Friday, April 22, 2011

CMS 2011 Spring Conference Wrap-Up

The CMS 2011 Spring Conference has officially wrapped up, and once again a large amount of information came directly from CMS on the state of the market, what their expectations are and what plans need to do to succeed in the new world of healthcare. As is customary, Jonathan Blum, Deputy Administrator and Director of CMS, had the keynote speech. 

Mr. Blum spoke about the 2012 CMS Priorities for the Medicare Part C and Part D Programs and beyond. CMS’s focus is on the following three items:
  1. Consistency
  2. Quality Improvement
  3. Continued focus on Compliance

CMS’s view of consistency means policy consistency. Simplifying programs, benefits and plan choices for beneficiaries; making navigation of the Part C & D programs easier for beneficiaries overall. CMS has a great deal of policy to implement via the Affordable Care Act, so they are seeking to allow systems and plans time to catch up by holding steady with policy issuance.

Quality Improvement
The 5 Star Bonus Payment System signals that CMS cares about quality, improving scores and rewarding good plans.  Ratings are provided as a consumer tool and payment mechanism.  As such, in 2012, 5 Star Plans will be allowed to market enrollment year round; while plans with 2 Stars consistently for 3 or more years will not be allowed to offer products to beneficiaries. Overall growth of 7% has been recognized in Medicare Advantage for 2011; this growth is even faster for 4 Star and higher plans. Plans are focused on improving ratings so beneficiaries gravitate to their plans.

Continued focus on ComplianceCMS has a heightened focus on compliance, audits, and performance. This can be seen in the way 2010 audits were conducted. Several overall trends appeared during the audits that all plans should take note of. The areas consisted of Part D Formularies, Coverage Determinations, Grievances, and Enrollment & Disenrollment Processes.

In addition, Mr. Blum stated that plans should understand their business better than CMS.  They should see and identify trends and issues before CMS. Understanding why their beneficiaries are calling is critical to correcting issues immediately. The top area of concern noted in the audit findings centered on oversight of a plan’s Pharmacy Benefits Manager (PBM). While CMS understands this is a delegated role the plan must remember they are ultimately responsible to the member and CMS to ensure their enrollees receive their medications. The oversight of the PBM must be conducted on a daily basis to avoid issues and ensure beneficiaries receive their medications at point of sale. Special attention should be paid to protected classes and transition of medications; multiple problems were cited in these areas. Proper and timely processing of coverage determinations and grievances is critical to remain in compliance. Also, plans must ensure their enrollment and disenrollment processes are working fluently. Take the time to build internal controls and workflow processes to avoid issues later down the road.

Overall, CMS is focusing on becoming more forthright. Compliance is of utmost importance.  Better Compliance + Better Performance = Higher Plan Reimbursement.  As the Medicare program continues to grow and expand the plans that do well will receive more members.


Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at

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