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Topic: Brain Food
Plans will shortly be receiving the Readiness Checklist from CMS. At first glance it looks like just a bunch of boxes to check off and answering yes and no questions. Here’s the rub:
It wasn’t too long ago that the clinical staff and practitioners in the medical management arena of health plans only focused on the quality and continuity of care with their members. These objectives were very important, and should continue to be the focus of any medical management team. However, in more recent times, it has become just as important for the clinical areas of health plans to become aware of the costs of care they incur and to become involved in the control of those costs.
As a seasoned veteran in healthcare operations I’ve seen firsthand the progression of data utilization by health plans. Despite decades of growth we’re not there yet.
Is it Groundhog Day or does this memo say the same thing as last year? Nope you’re not imagining things – In CMS’ Memo titled “Common Conditions, Improvement Strategies, and Best Practices based on 2013 Program Audit Reviews” that was released on August 27th, CMS outlines again the industry pitfalls and best practices around common areas of noncompliance identified as a result of CMS Program Audits. You may be saying to yourself “some of this looks familiar” well – you’re right.
September 4th was final submission day for Marketplace plans but some worried health plans were asking “what ifs” about their last submission for network access. These plans have re-submitted network updates after two CMS rejections that required correction for failing reasonable access. They have three consecutive wrong guesses on whatever standards CMS believes they have not met. They want to know what happens if CMS doesn’t approve their network access plan. Of course, they are still asking what standards need to be met.
For many, the medical loss ratio (MLR) is the ratio of the health plan’s incurred medical claims to the total premiums earned. However under the Affordable Care Act and for government health programs, the MLR is the ratio of medical claims plus quality improvement costs divided by earned premiums minus federal and state taxes and fees and payments in lieu of taxes.
As expected, CMS has been sending correction notices to health plans about their networks. Also, as expected, some plans have received a second rejection of their response to the first rejection. Now, time is limited since final corrections are due by September 4. Health plans are asking CMS to give them some idea about how to meet CMS expectations.