Double Your Value: Three Critical Ways CMS Audit Readiness and the Member Experience Program Intersect

What do the Centers for Medicare & Medicaid Services (CMS) program audits and member experience programs have in common? At their core, both activities are looking out for and protecting Medicare health plan members. CMS, in their oversight role, is responsible for ensuring Medicare Advantage (MA) and Prescription Drug Plan (PDP) members receive all the rights and benefits of original Medicare as well as the additional services agreed to in contracts with MA plans and PDPs. Operations has to own compliance with CMS as well as how operational functions touch and impact our members’ experiences. “The cornerstone of an effective member experience is cross-functional alignment, placing the member at the center of the health plan’s initiatives and core business functions” says Carrie Barker-Settles, Gorman Health Group’s (GHG’s) Director of Sales & Marketing Services. In days of shrinking payments, plans need to be even more efficient as they provide services to their Medicare members but without cutting corners that result in non-compliance or driving members away from our plans. We can each make a difference in the areas of compliance and member experience efficiently as the goals are so aligned.

Here are three critical ways you can increase your member experience program’s operational components and drive audit readiness.

1. Denials in Claims Payment and Appeals: One of the most negative things a member will experience with his or her insurance is having something be denied that he or she thought would be covered. This is reality with any health plan, but how a denial is handled can make things so much worse. Claims denials often include standard templated denial reason codes. Appeal upholds may be more customized, but not always. It is important to review member denial language in claims and appeals to make sure the language is clear and understandable to your members. Are they able to understand the next steps they should take if they disagree with the decision? This is a common audit finding and a big driver of dissatisfaction.
2. Claims and Appeals Development: Another action that should occur prior to denial of services is to completely develop the claims and appeals prior to the decision. Many plans experience trouble obtaining additional information from their contracted providers. When this occurs, what is the process to escalate that lack of response? Establishing a systematic process to obtain needed information to correctly determine approval or denial of service is critical to appropriate management, member satisfaction, and compliance.
3. Appeals and Grievances: Root cause analysis on your appeals and grievances and then taking action on what is identified is an important step to close out cases. Often only provider information is tracked and trended, or overall appeals and grievances reports are provided to the Quality Committee. Programs need to ask how complaint information is being used to improve the plan. A plan can enhance a member’s experience through analysis of what happened and what can be done to prevent that from happening again.  CMS expects to see thorough and complete investigations and resolutions when complaints are received, as do we all when we submit a complaint. Root cause analysis and follow-through will not only benefit all your members but support your need to demonstrate quality complaint processing to CMS.

Just as compliance is everyone’s job, so, too, is ensuring members have the most positive experience possible every time they interact with a plan. Regan Pennypacker, GHG’s Senior Vice President of Compliance Solutions, says it best, “I’m often asked what is the cost of non-compliance, or how much is the fine if we don’t do X-Y-Z? A final rule was released on September 6, 2016, which adjusts maximum civil monetary penalty (CMP) amounts allowed for all agencies within the Department of Health and Human Services (HHS). This, along with CMS’ recent memo on the 2017 CMP methodology, should demonstrate to the industry that the agency is prioritizing this aspect of enforcement for good reason. Denials, appeals, and access to care should be under constant evaluation by Operations and Compliance in order to identify opportunities for improvement.” She goes on to say, “Audit readiness aside, ask yourself if you are truly beneficiary ready.”

When we in Operations expect CMS compliance to be managed by the Compliance area or member experience to be managed by the Sales & Marketing area, we do ourselves a disservice and lose out on some of our most valuable benefits to our health plan. Implementing these steps will change the dynamics of our department by making our teams more member centric, promoting ownership, and making a live CMS audit easier.

GHG’s Operational Performance practice area consultants have been in your shoes. We have faced the multiple priorities and pressures to meet production goals and maintain team satisfaction at the same time. If you need assistance in setting up an audit-ready department or improving your support of member engagement, we can help.

Resources

At Gorman Health Group, we maintain the country’s largest staff of senior operations consultants.  Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more about how we can help you >>

Stay connected to industry news and gain perspective on how to navigate the latest issues through GHG’s weekly newsletter. Subscribe >>