Topic: Compliance

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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Part D and Hospice Rules Mucking Up Beneficiaries’ Last Days

John Gorman

Last week the Centers for Medicare and Medicaid Services (CMS) met with 30 hospice & healthcare organizations about suspending a new rule intended to avoid duplicate payments for hospice medications. This is a very big deal and the new rule is mucking up many beneficiaries’ last days. The National Hospice and Palliative Care Organization described the meeting as “an important first step at righting the wrongs being faced by dying Medicare patients.”

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Further Evidence That PBMs are Failing on Government Programs

John Gorman

At CMS’ oversight and enforcement conference last week Jonathan Blanar, the agency’s Deputy Director of Compliance Enforcement, presented the following slide. In this slide, you will see actions CMS has imposed against Medicare health plans in the last two years, and for what reasons. It’s further evidence that pharmacy benefit managers (PBMs) are failing Medicare beneficiaries and the plans enrolling them.

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4 Points to Ponder from CMS’ Oversight and Enforcement Conference

Regan Pennypacker

On June 26, CMS hosted their MA-PD Oversight and Enforcement conference. Not one of the topics was less relevant to the audience than another – they prepared ahead of time to present current, critical information related to their data-driven approach to oversight, best practices and common findings, preparing for an audit and enforcement actions. I was glad to see CMS invite plan sponsor staff to share their experiences. They included Todd Meek of SilverScript Insurance Company; Margaret Drakeley of Kelsey Care Advantage; Shannon Trembley of Martin’s Point Health Care; Marcella Jordan of Kaiser Permanente, and Jenny O’Brien of UnitedHealthCare. Their first-hand accounts are worth your full attention.

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