You Got Them . . . Now How Do You Keep Them?
Your plan's marketing and sales efforts have proven fruitful, and the Annual Election Period (AEP) was a success! The question is . . . do you have a member for life?
New members are bombarded with information they need to digest and questions they need to answer. And everyone speaks in acronyms, e.g., OOA, OEV, LEP, LIS, BAE, OHI, MSP, HRA, and POA. How many hand-offs will it take before your new members' questions are answered? Are your members aware of all the great services your plan can provide? Does their healthcare experience generate a feeling that you are all in it together? Do you have a complete and accurate dashboard of your members' needs?
At Gorman Health Group (GHG), we believe every member interaction — every member touch-point — creates an opportunity to leave your member with a positive impression. Developing a process where members have a positive experience with your plan should be the goal of every high-performing plan. Reaching out to members to ensure they are benefiting from all their health plan has to offer will translate to member satisfaction, loyalty, and the best marketing outcome money can't buy . . . a positive referral for your plan.
Developing a comprehensive member onboarding program not only requires data analytics at the member level but, most importantly, the ability to quickly solve those pesky problems that pop up with new enrollees.
GHG will work with your plan to develop a member onboarding process and dashboards to ensure you are capturing the data that is critical to providing 5-Star services and engineering a positive experience for your members.
When it comes to developing positive outcomes from member interactions, developing a robust onboarding process should be job number ONE!
Visit our website to learn more.
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Even as you are enrolling beneficiaries for the new plan year, your team should be working on your strategic positioning for the following year — reviewing the past year's performance, conducting feasibility analyses, testing assumptions — all to ensure future success. Contact us for more information >>
We have an unparalleled track record working with clients in government programs to develop cost-effective strategies and tactics to help plans achieve maximum potential for their products. We build highly efficient marketing plans, from demographic analysis to material development. We've reviewed, rebuilt and re-contracted dozens of distributions channels, supporting clients with expert counsel and unique tools. Learn more >>
The Risk in DIY: CMS Mandated Material
"Do It Yourself", or DIY, has been the rave for years now. From social media sites like Pinterest to television networks like HGTV, Americans have become fond of this philosophy. Now, I am a big believer in being self-sufficient and must say that I have been sucked into marathon viewings of DIY shows often (Nicole Curtis of Rehab Addict is no joke!). And, while I have seen my share of success stories, more often than not, I see DIY projects result in complete frustration from those attempting to DIY and very costly mistakes.
A prime example of this within the MA industry is the DIY approach to creating CMS mandated material. Year after year, I see organizations attempt to produce upcoming plan year material in-house with the intention of saving budget dollars, but ending up with a costly mess due to lack of subject matter expertise and lack of adequate resources. When you think about the overall importance that is placed on CMS mandated material and the level at which these materials are scrutinized by CMS, it begs the question, "Is the risk in DIY really worth it?"
Picture this: your organization decides to use existing staff to prepare mandated material for the upcoming plan year. Initially, the approach seems feasible and the cost savings looks attractive. Although the process is very time intensive, your organization completes the undertaking, or so you think. It turns out that the amount of time it took to review materials before HPMS submission could not be supported by your Medicare Compliance Department due to lack of resources. That results in functional areas being made accountable for not only the development of respective mandated material, but also the compliance review. With business-as-usual responsibilities not changing, the Enrollment department, which was tasked with creating ANOC/EOCs did not factor in a review for accuracy of information and compliance. Although your organization met the CMS distribution deadline, it is discovered that many of ANOC/EOCs contain cost-sharing errors and do not follow the CMS model templates and allowances. This discovery impacts about half of your membership and must be reported to CMS. CMS initially requires your organization to create errata for these documents, but when it is identified that the errors are so significant and high in volume, CMS requires your organization to recreate the affected ANOC/EOCs in their entirety and slaps on a civil monetary penalty. With a clear understanding of what led to inaccuracies in the first place, your organization seeks outside help from subject matter experts to limit the risk of non-compliance errors. It is later identified that an original version of an ANOC/EOC is still being sent to members upon request for a particular plan benefit package because a process for document version control was non-existent. In the end, this is a DIY project gone horribly wrong. The intention to save money by DIY resulted in something exponentially more expensive between CMPs and the exorbitant cost to reproduce materials. Most important of all, your beneficiaries were impacted by these inaccuracies.
I know we would all like to think that DIY is always a contending option, which it is, when you have the necessary resources and expertise to do so. But just as I will never claim to be an expert in building houses just because I've performed some wall patchwork here and there, organizations need to face the reality of the risks in DIY. Take the time to seriously consider how well-equipped your organization is to handle the development of CMS mandated materials as the season rapidly approaches. Is it time to bring in the experts?
Resources
For questions regarding consulting services for CMS mandated materials, contact me directly at rpennypacker@ghgadvisors.com
The Gorman Health Group 2015 Forum is April-7-9! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for the Gorman Health Group 2015 Forum today!
Reenergized After RISE…Now What?
It's the Wednesday after a jam-packed RISE conference, focused on "Best Practices and Actionable Tools for Improving Risk Adjustment and Achieving Exceptional Quality Performance."
I am sure I speak for most of my colleagues that attended the Summit when I say, "I'm reenergized, but what should I do first?" The large group sessions and the breakout meetings delivered valuable insights into why the Centers for Medicare & Medicaid Services (CMS) keeps moving the target for both health plans and providers. As usual, the presentations were top notch.
This year, a sea of risk adjustment vendors lined the conference room, each with a solution that touted superior performance in maximizing revenue by applying innovative technology, provider/member engagement strategies, and robust analytics. Bright lights, big graphics, dashboards that actually closed the Healthcare Effectiveness Data and Information Set (HEDIS®) gap for the colonoscopy measure??? So many options, all impressive in their own right, but where do you go from here?
When I attended these events on behalf of my health plan, I would bring a box of pens and a few notebooks, head back home, and try and piece it all together. Without fail, something would get lost in translation, or my presentation back to the executive team on my takeaways left us all wondering how we're going to prioritize these initiatives, generate buy-in from across the company, and put these strategies to work.
Hearing and sharing best practices with clinicians, analysts, and other thought leaders in the risk adjustment space always proves to be informative, practical, and actionable. There always just seems to be one thing missing - your co-workers and executives weren't there to hear how important ALL of this is, and decisions continue to be made in a silo, and programs are perpetually designed with a one-dimensional approach to risk, quality, and medical trend management.
Being the only consultant at the conference who wasn't aligned with a vendor, I was able to take a very agnostic approach to the entire event. I couldn't help but notice that more providers were in attendance, voicing their concerns about managing data, navigating the complexities for Hierarchical Condition Category (HCC) coding, and still trying to deliver quality care to their patients. I listened to the health plan representatives discuss the challenges of selecting the right vendor partners, making the decision to bring these risk adjustment business functions back in-house, and integrating people, processes, and data across their entire enterprise.
Now that I am back home, and before I head back out to work with clients on their risk adjustment strategies, I wanted to take this time to stress the importance of being thoughtful about which vendors you select, which strategies you choose to pilot, and which operational processes you decide to uproot.
Just remember a few things:
- Trust that what you are doing now is most likely on the right track - it just might need a little face-lift, especially when the final Call Letter is announced.
- Technology enables an organization to launch and manage interventions that support corporate priorities. Making these investments without a solid plan to leverage the tools and analytics will only set you up for disappointment. More often than not, creating the playbook falls on your "To Do List.
- Be confident that you know the basics, and taking your programs to the next level shouldn't rest on your shoulders alone - we heard loud and clear that this needs to be a cross-departmental, integrated approach in order to really move the needle.
If you can read the above takeaways and feel confident that you and your organization are on the right path, GREAT- please continue to share your best practices with your industry colleagues.
On the other hand, if you are on information overload and not quite sure how or where to begin, know that Gorman Health Group and our team of healthcare analytics and risk adjustment experts have a proven track record of helping our health plan and provider clients assess, prioritize, and design initiatives that make sense for you and the communities in which you serve.
If you have any questions or would like to hear more about how we can help, please contact me directly at dweinrieb@ghgadvisors.com.
Resources
Whether you rely on multiple vendors or a largely internal team, GHG can help you streamline the execution of your risk adjustment approach, and build a roadmap to ensure you're keeping pace with CMS expectations in both compliance and health care outcomes. Visit our website to learn more >>
Don't miss Dan's presentation next week at the Gorman Health Group 2015 titled "Risk Adjustment: Cracking the Code" where he will provide key takeaways from the final Call Letter and future implications, discuss vendor selection, management and oversight, as well as Provider Network strategies and the value of collaboration. Not yet registered for the event? No problem, register here today!
The Medicare "Doc Fix"
The "doc fix," as just passed by the House of Representatives, would fix the annual sustainable growth rate (SGR) calculation by eliminating it. The SRG was enacted nearly 18 years ago as a way to tie physician compensation under Medicare to the growth in the national economy. It has never worked well, and Congress has had to override it 17 times to prevent sizeable cuts to Medicare's physician payment rates. The current SGR cut is about 21% and will take effect March 31 of this year.
The House bill eliminates the SGR. The estimated 10-year cost of eliminating these cuts to physician fees is in the neighborhood of $175 billion. After adding the cost of extending the Children's Health Insurance Program (CHIP) and funding for community health centers, the total price tag over 10 years is $210 billion.
The doc fix has no direct impact on payments to Medicare Advantage (MA) plans. For many years, CMS would calculate the Medicare Fee-for-Service (FFS) per capita cost trends it used to set MA benchmarks by assuming that the SGR cuts would happen. Year after year, the cuts were rescinded, requiring CMS to add a sizeable correction to the next year's trend to compensate. But that was offset by the following year's SGR impact, leaving the trends chronically depressed. CMS finally fixed this with the 2014 benchmarks, which were calculated using trends that assumed that Congress would again rescind the SGR cuts. This policy was repeated in calculating the 2015 benchmarks. For both years, CMS assumed a 0% trend for physician fees.
However, the "doc fix" may still have a small indirect impact on MA. If the final bill looks like the House bill, physicians will receive 0.5% annual increases in fees through 2019. This 0.5% trend will be incorporated into the trend used to set the benchmarks. Since CMS has been using a 0% trend for physician fees, the doc fix will elevate the trends for 2016 and following years, at least through 2019. The impact will probably be in the range of positive 0.2%, or 20 basis points, more or less. The House's doc fix would also tie physician compensation to pay-for-performance scores after 2019. We will need to wait and see whether CMS interprets this as generating an increase or decrease in physician fees when they calculate the 2020 benchmarks.
The House bill would also reduce the trend applied to payments to post-acute providers, relative to prior year trends, and make a small reduction in hospital payments relative to current law. This may have a very small negative impact on the benchmark trend since it is based on projected trends in total FFS per capita costs. But the overall impact for MA benchmarks will still be slightly positive because of the positive physician trend.
A greater impact in future years may be the impact on physician claims payment. In the near term, physician contracts that are tied to Medicare-allowable fees will experience a 0.5% increase as the fees rise. Since prior years' annual SGR corrections have included similar nominal increases, it is probable that most MA plans have already incorporated a rise of similar magnitude into their bids and budgets, meaning that the pending doc fix may have no noticeable impact. Looking at the longer term, the performance-based payment program that CMS devises to calculate payments after 2019 may have a greater impact. MA plans should be watching this closely, since any physician contracts that are tied to Medicare allowable fees will automatically incorporate this same performance-based calculation. This may also be an opportunity for plans to develop new and better value-based payment models of their own.
For now, it's time to watch what happens in the Senate, to see if this thing passes. It won't come up for a vote until the Senate gets back from Spring Break in mid-April. By then, the SGR cut of 21% will have officially taken effect. In the past when Congress dawdled on the SGR, CMS has found temporary ways to avoid cutting doctor payments, and we expect they will be able to engage in the same sleight of hand this year.
Update as of 4/1/15. Note that the 21% cut went into effect April 1, since the Senate didn't pass the bill before it went on a two-week recess. CMS can hold claim payment a couple of weeks to allow the Senate to get its act together and pass the bill. However, the Senate will need to act quickly when it returns from recess. The current estimate is that the bill will be introduced on April 13. While leadership of both parties say everyone is on board in the Senate, that clearly was not the case in the hours leading up to the spring recess, since the bill never came up for a vote. This indicates that there may be some unresolved issues. Stay tuned! There may be some interesting maneuvering in the next few weeks.
Resources
Gorman Health Group's Summary and Analysis of the 2016 Draft Call Letter and the Medicare Advantage (MA) Advance Notice is now available. Download it today >>
The Gorman Health Group 2015 Forum is April-7-9! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
The Model of Care: More than Just a Technical Requirement
The Model of Care (MOC) represents the backbone of a health plan's operational infrastructure and offers powerful potential through which to drive quality improvement, service excellence and improved health outcomes.
Though only required for plans operating a Special Needs Plan (SNP), the MOC is not just a legal or regulatory requirement. The MOC captures and documents deep insights regarding plan leaders' strategic vision by which to provide services to members, to work with providers, to manage and coordinate care, and to conduct operations. It also includes a thorough analysis of a plan's staffing model, provider network and the local demographics of its members.
Perhaps because the MOC is such a lengthy and technical document, or perhaps because it addresses the entire spectrum of a health plan's clinical and operational processes and systems, MOC's are often developed and updated by a small team of highly experienced subject matter experts within a health plan. Despite CMS' requirement that all health plan staff and providers receive annual training on the MOC, plans often miss the opportunity to leverage their MOC's not only to comply with CMS regulations, but also to more deeply entrench their Quality Improvement (QI) and operational service models throughout the organization.
Developing and/or updating a MOC requires health plans to make important strategic and tactical decisions about the way in which their team, in conjunction with their provider network, will work together to coordinate care for their members. As a result, the MOC serves as the strategic plan for your care management, member services, provider relations, risk adjustment, Stars/quality and marketing teams.
By leveraging the strategic and tactical discussions necessary to develop a successful MOC, plans can use the MOC development process as a vehicle through which to develop, review, and enhance Star Ratings, Risk Adjustment and Provider Engagement strategies.
Gorman Health Group's team of experienced clinicians has a deep understanding of how to leverage Models of Care to refine, document and hardwire your strategic vision for collaborations with your provider network to improve Star Ratings and optimize risk adjustment performance.
If your plan is preparing to develop or update your Model of Care, contact us today and let's work together to help your plan achieve your strategic vision.
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Gorman Health Group is ready and available to execute a complete MOC evaluation that will provide the data and information needed to make smart decisions in refining your plan's strategy of managing your SNP population. Contact us today >>
Registration for the Gorman Health Group 2015 Forum is underway! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Room Rate expires on March 23. Register your team for The Gorman Health Group 2015 Forum today!
Marry Data to Build Accurate Customer Profiles
Have you ever played "Pin the Tail on the Donkey" as a kid and found yourself laughing when you got completely turned around and totally missed the donkey? That's what it's like when blindly developing benefits, products, marketing, and sales strategies without understanding what your current and prospective customers look and think like — except there's not a lot of laughing going on.
Utilizing enrollment and benefit data to gain an understanding of your marketplace is a great beginning to understanding your market. Taking the deep dive into the data gives you a greater understanding of your competitors, their benefits, and how different benefit, product, and possible provider strategies have affected the enrollment trend. It also gives you the ability to look at your own benefits/products and enrollment trends to try and build hypotheses of what is driving enrollment/disenrollment trends and develop premium, benefit, and product strategies to either reinforce the direction you are heading or to get back on track.
When you have the ability to add additional dimensions such as demographics, geographic, and psychographic elements to your current members and prospects to develop member and prospect profiles, it helps to gain clarity about your benefits and possible product development strategies to get a full picture of your market. This sets you up for changes that may need to be made or products to be developed in the future.
Analyzing these dimensions will also allow you to build a better pathway to smarter marketing and sales strategies to succeed. In June, when marketing and sales strategies are finalized, you don't know what your competitive advantage/disadvantage will be in the marketplace. Understanding how your 2016 products/benefits match your current membership and the prospective market and how your marketing and sales strategies will attack the market during the Annual Election Period (AEP) and subsequent year will give you a solid game plan to help crystallize your strategic vision.
Resources
GHG's Sales, Marketing, and Strategy division has developed a detailed analysis of the 2015 Annual Election Period (AEP). This allows health plans to understand existing opportunities in their market as well as the potential for new market opportunities.
The Medicare Advantage marketplace is evolving — are you prepared? Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. Visit our website to learn how we can help you >>
Even as you are enrolling beneficiaries for the new plan year, your team should be working on your strategic positioning for the following year — reviewing the past year's performance, conducting feasibility analyses, testing assumptions — all to ensure future success. Contact us for more information >>
Time is running out to register for the Gorman Health Group 2015 Forum, April 7-9, at the Gaylord National Resort & Convention Center. Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team today >>
Go-to-Market — No Department Left Behind
Although the next Annual Election Period (AEP) is a ways off, now is the time to start thinking about product development and overall strategy. In most organizations, the start of the "Go-to-Market" (GTM) strategy discussions begins with the C-Suite, Product Development, and Sales and Marketing. This keen group of professionals works sequestered and siloed for a period of time and then, voilà , they emerge with the lifeline of the health plan's benefits and strategy in their hands.
In order to launch a successful set of products (as well as strategies for selling these products), one of the most important and initial steps must be the creation of a fully integrated GTM governance structure to enable the organization to manage more effectively between strategy implementation, optimization, compliance requirements, and results tracking of an integrated marketing strategy. This will require the involvement of multiple functional areas, even those that aren't traditionally thought of (e.g., Medical Management, Pharmacy, Compliance, Member Services, Provider Relations, etc.), which means no department can be left behind.
"The failure to include Compliance as part of GTM initiatives is a prime reason for some of the regulatory pitfalls that arise and are discovered way too late," says Regan Pennypacker, Vice President, Compliance Solutions. "Whether your organization deals in Medicare, Medicaid, or a combination of these lines of business, the overall guiding principles will be the same. A culture of compliance starts at the top and is effectively integrated when each area of the organization takes ownership of compliance requirements and expectations respective to each functional area."
Execution and management of this initiative is no easy task. A successful GTM strategy brings Compliance and operational stakeholders to the table. Assigning the right accountable parties at the onset is critical to ensuring regulatory requirements are implemented and overall strategy is executed. For suggestions and solutions on how to build your GTM strategy and team, contact me directly, cknight-lilly@ghgadvisors.com.
Resources
Gorman Health Group's marketing experts have developed strategic plans for hundreds of Medicare Advantage Plans, Prescription Drug Plans, Special Needs Plans and Exchange participants. We will work with you to understand your market, mining demographic data for opportunity and finding the gaps in the competitive field into which your plan can fit. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Industry Ducks Bullets in 2016 Medicare Advantage Rate Proposal
Friday, February 20th after close of business, the Centers for Medicare and Medicaid Services (CMS), released its 2016 Advance Notice of Medicare Advantage Payment, known affectionately as "the call letter."
This one was the most anticipated in years, and the industry unexpectedly ducks bullets in it, in risk adjustment, Star Ratings, and elsewhere. It's got a few unicorn farts in it, and a couple puffs of Chanel No. 5 as well.
The lack of any shockers is the bigger positive for the industry, a turning point really. CMS is saying it won't settle its scores with payers through policy, but through enforcement, where the facts are often too tough for politicians to stick their necks out.
Last fall's surprise positive announcement that MA benchmarks were tracking to increase 2.02% next year started this year's dance. Now comes the draft call letter, and on April 6, the final, all of which will be different as CMS winds through its process and the full fury of industry lobbying is brought to bear. It's worth noting that this year a first-time majority of 53 Senators signed the annual "don't hurt Medicare Advantage (MA)" letter to CMS, vs. only 40 last year. The increased Congressional pressure and the fact that MA now represents one out of three beneficiaries is driving this call letter.
By our calculations, the 0.95% reduction in MA benchmarks claimed by CMS is really negative 1.76% all-in. This is the unicorn fart. The final number quoted by CMS, 1.1% positive, is in part because CMS is taking credit for a 2.0% improvement in risk scores as plans continue to improve their risk adjustment management skills. Kinda cheeky. Our read on the underlying trend is +1.53%, frankly, better than we anticipated.
On risk adjustment, anticipation was that CMS would take a lethal shot at prospective in-home evaluations, a tough fee-for-service normalization factor, and an increase in the coding intensity adjustment, but NONE of those happened.
On home visits, despite a hailstorm of bad press and advocacy group investigations, CMS isn't even dealing anymore, just laying out "best practices" and saying "we're watching you." The regulators laid out 8 criteria that would make the prospective evaluation more like a risk assessment conducted by a Special Needs Plan, including:
- Evaluation performed by a physician or qualified non-physician practitioner
- Includes all components of the wellness visit including health risk assessment
- Medication review and reconciliation
- Scheduling appointments and referrals with appropriate providers and community resources
- Environmental scan of the home for safety risks and need for adaptive equipment
- Verifies that the information obtained during the assessment is furnished to appropriate plan staff and providers
- Provides enrollees with a summary of the information collected
- Enrolls the beneficiary in disease management or care management programs.
Taking these steps and embedding risk adjustment management inside a health plan's Medical Management department would effectively audit-proof the company from the dreaded data validation audits expected to intensify this year.
Another shocker: CMS did the absolute bare-minimum on the coding intensity adjustment, and then heaved up a dangerous proposal to recalculate it starting in 2017. If implemented, CMS would cut payments to all MA plans by enough so that total payments would be no greater than under the pre-HCC, pre-PIP-DCG, pre-2000 AAPCC demographic model. This would make risk adjustment a zero sum game, in which individual plans could win or lose, but in which CMS would never pay out more than under the old AAPCC model. That would settle the score on home visits once and for all, and indelibly damage risk adjustment as a healthcare financing innovation.
A final surprise: CMS acknowledges it has a problem on Star Ratings for health plans serving dual eligibles and the low-income. The agency is cutting the weight of several Stars measures where vulnerable members score poorly, by a whopping 50% in 2016. This buys time for CMS and several plans overweight with low-income members and highly exposed to Stars underperformance to conduct additional research and take steps against what is driving the correlation.
It was, in the end, a surprisingly favorable call letter for health plans and other stakeholders, particularly capitated provider organizations. But we're still a long way from the Final Notice on April 6. How plans should react:
- First, write comment letters. Deadline is March 6 at 5 pm EST.
- The proposal to cap total MA payments at the same level as would have been paid under the pre-2000 demographic-only risk adjustment system is dangerous. Plans need to point out how the Congress, in the 1997 Balanced Budget Act, mandated a health-based risk adjustment system because the demographic adjustments were inadequate. We are not aware of any authority in that, or any other law, to allow CMS to set a cap on total MA payments.
- Take the guidance on home risk assessments seriously, and implement CMS' suggestions before they become mandates. Plans must hard-wire their risk adjustment program into their care management program, so they are actively managing the risks they identify.
- Don't rely on averages: the impact of CMS rates and other changes will vary from county to county, market by market. Let us help you examine the impact on your service area.
- Continued rate pressure means plans have to continue to get better and better at the key components of their business: risk adjustment, care management, Stars, and enrollment data reconciliation.
- Focus on the Stars metrics with the greatest weights, especially the intermediate outcomes measures and the plan-wide quality improvement measures. Determine if the reweighting of seven metrics will have a positive or negative impact on your plan, and react to offset any negative effects, by emphasizing other metrics where there is room for improvement.
It's going to be an interesting 45 days to the Final Notice, but one thing is sure in this call letter: CMS is conceding that Medicare Advantage has gone mainstream, and that its support in Congress can no longer be tangled with. CMS is showing its preference to impact industry behavior through its boot rather than its pen.
Resources
Join John Gorman, GHG Executive Chairman, and colleague, Bill MacBain, GHG's Senior Vice President of Strategy and former health plan CFO, as they provide a hard-hitting analysis of critical areas addressed in the document, including a look at the various components that make up the trend factor, a proposed change to how risk scores are determined, health risk assessments, and Star Rating measures on March 3, 2015. Register Now >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Risk Adjustment Data Validation (RADV) Audits Just Got Real
Last night the second-largest Medicare Advantage plan in the country, Humana, filed an SEC document detailing a US Department of Justice investigation into the company's risk adjustment coding and data collection practices. The investigation is an extension of a 2010 physician-led whistleblower action under the False Claims Act. The company has over 3.2 million Medicare Advantage members.
For years CMS has struggled to define the process and methodology it would use to pursue payment recoveries from Medicare Advantage plans which were overpaid under risk adjustment. In 2012 it finalized its process and launched its first round of RADV audits, on a parallel track with those being conducted by the Office of Inspector General at the Department of Health and Human Services.
The Justice Department's involvement in the Humana audit would appear to indicate the review is in the advanced stages and has been underway for some time. The methodology assures an extrapolated repayment to the Federal government for unsubstantiated codes submitted for risk adjustment. That this action also comes in connection with the False Claims Act and a qui tam whistleblower action could signal serious trouble for the insurance giant.
RADV just got real.
Resources
GHG can support your risk adjustment from start to finish when it comes to preparing for your RADV audit and prepare a readiness plan. We're standing by to support you in comprehensive audit coordination, limited audit oversight and targeted engagement services. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Countdown to Final Submit
Today is the final day for current or potential plan sponsors to submit their Medicare Advantage and/or Part D application for a new contract or service area expansion (or service area expansion for 1876 Cost Plans). By now, many of you have already hit final submit and are either celebrating or working on known deficiencies. Or, perhaps you are still waiting for documentation or a final quality check of your submission before you feel confident to submit. Here are a few of the things we learned this year along the way.
- CMS has not updated their Part D readme file to include the FDR chart noted in 3.1.1C. It seems a bit redundant to the information entered in the Part D Data section of HPMS, but to each his or her own. CMS provides no template for that chart so we can imagine either it is overlooked upon initial submission by the applicant, or it is submitted in varied forms.
- Despite making reference to an additional webinar to be held after the second user call, no webinar was scheduled nor was any announcement made to correct that statement. However, CMS staff demonstrated timely responsiveness to posed questions both directly sent to application contacts as well as through the DMAO mailbox.
- With an industry push for quality (read: limited) network establishment, applicants can expect a high level of scrutiny on exception requests. If providers are available in a service area, CMS has stated that applicants should not even submit an exception request, so put those pencils down and step up contracting efforts.
You have until 8:00 PM Eastern Time tonight to submit your application. There should be a good sense of what potential deficiencies exist, so maintain the momentum to fill those gaps. Embrace the reality that CMS may certainly identify additional gaps in the submission. Ensure that your team has time built into your implementation plan to address any additional deficiencies.
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We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Contact us today to ensure a smooth, compliant process.
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!