Pay me now or pay me later: Things to keep in mind when you set your 2014 budget
Back in the ’80’s Fram Oil Filters had an advertising campaign that featured an actor dressed as a mechanic, admonishing viewers to get their oil changed and get a new oil filter, to prevent costly engine damage. “Pay me now or pay me later,” he said.
When it comes to some key Medicare Advantage functions, the “pay me later” scenario can be perilous indeed.
Take data reconciliation, for instance. MA plans, especially those with drug coverage, need to reconcile at least a dozen different types of data with CMS: Enrollment data; Transaction reply reports; Retro processing contractor; Beneficiary churn ; Capitation payments; Premium data; Out-of-area residence; Subsidy payments; Medicare as secondary payer; Prescription claim (PDE) data resolution; Part D coordination of benefits (COB); Enrollment data validation; Compliance & reporting; Medicaid state roster and best available evidence of Medicaid enrollment.
The sheer volume of data and transactions dictates use of automated processes and controls to manage the reconciliation workflow. Spreadsheets won’t cut it, and quasi-manual processes rapidly fall behind the need for daily data import and analysis. Failure to reconcile results in incorrect claim and capitation payments, premium collection issues, enrollment and benefit errors, reduced quality scores, and the potential for excess repayment under drug plan risk corridor reconciliations. Even for small plans, there can be millions of dollars at stake.
Compliance is another area where failure to invest in automated systems now can cause a bad “pay me later” outcome. The cost of a bad CMS compliance audit isn’t just the staff time to correct problems. Most compliance problems are directly linked to member satisfaction issues, and a “bad” audit is symptom of deeper problems that lead to high member services call volume and disenrollment rates. Not only does CMS expect plans to be audit ready all the time, members expect things to go right all the time. We have found that the best approach is to use information technology tools to continually monitor compliance at the department level, to maintain complete and organized documentation, and to identify areas where compliance is lagging — where management intervention is warranted. Compliance programs need to be documented, regimented and sustainable. Compliance doesn’t wait to happen. It takes an organized and on-going campaign, supported by automated tools to remind, track, document, and spotlight problems.
A third opportunity for trouble is in how sales agents are trained, vetted, and monitored. CMS requires annual training, which is best done using computer-based learning systems. Embedded testing provides documentation of comprehension. On-going supervision requires diligent tracking of complaints and allegations to confirm, respond, and assess improvement. As with other complex tasks, an automated solution reduces opportunities for errors and omissions.
At a time when every dollar counts, it’s a good idea to consider budgeting for an investment in software solutions that solve these problems. Gorman Health Group has built software that supports our own consultants as they work with health plans on these issues, and these tools are available for health plans to use in their own operations. The GHG software is unique in that all of these applications are Web-based, fully hosted solutions that present no strain to IT resources. And GHG’s subject matter expertise drives each product’s unique functionality.
I invite you to contact my colleague RaeAnn Grossman, to start a conversation about your goals, the risks you face, and your available resources and budget for the 2014 year.
RaeAnn Grossman
Chief Sales and Marketing Officer
Rgrossman@ghgadvisors.com
Resources
Decision-makers from Health Plans and Provider Organizations are invited to join GHG for a free webinar on November 19th: “The future of the Government sponsored health care.” Register for this free event now >>
The Online Monitoring ToolTM (OMTTM) is a complete compliance toolkit designed to help organizations track the compliance of their operations. Visit our website to learn more about how the OMT can help your organization >>
The way in which you onboard, train and conduct ongoing oversight on your sales agents is critical. GHG created Sales Sentinel™ specifically to meet the needs of health care organizations operating in regulated government markets. Learn more here >>
Every health care organization is looking for improved outcomes, better compliance and enhanced process efficiency when it comes to managing membership and premium payments. GHG’s Valencia was designed specifically to meet those needs.