Network management, directory accuracy, service area expansions (SAEs), and the new triennial review process have placed many Medicare Advantage (MA) plans in flux and exposed serious issues – from policy to process to staffing and technology. As we move into the countdown for network development and expansion for 2020, a review of lessons learned will be helpful in planning and avoiding some of the pitfalls from 2019.

• In previous years, plans submitted their Health Service Delivery (HSD) tables with their applications, and, by the end of April, there was clear insight into which counties the Centers for Medicare & Medicaid Services (CMS) deemed to have an adequate network. This year provided a new challenge with bids being submitted prior to HSD tables being uploaded and reviewed by CMS.

As multiple new regulations on network adequacy and directory accuracy have been implemented, a lesson learned by many is there can never be too much communication and oversight in managing provider network contracting and credentialing data.

• Overall project management and poor communication between outside vendors during an expansion can lead to stressful situations and put the plan at risk for compliance actions. Planning ahead and including oversight and transition plans at the start of any project can lessen the risks down the road.

Here at Gorman Health Group, we have been brought in and have identified situations described and have outlined extensive work plans to include policy and procedure (P&P) changes, technology updates, network development plans, compliance solutions, and assisted plans in working through the corrective action needed.

We can’t stress enough how the cost of prevention and planning on the front end becomes even more cost effective when faced with correcting on the back end.

Summer is the best time to be proactive and start planning your next SAE or even your first step into the MA world. Alternatively, perhaps, summer offers just the right amount of downtime to start planning for updated oversight policies.

As you start your initial or expansion planning process and set new network monitoring processes in place to ensure preparedness, consider this: Gorman Health Group has a long history of providing the following:

• Leveraging long-standing relationships and nationwide experience coupled with a cost-effective team of Senior Consultants and Network Analysts to effectively stand up a contracted provider network
• Designing and developing a network strategy and product strategy that take into account the quality, financial, risk adjustment, and Star Ratings goals for success within the competitive landscape of your market(s)
• Developing the oversight and monitoring P&Ps needed to address the new network and directory requirements
• Preparing plans’ HSD tables for a CMS filing or bid submission as well as preparing network exceptions to include all the required elements.

Let us know how we can work together now to support your plan’s goals for the future. We’ve been there, fixed that, and will ensure your success. Contact me directly at emartin@ghgadvisors.com.

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