CMS Puts Plans on Notice with Recent Enforcement Actions
The Centers for Medicare & Medicaid Services (CMS) Program Audit reviews a subset of contractual requirements every year, and each year, leadership wants to know how they fared compared to others, when they are due for an audit notice, and what some of the most pervasive conditions were identified. How many of you, dear compliance-minded readers, have been asked, "What will it cost us if we stay non-compliant?" By the numbers:
- Just under $7.3 million in penalties were levied between October 2016 and February 24, 2017.
- 37 sponsors were audited, with a combined total of 115 contracts.
- The active contract with the smallest enrollment has 93 members (as of February 2017).
- The largest audited contract has almost 2.9 million members (as of February 2017).
- The 2016 average audit score was 1.22, a decrease from the 2015 average of 1.76.
- There are over 11.5 million members currently enrolled in a plan levied a Civil Money Penalty (CMP) for Contract Administration. That’s the population of Ohio, or 11 Rhode Islands¹.
CMP data points tell us not to focus on the score, the plan’s enrollment size, or number of contracts – none of this will alone tell the outcome of CMPs. There were a number of sponsors audited in 2016 with similar violations yet not issued CMPs, including violations which appear on CMS’ ever-referenced common conditions.
Do you delegate most key member-facing functions? Is there a palpable culture of a focus on other lines of business? Has your enrollment grown too quickly for operations to adjust? Are you in the midst of organizational changes? What have you done to prepare for your audit, or better yet, timeliness reviews? What do you plan on doing with this knowledge?
¹Annual Estimates of the Resident Population for the United States, Regions, States, and Puerto Rico: April 1, 2010 to July 1, 2016, US Census Bureau
Resources
Join John Gorman, our Founder and Executive Chairman, and Novitex Enterprise Solutions on Tuesday, March 21st to review policy analysis and forecasting in regards to government-sponsored health programs under the new Trump administration. Register now >>
Gorman Health Group’s Summary and Analysis of the 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter is now available. Download 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.
A Vendor's Oversight is Never Done
There are many industry voices adding their perspectives about the new administration and changes to come. However, the Compliance Officers I know do not have the luxury of stopping and truly considering the potential impact as they are managing the continuous pressures of their daily directives. Today I address a group of very industrious Compliance professionals not often addressed, and those are the staff responsible for Compliance Programs at first tier, downstream and related entities, or “FDRs.” Under Medicare regulations, plan sponsors may enter into contracts with FDRs to provide administrative or healthcare service functions on their behalf.
Building the relationship between the sponsor and FDR, just like any marriage, is very important for the partnership to be fruitful. In order to ensure a successful relationship, it is important for delegated entity Compliance staff to have a firm grasp on what the health plans face and to build a strong foundation to support those needs. So often we talk about the Centers for Medicare & Medicaid Services (CMS) Program Audit, so delegates supporting those services should already be in lock-step with their plan sponsor partners. However, that review methodology is a small subset of Medicare Advantage Prescription Drug (MA-PD) plan requirements.
One question we are often asked is: How are sponsors looking at FDRs? FDRs can be collaborative, cost-saving partners that bring significant value to an organization. However, we have also heard dozens of anecdotes of buyer’s remorse, some of which are in credit to the following:
- The sponsor’s Compliance Officer was informed months later that a business area contracted with an FDR.
- A key business owner did not ask the right probing questions during the sales presentation.
- No pre-delegation site visit was conducted to validate processes, or the right attendees were not included in the visit.
- The procurement process was not followed, and appropriate monetary penalties were not imposed for failure to perform.
As a Compliance professional at an FDR, what could you be doing to improve current relationships?
As a vendor, the sponsor is entrusting you to perform an activity on their behalf. If you are looking to partner for success, we recommend you take a look at current processes and evaluate if you are making the right impression from the beginning. You can be a proactive partner in supporting your sponsor, or you can be reactive, thereby weakening your product/service and increasing your and your sponsor's oversight. Whether you are thinking of contracting with a plan sponsor for the first time or you are already in the thick of it, ask yourself these questions:
- Do you “speak” CMS? Can you and your business leaders hold a fruitful conversation about current industry issues, recent CMS releases, and agency focus?
- What is the state of your Compliance Program? Is it in good shape? Have you tested mechanisms and safeguards lately? Do you have an independent audit of your Compliance Program Effectiveness on an annual basis?
- Are your record-keeping tools equipped to handle the many sponsor requests received, such as attestation data, training information, and exclusion list checks documentation?
- How does your organization demonstrate knowledge of CMS requirements, and, more critically, how do you demonstrate meeting or exceeding those requirements?
- Are you restrictive in how often you allow plan sponsors to audit each year?
To be successful in fulfilling the daily rituals of a delegated entity Compliance Officer, it requires a very particular set of skills (thanks, Liam Neeson), as they are often communicating with multiple sponsor contacts at a time. They are not off the hook just because they are not CMS-facing. And as history has shown, when a potentially large-scale, pervasive problem occurs, CMS can and will contact a vendor directly. Think about the above questions and evaluate your current resources to ensure CMS never feels the need to do so.
Resources
Join Nilsa Lennig Rudisill, Gorman Health Group’s Vice President of Sales & Marketing Services, and colleague Diane Hollie, Senior Director of Sales & Marketing Services, on January 31, 2017, from 1:00 - 2:00 PM ET, as they outline how to analyze your market and the necessary steps to develop a successful growth strategy. 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 >>
Opportunities for Growth in the New Administration
"Opportunities are like sunrises. If you wait too long, you miss them." ―William Arthur Ward
With the new administration coming into power this month, there is a lot of conjecture over what might happen. Overall consensus is the one business segment that is the most stable is Medicare Advantage. Trump is a supporter of Medicare Advantage, and so are Republicans, although long-term there is an opportunity to change the financing of premiums. The Marketplace (Obamacare) and Medicaid are in “limbo” until we get a better idea of what and when there will be changes and how drastic they will be for these programs. So if you are looking for growth in revenue and/or enrollment, Medicare Advantage can provide a good opportunity. The other good news is that in the past several years, the Medicare Advantage market has been stable, based on the metrics available, with few changes in average premiums, plan offerings, and insurer participation.
If you are looking at the opportunity to grow or expand, there are many parameters to consider. Whether you are a Medicare Advantage plan considering expanding either your service area or products, Medicaid plans looking to add either Medi-Medi plans or Special Needs Plans, or an Accountable Care Organization or Integrated Health System looking to jump into Medicare Advantage, now is the time to explore this opportunity. Many of our clients are finding the most prudent way to expand and grow is a strong, solid strategy and an implementation plan that begins with a feasibility study.
A feasibility study looks at the market, and that analysis helps to build a strategy going forward for three to five years. This analysis looks at the competitive, financial, and demographic factors of a market(s) to see what is the most viable. This leads to a feasibility model based on detailed financial projections, and Gorman Health Group’s feasibility study process utilizes an onsite strategy exploration to walk through the entire process of entering Medicare Advantage or expanding current products and service areas with an emphasis on risks and rewards. The next step is the development of product/network/benefit design and implementation phases to build a competitive and compliant organization with the proper financial and operational controls in place. Even existing plans need a new perspective to manage member retention, risk adjustment, and overall analytics to support an integrated care organization.
No matter what your situation, this opportunity could be your sunrise, so don’t wait and join us for our webinar on January 31, 2017 at 1:00 PM EST for an informative session on how to conduct a feasibility study and taking it to the next step. Register now >>
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2017: Taking Stock to Inform Next Steps
As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if you believe in the effects of Mercury in retrograde.
- The audit protocols continued to be a work in progress not only for sponsors, vendors, and industry partners like Gorman Health Group, but also for the authors at the Centers for Medicare & Medicaid Services (CMS). A myriad of industry comments were submitted for consideration as they relate to the draft 2017 version. By now, most sponsors should have already incorporated similar methodology into audit and monitoring processes as a complement to existing methods.
- Sponsors without established monitoring and oversight focus on the accuracy of their network information have been subject to CMS review, have sought outside assistance to verify network accuracy, or have worked or are working internally to varying degrees to remediate known gaps in their processes. Per CMS, the Medicare Parts C & D Oversight and Enforcement Group (MOEG), in coordination with the Medicare Drug & Health Plan Contract Administration Group (MCAG), are taking a comprehensive approach to monitor, audit, and validate compliance with network accuracy requirements. MOEG’s pilot will use MCAG’s monitoring results to audit and validate correction of deficiencies. Some of the highest Star-rated plans can tell you about their network validation efforts and best practices, and it’s not a one-way street ‒ providers need to collaborate with sponsors and be proactive when information changes. We may expect to see enforcement actions stepped up as a result of CMS’ maturing efforts in validation of network accuracy.
- Earlier in 2016, our Operations team highlighted areas to keep an eye on based on the 2017 Draft Call Letter. They included the one-third financial audits, timely processing of coverage determinations and redeterminations, as well as data integrity. CMS has since noted they will increase penalties for outliers of Coverage Determinations, Appeals, and Grievances (CDAG) auto-forward rates, and they confirmed they will continue to raise the consequences for ongoing noncompliance in this area in 2017. The appeals timeliness monitoring effort announced on November 29 will provide CMS even more data for review and action.
- Later in the year, our Pharmacy team recommended key strategies to prepare for the coming year, including conducting Pharmacy Benefit Manager delegation oversight audits and conducting targeted audits. Most, if not all, of the mentioned strategies require a group effort, which begs the question: Did you have the time and the resources to accomplish all you wanted to do by end of year?
This is a good time to rethink methodologies and reorganize in preparation for changes to come. The key here, especially this month, will be to take stock of what we do not have control over, set those things aside, and plan to take action where we can.
Resources
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We can help your MA-PD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Visit our website to learn more >>
Preparing For The 2017 Call Center Monitoring
On November 16, 2016, the Medicare Drug Benefit and C & D Data Group of the Centers for Medicare & Medicaid Services (CMS) issued the “2017 Part C and Part D Call Center Monitoring and Guidance for Timeliness and Accuracy and Accessibility Studies”.
In an effort to ensure continued call center compliance in 2017, CMS has contracted with IMPAQ International, LLC, to monitor plan sponsors’ call centers. Although the call center requirements are nothing new for health plans, CMS describes the elements which will be monitored and provides tips on how to prepare for the monitoring studies. IMPAQ will conduct two studies – the Timeliness Study and the Accuracy and Accessibility Study.
As we are quickly approaching January 1, now is the time for plan sponsors to identify call center compliance issues and work to not only clean up any messes but to also beef up your call center staff. Compliance actions may be on the line, but so is the face of your organization – besides providers, your call center staff engages your members and prospective members most often. A confident and well-trained call center staff is crucial to your prospective and current member experience! Carrie Barker-Settles, Director of Sales & Marketing Services, says, “One of the most important beliefs in developing a strong member experience is effective communication to the member. A health plan may want to consider what messages, tone, look, and feel they want the member to see, read, and hear with every touchpoint.
Contact us for ideas on how we can partner with you to efficiently monitor your call centers in preparation for the 2017 CMS Call Center Monitoring and to empower and revitalize your call center staff and strengthen your member experience.
Below are further details on the 2017 CMS Call Center Monitoring:
Timeliness Study
- Measures plan sponsor’s current member call center phone lines and pharmacy technical help desk lines to determine average hold times and disconnect rates.
- Conducted year-round with quarterly compliance actions.
- Plan sponsor’s will receive a compliance action for the Timeliness Study if: 1) it fails to maintain and average hold time of two minutes or less; and 2) it fails to limit the disconnect rate of all incoming calls to 5% or less.
- Results will be available quarterly through the Health Plan Management System (HPMS).
Accuracy and Accessibility Study
- Measures plan sponsor’s prospective call center phone lines to determine: 1) the availability of interpreters; 2) TTY functionality; and 3) the accuracy of plan information provided by customer service representatives.
- Conducted from February through May with compliance actions taken when an organization’s interpreter availability is less than 75%, its TTY score is lower than 65%, or its rate of accurately answering questions is below 75%.
- Results will be provided via HPMS and announced via an HPMS email.
Do this now:
- Verify the accuracy of your 2017 Part C and Part D call center phone numbers in HPMS by January 2, 2017.
- Conduct internal monitoring to identify any compliance concerns for timeliness.
- Ensure interpreter availability and monitor call center calls to ensure foreign-language calls are handled according to your policies and procedures.
- Ensure your call center staff is prepared to promptly respond to beneficiary questions – CMS has their timer set at seven minutes!
- Test all your call center lines to ensure your ability to accept calls.
- Regularly test your TTY device to ensure proper functionality.
- Ensure your call center staff is trained and ready to respond to questions regarding items listed in the Medicare Marketing Guidelines, Section 80.1.
- Ensure your call center staff is trained on the 2017 benefit information.
Resources
At Gorman Health Group, we want to change the perception that member experience is the responsibility of Sales and Customer Service, instead showing organizations that member experience is a comprehensive approach with full transparency and cross-functional leadership. Visit our website to learn more about our Member Experience Services >>
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Internal Controls - Taking the "Risk" out of Risk Adjustment
Risk adjustment has become more and more of a “hot topic” these days. The critical implications and takebacks that occur with submitting unsupported diagnosis information and data inaccuracies are staring to become more real for a lot of health plans. This year, the Government Accountability Office (GAO) took aim at the lackluster auditing around risk adjustment the Centers for Medicare & Medicaid Services (CMS) was providing. With this high-stakes visibility, it is quite clear the Medicare Risk Adjustment Data Validation (RADV) and Commercial Risk Adjustment Data Validation (H-RADV) will start to become stricter over time. The industry has already started to see a greater focus from CMS with developing more refined processes for the 2015 H-RADV audit that is currently being conducted. There are a lot of intricate details very specific to RADV and H-RADV processes health plans need to make sure they are monitoring and preparing for.
Auditing for risk adjustment is no longer a matter of “if” your organization will be selected but rather “when” your organization will be selected. Here we are in 2016, and CMS is initiating Medicare takeback payments for unsupported diagnoses from 2009 dates of service data submissions. The lapse of time between the data submission and payment adjustment is quite significant. Certainly not something a Chief Financial Officer likes to see.
Although the H-RADV and RADV auditing timelines and processes are significantly different, the underlying foundation of being prepared is the same. Data validations are labor intensive for many departments throughout the organization because they require optimal attention to detail. In order for a health plan to ensure all minute details are addressed appropriately, a readiness plan with specific processes and corresponding time allocation needs to be in place. This allows all departments involved to have visibility into knowing what is expected of them “when” information needs to be provided for a data validation audit. Dedicated individuals will be able to spend more time paying attention to detail in their assigned task rather than rushing to figure out a plan to produce the needed information requested by CMS.
A lot of health plans are firm believers that conducting 100% chart reviews is the golden ticket to being proactive against adverse data validation results. Conducting chart reviews and coding validations are only half of the battle. The increasing visibility of risk adjustment requires risk adjustment auditing best practices become a way of life and are visible in the day-to-day core operational and technical processes that are established.
Building foundational processes around the operational risk adjustment best practices and developing a RADV/H-RADV Readiness Plan will put your organization in a good position “when” the time comes.
Contact us today to learn more about how GHG can help your organization develop best practice approaches to risk adjustment and create a RADV/H-RADV Readiness Plan.
Resources
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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Preparing for the 2018 Medicare Advantage and Part D Application Season
On October 31, 2016, the Centers for Medicare & Medicaid Services (CMS) posted the 30-day releases of the 2018 Medicare Advantage and Part D new application and service area expansion instructions for public comment.
While this is not an annual process for each Sponsor, it is a yearly undertaking for Gorman Health Group. It is also a busy time for CMS staff who field the Notices of Intent to Apply and subsequent application submissions. Substantive proposed changes include the following:
- Chart of Required Attestations by Type of Applicant – The chart was revised to provide the applicants with clarification in identifying fiscal soundness requirements.
- Administrative Management – CMS clarified the information for the two-year ban period and inserted the date for the two-year period for the current application cycle.
- State Licensure – CMS clarified the information regarding licensure requirements, which should reduce the number of deficiencies related to licenses that automatically renew after the applications are due.
- CMS Provider Participation Contracts and Agreements – CMS removed the attestations due to duplicative and redundant language.
- Health Services Management and Delivery (HSD) –
- CMS clarified the information for applicants regarding Medicare certification requirements based upon public comments received in response to the 60-day comment period. Medicare certification is only required for applicable providers and facilities.
- CMS clarified the information for Regional Preferred Provider Organization (RPPO) applicants regarding the network requirements and contract agreements. The volume of RPPO applicants has been extremely minimal in previous application cycles.
- CMS clarified the instructions for applicants regarding the submission and process for HSD tables and Exception Requests based upon public comments received in response to the 60-day comment period.
- Revised attestation in Eligibility, Enrollment, and Disenrollment to include an additional option for beneficiaries to make a disenrollment request by calling 1-800-MEDICARE.
- CMS revised the signature authority for a Special Needs Plan upload document to include both Chief Executive Officer (CEO) and Chief Operating Officer (COO) based upon feedback from the previous application cycle.
- CMS clarified the information for applicants related to the regulatory requirements in the development of the Model of Care (MOC).
The Part D application documents note they made no substantive changes, instead providing a redlined version to outline updates made to reflect the 2018 cycle and instruction clarifications. Keep your eyes open for the final applications to be released sometime in January, along with the no-cost training calls CMS will hold prior to the submission date of February 15, 2017.
Resources
The application process for Medicare Advantage and Part D, the Health Insurance Marketplace, and ACOs is an arduous one. Completing the application requires the cooperation from your entire organization. Don’t let the application process get in the way of your day-to-day operations. Contact us today to ensure a smooth, compliant process.
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
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First Year Communication – Building Loyalty and Trust
How can you deliver customized and personalized products, services, and experiences to members? You and your team need to begin with understanding your membership. Defining your membership by both value and their needs provides line of sight to information that will influence loyalty and trust.
Questions that should be asked by you and your team to better understand your customers to build loyalty and trust:
- Does the health plan know what the customer really wants and needs?
- Is there a shared understanding of who the health plan’s most valuable customers are and how to meet their needs?
- How does the health plan communicate with their members to better understand their needs?
- Is health plan customer data integrated and easily accessible across the health plan?
- Do the right employees have access to the right information about the health plan’s members?
- Does the health plan have knowledge of the current inventory of member touchpoints that exist today?
- How does the health plan define “member?” Who is the member?
- How is the health plan currently perceived in the market today, not just by current members but by prospects, providers, employers, and community influencers?
Now more than ever, websites are becoming the primary resource by which Medicare beneficiaries not only research health plans in the buying process but also seek out information regarding their coverage once they are enrolled. The member website can support member communication by being clear and easy to navigate and, most importantly, by including a password-protected Member Portal. The Member Portal should include the following:
- Calendar of local events
- Health screening reminder banners
- Monthly member newsletter
- Real-time access to:
- Eligibility
- Benefit information
- Formulary information
- Claims information and status
- Care gaps information
- Wellness resources
- Access to plan documents
Diane Hollie, Gorman Health Group’s Senior Director of Sales & Marketing Services, says, “Medicare beneficiaries, especially baby boomers, want to access information in the format they are most comfortable with, and, for many, that is the web. Many beneficiaries want to access their information online, and having a strong interactive member web experience that is easy to navigate will reinforce the health plan’s initiative to drive first year communication.” This first year communication builds a foundation for future dialog that provides the member with valuable and time-saving information relating to the member’s personal healthcare.
Trust is essential to Medicare beneficiaries, and building relationships with members will harvest that trust. Taking an interest in your clientele, cultivating shared values, and implementing solutions to customer inquiries will support any customer service department in exceeding member expectations.
Instead of waiting for problems to occur, implement preventive services that can eliminate problems before they happen. By creating a path for customer inquiry resolution, you and your team can ensure member loyalty and trust, which ultimately results in member retention. There are two options for the member retention-focused customer resolution:
- Option One: Utilizing Existing Customer Service Department
- Enable existing customer service department to solve customer issues
- Become the customer’s trusted advisor and build customer loyalty
- Reduce customer complaints and create solutions to common customer problems
- Online communication – “click to chat”
- Option Two: Designated Member Experience Department
- Assign each member a single point of contact
- Execute on key member communication
- Drive attendance to member meetings
- Second-tier customer resolution
- Monthly complaints review
- Denied claims outreach, if applicable
- Welcome home call after discharge from hospital or nursing home
- Help navigate inquiries about provider access
This Annual Election Period (AEP), don’t just think about how to get new membership, think about how you will build that loyalty and trust for years to come.
For more information, please contact Carrie Barker-Settles at cbarkersettles@ghgadvisors.com.
Resources
Gorman Health Group's member experience assessment is designed to meet a health plan’s concerns for retention and service to the member while remaining compliant and also providing strategies to enhance cultural competence, presenting opportunities for the health plan and providers to efficiently deliver healthcare services that meet the social, cultural, and linguistic needs of members. Visit our website to learn more >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>
CMS Releases New Guidance on Coverage Determinations & Redeterminations
On October 18, 2016, the Centers for Medicare & Medicaid Services (CMS) issued enhanced guidance on outreach attempts to support coverage decisions in its memo titled “Guidance on Outreach for Information to Support Coverage Decisions.” In recent years, CMS Program Audits have consistently identified the failure of plans to have documented sufficient outreach attempts when more information is needed to make a coverage decision. Guidance hasn’t been clear on what CMS expected, but it was obvious based on audit results most plans were not meeting the level of outreach CMS considered to be sufficient. The memo has many critical points every plan should be reviewing and implementing.
Here are four items your plan should look at today to determine system and process capabilities to support the new clarifications:
- Ability to Begin Outreach Quickly – How quickly does your plan open a coverage request or redetermination? Most plans process expedited cases quickly, but standard requests are often in a queue that may take days to open and review for completeness. The new guidance requires the initial request for additional information for a standard Part C organization determination to be sent within two calendar days of receipt and a redetermination request to be sent within four calendar days. This means plans must not only be able to triage weekend requests for expedited versus standard requests but determine if standard requests need more information.
- Multiple Outreach Methods – CMS outlined several methods for requesting information. Those include telephone, fax, email, and standard or overnight certified mail. Many plans use one or maybe two methods. CMS indicated, upon review of cases, consideration will be given to the plan’s use of multiple means of communication.
- Documentation of Outreach Attempts – It is critical systems be able to both store and report on the methods and date/time of the communication. CMS noted for emails and faxes, the timestamp is the evidence. For mail, it is the date/time of the postmark, which is a change from the mail date often used in internal systems. For telephonic outreach, it is the date and time of the call. In addition to the date and time documentation, plans should document two other critical pieces of information for the outreach attempt: 1) the specific description of the required information being requested and 2) the name, phone number, fax number, email, or mailing address of the point of contact. In the case of a phone call, the plan should document with whom they spoke, what was discussed or requested, and what information was obtained.
- Ability to Enforce Response with Contracted Providers – CMS has often indicated there is a concern plans are unable to get timely responses from their contracted providers. In the new guidance clarification, CMS reinforces this requirement. CMS expects plans to set up contractual requirements to support contracted provider responses to requests for information. Additionally, CMS is looking to health plan physicians to outreach to contracted providers when more information is needed to make a determination and the provider did not respond to requests.
While the new requirements may be aggressive, they do provide additional clarity on what CMS is expecting health plans to complete in order to be compliant. The question is, what types of systems and process changes will be needed to store and report on these changes?
Gorman Health Group (GHG) subject matter experts have been a part of numerous CMS audits and have observed similar feedback from the auditors. We have worked on remediation projects to implement this type of enhancement as well as recommend this to our clients on operational assessment projects. We know the struggles these changes present and can assist you in working through them. Implementing these changes may be challenging, but the end results of higher compliance and consistent, fully reviewed decisions for members will be worth it.
If you have questions about implementing the changes outlined in this memo or whether your current processes are compliant, we can help. You can reach us through our website or by emailing me directly at jbillman@ghgadvisors.com
Resources
CMS conducts their audit and provides a list of risks and a short timeframe (ninety days) to correct the deficiencies. We can help. Visit our website to learn more about how we can help ensure the right actions have been taken to remediate the issues found >>
New Webinar: The 2017 Star Ratings are out! Join John Gorman, GHG's Founder & Executive Chairman, and colleagues Melissa Smith, our Vice President of Star Ratings, Lisa Erwin, our Senior Consultant of Pharmacy Solutions, and Daniel Weinrieb, our Senior Vice President of Healthcare Analytics & Risk Adjustment Solutions, on October 27 at 1 pm ET for a cross-functional review of the 2017 Star Ratings ― from key program updates and 2017 Part D insights to emerging Pharmacy and Pharmacy Benefit Manager issues, new medication measures, and strengthening the connection between risk adjustment and Star Ratings. Register now >>
New Webinar: On November 1 at 2:30 pm ET, join GHG's John Gorman and Melissa Smith as well as Eric Letsinger, President of Quantified Ventures, a firm committed to supporting the progress of the social enterprise community, and his colleague Brendan O’Connor, an Impact Manager, to learn how social impact investing can be used to improve health outcomes and Star Ratings and how your organization can benefit. Register now >>
New Webinar: During this webinar on November 9 at 1:30 pm ET, Regan Pennypacker, GHG's Senior Vice President of Compliance Solutions, and Cynthia Pawley-Martin, our Senior Clinical Consultant, join Melissa Smith and Jordan Luke, the Director of Program Alignment and Partner Engagement Group at the CMS Office of Minority Health, to provide perspectives on how to implement CMS-recommended best practices in the real world within a health plan in support of Quality Improvement and Star Ratings activities as we continue focusing on providing person-centered, holistic care coordination to our members. Register now >>
Directory & Provider Data: How Small Inaccuracies Could Lead to Big Risks
For the past year, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data Integrity is at the forefront of the initiatives enforced by government mandates, and provider data has topped the list of areas that not only need the most improvement, but the most oversight, correction, and potentially sanction. As we saw last year with the CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. By moving the online directory guidance in the Medicare Managed Care Manual from Chapter 3 (Marketing) to Chapter 4 (Beneficiary Protections), CMS has solidified the fact it is no longer acceptable to have inaccuracies in an area key for members to evaluate their health plan choices and find access to care. Now is the time to set new ongoing network monitoring processes in place that ensure your CMS network submissions and Health Service Delivery (HSD) tables mirror your online provider directories, guaranteeing you are prepared to address provider and member complaints stemming from directory inaccuracies.
A recent investigation by the Government Accountability Office (GAO)[1] identified serious deficiencies in CMS’ oversight and enforcement of Medicare Advantage (MA) network requirements and recommended greater scrutiny of the plans’ networks. The GAO found CMS reviews less than 1% of all networks and does little to assess the accuracy of the network data submitted by plans. It was found CMS relies primarily upon complaints from beneficiaries to identify problems with networks and does not assess whether plans are renewing their current contracts to continue to meet network requirements.
For MA plans who currently have the least stringent directory requirements of all government-sponsored health plans, this means plans are only required to outreach to the providers on a quarterly basis to validate the following information is correct:
- Provider’s ability to accept new patients,
- Provider’s street address,
- Provider phone number, and
- Any other changes that affect availability to patients.
Although seemingly straightforward, when coupled with several other nuances, the task becomes daunting and, in some cases, an operational impossibility. Real-time updates to provider demographics, grievance resolution, reconciliation of provider location, and notation of individual providers accepting new patients are a few examples of where a simple requirement can reveal so many gaps and pose so much risk. Inefficiencies capturing, storing, and governing provider data at the onset of the contracting and credentialing processes is a place to start, but what about the historic legacy information that needs to be sanitized? Add the individual specifications and data requested by and delivered from industry vendors and delegated entities, risk adjustment, the Healthcare Effectiveness Data and Information Set (HEDIS®), behavioral health, and the large, delegated provider and academic groups that should be providing the plan with a current roster each month – this is no small task.
At this point, you might be asking yourself:
- How do we bridge the gap between understanding our compliance risk and deploying a successful change in operations to ensure the loop is closed and successfully maintained at every point in the contract life cycle?
- How do we ensure vendor partners are supporting us and aligning their business practices with both the regulatory requirements and our key performance indicators for Star Ratings, risk adjustment, care management, and member experience?
- Is it possible to fix my content management system as it exists today, or do I need to rip and replace?
Gorman Health Group (GHG) can answer these questions, and we encourage you to follow along with us as we explore these questions and how they relate to the results from the first CMS pilot audit. Next week, we will provide in-depth detail on the operational and cross-functional elements of how this regulatory change will impact the entire industry. We’ll have commentary from several leading vendors in the industry and dig deeper into the downstream implications provider data inefficiencies can have on your plan as a whole. In the meantime, please contact us directly if you have questions or would like to schedule a time to meet with one of our industry experts to discuss how GHG can support your efforts to avoid risk and improve results.
[1] http://www.gao.gov/products/GAO-15-710
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