Rewards and Incentives: Are We There Yet?
Yes, Medicare Advantage is finally catching up to the rest of the health care industry, and we are now permitted to offer enrollees Rewards and Incentives.
On December 4, 2014, CMS released an HPMS memo titled "Rewards and Incentives Program Guidance" which provides additional guidance related to how Organizations must implement Rewards and Incentives Programs, which, as of July 22, 2014, CMS allows for Part C benefits.
Although the implementation of Rewards and Incentives is no easy task, I think the more pertinent question is how could this new guidance impact your Organization and our industry as a whole? Well, some of that, I think, will remain to be seen as these programs are implemented. However, I do think there are a few challenges and strategies that we should consider as we're implementing these programs - here are a few things to mull over as you're ringing in the New Year:
• What is the competitive landscape for Rewards and Incentives, and how will your Organization ensure that it is competitive while still remaining compliant?
• How will your Organization ensure that your Rewards and Incentives program will have an impact on enrollee behavior?
• How will your Organization track information regarding Rewards and Incentives?
• Last but not least, how will your Organization oversee the implementation of your Rewards and Incentives program to ensure compliance?
So, what is the trend? The fact that Medicare Advantage Organizations are now allowed to provide Rewards and Incentives (for Part C benefits) further indicates that CMS' main focus and main objective is the health of the Medicare population — as it should be, of course. However, we in the industry should take note - along with CMS' continued scrutiny via their program audits (and other mechanisms) of those areas that have the potential to cause beneficiary harm, they are also loosening the reigns in certain key areas such as Rewards and Incentives. The objective here is to ensure that Medicare beneficiaries have access to high-quality health care including any incentives that could in fact have a meaningful change in the way that beneficiaries approach their health care.
For more information or support, contact us today and a team member will be in touch with you shortly.
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Become a member of the Point to receive access to the analysis of all HPMS memos by GHG experts. Already a member? Access the HPMS memo mentioned in this article here >>
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Federal study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act
Federal investigators said in a new report that large numbers of doctors who are listed as serving Medicaid patients are in reality, not available to treat them.
Patients select their physicians from a list of providers associated with each Medicaid health plan. The investigators, led by the inspector general, Daniel R. Levinson, called the doctors' offices and found that in many cases the doctors were unavailable or unable to make appointments.
More than one-third of providers could not be found at the location listed by a Medicaid managed-care plan.
This can create a significant obstacle for an enrollee seeking care, impacting access to important benefits and treatment. Imagine being in the middle of a need for important medical care, picking up the provider directory and over half of the doctor's numbers you call are not valid.
If access to care cannot be relied upon, the foundations of the managed care programs are at risk. With the recent growth in Medicaid managed care, this becomes a more significant concern for the government as well as the industry. With the concern comes the potential for more stringent oversight.
New rules and standards to ensure timely access to care for Medicaid patients are under development. The push from the National Association of Medicaid Directors is to avoid overly prescriptive standards given the variances of State Healthcare markets.
CMS and OIG are in concurrence about tightening the standards, oversight and adequacy requirements.
We can help you wind your way through the new rules and the process for improved access to care. Contact us today.
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Gorman Health Group, LLC (GHG), the leading consulting firm and solutions provider in government health care programs, announced its further expansion into Medicaid, and the promotion of one of the nation's leading Medicaid experts, Heidi Arndt, to lead the division. Read more >>
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Hepatitis C virus (HCV) and treatment with Sovaldi® (sofosbuvir)
The medication Sovaldi® has revolutionized the way HCV is treated and at the same time has shocked health insurance payers and particularly Medicaid prescription drug budgets. With an estimated cost of $1000 or more per pill for a twelve (12) week course of treatment, the cost to treat one person can exceed $84,000.
According to the Centers for Disease Control & Prevention (CDC) there were an estimated 16,000 acute HCV infections reported in the US in 2009, the latest year statistics are available (http://www.cdc.gov/hepatitis). An estimated 75-85% of the people infected with acute HCV develop the chronic condition. The CDC estimates that there are 3.2 million persons in the US with chronic infection. Most people do not have symptoms and are unaware they are infected with HCV. HCV also affects those in lower socioeconomic classes and therefore the potential impact to Medicaid programs is even greater.
Sovaldi has a cure rate as high as 95%, with mild side effects during a twelve week course of oral therapy. Compare this with the previous drug of choice to treat HCV, interferon. Interferon is injected for up to a year and can have severe, flu like side effects. The cure rate for the most common strain, genotype 1, is 48-56%, depending on the length of therapy (M. Parikh, April 2011). The cost for the interferon treatment is $15,000 - $20,000. It is easy to see that clinically Sovaldi has the upper hand, but what cost can Medicaid programs, and ultimately taxpayers assume?
Some state's Medicaid programs, such as Oregon, are looking at ways to manage the use of Sovaldi by approving it only for their Medicaid clients who are showing signs of liver cirrhosis and have clean drug tests, for example (COOPER, 2014). In addition, what happens if a patient fails to complete their 12 week course of treatment? Should they be allowed to resume another full course of treatment?
This medication is a perfect candidate for coordinated medical and pharmacy management. Adherence is crucial to ensure completion of the twelve week course of therapy. If Medicaid programs are going to invest in paying for these types of expensive therapies it is vitally important that the medications are taken appropriately for the required length of time.
To learn more about how plans are investing in programs to help patients achieve better outcomes with the new Hepatitis C treatments, contact us >>
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Gorman Health Group can work with your organization on blending medical and pharmacy to improve care coordination, outreach and utilization management to meet the complex needs of your membership. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.
Medicare Secondary Payer — A Simple Process with a Big Impact
We've heard many organizations say, "We do MSP" or "MSP, it's easy, we've got it covered". MSP processing may not be rocket science but it's a regulated process with steps that need to be executed correctly. The MSP transactions that your organization submits directly affect the monthly payment to your Plan and impact your financial reports. Your organization needs to have a confidence level that is equipped with the proper tools to be efficient and compliant, and most importantly feel confident that the financials related to MSP are accurate.
If you‘re uncertain about your end to end process, then you may be missing something and that something could relate to millions of dollars.
Take a moment to review your current process with our MSP Quick Assessment Checklist:
- Tracking Tool: A comprehensive tracking tool is essential for a complete picture of your MSP population and should be:
- User friendly, efficient and compliant
- Provide inventory totals of open and closed cases
- Provide potential A/R of outstanding cases
- Show case responses (accepted and rejected)
- Types of outreach performed and number of attempts
- Dash board reports that provide up to the minute status of cases and financials
- Flexibility to create customized reports
- Audit Trail
- An easy way to be CMS compliant is to have an audit trail for each MSP case. Each step of the process, including outreach attempts, follow ups, responses and letters should be documented with a date and time stamp.
- Prioritize your MSP cases for efficiency
- Group your MSP cases by premium impact or carrier in order to increase efficiency and obtain the best results.
- Persistence
- One of the most difficult tasks in the MSP process is outreach. Many cases require multiple outreach attempts to carriers or employer groups to obtain validation. Ensure staff is provided proper training and sufficient time to perform outreach and the follow up that's necessary to resolve cases. Practice due diligence — do not submit cases for "development" as doing so could delay potential recovery for up to 100 days.
- Responses & Rejections
- Many times organizations fail to review ECRS responses or rejected records. Each rejection code should be reviewed and resubmitted if necessary. Always check your initial submission for keying errors. Don't miss out on money because you're failing in this area.
- Communication
- As a result of an enhancement to ECRS and Part D (4/2012) terminations or delete requests to an MSP occurrence will automatically be applied to a linked drug occurrence record. For example, if a CWF Assistance request is submitted to add a termination date (TD) to an MSP occurrence, the termination date will automatically be applied to the linked drug occurrence. There is no need to submit a separate Prescription Drug Assistance Request. Partner your Part C and Part D areas within your organization to streamline processes, share information and look for efficiencies.
GHG has tools and experienced consultants that can assess your MSP process and provide analytics on your current state process to look for gaps or processes that may be negatively impacting MSP. We can work to create Business Process Redesign plans for a more complete and compliant process.GHG can also provide MSP Analysts to work remotely or onsite for large scale reviews, backlogs, or current work support.
If you're currently tracking your MSP cases on Excel spreadsheets, then it may be time to set up a demo of GHG's Valencia— MSP Module. Valencia is the software solution we use when we work with organizations to recover revenue and clean up data.
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Registration for the Gorman Health Group 2015 Forum is now open! Register your team for The Gorman Health Group 2015 Forum by December 31, 2014 and SAVE 30% off your ticket using promo code: EarlyBird30 at checkout.
Exchanges - Risk Adjustment - Ladies and Gentlemen, Start Your Engines
Seriously, the first question is, "what do you have under the hood for risk adjustment in your health plan?" If you're running a stock claims engine that merely matches up with your enrollment file for CMS Edge Server processing, and you don't have a risk adjustment operation, you may be breathing fumes from your competitors. Now, for health plans accustomed to competing against each other, we have a new type of competition. Further, it's not just plans on the Exchanges, it's all health plans on or off the Exchanges. Up to now, health plans have been competing for market share on the basis of premiums, benefits or brand; but with Exchange risk adjustment, competition takes on new meaning. You can gain or lose dollars. Some plans will transfer dollars to competitors on the market share they painstakingly managed to enroll. Ouch!
The process is very much underway at CMS with Edge Server testing. Plans are calibrating their systems. This means passing CMS testing for submission of test files, as well as understanding processing for acceptance and rejection of individual claims. Health plans must submit their first production by December 5, 2014. Beginning in mid-December, CMS will provide the first estimate reports to health plans for their review and feedback. After that, CMS will process files monthly until the final processing that occurs in May 2015, when risk scores are finalized for 2014. By July 2015, CMS expects to notify plans of any payments due when their risk scores indicate lower risk. For those receiving dollars, getting risk score payments will be no accident. So, while appeals can be filed, the process is upon us and, it will be too quick for any plan giving up dollars.
Right now, most plans' IT staffs are clarifying processing details. However, it is clear that some IT staffs are struggling with the basics, indicating few supports and a lack of horsepower in their risk adjustment engines. Most likely, these are plans that are not offering products on the exchange, and have limited familiarity with CMS requirements. To say they are back of the pack in this new form of competition, and have failed to understand this threat, is an understatement. Being caught unaware of their unknown risk score values relative to competitors' scores should be significantly unnerving to their leadership.
These leaders need to gauge their understanding and determine how quickly and sophisticated they can get. This includes ensuring that leaders develop the processes needed to identify proper risk scores, develop coding necessary to support diagnoses, and initiate analytics needed to identify gaps that require further investigation. So, the right time is now to lift the hood. Getting a risk adjustment engine to run over the next six months will be crucial to getting the most optimal risk score that properly reflects the health status of the members they have enrolled.
Resources
Gorman Health Group supports our clients in evaluating the efficiency, compliance, and strategic value of their risk adjustment programs from start to finish, and helps ensure that the procedures for capturing, processing and submitting risk adjustment data to CMS are accurate, timely, and complete. Visit our website to learn more >>
Listen as Janet Fina, GHG's Vice President of Risk Adjustment, together with colleague, Carol Olson, GHG's Director of Risk Adjustment, addressed areas for documentation improvement that will allow for accurate reimbursement and disease and case management opportunities. Become a member of the Point to access the recording >>
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 Importance of a Proactive Call Center
During the AEP we know how critical a role our Member Services team plays. During this time, they are integral to helping prospective enrollees understand the benefits of your Plans, and play an important part in the retention of your current members. Having a strong proactive Member Call Center is crucial in today's environment. Test your call center — see if they pass the test. A proactive Member Service Call Center Department should at a minimum, do all of the following:
- Highly trained call center representatives develop "one on one" member relationships
- Becomes a one stop resource for seniors (meal on wheels, etc.)
- Track and trend Members' problems and resolutions (problem solving)
- Reduce members voluntary disenrollment with focus on first-time call resolution of Member's problems
- Take the time to educate members (benefits, Providers, and Claims)
- Look for opportunities to engage the member in Care Management services
- Provide outreach reminders to members (Member Newsletters, appointment reminder postcards, etc.)
- Proactively, through outbound calls, identify first level problems and implement resolutions
- Provide new members orientation (an educated member is a happy member)
- Provide consistent training to help reduce the number of members' appeals and grievances
- Have Quality Improvement initiatives consistently in play to help improve the Star measures
- Support members in accessing care, even making appointments for them if necessary
If you can answer yes to all the bullets above regarding your current Member Service/Customer Service Department, then you are on the right road to increased retention. If not, then leveraging member's satisfaction is an important retention tool that should be looked at going forward. Now is the time for forward thinking initiatives!
Stats: 30% of Medicare beneficiaries are enrolled into a Medicare Advantage Plan (MA/MAPD). And over 15% of Medicare Advantage Companies Fail to meet the government standards for customer service through a call center for 2014. (Source: https://www.healthpocket.com/healthcare-research/infostat/medicare-advantage-customer-service-ranking.)
Resources
John Gorman, GHG's Founder and Executive Chairman discussed why assessing your current position and developing new strategies to drive profitable market share growth is crucial for continued success. Become a member of the Point to access the webinar recording >>
Gorman Health Group can 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 >>
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 >>
NY Times article reiterates compliance trends in Medicare Advantage
As many of you have already read, the NY Times ran a scathing article on October 12th titled "U.S. Finds Many Errors in Medicare Health Plans" shining a light on serious Compliance issues we've all been aware of over the past several years. Is the continued lack of non-compliance really news to anyone in the industry? Most certainly not — we have all been tracking the continued issues of non-compliance, increased CMS Compliance actions, and have read the audit reports posted on the CMS website. What the NY Times article did was remind us that the compliance trends in Medicare Advantage are a serious matter which should not be taken lightly.
The fact is, Medicare beneficiaries have not had access to their care; both Medical care and Prescription drugs.This is simply not acceptable — period. That being said, I have personally worked on the Plan side, on the consulting side, and as a CMS sub-contractor, and I know, firsthand, the challenges we face in the implementation of the thousands of Compliance requirements. This is no easy task, and anyone who thinks it is, simply doesn't understand plan operations. By and large, what we find is that Organizations want to be compliant; but they don't have the tools or resources to implement and manage this highly regulated program. So, what do you do next? Here is what we recommend:
- If you haven't done so already, go through the exercise of a Mock CMS audit - find your deficiencies now, both for the sake of the beneficiary, and for the sake of your CMS contract.
- Focus first on those issues that have the most beneficiary impact — ensure that your members have access to care as your number one priority.
- Document your remediation efforts and measure outcomes — issues aren't resolved overnight, but ensuring that your remediation plan is working is the key to success.
If you're not sure where to start, we can help. Please find here a description of our Mock CMS Audit Service, or contact us directly.
Resources
On Friday, Sept, 12 a GHG team member provided GHG's perspective on trends relating to CMPs, the CMS audit findings and oversight activities that have taken place in the last six to 12 months, as well as tips on how to avoid and remediate CMS findings. Become a member of the Point to access the webinar recording >>
All Medicare Advantage and Prescription Drug Plans must ensure that they are audit-ready all the time so that each CMS audit is routine. Save the fire drills for fires, and receive standing ovations for the organization's final performance. 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 >>
Reversing the Trend: Improving Care Coordination
The good news from the 2015 Star Ratings is clear: Medicare Advantage plans held steady or improved in almost 70% of the 46 Part C & D Star measures. But the more subtle message hidden underneath the 15 measures where performance declined in 2015 is similarly clear: health plans have not yet mastered population management and care coordination in a way that improves health outcomes. By linking the Quality Bonus Payments to 4 Star performance, the Centers for Medicare & Medicaid Services (CMS) is conveying their message: health plans must effectively coordinate the diagnosis to the healthcare activities for their members in order to drive improved health outcomes and satisfy members.
Gorman Health Group is often asked how plans can achieve Star Ratings success. As 2015 draws to a close, the following are a few key near-term suggestions on which to focus in order to achieve Star Ratings success in 2016:
- Create (or review) 2016 Stars work plan(s), evaluate customer service and medical/case management work streams, and processes to identify areas for improved care coordination.
- Evaluate provider and pharmacy network strategy to ensure that infrastructure supports Stars goals.
- Evaluate Stars performance among provider and pharmacy networks and develop targeted activities with under-performers.
Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.
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Gorman Health Group can evaluate your Star Ratings approach and identify tactics you can begin implementing immediately to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. We can help you identify clinical, operational, and networking opportunities to increase your score for 2016 and beyond. 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 >>
They Still Don't Like It
In the October 8, 2014 memo entitled "Contract Year 2014 Part D Formulary Administration Analysis (FAA)", CMS reiterates their concern with the accuracy of formulary coding. For the April 2013 analysis, 9 out of 88 (10.2 %) plan sponsors were found to have failed FAA, meaning that greater than 20% of the sampled rejects were determined to be inappropriate. The parameters for the 2014 FAA are:
- Sponsors will be required to submit all point-of-sale (POS) rejected claims relating to the following 4 categories: 1) non-formulary status; 2) Prior Authorization (PA); 3) Step Therapy (ST); and 4) Quantity Limits (QL).
- Larger plans (≥ 20,000 enrollees) should submit rejected claims data for service dates of June 1, 2014 through June 14, 2014 and smaller plans (< 20,000 enrollees) should submit rejected claims data for service dates of June 1, 2014 through June 30, 2014.
If you were one of the plans selected for the FAA, you were required to upload files to the Acumen site between October 16 and October 22. CMS will then select a sampling of the rejected claims for review. Those plan sponsors who meet or exceed the failure threshold will receive a notice of non-compliance and depending on how badly the plan sponsor exceeds the failure threshold, additional sampling and compliance actions may result.
Not to beat a dead horse, but this should again remind us of the importance of formulary benefit administration testing---rigorous and extensive at the beginning of the plan year and at every point during the plan year when formulary changes are made. You can't afford NOT to.
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Beneficiaries should be able to receive the Part D drugs they are entitled to, consistent with CMS guidance, from January 1st through December 31st of the plan year.
We can help your MAPD or PDP develop and implement efficient and compliant internal operations and prepare effectively for CMS audits with professional services and unmatched compliance tools. Contact us 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 >>
Application season is here: How's your network holding up?
Once again we are in the midst of application season for health plans applying to become a Medicare Advantage Health Plan, expanding their MA geographic footprint or getting into the Health Insurance Exchange space. Regardless of the scope or the specific enterprise, network adequacy and accessibility is a major cornerstone of any MA or Exchange initiative.
In addition, network adequacy and accessibility are no longer the only requirements for constructing and managing provider networks. Today's healthcare climate and market competition demands that Health Plans offer their membership provider choices which have been vetted for quality of outcomes and fiscal efficiency, ie. value based provider networks. That in turn requires health plans to find ways of evaluating their existing provider networks or newly recruited providers on the basis of past clinical and financial performance, and establish forward looking performance metrics by which to manage provider behavior and reimbursement tied to the delivery of clinical care.
Given that time is short, MA applications are due in March 2015 and Exchange networks must be in place by January 2015, many health plans are hard pressed to evaluate network adequacy, accessibility and develop appropriate reimbursement strategies on their own. That is where the Gorman Health group can help. We have a long history of helping Health Plans offer their members the best network possible. Give us a call, tell us your needs and let's work together to offer the best network product to your members.
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. Join the Point today to access this webinar recording.
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.
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. Find out how GHG can help >>
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 >>