The Centers for Medicare & Medicaid Services (CMS) annual fall conference never misses in providing important information for Sponsors. This year’s conference was held in Baltimore on September 6, 2018. Conference materials can be found on the Compliance Training, Education & Outreach website here. CMS covered many areas, but here I’m focusing on two key areas of the conference: Medicare Communications and Marketing Guidelines (MCMG) updates and appeals and grievances classification best practices.

MCMG

One of the most important clarifying statements from CMS was definitively communicating the MCMG replaces the Medicare Marketing Guidelines (MMG) and any guidance within it. What does that mean? If previous MMG guidance is not dictated in the MCMG, Sponsors should consider that guidance obsolete. While many had assumed that was the case, it’s always better to get clarity straight from the source. This single statement should resolve many looming questions by Sponsors.

Of equal significance was CMS further outlining the meaning of “marketing” material. In order to be considered “marketing,” the material must meet both intent and content requirements. If only one of these distinctions is met, the material would not be considered “marketing.” The example used to help drive this message was the Evidence of Coverage (EOC). The EOC has content that would meet “marketing” definitions, however, the intent is not to persuade a beneficiary to enroll, so it is considered a communication. This new guidance will eliminate much burden for Sponsors in relation to the number of materials requiring CMS review and submission. While this removes some administrative burden, the oversight may need to be more stringent as health plans are now even more responsible for correct classification of documents and ensuring documents still comply with all CMS requirements. Additionally, documents must be available upon request.

Other noteworthy clarifications from CMS:

An updated MCMG was distributed by CMS on September 6, 2018.

APPEALS & GRIEVANCES

In their continued effort to help Sponsors in the appeal and grievance space, CMS and Sponsor representatives presented classification best practices. CMS reminded Sponsors of key words when classifying appeals and grievances:

Inquiry —– a question
Grievances —– a dissatisfaction
Coverage/Organization Determination —– a decision to provide or pay
Appeal —– a dispute of a previous decision

Several health plan speakers shared their best practices. Some of the valuable recommendations that changed their organization included:

• Centralized Customer Service staff focused on identifying appeals and grievances. Staff training focused on real-life examples and involved frequent refreshers.
• Cross-functional all staff on grievances, coverage and organization determinations, and appeals. Training not only included correct identification and classification but also the downstream member and CMS impact of failure to correctly identify complaints. This holistic approach supports the member experience and greater CMS compliance.
• Intake staff who review cases quickly to identify any potential misclassification of cases. Root cause analysis as a routine part of processing. So often the focus is on resolving the identified issue for that member, which is critical. Equal importance is remedying any systemic concerns to prevent the problem from impacting other members. The presenters discussed how root cause was discussed in routine meetings with other departments for brainstorming and resolution.
• Embedded Compliance staff within the business units. A great trend in the industry in recent years is to have an operational Compliance person located in critical operations units. They are available to help staff work through complex issues where a keen eye on regulatory guidance is needed. This keeps cases moving forward and allows staff to feel supported all while maintaining high compliance.

CMS conferences have always been valuable resources in clarifying new changes or functions that have the attention of CMS. Don’t miss utilizing this valuable resource to stay current.

Gorman Health Group provides training tools, conducts mock audits, and supports process improvement initiatives related to Parts C & D appeals and grievances? We also provide interim staff for clients when they have a need in this area.

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