ICD-10 Transition — Ready or Not?
It's a New Year and there are 262 days left until the October 1, ICD-10 implementation deadline. The road to ten has been very challenging with respect to "Go or No-go" implementation timelines. Due to several delays, many organizations literally stopped transition efforts and redirected funding budgets to other priority projects.
The big day is coming! Currently, it is a known fact that CMS is operating under the October 1, 2015 scheduled deadline. It is now crunch time and with the compliance deadline set organizations have minimal time to complete the transition. Thoughtful planning, and executing conversion plans, will overall make the difference between a successful transition and missing the deadline.
What happens if your organization is not fully ready?
What is your plan for remediation?
The transition does not have to be painful. Timing is everything. Health plans and organizations, such as providers, clearinghouses and vendors can still benefit by using the time left to focus and implement additional readiness and deployment strategies for the code switchover.
The International Classification of Diseases, Tenth Revision (ICD-10), consists of two new areas, clinical modification (ICD-10 CM) for diseases and procedural coding system (ICD-10 PCS) and will replace ICD-9. The switch in code sets will provide expanded detail for inpatient, ambulatory and managed care organizations to better define medical conditions. The conversion is a significant change to the standard healthcare coding systems.
So what exactly are the differences between ICD-10 and ICD-9?
- ICD-9 codes have three to five numeric digits, while ICD-10 has three to seven alphanumeric digits - the switch in 2012 to HIPAA 5010 transaction standards for electronic claims paved the way for practices and payers to be able to accommodate ICD-10 changes
- CMS will transition all diagnosis codes from 13,000 old codes to approximately 68,000 codes included in the ICD-10 version
- ICD-10 has more specificity with a lot more codes, which provide more detail and granularity than the old codes
- Diagnosis Procedure Codes Systems (PCS) will increase from 3,000 ICD-9 to 87,000 ICD-10 PCS
Based on these changes, transition to ICD-10 requires extensive detailed planning, and comprehensive readiness efforts organizational-wide. It's virtually more than just a coding function. Diagnosis codes affect almost every core functional and operational process, system and reporting. Failure to prepare for the conversion will have dramatic impacts on financials and ultimately the member experience.
By leveraging in-depth regulatory interpretation and guidance with complete operational knowledge base Gorman Health Group provides ICD-10 best practices through financial analysis and impact assessment, which includes people, process and technology. Gorman Health Group will identify gaps between current operational "as is" process flows and recommend future optimal "to be" process flows required for the implementation. The analysis will highlight the impact on margins by line of business and measured through people, process and technology. Additionally, risks and potential return on investments (ROI) for the identified gaps can be provided.
Gorman Health Group ensures end-to-end operational process re-design including but not limited to the following functions:
- Claims
- Benefits & Product
- Configuration
- Codification and mapping
- Contracting
- Division of Financial Responsibility (DOFR)
- Prior Authorization
- Provider Pricing
- Quality Control
- Revenue Cycle
- Reporting and Analytics
- Metrics
- Vendor Alignment
- Vendor Management and Oversight
- All Other Hand-offs "Operational" Areas
If you are behind the eight ball and not exactly on track let us proactively work with you on an expedited readiness plan, contingency plan development, post-production support, post-transition analysis, knowledge transfer, monitoring and reporting. Gorman Health Group includes some of our industry's most experienced and proficient ICD-10 and operational subject matter experts.
Make your New Year's resolution to stay on track with transitioning to ICD-10. Time is running out and October will be here before you know it.
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Data Smog - CMS's Clear Vision for the Future of Data & Analytics
We all feel a little bit like hoarders with the vast amount of data we collect and store. We can also agree that it's a challenge to utilize that data for its best purpose and integrate it appropriately across an organization.
Recently in an article, Niall Brennan, the Centers for Medicare & Medicaid Services' (CMS) first Chief Data Officer, said their view about the role of data and analytics is changing. CMS has adopted a core mission to improve data collection and dissemination due to the substantial growth of both the number of data users as well as the vast amount of data it collects.
It's not just about collecting and storing data anymore, it's about aggressive analytics. CMS recognizes the importance of data analytics and the proper use of all that information but continues to struggle with numerous data sources and various systems that don't share data. Mr. Brennan is tasked to optimize and maximize data created by CMS's systems for all users.
This recent announcement is a good reminder for health plans to also take a look at how they collect, analyze, and utilize data. Health plans need to ensure their data is accurate, analyzed diligently and utilized appropriately for it to be relevant. The success of your organization relies on clean accurate records and meaningful data. Accurate data = optimal revenue.
CMS's new vision has elevated the importance of the data and analytics role within an organization. What was once considered a behind the scenes supporting role has now taken center stage. Get ready for your curtain call, the world of data and analytics is changing.
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GHG has experienced Consultants that can help with your Data Analytics. We can review your data architecture and assess processes to look for efficiencies and opportunities. Let us help you optimize your analytics and get all that data under control. Visit our website to learn more >>
John Gorman, GHG's Executive Chairman together with colleagues, Glenn Ellerbe, and Mae Regalado, Senior Consultant, gave 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, plus shared procedural practices and audit metrics ensuring workflows are best in-class." Access the recording here >>
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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Best Practices in Medicaid Claims Administration and Oversight
Every Medicaid operation needs high-performing claims administration. With strict medical loss ratios as required by healthcare reform, ongoing regulatory changes, timeliness, and payment accuracy relevant to provider pricing and benefit administration, covering operating costs poses significant challenges. Claims adjudication must be efficient and cost effective.
Claims adjudication is the process of paying or denying claims after a series of comparisons (automated system logic or manually by claims staff) against a comprehensive set of requirements. These requirements are as follows:
- Eligibility verification
- Benefit administration (deducible, coinsurance, copayment, accumulators and Maximum Out of Pocket (MOOP))
- Authorization criteria
- Provider verification
- Financial data and reimbursement guidelines (contracted or non-contracted)
- Claim edits
- Encounter edits
- Correct coding edits (based on line of business and state or federal guidelines)
- Medical review
- Coordination of benefits
Best practices of efficient Medicaid claims operations are as follows:
- Develop a strategy in enhancing claims quality control and oversight activities
- Implement quality control auditing through pre-payment auditing reviews
- Create a comprehensive oversight and monitoring reporting system
- Ensure that processes starts ticking when the claim reaches the organization, not necessarily when it reaches the claims department
- Increase auto-adjudication by complete set-up of pre-processing and routing logic. This results in higher first-pass rates and reduction in manual handling, which provide significant savings in operating costs
- Continue to redefine procedures, as well as provide a mechanism to understand all terms and conditions of the State contractual agreement relating to overall operations, claims and encounter processing
- Define and design configuration build at the product level by delineating lines of business (i.e., Medicare rules vs. Medicaid rules) which results in compliance with applicable regulations
- Continue to define or redefine claims adjudication policies and procedures, and data management, including consistency within each product
- Implement processes that monitor end-to-end claims adjudication
Execution of these best practices, and automating each procedural step of the claims cycle, results in quicker claim resolution. Monitoring operational performance helps track, adjudicate and measure claims as they flow through claims administration operations. As operational performance improves, auto-adjudication rates rise and the total cost per claim falls.
Gorman Health Group includes some of our industry's most experienced and proficient claims administration subject matter experts. Our consultants can help your organization implement best practices in claims administration. Please contact us at ghg@ghgadvisors.com to get started.
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GHG will help you by providing creative solutions to maximize cost effectiveness while building a solid framework to deliver results from eligibility to provider contract management to claims. Visit our website to learn more >>
Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
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 >>
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
Resources
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 >>
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 >>
Data the Silent Killer
As a seasoned veteran in healthcare operations I've seen firsthand the progression of data utilization by health plans. Despite decades of growth we're not there yet.
In the 1950s and 60s data processing began to take hold. Unfiltered data was the norm. Not much was done with it. Data validation was in its infancy. Business decisions were mostly driven by non-analytical factors.
In the 1970s and 80s information management began grouping similar data and identifying patterns. Basic analytics such as the categorization of data facilitated the ability to draw certain assumptions. On occasion those assumptions were valid but, more often than not, not broadly applicable. We realized what making "assumptions" yielded.
Data usage and sophistication improved considerably in the 1990s and early 2000s. The ability to dig much deeper into the groupings of data to find those unique characteristics to either prove or invalidate business assumptions became the mainstay. Better analytical processes improved knowledge and predictability in business decisions. Data management was equated to business intelligence, highlighting the awareness that data functions effectively drive business operations. Improved ability to manage and report data ushered the evolution of Big Data. Analytics and reporting is assumed (there's that word again) to be truthful...the data doesn't lie!
Today, health plan data is heavily relied upon. Data must be valid, accurate, and reproducible; it is the sole factor for health plan payments, performance ratings, patient care plans, and just about every other aspect of health plan operations. Data has become the lifeblood of a managed care organization. But…what if your data is distorted and data leakage is occurring?
What if claims and encounters are improperly adjudicated and reported?
What if membership and provider data is inaccurate?
What if the data used in Disease Management programs relies incorrect metrics to optimize interventions?
What if the data required for risk adjustment submission and payment is inaccurate? How much will it cost your plan?
Poor data management, inaccurate and inadequate analytics can slowly drain a health plan of its revenue and ability to make strategic business decisions. Consider this much like high blood pressure is the silent killer in human beings; data leakage is the silent killer of health plans.
Gorman Health Group has decades of experience assisting health plans with their data management. Please contact us for an End-to-End Data Management Assessment. We will assess the current state of your Data Management against industry best practices and your desired future state, and we'll assist you in getting there. Let us help you identify and control your health plan Silent Killer.
Resources
Join us on September 19 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 >>
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 >>