CMS gears up for major quality performance program overhaul for ACA program
The Centers for Medicare & Medicaid Services' (CMS') recent issuance of the 2017 Letter to Issuers in the Federally-facilitated Marketplaces and Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule affirms the agency's plans to elevate the importance and transparency of quality performance by Qualified Health Plans (QHPs). Despite the continued absence of financial incentives for high-quality QHP performance, CMS' approach to quality oversight for QHPs is looking much like the early years of the Star Ratings program within Medicare Advantage (MA).
Similar to the MA Star Ratings program, CMS will use a 5-star scale to assign a Quality Rating System (QRS) rating to each QHP based on validated clinical measurements and enrollee survey responses. This year marks the first year QHPs must display these quality ratings prominently to consumers on their websites during the open enrollment period. Public reporting of these clinical measurements and enrollee survey responses will not only offer both consumers and providers new insight into a QHP's clinical quality performance but will also spotlight the consumer's perception of the QHP's operations.
The Affordable Care Act requires QHPs to submit a Quality Improvement Strategy (QIS) for the 2017 plan year if they offered coverage through the Marketplace in 2014 and 2015 and meet certain additional criteria. CMS requirements for the QIS, which must be submitted during 2016 and implemented no later than January 2017, include implementation of:
- A payment structure that provides increased reimbursement or other incentives to providers or enrollees to improve quality and reduce costs by incentivizing high-value rather than volume-driven care, and
- At least one of the following:
- Activities for improving health outcomes;
- Activities to prevent hospital readmissions;
- Activities to improve patient safety and reduce medical errors;
- Wellness and health promotion activities; and/or
- Activities to reduce health and healthcare disparities.
Because strong quality performance is necessary for long-term viability, QHP leaders will likely set new quality-related performance goals and evaluate whether current operations may need to be adjusted to meet those goals. Achieving such goals amidst the ongoing industry evolution, within the competitive environment, and within budgetary constraints will require innovation and creativity. Fortunately, many QHPs can lean into their own organization's Star Ratings experiences, expertise, and successes to help with these efforts.
An increased focus on quality, enrollee experience, and outcomes within a QHP will likely require new, short-term resource investments. Investments may be needed in areas such as population health management tools and analytics; member outreach, support, and education; and provider education, support, and engagement. By collaborating with their MA colleagues, QHP leaders may be able to leverage and expand MA tools, tactics, and expertise to simultaneously avoid the "learning curve," minimize provider abrasion, and optimize outcomes through such investments. With careful planning and strategic deployment of resources, a QHP can leverage its short-term investments for long-term return on investment.
Whether your organization is developing a QIS for your QHP, seeking insight to help align your QIS with successful Star Ratings strategies and tactics, or needs help interpreting the quality data recently provided by CMS, we can help. For additional questions and inquiries about how Gorman Health Group can support your QHP quality programs, please contact me directly at msmith@ghgadvisors.com.
Resources
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Operations Mistakes Will Be Costly — Highlights of the 2017 Draft Call Letter
There was a time when operational areas were shooting for 98% accuracy as the "golden" number. In today's age of data and focused audits, even 99% may not be enough. The Call Letter doesn't have many surprising new risk areas for Operations. No new crazy regulations to ponder how we can possibly implement them. Instead, they have something worse: the addition of teeth to the new regulations. Why is this worse? Because the focus is on areas Operations and plans often struggle with and eventually accept status quo as good enough. How many times have you heard or possibly said, "What are our peers doing?" and used them as the measuring stick.
Some of the key focuses to keep operational eyes on are:
- One-Third Financial Audit Results — Don't skip this section thinking this is Finance and doesn't involve Operations. One-third financial audits are full of operational reviews with direct member impact. The Draft Call Letter is indicating, beginning with 2017, one-third financial audits for plan year 2015 will have potential enforcement action like civil money penalties (CMPs) assessed for findings with adverse beneficiary impact. The Centers for Medicare & Medicaid Services (CMS) specifically calls out increased or incorrect cost-sharing or copayments as items of concern. Reviewing your benefit setup and claims processing to ensure controls are in place for adequate application of copays is a fundamental process but one in which CMS is seeing discrepancies year after year. Plans should review their controls or Medicare Secondary Payer (MSP) processes, their provider fee schedule process, and their benefit setup processes to ensure beneficiaries are protected and benefit designs are operationalized each year as filed with CMS.
- Timely Processing of Coverage Determinations and Redeterminations — Your plan may delegate coverage determinations and possibly redeterminations, but whether delegated or processed in house, the plan is responsible. CMS is seeing a continued high volume of auto-forwards of coverage determinations and redeterminations to the Independent Review Entity (IRE) when these functions are not processed within required time frames. CMS is indicating they will be taking action against plans with high volumes—no waiting for an audit and a review of the results. CMS has the data to know there is a problem. Have you looked at your numbers? Do you know your auto-forward volumes? Better yet, do you know the root causes and mitigations to ensure there are no auto-forwards and no negative beneficiary impact?
- Data Integrity — Once again a misleading title that has big operational impacts. CMS is raising concerns CMS program audits are identifying issues that may impact Star Ratings data used for Star Ratings. CMS is indicating they are looking at tying audit findings to data submitted for Part C and Part D reporting and Star Ratings where the audit may have raised concerns. CMS is indicating finding issues within other reviews, such as program audits, may result in review of submitted data for Star Ratings. They are right—it is a holistic approach health plans should be using to get ahead of this curve. If during an internal audit at the health plan a finding occurred indicating grievances were under-reported, is there follow-through to reconcile that under-reporting and revise Part C and Part D grievance reports? In our often-siloed departments and processes, that type of follow through doesn't often occur.
We are all busy. Few of us in Operations have the luxury of focusing on one product or function. We are all trying to keep multiple balls in the air. But if we don't take time to evaluate, stabilize, and set up good controls, we won't survive unscathed. The last thing any of us want is an enforcement action that will take time and energy to resolve and will ultimately impact our members, resulting in most or all of the balls crashing down. Our multi-disciplinary team of consultants has been in your shoes—we have juggled the same balls and are ready to partner with you. Contact us to get started >>
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For actionable advice and best practices, join us at our annual Gorman Health Group 2016 Forum, April 19-20, at the Worthington Renaissance Fort Worth Hotel in Fort Worth, Texas. During this year's information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn't. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth. Register now >>
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CMS Releases New Medicaid Rule, OMB in Final Review
Last week, the Centers for Medicare & Medicaid Services (CMS) finalized the new Medicaid rule — a 653-page proposal requiring Medicaid managed care organizations (MCOs) to enhance their network adequacy, establish quality ratings, set a medical loss ratio (MLR) threshold of 85%, and develop a robust managed long-term care program. The new Medicaid rule has now been sent to the Office of Management and Budget (OMB) for final review. This means the new Medicaid rule could be published by mid- to late May. There are 39 states and the District of Columbia that currently outsource their Medicaid programs and about 46 million lives that will be affected by this new change.
Some of the proposed changes that were up for consideration:
- Medical Loss Ratio — CMS proposed an MLR of 85% for Medicaid managed care plans, the industry standard for Medicare Advantage (MA) plans. CMS proposed to mostly use commercial rules in calculating and reporting MLR due to the "need for consistency" between plans in the Marketplace and in Medicaid.
- Appeals and Grievances — The proposed rule made a few updates to the appeals and grievances process to align with MA plans. For example, the rule seeks to shorten the time frame in which MCOs and Prepaid Inpatient Health Plans (PIHPs) have to make a decision about a standard appeal from 45 days to 30 days, the same as MA plans. The expedited appeal time frame would be shortened from 3 days to 72 hours, also the same as MA.
- Beneficiary Protections — Under current regulations, coordination and continuity of care focus on primary and acute medical care. The proposed rules aim to reduce coordination issues beneficiaries with chronic and complex conditions face. The proposed rule also seeks to align enrollment practices between Medicaid fee-for-service, Medicaid managed care, and Marketplace coverage.
- Create standards to evaluate network adequacy and ensure beneficiaries are receiving accurate network information.
- Medicaid Managed Care Quality Rating System — Align with existing MA and Marketplace rating systems. Standardize quality metrics among states and plans.
- Updates to rate development standards and actuarial soundness of capitation rates, with a focus on federal oversight and a more detailed process to ensure actuarial soundness.
- Calls on states to update quality strategies at least once every three years. Currently, some states are operating on strategies drafted more than five years ago. States are called on to develop a description of quality metrics and performance targets the state will use to assess Medicaid managed care quality.
Let the team of experts at Gorman Health Group (GHG) help you prepare for the upcoming changes that could impact your organization. GHG's risk adjustment experts can help analyze the financial impact, develop feasibility models to help with meeting the new MLR requirements, and provide guidance on streamlining operations. GHG's Compliance Solutions can assist in the development and monitoring of these new contract requirements, and our clinical team can assist with reviewing and developing integrated care models to provide quality initiatives that are effective and efficiently managed to get optimal results.
For more information, contact me directly at sjanicek@ghgadvisors.com.
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There's a Lot to Like and to Fear in the 2017 Medicare Advantage Call Letter
On Friday after the close, the Centers for Medicare & Medicaid Services (CMS) released the 2017 Medicare Advantage (MA) Call Letter with proposed policy and payment changes. There's a lot to like — and much to fear. On payments, CMS came in with higher-than-expected rates that make clear the long walk in the desert from cuts in the Affordable Care Act (ACA) is over. But on compliance, they are rolling out the firing squad with a broad mandate, and the Administration will leave its mark long after Obama has left office.
What We Like:
- The draft offers all-in rates of +1.35% and a trend of +3.05%, better than last year and better than expected.
- CMS is leaving home visits for MA risk adjustment untouched. If ever CMS was going to clamp down on this after years of threats, this was the time — in the last year of the Administration. By not doing so, we think they're closing the book, acknowledging much good also comes from these house calls, and the home is the most underutilized source of care in the delivery system for seniors. Despite MedPAC recommendations and a drumbeat of op-eds, CMS didn't want to throw the baby out with the bathwater.
- There are big proposed changes to risk adjustment and Star Ratingsfor MA plans serving dual eligibles.
- CMS would launch a new payment system with six subcategories: full duals, partial duals, and non-duals, for both aged and disabled beneficiaries. The net effect is like a crude, mega-risk adjuster, paying plans with more duals bigger, more accurate payments, while paying slightly less to plans with fewer duals.
- On Star Ratings, CMS is proposing an adjustment on three key measures — the overall plan rating, and Part C and D summary ratings — which will increase ratings for plans with higher proportions of duals and could increase bonus payments if the plan is 4+ stars. This is a big win for the industry.
- The health insurer issuer tax has been suspended for a year (and will return in 2018).
What We're Worried About:
- The rapid acceleration from 10% to 50% encounter data driving risk adjustment could depress risk scores. It's clear CMS is moving to 100% encounter data as quickly as possible and likely presages the use of encounters and not Fee-for-Service (FFS) claims to calculate risk factors as well as the phase-out of the coding intensity adjustment.
- CMS is proposing changes for Employer Group Waiver Plans (EGWPs) that amount to a "tax" on sponsors designed to reduce Medicare's spend on these 3 million of the 18 million beneficiaries in MA. EGWPs typically bid much higher than individual MA plans, and the proposal will likely result in a cost-shift to group members or a reduction in supplemental benefits. There was no estimated impact given, so watch this closely.
- CMS made it clear Star Ratings low performers will be executed by firing squad as early as next week. The Call Letter states plans rated below 3 stars for 3 consecutive years will be terminated in February 2016 for a December 31 effective date. Three to six plans qualify for termination. This will be the timeline for future years, and CMS states these decisions are non-negotiable.
- Huge news here on the compliance front:
- CMS notified Part D sponsors it's stepping up enforcement actions on coverage disputes and complaints, the leading noncompliance issue for plans.
- Plans failing the financial audits conducted on one-third of plans each year will no longer be subject to corrective action plans but rather sanctions and civil monetary penalties.
- CMS is ramping up audits and enforcement actions in network adequacy, provider directory accuracy, and medication therapy management programs.
As always, we now enter the frenzied public comment/lobbying phase where the industry tries to get an even better deal, with the final policies announced April 4. As these things go, MA plans should be generally happy about the financial picture while getting down to the busy work of getting the compliance house in order. Most of what's proposed here, we think, becomes the "new normal" long after Obama has left office.
Resources
Join John Gorman, GHG Executive Chairman, and colleagues, Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, GHG's Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document. Learn what the proposed "methodology changes" could mean for your organization and its partners, and the steps you can take to soften the impact on Tuesday, March 1 from 2:30-3:30 pm ET. Register now >>
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10 Years of Star Ratings: Lessons Learned
The year 2016 marks the tenth year Medicare Advantage (MA) plan performance data has been collected for evaluation under the Centers for Medicare & Medicaid Services' (CMS') Star Ratings program. While we await the "new news" from CMS about new Star Ratings measures and other program updates in the impending Advance Notice, we thought it appropriate to celebrate this important milestone by looking at lessons learned through our first 10 years of Star Ratings and share some insights on how plans can leverage these lessons through the program's continued evolution.
Star Ratings, and the quality bonuses associated with strong Star Ratings performance, put MA plans squarely on a fast-track to rapidly improve MA beneficiaries' experience of healthcare (including quality, access, and reliability), to improve the health of the MA population, and to reduce or control the cost of healthcare within MA. As a result, MA plans have made tremendous investments of effort and resources over the past few years in the sprint to develop, deploy, and measure a whole host of tactics intended to achieve the all-important 4-Star Rating. The downside: these years of "trial and error" were often challenging, the work was often tiring for key personnel, and many plans built programs, reports, and tactics that may have worked well for yesterday's measures but which may not be ideally suited to support CMS' longer-term outcomes focus within the Star Ratings program. The upside: we now know, in great detail, the workflows, tactics, and population health strategies that efficiently and effectively support not only strong performance on quality measurement programs but also progress towards the Triple Aim.
During these last few days of calm before the annual Advance Notice and Call Letter season begins, here are a few strategic questions for your team to consider as you review CMS' proposed program updates during the coming weeks:
- Is your Star Ratings work plan achieving the level of success you desire?
- How will your Star Ratings work plan need to be updated to meet CMS' Star Ratings program updates? Are your 2016 tactics capturing the potential new measures under consideration by CMS?
- Which elements of your Star Ratings work plan are working well, and which need to be adjusted to achieve your goals?
- How are you leveraging the "basics" of Star Ratings such as care coordination, comprehensive diabetes care, medication adherence, and medication therapy management within your Medicaid, Accountable Care Organization (ACO), Marketplace, and Commercial populations?
- How effectively has your Star Ratings strategy improved outcomes and/or reduced costs?
- Do current workflows adequately address members' social and lifestyle needs (e.g., nutrition needs, stable housing, transportation, etc.)?
- How streamlined do your providers perceive your Star Ratings programs to be? How aligned are your Star Ratings programs with the many other quality programs in which your providers participate? How can your providers best support your quality needs?
Star Ratings success requires forward-looking precision to meet the needs of your members and your providers within the constraints of your budget while delivering strong performance in areas where your population or network under-performs the national average.
We understand success isn't easy, and evolution can be difficult. Whether you are looking to improve performance on just a few measures, need assistance interpreting the impending announcements in the Advance Notice, or are ready to more comprehensively evaluate your current Star Ratings program, we can help. For additional questions and inquiries about how Gorman Health Group can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.
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This Is the Year to Get It Right
Five consecutive years of very similar audit protocol, continuous partnering with sponsors to identify improvements, and numerous best practice/common conditions memos. Where are you in audit readiness? Did you evaluate the items in the 2016 Readiness Checklist sent in November? I will get back to that! In the meantime, the Centers for Medicare & Medicaid Services (CMS) has started sending audit letters, so we are aware of sponsors and Pharmacy Benefit Managers (PBMs) alike who are prioritizing CMS' requests. Early bird catches the worm, am I right? Presumably these plans have larger enrollment, since they will only be required to provide rejected claims for the one month of January.
Some priorities have not changed: Formulary Administration, Compliance Program Effectiveness, Organization Determinations, Coverage Determinations, Grievances and Appeals, and Model of Care activities are all still part of the base protocol. CMS has committed to releasing pilot protocol to review Medication Therapy Management (MTM) as well as Part C Provider Network Adequacy. Why this additional focus?
- CMS' focus on the reduction of opioid use may be one aspect of piloting the MTM protocol.
- The additional focus on Medicare Advantage (MA) networks is critical. In the past, there was not a requirement to evaluate providers to determine if they were open to new patients or not. If they were contracted and credentialed, then they were used for network adequacy. That does little good for a new member who cannot access that provider.
If you haven't done so, it is time to circle the wagons. CMS is managing a continuous cycle of new audits, audit report finalization, corrective action plan (CAP) review, and validation requests for a variety of sponsors. You cannot change past data, but you can put in place changes that could make improvements for you going forward. Nothing is more important (arguably) than ensuring your Compliance Program is strong. If you have a robust (and documented!) system for auditing and monitoring, you have a greater chance of finding shortfalls before CMS does. Earlier, I mentioned the 2016 Readiness Checklist, which was released on November 20, 2015. This is the sentence that keeps me up at night:
Should you identify areas where your organization needs assistance or is not/will not be in compliance, your organization must report those problems to your Account Manager directly by email in a timely manner.
While this could be viewed as a requirement to notify CMS upon checklist review (which should have been done prior to 1/1), a conservative interpretation would state that at any time, should you identify areas where the organization won't be in compliance, the organization must report to the Account Manager. If you look at it that way, then anything on that checklist pertinent to the program audit areas and identified as non-compliant in your audit period best be indicated as disclosed and not self-identified. Otherwise, CMS might ask why they didn't know about it prior. If you have not received an audit notice yet, do yourself a favor and evaluate your recent disclosures. The list you send to CMS will encompass items from January 1, 2016, through the start of the audit notice.
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CMS audit practices have radically changed in recent years. Now with only days to prepare for CMS audits, organizations must become proactive in creating a culture of compliance. From a gap analysis to a comprehensive, deep-diving Part C and D audit, our team can help you minimize your compliance risk and maximize your time and resources. Visit our website to learn more >>
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Is Value-Based Insurance Design All It's Cracked Up To Be?
There continues to be a lot of buzz about value-based insurance design (VBID). VBID is the idea that consumers' out-of-pocket medical costs should be based on the value of a service to their health and not the price. Health Affairs defined VBID as "an approach that attempts to improve the quality of care by selectively encouraging or discouraging the use of specific healthcare services, based on their potential benefit to patients' health, relative to their cost."
Treatments, medications, and procedures evidence has shown to be effective and recommended for a condition are provided at no or low cost to the patient. Care that is ineffective or unnecessary is priced higher to discourage utilization. Corporations like Pitney Bowes, Caterpillar, and Marriott, and organizations like Oregon Educators Benefit Board and the Colorado Springs School District 11 have implemented several models of VBID. Reported outcomes include savings from reduced adverse events like hospitalizations and emergency department visits.
Some Medicare Advantage Special Needs Plans have designed their benefit structure along the lines of the value-based model. For example, members who have diabetes have $0 copays for necessary medications and may have additional benefits like gym classes, cooking classes, and Certified Diabetes Educator access.
Designing a value-based benefit for Medicare patients with chronic conditions begins with a review of the peer-reviewed treatment guidelines. These treatment guidelines can be accessed at https://www.guideline.gov/. Medications designated as first-line therapy should be provided at very low or $0 copays. Medications lower on the list, such as third- or fourth-line therapy, can be placed on a different/higher tier. Lab tests, provider visits, and other recommended therapies (physical therapy, exercise, dietary requirements, etc.) can also be provided at low cost to the member. Most chronic conditions lend themselves to a value-based design. Barriers like the cost of a custom formulary will hopefully be resolved by more industry uptake of VBID.
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Gorman Health Group can map the right strategy for realizing value-based care by aligning clinical and revenue cycle workflows for faster and more accurate payment, redesigning care delivery models to benefit from outcomes-based reimbursement, transforming the quality and effectiveness of care, as well as designing a value-based benefit for your members with chronic conditions. Visit our website to learn more >>
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Star Ratings Update: MedPAC Votes to Eliminate Double Bonuses
Star Ratings is already a hot topic in 2016, and we're only one month into the new year. In most recent news, the Medicare Payment Advisory Commission (MedPAC) unanimously voted last month to eliminate the double bonuses associated with Star Ratings, while also virtually unanimously voting to exclude diagnoses collected during in-home assessments from the Medicare Advantage Risk Adjustment model. Although the Centers for Medicare & Medicaid Services (CMS) may opt to take an alternate approach to resolve Risk Adjustment issues within Medicare Advantage, and since CMS can't independently remove double bonuses with amending certain elements of the ACA legislation, this new development is a great reminder of the need to periodically pause and evaluate the value and ROI of programs which remain prominently placed on CMS' radar screen.
When CMS continued their support of in-home assessments in the 2016 Call Letter, we all breathed a collective sigh of relief. And since that announcement, we have seen significant effort by both health plans and vendors to make these assessments even more clinically and socially focused while simultaneously aligning them with Star Ratings measure needs. As a result, any strategic changes made in response to MedPAC's January votes could have a pervasive impact on the care models and operational structure health plans have come to rely on for Star Ratings success. CMS' response to MedPAC's recommendations, along with the plethora of other potential Star Ratings program updates may not only impact health plans and providers, but could also impact a wide array of health services purchased through vendors.
Many health plans (and their vendors) have leveraged risk assessment work streams to hardwire carefully-planned and strategically-prioritized clinical care and care planning activities into in-home assessment workflows in order to seamlessly impact Star Ratings and achieve multi-faceted return on investment (ROI). In addition, the data collected during risk assessments is often stored in centralized data warehouses and used throughout the health plan as a foundation for population health, care management, and consumer experience strategies. And if that wasn't enough, because members often value the relationship with, and advice received from, the clinician they allow into their home, any changes to in-home assessments introduce a host of new risks relative to self-care and disease management, member satisfaction, and consumer experience.
As we await guidance from CMS regarding their response to MedPAC's recommendations and regardless of how CMS ultimately responds to both issues, this is a great time for leadership to study and thoughtfully consider a number of decisions which could result from either the elimination of double bonuses or changes to CMS' treatment of in-home risk assessments:
- What is the downstream Star Ratings impact of any benefits proposed for reduction or elimination?
- How have quality, medical management, pharmacy, Star Ratings measure gap closure, member retention, and other strategic priorities been hardwired into in-home risk assessments?
- What is the secondary ROI from in-home risk assessments on Star Ratings measures, health outcomes, medical loss ratio (MLR), member satisfaction, and member retention?
- Are current work streams adequate to support strong 2016 performance on new Star Ratings measures under consideration for addition to the Star Ratings program?
- How is each department using the data collected during in-home risk assessments?
- How well positioned is the provider network to serve the care planning and care management needs of members currently receiving in-home assessments?
- What types of alternative workflows and tactics will be used in the event diagnoses obtained from in-home assessments are not allowed for risk adjustment purposes?
Because time is of the essence in our industry, strategic planning and change management never ends. As John Gorman has said for years, it will be the most adaptable plans which will both survive and thrive through the tumultuous industry evolution.
In-depth analysis and industry-leading commentary on the key announcements from CMS and MedPAC can be found in this recently created white paper.
Gorman Health Group (GHG) can help you adapt your Star Ratings approach to account for these potential changes and streamline your Star Ratings strategy to influence health outcomes while remaining compliant with CMS regulations. For additional questions and inquiries about how GHG can support your organization's Star Ratings programs, please contact me directly at msmith@ghgadvisors.com.
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Network Adequacy Top of Mind for CMS
The Centers for Medicare & Medicaid Services (CMS) continues to reinforce its focus on health plan provider networks with several recent announcements.
The release of the new Network Management Module (NMM) within the Health Plan Management System (HPMS) is the tool CMS will utilize for monitoring network adequacy. The NMM functionality allows both CMS and organizations to evaluate health services delivery (HSD) provider and facility networks separate from the annual application process. The NMM employs the same evaluation criteria and calculations currently used by the automated network review portion of the Medicare Advantage (MA) initial and Service Area Expansion (SAE) application process. Please note organizations can access the NMM functionality to submit their network tables for an "organization-initiated" automated review. Results generated for an "organization-initiated" review will only be available to your organization and not be viewable by CMS. Our subject matter experts at GHG are able to assist plans in utilizing this new functionality as part of an overall network audit and maintenance policy plans should adopt to continually assess how their network, as its largest asset, meets the goals of the organization.
Additionally, CMS released the Draft 2017 Letter to Issuers in the Federally-facilitated Marketplace (FFM) on December 23, 2015, and is proposing new policies on network adequacy and monitoring to provide more transparency and detail to be Qualified Health Plans (QHPs) in an FFM to fulfill the requirements to provide reasonable provider access to their members. Plans have the ability to review the draft letter and provide comments back to CMS by January 17, 2016. We have provided a link to the full draft letter, and, as with MA plans, Gorman Health Group (GHG) has the ability to manage your network adequacy reports and audit for all QHPs.
Lastly, on January 13, 2016, CMS provided training on the summary of changes to the 2017 MA applications. One of the key points addressed is the SAE application will require HSD Tables for the entire Medicare Advantage Organization (MAO) network at the contract level, not just the counties the application is proposing to expand into with the SAE request. The change comes as CMS has indicated plans should have tighter control on their existing provider networks to ensure adequacy is met over the life of the contract.
At GHG, we have experts who have worked directly with managing provider networks and adequacy for over 20 years, including detailed analytics such as specialty code mapping and software which is critical in building the infrastructure needed to fully support the quality and financial goals the network brings to your health plan. Please reach out if we can provide guidance regarding the rules and regulations for all government-sponsored health plan networks.
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Update on CMS Spotlight on Provider Directories and Network Adequacy
As we learned from the 2016 Call Letter, the Centers for Medicare & Medicaid Services (CMS) is placing a renewed focus on Medicare Advantage plans' provider network with emphasis on both online provider directories and network adequacy. CMS plans to monitor compliance of plans' adherence through direct monitoring with additional contract funds and through the development of a new network adequacy audit protocol to be tested in 2016 which will determine whether the provider network meets published CMS adequacy standards. The compliance and enforcement of the new protocols will include civil money penalties and enrollment closures.
Recent beneficiary complaints have brought into focus the accuracy, or lack thereof, with Medicare Advantage Organizations' online provider directories. Beneficiaries, and sometimes-referring providers, have shown frustration in attempting to make an appointment only to find the provider is no longer accepting new patients, has moved, or is no longer participating with the plan. CMS has supplemented their current guidance on provider directories with additional updates on August 13 and November 13, 2015, and expects plans to:
Establish and maintain a proactive and structured process in which to verify the availability of its contracted providers.
In their August 13, 2015, update, CMS clarified the requirement does not apply to entities such as hospitals, and plans should use a method likely to achieve the highest response rate. This process was further updated on November 13, 2015, and effective immediately will now include outreach on a quarterly basis to verify:
- There has been no change in a provider's address or phone number and determine if the provider's panel is open or closed to new patients. CMS provided additional guidance that plans should include a notation in the online directory identifying providers who are accepting new patients or a notation identifying providers who are not accepting new patients;
- Establish a policy to review and address beneficiary complaints when they are denied access to a provider(s); and
- Include a provision for real-time updates to the online directory. In a memo released on November 13, 2015, CMS further defined "real-time" to mean within 30 days to be consistent with other Marketplace regulations.
It is important to note CMS' core focus remains ensuring provider directories are accurate for Medicare beneficiaries and their caregivers who rely on them to make informed decisions regarding their healthcare choices.
As you prepare to meet the new challenges for maintaining an up-to-date provider directory, changes to network submissions for service area expansions, or preparations in anticipation of the network adequacy (pilot) audit, please feel free to reach out and let us know how Gorman Health Group can assist you!
Contact me directly at emartin@ghgadvisors.com to learn more.
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