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

Consistency
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.

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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 Pamela.Argeris@merrillcorp.com.

Making Sense of 2010 Enrollment and Disenrollment Guidance from CMS

CMS recently released their updated 2010 guidance for Enrollment and Disenrollment.  A surprise awaited with a new model enrollment forms (exhibit 1 and 1a) along with new notices.

There are also NEW MA exhibits 34, 35, 36 and NEW PDP exhibits 33, 34, 35.  

Exhibit 33	NEW! PDP Model Notice to Research Potential Out of Area Status
Exhibit 34	NEW! PDP Model Notice for Disenrollment Due Out of Area Status (No Response to Request for Address Verification)
Exhibit 35	NEW! PDP Notice of Disenrollment Due to Out of Area Status (Upon New Address Verification from Member)

As with any guidance from CMS, the first step is identifying what’s new, then moving forward with an analysis of how it will change your business; what it could add, change or remove for your processes.

We’ll be providing more on these guidelines as enrollment deadlines approach.

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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 Pamela.Argeris@merrillcorp.com.

CMS Audits Aim For “Real Time” Reviews

In years past, the norm for CMS has always been to conduct retrospective audits – essentially a review of data from prior months’ (EX. CMS would arrive at the plan in October to review data from January through June).

Audits were primarily focused their efforts on universe pulls and standard operating procedures along with any known escalated events that came through their jurisdiction such as CTMs.

Moving forward CMS will be conducting audits of plans on a more "real time" basis. They are conducting more "focused" audits and they are keeping a tight view of all plan CTMs and their occurrences.

Also, MA plans are now directed to report more in-depth information to CMS beginning with HEDIS and other metrics. With this increased scrutiny of plans and Medicare Improvements for Patients and Providers Act's arrival in 2008, the theme of tighter monitoring continues to resonate throughout regulation for 2010.

As such, better procedures and business processes are no longer discussion points, but key elements in maintaining quality and compliance (see: The 2010 Call Letter, Marketing Guidelines, and Enrollment and Dis-enrollment Guidance).

As with any guidance and changes from CMS, the first step is indentifying what’s new, then moving forward with an analysis of how it will change your business; what it could add, change or remove for your processes.

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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 Pamela.Argeris@merrillcorp.com.