High Value Network: Generation 4.0
When it comes to healthcare, two truism's are that medical costs are going up along with demand for healthcare services. And when it comes to organic growth of healthcare volume and expenses, government programs represent a major driver, particularly when considering that on a daily basis thousands of baby boomers age into Medicare. During the last several years CMS has published a number of demonstration programs which are intended to improve the quality of Medicare patient outcomes while promoting financial efficiency on a unity cost or per procedure basis.
Commonalities among the various demonstration programs include: providing financial incentives when providers and plans (through STAR ratings) achieve specific quality and financial metrics, that when properly implemented, result in improved patient outcomes at a reduced cost. Not surprisingly, the discussion among many health plans has started to focus on how to manipulate the size and inherent "quality" of provider networks to achieve performance gains.
The concept is not new, in that payer efforts at developing "Centers of excellence", proprietary physician networks, private label networks, etc., have been around for at least two decades. These efforts were driven by market considerations, provider availability and consolidation, expectations around consumer demand and use of services. Many times high cost hospitals were screened out and networks were defined by the plan offering, e.g.. PPO, HMO POS and the like. Provider price concessions were expected in return for volume. Provider performance, at least as defined by improved patient outcomes, was not a major consideration in the design of these networks.
At least not until now. Given the current climate of healthcare reform, shrinking payer margins, provider flight from Medicare, percentage declines in medical school enrollment and CMS initiatives to constrain medical expense through improved coordination of care and elimination of unnecessary procedures, Medicare Advantage, Medicaid, and commercial health plans are exploring how the design of networks, around performance, can lead to better patient outcomes and better managed financial costs. Thus, the approach to network design is shifting way from preferred pricing in exchange for volume to a network design strategy focused on horizontal and vertical integration, superior treatment outcomes, more efficient use of resources as well as a willingness to share in financial risk. Population management strategies, establishment of consensus clinical protocols and reimbursement strategies tied to CMS STAR ratings, as well as additional quality and financial metrics, dictate network performance and thus health plan sustainability.
Tracking the measurement and reporting on agreed to metrics require a level of analytical sophistication that was not apparent in the early days of network design. The development of high value networks suggests that payers and providers must share a common vision for network design and consensus agreement on expectations around network performance. In addition network design efforts will require unwavering leadership commitment to ensure long term sustainability.
In the final analysis high value network design is a partnership enterprise between the health plan, the provider and the patient. Contributing components include health services/medical management, provider contracting, actuarial services, finance, analytics/ decision support and management.
As a diversified health services consulting company the Gorman Health Group is well positioned to become a partner in this effort from start to finish including the development of the most appropriate network design strategy to development of performance payment models to the implementation of the final network including assurances that the final network meets CMS network adequacy requirements. When you are ready, give us a call.
Resources
On Friday, September 26, John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, discussed the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Access the recording here >>
From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Visit our website to learn more >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Does your current Model of Care coincide with the new requirements?
The Centers for Medicare and Medicaid Services (CMS) revised the Model of Care (MOC) requirements, reducing core clinical and non-clinical elements from 11 to 4. Subsequently, the National Committee for Quality Assurance (NCQA) revised their scoring guidelines and methodology, based on this change.
What does this mean for health plans that are scheduled to resubmit applications for their MOC renewal in 2015?
Plans that are seeking to continue authorization to manage a Special Needs Plan (SNP) during the upcoming year must submit a MOC narrative to CMS as part of their SNP application by February each year. The SNP approval process itself focuses solely on the MOC requirements. Plan submissions are designed to go through Health Plan Management System (HPMS). As in previous years, the MOCs are reviewed and scored by NCQA, utilizing a scoring method designed with CMS. All of the elements and factors are scored on a scale of 0-4, with a minimum score of 70 percent required for a plan to pass.
For Medicare Advantage plans that need to modify their MOCs to accommodate the new core requirements, Gorman Health Group is ready and available to assist in that transition to help you reach a goal of obtaining higher MOC scores. We will guide your medical management staff to provide clear and concise responses to the multiple factors within each element, and also work with you to submit complete and detailed narrative responses to the following required elements:
1. Description of the SNP Population;
2. Care Coordination;
3. Provider Network; and
4. MOC Quality Measurement & Performance Improvement.
Insure you have a successful submission and approval process. Contact us today >>
Resources
The effective use of health information technology, or medical economics, can be one of the best assets for a health plan in controlling costs and service levels, especially when there may be an increase in plan membership. Learn important strategies for a plan's medical management team. Read more >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Reasonableness — The Last Chance
After four tries, some Marketplace health plan applicants have still failed to meet CMS reasonableness standards for 2015. Some of these applicants complained that they did everything they were told to do but were again rejected. Others are still asking for definition and written standards. Unfortunately, most understand that nothing in writing exists beyond the regulation.
In response, CMS encouraged them to call and discuss their issues next week when the subject matter expert is available. Their appeal is limited to a phone conversation with this lone CMS interpreter of reasonableness. These applicants need to have definitive data about available providers, population and time and distance to convince this reviewer. Demonstrating the use of a deliberative process may be the lesson for 2016 applicants but for 2015, time has run out.
Resources
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. Learn more about how GHG can help you tackle the application process >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
It's a Marathon - Not a Sprint
Plans will shortly be receiving the Readiness Checklist from CMS. At first glance it looks like just a bunch of boxes to check off and answering yes and no questions. Here's the rub:
Starting to figure out whether or not you have 30 boxes of non-readiness to report to your Account Manager is not a good way to roll into 2015. The previous year's readiness checklist should inform your priorities for the year's operations. Your relevant questions are: Who and what department owns this? Do we have policies and procedures, business processes and reports for this? Have we had any CMS outlier notifications about this? Did we audit this? Anything that you answer as "not ready" is automatically a priority.
You can't start being ready when the checklist arrives. Plans should be preparing to "be ready" all year long. For instance, here's what has to be done for Coordination of Benefits readiness:
CMS expects health plans to establish/maintain systems and procedures for at least weekly COB data report/file processing by not only receiving COB information from various sources, but also applying the COB information to claim payment system(s). Health plans may not understand how to interpret the CMS COB file and use internal sources, such as enrollment forms, claims, provider services, and member services to identify other health information for COB. Health plans need to be able to clearly categorize the various types of records and perform distinct validation, outreach and processing for group coverage, non-group coverage, third party liability, federal/state programs, as well as charities.
The important step of validating the other health information from CMS and other internal sources is often overlooked and a critical step to maintaining COB information in CMS systems. Without this step, information is outdated causing incorrect claim processing, member abrasion and escalated issues. CMS expects that organizations utilize the Electronic Correspondence Referral System (ECRS) to send COB updates to CMS timely and accurately, but health plans often fail to work the ECRS response file rejections and update internal claim system COB flags or other coverage information. Readiness planning should include the final, most often overlooked, yet most vital step: Reconciliation. An effective reconciliation process will work all COB related reports including TrOOP Balance Transfer exception reports, COB error reports, reconcile enrollment, claim and pharmacy systems, as well as monitor claim payment accuracy and recovery of other liabilities.
Resources
The biggest risk health plans face in government programs is managing membership and financial data. With Gorman Health Group's Valencia, you'll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments.. Learn more about how Valencia can help you >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Data the Silent Killer
As a seasoned veteran in healthcare operations I've seen firsthand the progression of data utilization by health plans. Despite decades of growth we're not there yet.
In the 1950s and 60s data processing began to take hold. Unfiltered data was the norm. Not much was done with it. Data validation was in its infancy. Business decisions were mostly driven by non-analytical factors.
In the 1970s and 80s information management began grouping similar data and identifying patterns. Basic analytics such as the categorization of data facilitated the ability to draw certain assumptions. On occasion those assumptions were valid but, more often than not, not broadly applicable. We realized what making "assumptions" yielded.
Data usage and sophistication improved considerably in the 1990s and early 2000s. The ability to dig much deeper into the groupings of data to find those unique characteristics to either prove or invalidate business assumptions became the mainstay. Better analytical processes improved knowledge and predictability in business decisions. Data management was equated to business intelligence, highlighting the awareness that data functions effectively drive business operations. Improved ability to manage and report data ushered the evolution of Big Data. Analytics and reporting is assumed (there's that word again) to be truthful...the data doesn't lie!
Today, health plan data is heavily relied upon. Data must be valid, accurate, and reproducible; it is the sole factor for health plan payments, performance ratings, patient care plans, and just about every other aspect of health plan operations. Data has become the lifeblood of a managed care organization. But…what if your data is distorted and data leakage is occurring?
What if claims and encounters are improperly adjudicated and reported?
What if membership and provider data is inaccurate?
What if the data used in Disease Management programs relies incorrect metrics to optimize interventions?
What if the data required for risk adjustment submission and payment is inaccurate? How much will it cost your plan?
Poor data management, inaccurate and inadequate analytics can slowly drain a health plan of its revenue and ability to make strategic business decisions. Consider this much like high blood pressure is the silent killer in human beings; data leakage is the silent killer of health plans.
Gorman Health Group has decades of experience assisting health plans with their data management. Please contact us for an End-to-End Data Management Assessment. We will assess the current state of your Data Management against industry best practices and your desired future state, and we'll assist you in getting there. Let us help you identify and control your health plan Silent Killer.
Resources
Join us on September 19 for an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Groundhog Day: CMS Issues Best Practice Memo Related to Common Audit Findings
Is it Groundhog Day or does this memo say the same thing as last year? Nope you're not imagining things - In CMS' Memo titled "Common Conditions, Improvement Strategies, and Best Practices based on 2013 Program Audit Reviews" that was released on August 27th, CMS outlines again the industry pitfalls and best practices around common areas of noncompliance identified as a result of CMS Program Audits. You may be saying to yourself "some of this looks familiar" well — you're right.
In fact, it appears that CMS is getting weary of repeating themselves year over year and they've included some language with teeth in this most recent memo. CMS makes two key statements in the 2014 memo — the first is that due to the number of repeat findings year over year, it has been determined that Organizations are not using this memo as CMS intended. The second, and more pointed statement is that Conditions noted in one or more memo will be considered "aggravating circumstance" during an audit and this may adversely affect the overall audit score.
So — what does this mean to your Organization? It means that if you haven't yet done so, now is the time to review each best practice memo provided by CMS and ensure that the recommended process is in place. If not, it's time to create and implement a corrective action plan for each best practice mentioned by CMS that would apply to your Organization. Remember, CMS understands that Organizations aren't perfect, but demonstrating that you're able to identify issues and put a plan in place to remediate those issues is always required.
Resources
GHG's team of experts can help you minimize your compliance risk and maximize your time and resources. Contact us today to learn how we can help ensure you are audit ready all the time >>
On September 10, join us for an exploration of why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Passing Marketplace Reasonableness — One More Chance
September 4th was final submission day for Marketplace plans but some worried health plans were asking "what ifs" about their last submission for network access. These plans have re-submitted network updates after two CMS rejections that required correction for failing reasonable access. They have three consecutive wrong guesses on whatever standards CMS believes they have not met. They want to know what happens if CMS doesn't approve their network access plan. Of course, they are still asking what standards need to be met.
Rest assured, CMS says they will have another bite to justify reasonable access. However, time periods shrink. The window opens on September 23 when CMS notifies health plans about needed corrections and responses are due on September 25.
CMS is well aware that failure to get a pass has unwanted consequences for everyone. Service areas will need to be reduced with compounding changes to plan packages that necessitate more CMS re-review and approval. So, everyone wants a good justification but CMS is not backing off given the potential for political backlash. Failure is an option. Health plans worried about their last re-submission can't count on CMS reviewer fatigue. Health plans asking these "what if " questions need to prepare a contingency narrative by either finding and fixing any weaknesses or documenting metrics that demonstrate access. Waiting to correct over a two-day window, is not sufficient time to prepare the last chance narrative justification for reasonable access.
Resources
Gorman Health Group's network evaluation service deploys an automated software solution that uses metrics based on population, provider ratios and time/distance standard. Learn more >>
Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register now >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Em El AR Passive Statistic or Call to Action?
For many, the medical loss ratio (MLR) is the ratio of the health plan's incurred medical claims to the total premiums earned. However under the Affordable Care Act and for government health programs, the MLR is the ratio of medical claims plus quality improvement costs divided by earned premiums minus federal and state taxes and fees and payments in lieu of taxes.
This is not the time or place to get into a discussion about the rules for what is included in the calculation of the Medicare Advantage MLR, but rather focus on what are some of the drivers of the medical spend which makes up the greatest proportion of the MLR and what health plans should be focused on to control that medical spend without sacrificing the quality of services provided or the expected outcomes.
Most payers and provider sponsored health plans collect data based on provider submitted claims, and in most cases translate the data into an annual statistic referred to as the MLR. That is where the common ground begins to turn into quicksand. Why? Because not every health plan has either the capability or knows what to do next with the data that is being collected. Some plans will ask the questions related to what are the drivers behind the MLR, such as: what are the medical utilization outliers; are the providers coding inaccurately; are the referrals and referral patterns from PCP to Specialist or from Specialist to inpatient settings appropriate? What about the use of the ER, or the use of pharmaceuticals? Is the claims configuration process and adjudication process supportive of the provider contracts that have been negotiated? And so it goes.
The point is that even the more sophisticated Plans at times, are at a loss to identify all the drivers that impact the MLR, and therefore Plans are not able to address completely all the existing outliers that drive the MLR. Without that information, a Plan's success in developing short, intermediate and long term strategies and initiatives focused on population management, medical management and financial planning is not fully realized.
A comprehensive understanding of the various elements that drive medical expenses and hence the MLR will enable Plans to develop forward looking assumptions regarding premiums for lines of business, projections on utilization of clinical services, and provider contracting budgets, just to name a few. Recognizing specific drivers of medical expense can assist health plans in transitioning from fee for service (FFS) driven contracted networks to "value based" networks as well as working proactively to lead a transformation of population management .
Such understanding can lead to health service initiatives around how to best impact provider practice patterns regarding member access, coordinated treatment planning, appropriate referral patterns and improved coordination of care via elimination of duplicative or unnecessary procedures.
Ultimately, the goal should be the development by the Plan of a medical expense management plan that is characterized by a forward looking and dynamic approach to proactive medical management and includes provider initiatives supported by performance based measures.
The bottom line is that for many of the health plans, the issue is not lack of data but how to ask the right questions of the data in order to create actionable efforts that lead to improved performance by the plan and provider and results in improved outcomes to the member.
And sometimes it takes an outside objective partner with a fresh approach to data analysis and understanding of industry best practice to interpret what the data implies. That is where we at the Gorman Health Group can help. Contact us today. You will be glad you did.
Resources
On September 26, Join John Gorman, GHG's Founder and Executive Chairman together with colleague, John Nimsky, Senior Vice President of Healthcare Innovations, as they discuss the vehicles for achieving what could be characterized as a reengineering of the health care delivery process and its effectiveness. Register today >>
On Tuesday, August 19, GHG's Senior Vice President, Bill MacBain and Senior Vice President of Healthcare Innovations, John Nimsky, explored the drivers and trends in cost and revenue which affect your MLR. Access the webinar recording by becoming a member of the Point >>
In addition to our continued work launching new entrants into the MA market, we are helping many experienced plans develop smart networks: accountable care, shadow capitation, and payment bundling within their current service areas and networks. Contact us today to learn how we can help you >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
The Clock is Ticking...
If you are a veteran of Medicare Risk Adjustment reporting, you are probably in high gear planning or implementing year end programs to optimize 2014 and 2015 revenue. But is the same old approach you used last year the right approach for this year? Or maybe you are new to Medicare Risk Adjustment or Commercial Risk Adjustment reporting and not quite sure of what programs you should be doing this time of year.
GHG has experienced Risk Adjustment analysts and consultants that can help you meet and exceed your yearend goals. Below is our checklist of processes you should be doing now to help ensure complete and accurate Risk Adjustment data reporting for yearend:
- Implement analytics that appropriately consider the new Medicare blended HCC model.
- Suspect targeting for Medicare and Commercial chart reviews — Employ a targeted approach to cast a wide net, but optimize program results.
- Suspect targeting for 2014 Medicare and Commercial member outreach — Member calls, in-home assessments, provider interventions — one approach alone won't get you there.
- Chart review execution — Know what your vendors are coding (do they include Rx HCCs?). Could computer aided coding reduce costs and improve ROI? What is the quality of the vendor reviews...would they hold up in an audit? Are they also looking to delete codes?
- Commercial Risk Adjustment — Select an independent vendor to perform your required audits.
- Audit Readiness — Execute the appropriate data quality audits now to minimize audit risk next year.
- ICD — 10 — Revisit or develop an implementation plan…ready or not here it comes!
Plans need to be proactive in their data capture to submit data before the January 31, 2015 deadline for Medicare and April 30, 2015 deadline for Commercial. Data accuracy also needs to be a priority with both programs to minimize audit risk and government take-backs.
Our team of experts can show you the way. Please contact us today.
Resources
Gorman Health Group can help ensure that your procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete. Visit our website to find out how GHG can help ensure you are ready for that RADV audit when CMS calls >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>
Join us on September 19 for an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy." Register today >>
Hospice Guidance Turns 180 Degrees
After 70 Senators signed a protest bill and the hue and cry from hospice providers, patients and prescribers got too loud, CMS rescinded its' previous regs for hospice patients and published new guidance on 7-18-14. Previous guidance required health plans to place prior authorization edits on all medications after a member was identified as being a hospice patient. So, all the medications that the member was previously receiving under their Part D benefit were denied at point of sale. This caused a significant hardship to hospice providers who many times had to pay for the hospice member's medications. The philosophical and medical issue continues to be what medications should be continued and which medications should be discontinued when members are in their hospice benefit. Should antihypertensive, antihyperlipidemic, diabetes and other chronic medications be continued for hospice patients? Rational and substantive arguments exist for the continuation of some chemotherapy medications which keep tumor growth in check and are considered to be palliative for some patients.
The new guidelines require plan sponsors to place beneficiary level prior authorization requirements on four categories of prescription drugs:
- Analgesics
- Antinauseants (antiemetics)
- Laxatives
- Antianxiety drugs (anxiolytics)
These categories are assumed to be "related to the terminal illness and/or related conditions". Hospice providers will provide these medications. Plan sponsors are expected to continue to provide other medications which may have CMS approved utilization management edits including quantity limits, step therapy and prior authorization. Retrospective review is expected to determine whether other medications were "unrelated to the hospice beneficiary's terminal illness".
Resources
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 >>
The Online Monitoring Tool™ (OMT™) is a complete compliance toolkit designed to help organizations track the compliance of their operations. Modules developed specifically for MA and Part D sponsors address distinct operational and compliance needs. Learn more about OMT™ here >>
Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>