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Topic: Brain Food
You’ve got your nose to the grind stone working to meet all the waves of operational changes and requirements related to Medicare, Medicaid, Obamacare, and Health Care Reform – you literally don’t even have time to glance upward to the skies. Understandable. But it can cost you.
We have written many articles on the importance of maintaining accurate, reliable data. Data is everywhere and in many versions. Health plans need to be very careful to input only that information coming from a reliable source of truth. In government programs, that reliable source of truth is prescribed to be information contained within the government’s systems. “Scrubbing” data means reconciling against that reliable source of truth. For health plans, this means reconciling with information within the government’s systems, regardless of whether that information is right or wrong. Correcting the government’s erroneous information requires adherence to prescribed processes.
Now that the smoke has cleared and the ink is dry on the formulary/transition and bid submissions, it’s okay for plans to breathe for a couple of weeks. Then—if you’re implementing a new Pharmacy Benefit Manager (PBM)—it’s time to roll up your sleeves and get started with conceptualizing and developing a road map for the next six months. It’s important to start early and work steadily to make decisions, create processes, and complete training. During this time, you must continue to partner with your current PBM to process claims, make coverage determinations, and oversee and monitor all the delegated functions according to the plan you have in place. With the new PBM, you have the opportunity to tweak some processes that perhaps weren’t working exactly as you had envisioned originally.
Now that the 2014 EDGE server submission is complete, it will soon be time to audit a large sample of the data. Are you ready?
This is the time of year when most plans have either completed, or are in the process of completing, their annual evaluation of their Quality Improvement (QI) Program Description and Work Plan for operating year 2014. In the 12+ years I have worked for Gorman Health Group (GHG), I have seen a range of evaluations – from great evaluations to those that are just a couple of pages without content. Let’s examine some mistakes and discuss some industry happenings that are often missed in the overall QI world. Before we go on to discuss, let’s remind ourselves what the Centers for Medicare & Medicaid Services (CMS) is looking for in a QI Program Description, which is based upon the regulation 42 CFR § 422.152:
Per the announcement by CMS on Tuesday, the proposed Medicaid rule would require plans to implement an 85% medical loss ratio (MLR). Implementing an MLR for Medicaid would bring the programs in line with the private health insurance market and Medicare Advantage. However, as mentioned by GHG’s Sunmi Janicek, it would not be without challenges. The compliance costs for Medicaid plans with the increase in diligence needed in identifying & documenting costs incurrent to improve quality could be high. Additionally, the CMS proposed rule would impose new standards for beneficiary access and availability to the MCOs provider network.
Some important points came out of the Centers for Medicare & Medicaid Services’ (CMS’) Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast; the presentations and videos of the event can be found here in CMS’ Event Archives. If you did not have a chance to attend or watch it live, please watch the videos for important changes pertaining to many aspects of the MA-PD program. Speakers addressed Part C and Part D call letter updates, policy and technical changes, Quality Improvement Project (QIP) and Chronic Care Improvement Program (CCIP) lessons learned and best practices, the new network management module, enrollment updates, and fraud, waste, and abuse (FWA).