Provider Relations | GHG Advisors

Blending Network Strategy and Product Strategy

As more and more health systems and provider organizations successfully manage the shift from patient care to population health management, long-term health plan strategic planning should be blending network strategy with product strategy as a key indicator of the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay for performance and upside risk arrangements, and as providers have seen the margins narrow and plateau, plans have had to adapt and move beyond simple incentivizing for behavior change. We heard from the Centers for Medicare & Medicaid Services (CMS) the Accountable Care Organizations (ACOs) with upside-only risk have not performed as well or increased savings in comparison to those ACOs with downside risk and skin in the game. Systems that have ventured into managing downside risk and percent of premium arrangements and that have been successful have an appetite for more. Certainly moving up the food chain from a provider to a payer has been a topic of conversation among CEO’s of large integrated delivery systems. They have worked hard to align physician trust and referral networks, build a strong name brand in their local communities, and negotiated contracts with health plans that have met and exceeded care and cost containment goals, and the question of where do we go from here is top of mind.

As we have met and strategized with provider systems from baby steps to pay for performance to negotiating their first risk deal, there has been and still is, in some cases, a strong reliance on health plans to set clinical pathways and benchmarks. From the provider perspective, the reporting and transparency with the plan partners has been a key consideration in whom to collaborate with and how they have set internal benchmarks. However, systems are starting to realize and explore the administrative support organizations available and stepping out on their own to become a Provider-Sponsored Organization (PSO), which doesn’t seem as scary as it may have five years ago. Still, in meeting with providers, the biggest misconceptions have been what does it mean to be and how do the requirements differ from a PSO versus a Provider-Specific Plan (PSP-Narrow Network), do we meet the requirements, and what is the best option for us?

The answers to those questions spark the first steps when we begin to traverse the local healthcare landscape and blend the network and product offerings. Diane Hollie, our Senior Director of Sales, Marketing and Strategy states “Brand is very important when blending two organizations. Will members be buying the Plan for its reputation and benefits or will the Hospital System attract a member base the Plan is currently not attracting and why?”

When plans and providers consider entering into a co-branding PSP (aka Narrow Network) options, a few key considerations are:

The majority of Narrow Network PSPs are Health Maintenance Organization (HMO) products and have risk-sharing contracts.
Increase in volume – Can the health system handle the influx of new patients? If the primary care system is at capacity, what is the strategy to ensure new Medicare members are seen timely?

Resources:

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by GHG Advisors

CMS June Network Submission Deadline Fast Approaching

In early February, there was a bit of a scramble when several plans received notices they had approximately a week to submit their Health Service Delivery (HSD) tables for a network adequacy review. Fortunately, for some, the communication should have indicated the gates were open for plans wanting to test adequacy and receive technical feedback. While it was a stressful 24 hours pending the Centers for Medicare & Medicaid Services (CMS) response on the notice, we hope the false alarm sparked the much needed jump-start to ensure a compliant network adequacy monitoring program is in place.

Unfortunately, we know fire drills do not often produce the continued preparedness needed. Ask kids who grew up in the northeast how many times they shivered in the cold when a fire alarm went off and they did not grab their jackets! Oftentimes, we get busy with pressing contract negotiations or deadlines and push preparing or incorporating a new process off to the side. However, with the shift in network adequacy from an application function to a plan operational requirement, plans that fail to meet network adequacy requirements will be subject to compliance/enforcement actions such as being suppressed from Medicare Plan Finder for the upcoming Annual Election Period until deficiencies are cured or ensuring access to care by allowing members to see an out-of-network provider at in-network cost-sharing. Additionally, the short time frame in which a plan will have to submit their compliant HSD tables to CMS leaves little to no time to mitigate network deficiencies by contracting with new providers and/or doing the detailed research required to validate filing an exception. CMS as well as many states have put sanctions and monetary and enrollment penalties in place for deficiencies in network adequacy and directory accuracy. Plans no longer have a grace period to put off ensuring a compliant network monitoring program is in place.

CMS indicated they will provide plans selected for the network review 60 days’ notice prior to the June submission date. By my calendar, April is just a few days away, and June will be approaching fast. Do not let April Fool’s Day prank you with network gaps. Be prepared, and let’s start spring with a bounce in our step and a plan of action!

At Gorman Health Group, we have provided expertise to government-sponsored plans in effective network management and ensuring compliance with state and federal regulations. Feel free to reach out and discuss how we can assist you in developing the network monitoring program needed to ensure your organization not only meets initial reviews and audits but also develops a comprehensive program that truly utilizes your plan’s largest asset – your provider relationships.

Resources:

Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now

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.

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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by GHG Advisors

CMS Reports Medicare Advantage Provider Directories Continue to be Plagued with Inaccuracies

The Centers for Medicare & Medicaid Services (CMS) issued its Round Two online provider directory review, and the results were dismal. Plans reviewed showed an overall inaccuracy average higher than Year One plans. We can try to marginalize the results and say the average inaccuracy found by location was 48%. Nevertheless, the fact remains that nearly half of all directory locations reviewed were inaccurate. Breaking it down further, the inaccuracies ranged from 11% to 97.82%. We are living in an age of tech-savvy consumerism. If our GPS or Google results proved incorrect half of the time, we would not be satisfied. If results proved correct less than 3% of the time, we would be outraged.

"The report is a black eye for our industry," said John Gorman, Gorman Health Group's Executive Chairman in a recent Modern Healthcare article. "It's easy to fix. We have to do better."

Group practices continue to be a driver of non-compliance with plans listing information at the group level rather than the provider level. In addition to access to care concerns for beneficiaries, often the same database used for provider directories is also used when plans submit their Health Service Delivery (HSD) tables to CMS. By listing every group provider at all office locations, a plan is also inflating their network adequacy results. CMS has intimated any gaps between a plan’s online directory and their network adequacy need to be mitigated in short order and an internal process in place to ensure their continued alignment.

CMS noted the lack of internal auditing and testing remains a compliance gap. Plans have not built the necessary monitoring and oversight needed to be compliant. While there are pilot programs and a few vendors have emerged, technology at large to assist with the administrative burden is lacking. However, until technology or a central database is available, the onus is on the health plan and its providers to work together to ensure data accuracy. Health plans cannot assume a provider will be prompt and forthcoming with changes; a proactive, methodical outreach program coupled with diligent monitoring and oversight must be put into place.

Data inaccuracy tentacles are far reaching and jeopardize the success of numerous key health plan business functions and minimize the return on investment of supplemental investments such as Star Ratings or risk adjustment programs. CMS notes during their outreach in Year Two, information had been out of date for long periods. Providers were found to be retired or deceased for years. As one example of the financial impact, during recent network development projects to support service area expansions, the Provider Strategy team found the data inaccuracies in plan-provided contact information, currently in use for other lines of business, resulted in a significant number of additional hours expended to research and locate or determine the status of providers. The number of inconsistencies found were on par with the overall CMS average for Round Two; additionally, as CMS notes, we found a number of providers who had been retired, deceased, or relocated for a number of years, corroborating the need for plans to proactively reach out to providers on a routine basis

For Year Two, 23 plans were issued a notice of non-compliance, 19 plans were issued warning letters, and 12 were issued warning letters with a request for a business plan. This isn't just a compliance concern -- few things can tank your Star Rating and member experience scores faster than a shoddy provider directory or unexpected medical bills. Before your plan becomes a statistic, reach out to us at Gorman Health Group for assistance. We can provide a wide range of services – from performing a mock review to having a plan self-assessment available through our Online Monitoring Tool™ (OMT™).

Resources:

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.

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

by GHG Advisors

CMS Announces Changes to the Network Review Process for Medicare Advantage Organizations

As anticipated, the Office of Management and Budget (OMB) approved the Centers for Medicare & Medicaid Services’ (CMS’) move to network adequacy reviews on a three-year cycle, unless there is a triggering event that would reset the timing of a Medicare Advantage Organization’s triennial review.

What does that mean for Medicare Advantage plans?

Initially, CMS will pull a sample of active contracts, including those that have not had a full network review since contract initiation, and provided the plans at least 60 days’ notice before the June deadline to submit their networks. If you are a plan that may fall into this category, you have a few short months to ensure your network meets current Health Service Delivery (HSD) table requirements. When considering all the factors that can affect your adequacy, such as changes in required number of providers or simply a change in the location of members in the CMS beneficiary file, it is imperative to begin analyzing the adequacy of your network as soon as possible. Should you fail to meet current standards, there will be limited time in which to mitigate any gaps and be prepared to present to CMS.

For those Medicare Advantage plans that are not in the initial or service area expansion (SAE) application process, CMS will provide the opportunity in February 2018 for plans to upload in the Health Plan Management System Network Management Module and participate in an informal review. However, because of the shift from an application process to an operational function, initial and SAE applicants will have until June to formally submit their networks to CMS. Another key change for SAE applicants: CMS will only review your expansion counties and not your entire network.

CMS has been moving in the direction of ensuring beneficiary protections by establishing new and stringent changes in network adequacy and directory guidance. They have been clear that organizations failing to meet network adequacy standards as well as directory standards will be subject to compliance and enforcement actions. The time to invest in your provider network management program is now.

At Gorman Health Group, we have provided expertise to government-sponsored plans in effective network management and ensuring compliance with state and federal regulations. Feel free to reach out and discuss how we can assist you in developing the network monitoring program needed to ensure your organization not only meets initial reviews and audits but develops an comprehensive program that truly utilizes your plan’s largest asset – your provider relationships.

Resources:

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.

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

by GHG Advisors

Provider Network Management New Year’s Resolutions for 2018

Many of you and your teams are in the frantic, end-of-year trenches renegotiating current provider agreements or working on contracting new providers for a service area expansion, and it is easy to lose sight of all the changes swirling around the provider network arena. As we head into 2018, we would encourage you to incorporate these three key items into your Provider Network Management Department’s performance appraisal goals.

Dust off the antiquated access and availability policy and procedure and take the opportunity to develop an organic network monitoring program that fosters growth, collaboration, and partnerships with your providers. By the Centers for Medicare & Medicaid Services (CMS) moving network reviews from an application process to a plan operational requirement, plans will be subjected to stronger compliance actions. The short time frame in which a plan will have to submit their compliant Health Service Delivery (HSD) tables to CMS leaves no time for mitigation of network deficiencies. Plans need to be more diligent than ever to build a continuous network monitoring program to ensure continual compliance with CMS. In addition, while we have the policy down off the shelf, why not take the opportunity to break down the silos and see how that policy is working for Medical Management, Member Services, and your Star Ratings work plan.

Plans have been making strides in shifting their networks towards value-based contracting, incorporating quality metrics, Star Ratings, and a variety of population health initiatives. However, a significant portion of Medicare Advantage (MA) remains based on traditional fee-for-service (FFS) reimbursement. As we evaluate the impact Medicare Access and CHIP Reauthorization Act (MACRA) will have on MA provider contracting starting 1/1/19, the traditional reimbursement statement current MA contracts typically use, “Provider will be reimbursed according to X% of the Medicare Fee Schedule,” becomes an old stand-by with potentially serious consequences. At a minimum, plans need to clarify the change MACRA will bring to the definition of “Medicare Fee Schedule” in their existing provider agreements and carefully evaluate how it aligns with any penalties/bonuses that can occur under both Advanced Alternative Payment Models (APMs) and Merit-based Incentive Payment System (MIPS).

As much as I would like to say there have been significant improvements in data integrity, inaccurate provider data continues to plague health plans and has far-reaching tentacles into health plan operations as a whole. We saw plans have quick success in updating provider directories only to fail at building sustainable processes with checks and balances and end up only slightly better than the first effort.

Please reach out to Gorman Health Group for assistance in developing a network management strategy to include the key items above.

Resources:

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.

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

by GHG Advisors

Three-Year Network Adequacy Review for Medicare Advantage Plans

If the Centers for Medicare & Medicaid Services (CMS) knocked on your door today, would you be ready to submit a compliant provider network within 60 days? CMS estimates the proposed three-year network adequacy review for Medicare Advantage (MA) plans would mean just that for approximately 304 MA plans for calendar year 2019.

Normally this time of year we remind plans to start contracting with providers in order to meet CMS network requirements for new and service area expansion needs. This reminder still rings true. Given the lead-time it can take to negotiate contracts with providers and facilities, plans need to be proactive in the recruitment/contracting department to ensure you have a compliant network within your proposed expansion area. Moreover, while the proposed CMS changes may not require plans to submit a Health Service Delivery (HSD) table with the initial or service area expansion application, it does not negate the requirement to meet CMS standards for an adequate provider network.

The three-year network review would require plans that have not had a triggering event within the past three years to submit their HSD provider and facility files via the Network Management Module within the CMS Health Plan Management System (HPMS). Currently the triggering events are:

1. Initial Application
2. Service Area Expansion (SAE) Application
3. Initial Offering of a Provider-Specific Plan
4. Potentially Significant Provider/Facility Contract Termination
5. Change of Ownership
6. Network Access Complaints
7. Organization-Disclosed Network Deficiency

Reviewing plan network adequacy was born out of beneficiary protections and member complaints. And while there is some concern moving to a three-year cycle could impact beneficiaries negatively by lessening the upfront review, there is greater concern for beneficiaries enrolled in a plan that may not have had any sort of triggering event and have never had their provider network reviewed since they first applied. By moving the network reviews from an application process to a plan operational requirement, plans will be subjected to stronger compliance actions. The short time frame in which a plan will have to submit their compliant HSD tables to CMS leaves no time for mitigation of network deficiencies. Plans need to be more diligent than ever to build a continuous network monitoring program to ensure continual compliance with CMS.

If you are looking to expand your network footprint or want to be proactive in reviewing your current network status and building a compliant network monitoring plan, Gorman Health Group can help. Our veteran teams of consultants are available to assist with all your contracting and expansion needs as well as with the review of your current network and helping you develop a monitoring plan before CMS knocks on your door.

Resources:

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by GHG Advisors

Top Challenges in Provider Data Management

While health plan provider directory inaccuracies have been at the forefront of the news, regulatory agencies, and consumer protection agencies, the directories are only the tip of the iceberg in how difficult provider data management is for health plans. Plans continue to gather information on providers in a multitude of ways and from a variety of functional areas, continue to create conflicting repositories of provider data, and thus continue to face the painstaking and almost always manual validation of provider information.

As we have worked with clients through Medicare Advantage service area expansion applications, exception process, and the upcoming bid filing, we have repeatedly seen plans faced with spending hours having their provider teams manually tracking down providers and correcting provider information in order to prepare accurate Health Services Delivery (HSD) tables and exception request forms. A few of the top challenges found have been the following:

The CMS Provider Supply File: Centers for Medicare & Medicaid Services (CMS) offered an olive branch in providing the list of servicing providers they use as a source when reviewing a plan’s provider network. Plans, however, had a difficult time validating the provider information they had internally against the Provider Supply File and using it to their advantage in preparing network exceptions.
Inter-plan relationships and provider sharing between lines of business oftentimes had unclear boundaries on which providers could be used or were contracted for the various products at hand.
When reviewing an overall coverage area, they appeared complete; when broken out into potential provider-sponsored plan (PSP) offerings, provider gaps were found.

With all three of these situations, plans were affected by a lack of time to mitigate the compliance risk facing their networks. As health plans move forward in finding ways to keep their directories in compliance, we challenge you to take a step back and look at provider data management in a holistic manner to solving directory, credentialing, and network adequacy issues, improving care management with better data management on what your network partners offer, improving relationships with your Star Ratings and risk adjustment vendors, and ensuring a strong network management program. With a spotlight on network management across all government-sponsored programs, let Gorman Health Group be your partner in designing a provider data management system that will meet your needs.

Resources:

GHG’s multidisciplinary team of experts will assess the alignment of your products, your current network and your market to 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 >>

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

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. Contact us today >>

by GHG Advisors

Teaming with Providers: Collaboration to Achieve Results

When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs).

As health plans continue adapting to the growing influence of quality metrics on their provider network operations, building an effective team with your providers has never been more important or more challenging.

However, factor in the necessities of compensating members of the team for their role, of each side meeting its profit targets, and the competing priorities faced by often short-staffed offices, it should come as no surprise many health plan staff members and providers are left wondering how to make it happen.

We have focused on designing incentive plans to promote compliance with regulatory requirements but to also meet our clinical and financial goals. To remain provider centric, it is imperative we as plans understand where providers are in the spectrum, not only in their ability to take on risk and make the shift from fee-for-service (FFS) to value-based reimbursement, but also in their overall infrastructure. During various projects, we have shadowed highly-skilled provider relations representatives as they travel in the field to meet with office managers and providers. Often we have found plans have incorrect office addresses. If internally we are not able to easily find our providers, it is doubtful our members or the vendors we hire, for example, Star Ratings and risk adjustment vendors, will have an easy time finding our providers either. This lack of correct provider demographics affects your sales and marketing team, enrollment, member services, and clinical teams. It prevents your internal team members and vendors from gathering the information they need in a timely manner.

How do we as a health plan balance the range of providers in our network? How can we ensure the employed doctor with a large integrated delivery system has his/her needs met while at the same time engaging the single-office practitioner and ensuring his/her goals are met?

Meeting the needs for each of these scenarios and others starts with how well defined our provider incentive programs are. Do they adequately support the clinical and financial goals of the plan and the provider? Have we built an incentive program that has achievable and actionable benchmarks for each type of provider in our network?

Whether your providers are still FFS or at full percentage of premium risk, a few building blocks will ensure success:

Healthcare Is Local: Have we done our benchmarking for incentive programs at the local/regional level to ensure we are measuring apples to apples and taken into account the local practice of medicine?
Prioritization: Ensure Clinical, Risk Adjustment, Star Ratings, Claims, and Network Operations are all collaborating and prioritizing their “asks” of the providers and working together to ensure the needs of the providers are met.
Education, Education, Education: By arming your leaders with the education necessary to purchase the best reporting tools, they are able to develop the goals and framework necessary for the frontline staff to educate and respond to providers.
Data Validation Reviews: Data integrity starts with collecting and configuring the provider data at the start of the contracting and credentialing process and becomes critical for downstream health plan operations.
Focus on Actionability: Health plans often provide catalogs of reports each month showing providers numerous views of their panels and sometimes forget providers are taught evidence-based medicine and how to care for patients, not administrative functions. By telling providers to improve care, we can make them vulnerable and defensive. By collaborating to improve processes and coordination for better patient satisfaction and outcomes, we can let providers be providers.
Continuous Measurement, Re-Evaluation, and Reward: While we naturally monitor our outcomes and re-evaluate our processes, we sometimes forget to reward ourselves for a job well done. We can build in contractual provider incentives, but peer recognition and a “thank you” are often simple but overlooked motivators.

There is no one straight line to navigate the path from FFS to pay for performance to risk for the plan or the provider, but there is one way to ensure success on that path ‒ collaboration between the plan and the providers. At Gorman Health Group, we are experienced in breaking down the silos and barriers and helping health plans be transparent in their actions and reporting. We can support your health plan to build the trust needed to ensure it is more than just “checking the boxes” on the incentive plan but rather seeing the success in better patient outcomes and lower expenditures.

Resources

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by GHG Advisors

January Release of the Draft MMG - Perfect Timing

It’s still January, and, yes, the Centers for Medicare & Medicaid Services (CMS) has released the draft 2018 Medicare Marketing Guidelines (MMG). Perfect timing! The Annual Election Period (AEP) has come and gone, and here we are once again, having post-mortem discussions on what went right, what went wrong, and where to go from here. Once you have gathered all the necessary data, the next logical step is to begin planning for 2018 and revising your sponsor and organization strategies for Sales and Marketing. Don’t forget to review and provide feedback to CMS on the draft MMG changes. Although there weren’t many major updates (CMS provides mostly clarifications this year), there are a few key items that we highlight below:

30.5.1 – Multi-Language Insert
CMS essentially removed the standard Multi-Language Insert (MLI) section we have all become familiar with and defers to the requirements under Section 1557 and all questions to the Office for Civil Rights (OCR). Given the many interpretations of Section 1557 compliance and the confusion we saw around implementation of these requirements, it should be interesting to follow industry updates now that CMS is deferring sponsors to consult with OCR. Now more than ever, make sure your organization understands the requirements, documents the implemented process adopted within your organization, and consistently and compliantly operationalizes this process.

50.4 – Disclaimer on Availability of Non-English Translations
Previously, sponsors which met the five percent threshold for language translation were required to include the applicable disclaimer on all marketing materials. In the MMG draft, CMS updates the disclaimer and simplifies the requirement to a set list of documents only: Annual Notice of Changes/Evidence of Coverage (ANOC/EOC) or EOC, Low-Income Subsidy (LIS) Rider, Formularies, Star Ratings, Summary of Benefits (SB), and the Part D Transition letter. In addition, CMS proposes requiring the non-English translation of the disclaimer only – the English version is no longer required. Consider this draft change as you prepare marketing materials for 2018.

70.11.2 – Provider Affiliation Announcements
Here, CMS clarifies sponsors and/or contracted providers may not announce new or continuing affiliations until the contractual agreement has been approved. If implemented in the final MMG, organizations will need to ensure contractual agreements are complete and approved before any announcements of the relationship are published. CMS removed some announcement parameters from the section as well. For example, CMS previously stated announcements could be made once within the first 30 days of new contract agreement. Since this implied the contracts needed to be in place, clarification was needed to the section since they removed the sentence which limited the number of announcements. Also, CMS reminds sponsors affiliation announcement materials that contain benefits, premiums, or cost sharing are considered marketing materials. It is up to the sponsor to ensure providers adhere to distribution and mailing guidance.

100.7 – Third-Party Websites
Brand new section to the MMG! Sponsors are now required to submit third-party marketing websites that contain plan names or logos, even if there is no benefit information included, to CMS’ Health Plan Management System (HPMS). This includes any online forms that need to be filled out to receive more information about Medicare Advantage (MA) or Part D plans, including generic forms used to obtain information about non-MA or Part D plans. CMS includes that third-party websites may not:
1. Request health status information, such as pre-existing conditions, weight, and whether a beneficiary smokes;
2. Provide misleading information, such as identifying a Medicare Supplement plan as an MA plan;
3. Use prohibited terminology, including unsubstantiated absolute superlatives.

This list looks like it is made up of no-brainers and is consistent with requirements, but chances are, CMS has included this in the draft MMG because it is occurring in the industry. When preparing your website development, review, and submission schedule for 2017, don’t forget to include your third-party marketing websites. This will be on CMS’ radar, and it is up to the plan sponsors to ensure compliance of their third-party marketing website vendors.

120.4.1 – General Rules Regarding Compensation
CMS adds new language to this section indicating that plans may not pay agents/brokers who have not been trained and tested. If implemented in the final MMG, organizations will need to update payment processes to ensure agents who have not passed the training and testing are not paid.

The above is not an exhaustive list of the draft 2018 MMG updates. CMS is specifically requesting comments and questions from plan sponsors on proposed updates on provider affiliation announcements and third-party websites. Consider how this will impact your organization, and be sure to take advantage of CMS’ request for comments!

In addition to the release of the draft MMG, another hot topic we must also consider for our 2018 planning is provider directory accuracy. Last week, 21 Medicare health plans were warned to fix their provider directories – 18 warning letters and 3 warning letters with a request for a business plan to outline efforts to correct errors. In addition, 31 notices of non-compliance were delivered. Plan sponsors must have compliant directories. As recently as January 17, CMS released a memo titled “Provider Directory Policy Updates,” reiterating existing policy but also providing additional guidance. Don’t fall short on this – it’s no easy task and cannot be taken lightly. Spend time on this topic and develop robust data gathering techniques to keep your directories accurate.

Not sure how best to plan for 2018 or decide which strategies are best for you? This is not a one-size-fits-all industry, and we are here to help. Let us partner with you in developing appropriate, compliant, and effective sales and marketing strategies.

Resources

Don’t miss our webinar on Tuesday, January 31, at 1:00 PM EST, where we will provide an informative session on how to conduct a feasibility study to develop a successful growth strategy for your organization. Register now >>

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.

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

by GHG Advisors

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!

Resources

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.

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

by GHG Advisors