, the recommendation is to move to a more personalized notification approach," indicated Regan. "This will allow beneficiaries to make a more informed decision and will also aid pharmacies in understanding their network status."

A senior consultant of Pharmacy & Clinical Solutions at GHG, stated, "The Readiness Checklist is always an excellent method of making sure you have the bases covered for new guidance which takes effect in the new plan year (2016)."  Deb went on to indicate there are three items plan sponsors must pay particular attention to in the 2016 Readiness Checklist for Part D.  They are as follows:

  • The long-delayed requirement "physicians and other eligible professionals who write prescriptions for Part D drugs are required to be enrolled in Medicare in an approved status or to have a valid opt-out affidavit on file for their prescriptions to be coverable under Part D, unless the prescriber is an ‘Other Authorized Prescriber'." This takes effect on June 1, 2016, and, therefore, plans must confirm their contracted providers, including dentists, are eligible to furnish Part D prescriptions.
  • Also, providers must have a valid prescriber National Provider Identifier (NPI) number for Part D claims to be valid. Specifically, "for plan year 2016 and thereafter, claims for covered Part D drugs must include a valid prescriber NPI. Part D sponsors must submit to CMS only prescription drug event (PDE) records containing an active and valid individual prescriber NPI."
  • Starting on January 1, 2016, it is CMS' expectation Medicare Advantage Prescription Drug (MA-PD) plan members will not leave a network pharmacy without their prescription for a medication(s) where coverage may available under either Part D, Part A, or Part B. Plan sponsors and/or their PBMs must have processes in place so the network pharmacist can exchange information with the plan sponsor or PBM about the member to make the determination about which arm of Medicare will pay.

Parting words from Regan, "CMS makes it clear these are key requirements, and the checklist is not an exhaustive list. Consider these items to be hot topics CMS will hang their hat on in the coming year." The key to successful MA and Part D programs is to know your business better than anyone, including CMS. The Readiness Checklist is one additional tool to do just that.

Resources

If you need assistance in assessing your organization against the Readiness Checklist or in strengthening your MA or Part D program, GHG's knowledgeable team is here to help you. We've been in your shoes and know the pain points and how to move through them. We can help you prevent that punch from being a knock out. Contact me directly at jbillman@ghgadvisors.com.

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095.Register today >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Proposed Changes to the CMS-HCC Risk Adjustment Model

Policy changes governing risk adjustment in plans for Medicare-Medicaid dual eligibles may soon be coming.

In response to concerns about the accuracy of the Centers for Medicare & Medicaid Services (CMS)-Hierarchical Condition Category (HCC) risk adjustment model for predicting costs of dual eligible beneficiaries, CMS recently released a Health Plan Management System (HPMS) memo stating it will evaluate how well the model performs for these beneficiaries based from concerns raised that "the model may disproportionately affect specific populations, particularly dual eligibles."

These proposed changes will not affect the clinical relevance CMS has already included in the existing model or on non-dual eligibles. However, this new approach is a clear "win" for plans having significant numbers of full dual eligibles, both Dual Eligible Special Needs Plans (D-SNPs) and otherwise. The under-payment in the current system is pretty severe, based on the statistics in the CMS memo, and this new approach will fix that.

"This is an interesting change and will definitely have downstream impacts," said a member of the Operational Performance team at Gorman Health Group (GHG). "There isn't a lot of reconciliation on the Medicaid status. Health plans have to go by the designation by the state of what type of dual eligible someone is as there is no independent way to validate that level of coverage.  So there isn't any additional reconciliation which will occur.  Health plans can no longer submit updates to Medicaid eligibility through the retro processer.  That data is much cleaner now than in past years and is fixed quickly due to Low-Income Subsidy (LIS) status cost share implications for dual eligibles."

Further, SNPs determine the type of dual eligible they will cover during the application process.  They validate the member is eligible, based on that status at time of enrollment, but there is no submission or correction of that status.  They have to use the state's data to validate whether they are a full dual-eligible, Specified Low-Income Medicare Beneficiary (SLMB), or Qualified Medicare Beneficiary (QMB), etc.

What may be a challenge is identifying more clearly who is in what status to allow for projections and reconciliation of risk adjustment status.

I cannot stress the dire need for your Risk Adjustment team to be in constant collaboration with the core operations leaders within your organization to be sure the necessary reconciliation is occurring and that you have a solid data management and analytics strategy in place.

Initial Highlights:

a. The Impact on Partial Dual Eligibles

Some SNPs have most likely been generating some of their profits by enrolling partial duals for which the current HCC model generates some over-payment.  The new model will eliminate this, and SNPs with significant partial dual populations need to start planning now.

b. Member Eligibility and Reconciliation

Beneficiaries could have months in one or more of the six sub-populations. Tracking a member's status and the hierarchy of the status in the base year will be important as plans forecast and reconcile their risk adjusted payments. If CMS moves forward with reviewing predictive ratios for six segments as it states in the HPMS memo, it will be very important for plans to ensure they are updating a member's Medicaid eligibility (QMBs/SLMBs, etc.) in a timely manner, which is currently a requirement, and the accuracy will be even more critical for projections and reconciliation of risk adjustment status.

Takeaways:

a. New Opportunities to Manage Trend and Control Utilization Costs

With improved accuracy for predicting cost, comes an opportunity for plans to be more targeted and efficient with their efforts to manage trend and control the utilization of those beneficiaries that are seemingly very costly (or at least are predicted to be very costly).

Processes around moving patients to and from the community and back to institutional settings will need to be seamless, clinically appropriate, and efficient. Politics and system loopholes allow facilities and health systems to game the system, keeping people in beds or reserving space in order to receive the reimbursement associated with the patient's status. Controls will need to be put in place: Utilization Management and Compliance need to be involved to keep a close eye on patterns for both beneficiaries and providers.

Data has had a staggering increase of importance and remains an integral part of the healthcare industry. The need to have refined data management processes to ensure data integrity and quality analytics is at an all-time high. Achieving this should be at the forefront of health plans' minds, especially with impending policy changes.

This proposed model will improve payments a little for the least expensive non-dual members, while reducing payments a little for the most expensive.  But the most expensive probably have the most unreported and under-reported diagnoses, so a good risk adjustment program could compensate for the small predicted impact of this new approach.

CMS is soliciting feedback on their approach to revising the CMS-HCC risk adjustment model to better predict costs for beneficiaries based on their dual status and aged/disabled status for Payment Year 2017. If you wish to submit comments, please submit them to RiskAdjustment@cms.hhs.gov , with the subject heading "Proposed Updates to the CMS-HCC Risk Adjustment Model," by November 25, 2015.

If you are unsure how this will affect your organization, or how to accurately communicate your ideas to CMS in two weeks, our integrated team of experts specializing in risk adjustment, analytics, compliance, pharmacy, and operations can work with your organization to ensure you have the right processes in place to ensure a timely submission to CMS. Contact us today >>

Resources

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Is Your Customer Service Ready? Top 5 Lessons Learned in 2015 Rolling into 2016

It's only a few months until we ring in a new year.  Time flies, but there is still enough time to ensure we put our best foot forward as we begin 2016.  Here are the top 5 lessons learned in 2015 as we roll into 2016 to ensure Customer Service is ready for the New Year:

  1. What were your member's pain points in 2015?  Reviewing grievances and appeals and Complaints Tracking Module cases (CTMs) has many purposes.  High on that list is to improve the impacted process, but of course it goes beyond that.  Sometimes we forget to close the loop and review and educate Customer Service staff on managing the pain points and how to work through difficult topics with our members.  Better prepared Customer Service means better educated and knowledgeable members.
  2. Are all tools and support materials updated for 2016?  There is a close-out for issues and claims from 2015, so for a period of time, Customer Service will heavily rely on two sets of information.  A clear understanding of what is in place for 2016 and how to find the correct information is critical to preventing confusion for Customer Service and members.
  3. Have you tested your compliance with the various required timeliness standards?  Can all Customer Service staff secure a translator within 7 minutes?  Do they all know to stay on the line with the member and the translator once the translator is secured?  Have you tested your TTY lines to ensure they reach a live agent during all hours of operation, 8 am — 8 pm?  We are all monitoring average speed to answer and disconnect rates, but translator and TTY availability is harder to monitor, and every year the Centers for Medicare & Medicaid Services (CMS) finds plans failing to adequately manage non-English language and TTY calls.
  4. Can your Customer Service staff recognize complaints about coverage for drugs as coverage determinations?  In a recent CMS enforcement notification, the first item called out in the health plan sanction letter was the plan improperly classified coverage requests as grievances or customer service inquiries.  The coverage determination request process should begin at the time of the original call.  It is critical Customer Service staff can recognize and correctly process these calls.  Have you pulled your Customer Service call logs to see if these are being correctly identified and routed appropriately?  That's what CMS will do in an audit―don't let them discover it first.
  5. Have you set up a process to ensure all letters and communications sent to members are also available to Customer Service?  Everyone hates being blindsided by an issue or new information.  At most plans, this is an everyday occurrence in Customer Service.  Have you set up a common repository for all member material to be stored, and copies of the member materials placed there, before the information is mailed?  An informed Customer Service Department shows cohesiveness and gives members confidence in your program.

Customer Service is the heart of a health plan.  Ensuring your Customer Service staff is top-notch and has the tools to perform at the highest level for every call is critical to your plan's success.   Gorman Health Group's experienced Operations team can work with you to set up knowledgeable, well-trained Customer Service and Operations departments.   We've been in your shoes and know your struggles and how to solve them.

Before we ring in the New Year, let's double check that our members will have everything they need from your Customer Service Department to start the year right!

 

Resources

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 >>

Registration for the GHG 2016 Forum is now open! This year we are offering a tiered pricing schedule. Register between now and November 30 to receive the biggest savings at $795. Come December 1, the price increases to $1,095. Register today >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

2016 Star Ratings are Working, and the Bar is Rising

The Centers for Medicare & Medicaid Services (CMS) released the 2016 Medicare Advantage (MA) Star Ratings early this year, on Thursday morning.  The usual practice is to wait until Friday after the close.  It was a shift designed to move markets, and the news was mixed. Overall, Star Ratings are working to improve quality in many areas of health plan performance, but insurers and their provider and pharmacy benefit partners are struggling on a similar number of metrics. What is clear is that Star Ratings are now the fulcrum of competition in government health programs — and man, this stuff is hard and getting tougher.

There are clear winners and losers in this release.  There is a "Divine Dozen" of 5-Star-rated plans, including a couple of new arrivals to the 5-Star world. CIGNA traded its 5 Stars in FL (the legacy HealthSpring plan at the legendary Leon Clinic) for its Arizona plan. Sierra (9 states), Tufts (MA), Group Health of MN, and Essence (IL and MO) made it into the Pantheon.  Repeat 5-Star rock stars include Kaiser in 8 states, Martin's Point (ME and NH and will soon own Medicare in Northern New England), and Gunderson in IA and WI.

The half-dozen "walking dead" — plans scoring below 3 Stars for 3 consecutive years —included Wellcare of LA, Sierra Health, Touchstone, Cuatro, Windsor, and GHS (owned by HCSC).   Three will be terminated by CMS at the end of 2016.

Star Ratings are proving to be tremendously effective in moving markets and forcing industry investments in population health and the member experience and are driving big improvements in Medicare quality.  Roughly half of MA plans (179 contracts) earned 4 Stars or higher for their 2016 overall rating, a nearly 9% increase in a year and the first time a majority scored over 4.  On an enrollment-weighted basis, over 70% of MA enrollees are in contracts with 4+ Stars, a nearly 11% increase year over year.

But below the water line, at the metric level, the news was mixed and cautionary:

  • The good news: Average Star Ratings increased for 10 Part C measures and 5 Part D measures. We saw significant improvements in several challenging, longitudinal Health Outcomes Survey (HOS) measures: Improving/Maintaining Mental Health, Monitoring Physical Activity, Part D Appeals Autoforwards, and High Risk Medications. There were smaller improvements on many other measures, where removal of the 4-Star thresholds helped plans improve ratings.
  • The bad news: Average Star Ratings DROPPED for 16 Part C measures and 6 Part D measures. We saw significant decreases in several screening measures (colorectal cancer screening, diabetes kidney disease monitoring) and the HOS measure of improving/maintaining physical health.  And there was a big drop on the Medicare Plan Finder (MPF) Price Accuracy measure, where the cut points have gotten so small that 97% accuracy only gets 3 Stars, 99% results in 4 Stars, and it literally takes a perfect 100% to earn 5 Stars.

We knew the removal of the 4-Star thresholds would produce a tremendous amount of fluctuation in the measure cut points, and that's exactly what happened.  It's like playing "Pin the Tail on the Donkey" during an earthquake, making it really hard for health plan leaders to predict where their ratings will ultimately land while they still have time to influence them.  For example:

  • The average rating on the Diabetic A1c Control measure increased from 3.3 in 2015 to 3.9 in 2016.  But there was no change whatsoever in the average performance rate for this measure — in both 2015 and 2016, the average compliance rate was 76%.  The improvement on this measure can be entirely attributed to CMS relaxing the cut points once the predetermined threshold was removed.
  • In contrast, the Controlling Blood Pressure measure rating dropped from 3.7 in 2015 to 3.4 in 2016.  The compliance rate actually increased from 65% in 2015 to 71% in 2016.  This is an example of where the removal of the predetermined thresholds tightened the pressure on this measure — in fact, the 4-Star threshold increased 12% upon removal of the predetermined thresholds.

The Star Ratings data for 2016 pretty much emasculated industry arguments for relaxing metrics for Special Needs Plans (SNPs).  SNPs saw improvement in their quality scores roughly equal to that of HMOs and PPOs: MA plans operating SNPs averaged a 3.61 rating in 2016 (up from 3.47 in 2015), while plans with HMO/PPO-only contracts averaged 3.87 in 2016 (up from 3.79 in 2015).

Non-profit MA plans are pounding for-profits into the sidewalk on quality. About 70% of non-profit MA plans received 4+ Stars vs. 39% of the for-profits. Much of that discrepancy is due to culture. Non-profits tend to be far more focused on the all-important member experience measures and are more collaborative with their provider networks.

Methodological changes by CMS ensure the Star Ratings bar will continue to rise.  2016 is the first year plans with 500-999 members were rated. Only 369 Medicare Advantage Prescription Drug Plans (MA-PDs) were rated in 2016. 188 more plans weren't rated, but may be in 2017 — and this dilution will warp the bell curve plans are graded on, especially when considering most of those 188 are provider-sponsored, and strong performers will emerge. 4+-Star plans have the most to lose in this environment, and no one can afford to get comfortable.

Some takeaways:

  • Stars must be managed as a program and a corporate priority, not as a group of measures.  The effort must be directed by dedicated executive leadership and support.  No plan improves Star Ratings doing it off the side of their desks.
  • The removal of the remaining predetermined thresholds means there is no way for plans to "pick and choose" a subset of measures to focus on.  It has to be improvement across the board.
  • The bar continues to rise fast among Part C Star Ratings measures.  The "low hanging fruit" has been eaten. Part C Star Ratings success is no longer easily influenced by slick reports provided to physicians. Plans need to help providers execute on gaps in care plans and eliminate barriers to care for the vulnerable. There's a reason the 5-Star plans are mostly provider-sponsored, vertically integrated, collaborative, and member-centric by nature.
  • Star Ratings measures need to be woven into every department's work streams.  This includes not only quality, care management, health services, and pharmacy, but also risk adjustment, network operations, and compliance.
  • Lagging SNPs need to work harder and smarter and assume no CMS help on the measures for the low-income and disabled.  To the contrary, recent draft measures for dual eligibles from the National Quality Forum focus on mental and behavioral health and will prove an enormous challenge.

If you achieved 4+ Stars this year, congratulations, it's an increasingly impressive accomplishment.  Now get back to work.  There are 178 plans at 3-3.5 Stars who are close on your heels and feeling the urgency.  Now add the 188 unrated plans who will smash the bell curve in 2017.  A 4-Star plan's equal effort in 2016 only guarantees a score that starts with a 3 the next year.  Keep. Moving. Forward.

If you missed your 4th Star this year, panic a little, but then get it together. Fast. In a competitive market, you're circling the toilet bowl but aren't flushed yet.  You still have time to influence your 2017 Star Ratings and must make improvement the focus of your benefit, formulary, and network designs in the months ahead. You have big decisions to make and must invest time and resources wisely and with a sense of urgency.

Once again, the 2016 Star Ratings prove the world's biggest experiment in performance-based payment is working and forcing insurer evolution.  And evolution isn't about size, it's about continuous adaptation.

 

 

Resources

Whether your plan missed the overall 4-Star Rating necessary to earn Quality Bonus Payments, or whether the new 4-Star cut points have introduced new risks of maintaining your overall 4-Star rating, we can help.  Our team of experts understands the Star Ratings program and knows how to influence performance.  Contact us to learn more >>

Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Do More Than Survive AEP

How quickly another Annual Election Period (AEP) is upon us.  This time of year is the perfect time to review your new member onboarding activities and AEP strategy.  We all know the sale doesn't end when the application is turned in and membership begins.  This is where the rubber hits the road.

These are the four questions to consider going into AEP:

  1.  Are all plan resource documents updated with the 2016 plan benefits?  Picture this: A friend newly eligible for Medicare recently enrolled in a Medicare Advantage plan.  He experienced a benefit problem that nearly ended in a sales allegation all because a representative was relying on outdated benefit information.  This would have been avoided if everyone at the plan had the new benefit designs.
  2. Does health plan staff see the big picture?  It's easy for us to focus on our individual operational components.  After all, the number of regulations and processes to manage a compliant Operations Department is significant and takes our full attention, but the big picture allows for cohesive programs and the ability to see what part we play.  Does Enrollment know the top issues that Reconciliation experiences?  Is there a feedback loop established to catch improvement opportunities early as we move into AEP?  Has Sales shared the advertising schedule and advertisements with Customer Service?  Customer Service can maintain that strategy and answer member questions about the campaigns for 2016.
  3. Are operational oversight tools in place?  Not only should all operational staff know the requirements governing their processes, they should know how to tell they are meeting those requirements.  The ability to oversee our own processes and know we are in compliance is empowering.  Not only can corrections occur immediately, but staff can be confident and efficient, focusing on the important actions supporting new and existing members.
  4. Is everyone focused on the goal — ensuring a positive member experience?  If applications are incomplete, is the Enrollment staff focused on sending a letter to get the application off their plate or focused on reaching out to the member to complete the member enrollment?  Are welcome calls in place to answer any lingering questions and ensure new members feel confident and engaged in their plan choice?

AEP was quick to arrive—it will be equally quick to come to an end.  Make sure it's the AEP you designed rather than the AEP you survived.

 

Resources

In Operations, we naturally focus on our own internal processes and efficiencies, but now is the time to invest in making sure staff knows how their contributions impact members and the health plan.  Gorman Health Group's experienced Operations team can work with you to set up strategic, efficient, and knowledgeable operations.   We've been in your shoes and know how to navigate through AEP. Visit our website to learn more >>

Join us on Friday, October 9, from 1-2 pm ET, as John Gorman, Founder & Executive Chairman at Gorman Health Group (GHG), examines the state of government healthcare programs and outlines proven tactics market leaders are implementing to cut costs, increase member satisfaction, and drive sustainable growth. Register now >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

The CMS Fall Conference: 4 Ways to Solve the Preparedness Problem

The Centers for Medicare & Medicaid Services (CMS) held their Fall Conference and Webcast on September 10 in Baltimore.  The presentations and videos from the event are found on the Compliance Training, Education & Outreach site here.  CMS covered various aspects of the Medicare Advantage Prescription Drug (MA-PD) program, but here I've focused on four lessons I heard loud and clear: work with CMS, prepare ahead of time, seek continuous improvement, and don't wait until the last minute.

Linda Anders from CMS hosted two Aetna representatives who discussed lessons learned in beneficiary and pharmacy outreach stemming from strategic network changes taking place over 2014 to 2015.  They had developed a communication strategy but soon understood a lack of clarity and misinformation caused significant beneficiary and pharmacy confusion.  Ms. Anders stressed there is much to be learned from Aetna for any plan contemplating changes to their program.  Aetna recognized their Part D network configuration was "generally consistent" with CMS requirements.  It is recommended any plan contemplating program changes not tested in the industry work closely with CMS on these initiatives.

Gregory Woods gave valuable information regarding the Value-Based Insurance Design (VBID) Model Test.  Things will move quickly for the VBID model.  While they are beginning this test for 1/1/2017 effectives, the Request for Application (RFA) responses will be due sometime this November or December.   This is new, so Compliance and Product teams, prepare yourself for a new onslaught of questions from Clinical and Actuarial, because they are coming.

As a lead-in to a presentation from MAXIMUS Federal Services, CMS confirmed they are working with a small number of plans on point of sale rejections. They hope to share more information about that in the 2017 call letter.  Some helpful reminders were then provided regarding appeals going to MAXIMUS.  Make sure your organization is referring to the most updated process manuals provided by MAXIMUS for Part C and Part D appeals.  Additionally, there is a significant amount of appeals data dating back to 1997 showing your plan's percentage of upholds and overturns.  Organizations can compare to other plans to benchmark or simply leverage to spark internal process improvements.  Cathleen MacInnes, Project Director, also addressed the development of a submission portal for electronic upload of case info to MAXIMUS.  If your organization is interested in participating, contact either her or her Part D counterpart.  From an operational perspective, that should make sharing case info much easier, so long as it is secure, secure, secure.

The icing on this conference cake was the update from Jennifer Smith, Director, Division of Analysis, Policy and Strategy, Medicare Parts C and D Oversight and Enforcement Group, on 2015/2016 program audit protocol, processes, and activity.  The changes she outlined are exciting — here are some, and since I've already written plenty, you can either watch the video or contact me for more details and my thoughts.

  • Edits to record layouts will include not only those outlined during June's Oversight and Enforcement conference but also additional edits based on plan and auditor feedback. Extraneous fields will be gone, headers will be added to record layouts, and more clear instruction will be incorporated as to what should be included and excluded.
  • Beneficiary Impact Analyses (BIAs) will not be requested at the time of the self-identified and self-disclosed issue reporting.  Organizations should still anticipate a BIA request if an issue is found during an audit.
  • CMS is also revising their policy on the "three strikes" for universe submission.
  • The two anticipated pilot audit areas are being moved to 2016.
  • Compliance Program Effectiveness (CPE) will be conducted either onsite or virtually.

"It is also important to remember the audit protocols are more like a pop-quiz than a final exam," says Charro Knight-Lilly, Senior Vice President of Client Relations.   Don't lose sight of the need to comply with all requirements and testing performance through monitoring, auditing, and annual risk assessment.  Ms. Smith said something that resonated with me and likely others in the industry:  Don't wait until the audit notice to practice universe pulls and activities.  If you do, you are behind the 8-ball.

Resources

CMS outlined areas of poor performance within the release of the Outlier Notification in August.  In addition to audits and Corrective Action Plans (CAPs), this notice also referenced Compliance Letters (C and D) and Star Ratings (C and D) as areas of concern and indicators of poor performance.  Both of these areas require advance planning, preparation, and coordination in order to make an impact a minimum of one full year later.  Don't exhale as we head in to the 2016 Annual Election Period (AEP) — now is the time to plan strategy for 2017.  Contact us to learn more.

Join John Gorman, Founder and Executive Chairman at GHG, for our upcoming webinar on MA-VBID Model plan requirements, needed strategies for data analysis and benefit development, as well as what you need to be doing now to prepare for January 2017 on Tuesday, September 29, from 1-2 pm ET.  Register here

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG's weekly newsletter. Subscribe >>

by GHG Advisors

Government Sends Stark Reminders that Insurers' Biggest Customer is Still the Regulator

Since we opened our doors 19 years ago, we've preached to health insurers to think of the government as your business partner.  This week, we got several reminders that insurers' biggest customers -- Medicare, Medicaid, and ObamaCare -- are still the regulator.  As business conditions improve for health plans across these business lines, government expectations are rising, and scores are about to get settled, as they always are in the second term of a Democratic administration.

We see it in enforcement activity from the Centers for Medicare & Medicaid Services (CMS).  We see it in a steadily-rising bar of Star Ratings and other performance measures for health plans for all three programs, the basis of looming contract terminations.  And now the White House jumps in with an aggressive schedule of risk adjustment data audits, openly seeking repayments and dropping "f" bombs: fraud, that is.

They named a great film after a moment like this: "There Will Be Blood."

You can't argue with the numbers: 2015 remains the most punitive year in Medicare Advantage history.  Look at the trend:

CMS is also being much more aggressive this year with data-driven oversight and enforcement.  Communications to health plans who are "outliers" in various performance measures, especially in member communications and consumer protections, began recently.  A pattern we are seeing play out is CMS chasing down all clients of noncompliant pharmacy benefit managers; where poor Part D performance is seen in one plan, the agency then begins auditing that vendor's other customers, assuming they'll get the same findings.

We know that Star Ratings and expanding reporting requirements in Medicare Advantage and Part D mean the bar is rising and establishes data-driven thresholds against which health plans can be penalized and terminated beginning in 2016.  CMS announced sweeping new reporting requirements for both programs this week, which inevitably get picked up in Medicaid and ObamaCare rules in following years.

And now the White House is piling on.  In Washington, we talk a lot about "setting the terms of debate." Our industry has lost the debate on risk adjustment coding and has allowed anti-managed care advocates to define payers' inaccurate diagnostic coding as fraud.  A just-disclosed February 2015 letter from President Obama's Budget Director to Health Secretary Sylvia Matthews Burwell stated, "While some progress has been made on this front, we believe a more aggressive strategy can be implemented to reduce the level of improper payments we are currently seeing...we must continue to explore new and innovative ways to address the problem and attack this challenge with every tool at our disposal...the government estimate of $12.2 billion in these mistakes for fiscal year 2014 remains a concern." He extended his mandate beyond Medicare Advantage to over $3 billion in questionable payments from Medicaid. This means a spike in data validation audits for payers across both programs with the threat of improper payment clawbacks and even prosecution under the False Claims Act.

There has never been a more Golden Age of opportunity for health insurers in government programs.  But the threats are escalating as well, and as my politics professor told me, "99% of political wounds are self-inflicted."  Plans caught up in this dragnet will have gotten plenty of warnings.

 

Resources

The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. Click here to review the Part C highlights that merit your attention in a blog posted by Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group (GHG).

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by GHG Advisors

The Affordability Review — “Reading the Tea Leaves"

The fall season is a good reality check — back to school, cooler weather, end of summer, and …. Budgeting/financial forecasting. Forecasting is like predicting the future — you have to know how to read the tea leaves and see the efficiencies and interdependencies of your current performance to have a better idea of future performance and challenges.

Regardless of lines of business and marketplaces, companies need to manage to an acceptable loss ratio. Government regulations use this metric across different products and populations. Medicare Advantage demands at least 85% medical loss ratio (MLR), and many Medicaid plans and special needs populations require at least 90% MLR. Administrative costs are constantly squeezed, and risk adjustment is an ongoing process that is sometimes hard to quantify relative to the amount and timing of the additional revenue.

So the process of going through an affordability review is like a readiness audit. It is better to be proactive and look for opportunities before it is too late. An affordability review consists of several steps. An initial onsite visit, including interviews with management across the key departments of medical management, networks, pharmacy, claims, finance, risk adjustment, and marketing, can set the foundation for an in-depth review of internal financial and operating reports. An objective review of claims trends, based on cost and utilization drivers across members, providers, and services, can result in improved financial and operational performance. With collaboration among subject matter experts, initiatives with financial targets and action plans can be developed and monitored.

Even with new products and demonstrations, reports and a monitoring process should be in place on day one. Many Centers for Medicare & Medicaid Services (CMS) demonstrations only last for three years, so waiting for claims data and trends minimizes your window for mitigation.

Resources

Gorman Health Group has subject matter experts in operations and analytics to provide assistance with this process and help cultivate a corporate awareness and discipline toward financial outcomes that deserve a spot with quality and compliance. It is everyone's responsibility. Contact us to learn more >>

Stay connected. Subscribe to Gorman Health Group news and updates via our weekly newsletter.

by GHG Advisors

Financial Impacts of Unscrubbed Data

We have written many articles on the importance of maintaining accurate, reliable data. Data is everywhere and in many versions. Health plans need to be very careful to input only that information coming from a reliable source of truth. In government programs, that reliable source of truth is prescribed to be information contained within the government's systems. "Scrubbing" data means reconciling against that reliable source of truth. For health plans, this means reconciling with information within the government's systems, regardless of whether that information is right or wrong. Correcting the government's erroneous information requires adherence to prescribed processes.

The most effective way to process transactions with government programs is using the government's own data. This is most effective because it greatly lends itself to automation. A clear example of how this works is in Enrollment processing using what we call an "Intelligent Front-End." The objective of an Intelligent Front-End is to import the government's data and then utilize that same data in transactions back to the government. This Intelligent Front-End also receives data files from the government and then utilizes that same data to trigger required actions within the health plans' systems. This tactic ensures reconciliation, compliance, efficiency, and manageability.

Another example of utilizing "scrubbed" data is in validating health care providers' information. This is critical for provider credentialing, contracting, medical claims processing, pharmacy claims processing, risk adjustment, and encounter data submissions. The monthly National Plan and Provider Enumeration System (NPPES) National Provider Identifier (NPI) downloadable files and weekly incremental NPI files provide an abundance of information. Combining the Medicare Exclusion Database (MED) and Office of Inspector General List of Excluded Individuals and Entities (LEIE) helps to build a national universe of health care providers' information. Automating reconciliation with this comprehensive database can tremendously expedite provider set-up for processing claims from non-contracted providers. This helps to avoid interest payments for untimely processed claims.

It is imperative for health plans to keep current on updates to payment codes. This includes:

  • International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM);
  • International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM);
  • International Classification of Diseases, Tenth Edition, Procedure Coding System (ICD-10-PCS);
  • Current Procedural Terminology (CPT);
  • Healthcare Common Procedure Coding System (HCPCS);
  • Modifiers;
  • Revenue Codes;
  • Place of Service;
  • Bill Types;
  • Condition Codes;
  • Occurrence Codes;
  • National Drug Codes (NDCs).

Finally, it is absolutely necessary for health plans to keep current on updates to fee schedules and prospective payment pricers. Provider payment disputes are on the rise. Ironically, so are overpayments to providers. Ensure payment accuracy by utilizing up-to-date fee schedules and pricers.


Resources

Gorman Health Group (GHG) includes some of our industries most experienced and proficient health plan subject matter experts. Our consultants can help your organization with developing or improving your Intelligent Front-End, scrubbed health care provider information and national provider database, and assess whether your claims adjudication codes and payment systems are current and used appropriately. Contact us today to get started. >>

Stay connected. Subscribe to Gorman Health Group news and updates via our weekly newsletter.

Don't miss Gorman Health Group's Chief Consulting Officer, with colleagues Jane Scott, Senior Vice President of Clinical Innovations and Regan Pennypacker, Vice President of Compliance Solutions, as they discuss your member experience and the factors that influence success and failure, as well as prominent compliance and service issues plaguing the industry. Register today >>

by GHG Advisors

Takeaways from Accountable Physician Groups' Annual Summit

Twice a year I get the honor of speaking to the California Association of Physician Groups' (CAPG) annual summit and DC policy meeting.  CAPG represents accountable, capitated physician groups, and now has members in 39 states.  They're always among my favorite speeches given how sophisticated the audiences are.  Here's a few takeaways from my talk last week on "The Future of Government Programs":

  • Forevermore, physician group revenues and earnings will be dominated by Medicare Advantage, Medicaid and dual eligible health plans, and the ObamaCare plans, most likely in that order.
  • Everything that Medicare Advantage (MA) does, the Medicaid, ObamaCare, and commercial markets follow 3-5 years later.  Nobody knows this better than the CAPG members from CA, which the rest of the nation lags. Want to still be attending CAPG meetings in 2020? Master Star Ratings and risk adjustment.  They'll apply to all lines of business if they don't already, and they are the keys to survival already in MA.
  • Value-based contracting is in its infancy but will soon define all health plan contracts with physician groups.  Fee-for-service is dead.  Performance-based capitation is the only future.  To master it a physician group needs a range of capabilities, including eligibility verification, interoperability, actionable clinical intelligence in real time, standardized care processes, and chronic care management, across all business lines.
  • Most Accountable Care Organizations (ACOs), especially the 424 in Medicare, will not see a return on their investment.  They will have spent millions to participate in these experiments and around 80% won't see a payoff.  2016 and 2017, when Medicare Advantage benchmark rates turn into a tailwind, present the perfect opportunity for ACOs to "move up the food chain" to become health plans.
  • Dual eligibles are the biggest opportunity of our lifetimes, and there is no question that Special Needs Plans designed to serve them can be profitable.  SNPs are a principal mechanism for states to shift long-term care risk into the private sector, and will be a central product for ACOs converting into Medicare Advantage. But they require a range of capabilities most physician groups lack today, such as enabling and social services that duals must have from their insurer.
  • In all government programs, the "5/60 Rule" governs.  5% of members often account for 60% of costs.  Any physician group that aspires to bear risk must be able to identify and intervene with their 5 percenters or they won't be risk-bearing for long.
  • The biggest vulnerabilities for MA plans are consumer protections like appeals and grievances and complaint management, and who they have selected as their pharmacy benefit manager (PBM).  Most PBMs are frankly terrible at Medicare Part D administration, and Star Ratings now count far more in Part D than in Medicare Advantage to a health plan's overall score.  Physician groups typically have little or no experience with either PBMs or consumer protections.
  • Retail pharmacies and the home are the most underutilized sources of care to government programs beneficiaries.  Any successful physician group evolution will involve better integration of both sites for the chronically ill.
  • Most at-risk physician groups are directly involved in coding and reporting for risk adjustment.  Federal agencies are paying unprecedented attention to upcoding in Medicare Advantage with an eye to hundreds of millions of dollars in clawbacks and recoveries.  The emphasis at physician groups involved in risk adjustment must move from chart reviews and claims extracts to more holistic member evaluations, and from a culture of "what can we get?" to "how do we stay out of trouble?"

Evolution is a messy business.  Nowhere is that more the case than in physician groups evolving from fee-for-service to value-based contracting and becoming insurance companies.  If it was an easy business, we'd be out of business.

Resources

Don't miss Gorman Health Group's Chief Consulting Officer, with colleagues Jane Scott, Senior Vice President of Clinical Innovations and Regan Pennypacker, Vice President of Compliance Solutions, as they discuss your member experience and the factors that influence success and failure, as well as prominent compliance and service issues plaguing the industry. Register now >>

From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements.  Let's get started. Contact us today.

Stay connected. Subscribe to Gorman Health Group news and updates via our weekly newsletter.

by GHG Advisors