Why Is Conducting a Part D Operational Assessment so Important?

Medicare Part D is a complex program that is continually in motion. The Centers for Medicare & Medicaid Services (CMS), in an attempt to provide clarity to stakeholders, actively publishes updated guidance to sponsors to assist in process improvement and encourage optimal beneficiary outcomes and experience. Keeping up with Health Plan Management System (HPMS) memos, best practices, yearly call letters, and webinar information is challenging.  Dynamic and ever-changing guidelines inevitably bring uncertainty and risk. Understanding these guidelines and operationalizing a compliant program is key to a successful program and financial sustainability.

For an organization to succeed in this fluid environment, it must achieve higher quality and Star Ratings, improve beneficiary satisfaction and retention, while staying on top of compliance and operational efficiency. CMS expects all plan sponsors to carefully and regularly evaluate risks to their organization. Emphasis is placed on compliance, identification and prevention of fraud, waste, and abuse (FWA), and oversight of first-tier, downstream, and related (FDR) entities.  Additionally, in recent years, there has been increased focus on coverage determinations, appeals, and grievances. All of these areas can have an impact on a plan’s Star Ratings and financial outlook.

Conducting a comprehensive operational assessment is an excellent strategy to identify a plan’s strengths and weaknesses and evaluate the adequacy and reliability of operations. Information is gathered and evaluated from multiple sources such as current policies and procedures, oversight activities, reports, and operational processes. Comprehensive evaluation of this information will proactively identify areas of risk, allowing plans to strategically adapt to the changing environment to reduce identified risks. Gorman Health Group, with our team of industry experts, can provide an assessment of areas of greatest risk exposure along with solutions based on best practices, ensuring the organization is well positioned for future success.

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Our broad array of services can assist you in post-audit remediation, implementation of best practices, PBM contracting and implementation, interim staffing, clinical process re-engineering, Star Ratings improvement, and claims and PDE assessment and adjustments. Visit our website to learn more about our Part D services >>