Topic: Compliance

Bombshells from MedPAC on Medicare Advantage Retention

John Gorman

The Medicare Payment Advisory Commission (MedPAC ), the nonpartisan blue-chip Congressional uber-nerds on our favorite entitlement program, met this week and the staff report presented a couple bombshells on retention rates in Medicare Advantage (MA).

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CMS’s Star Ratings Firing Squad Gets Squirt Guns

John Gorman

Last week, in a surprise move, the Centers for Medicare and Medicaid Services (CMS) reversed its threat to terminate all Medicare Advantage and Part D health plans with 3 or fewer Stars for more than 3 consecutive years.  Roughly a dozen health plans were lined up in front of the firing squad as an example to the industry for months — and then CMS issued squirt guns to the executioners. 

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Groundhog Day: CMS Issues Best Practice Memo Related to Common Audit Findings

Betsy Seals

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.

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Passing Marketplace Reasonableness – One More Chance

Steve Balcerzak

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.

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Sales Allegations – What is the best practice?

Betsy Seals

It’s just about that time of year again. Yes, you’ve got it – Sales Allegation time. During AEP, Organizations receive an influx of complaints of alleged sales misconduct “Sales Allegations”. And, every year we receive some of the same questions around how these allegations “should” be investigated and closed. The rub is, CMS is all but silent on the specific requirements around investigation and closure of Sales Allegations. So, here are a few critical pieces to keep in mind: Read more

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Outbound Enrollment Verification (OEV) – To call or not to call?

Betsy Seals

With the release of the 2015 Marketing Guidelines, CMS made a few key updates to the Outbound Enrollment Verification (OEV) Process. One of the most significant updates is that CMS now allows organizations to complete the OEV process via direct mail or email (if the beneficiary opted-in for email). This change actually provides significant opportunity for organizations. The way we see it, organizations will now need to choose one of two paths. The first path is to continue using outbound telephone calls to fulfill the CMS requirement. If your organization has developed and implemented an effective OEV process, by all means continue with this process. However, if you’re thinking “why would we continue the current process when our OEV process has been riddled with issues of non-compliance?” Well, we agree.

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Rejected Claims Review–You Gotta Do It!

Debra Devereaux

The question arises from almost every client, “Why do we have to do daily rejected claims review?” The answer is that there is no better way “to take the temperature” of Part D compliance than rejected claim reviews. Everything that can and will occur happens at Point of Sale. At a minimum you can detect problems with the following:

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