compliance-process

Pressure on member-facing staff at the beginning of a new year

January and February are usually busy months for Medicare Advantage Organizations (MAO). New enrollees are still learning to navigate around the health plan to access medical services. Some are finding out the benefits they have signed up for are not what they are expecting. A multitude of reasons drives up MAOs’ member call volumes, frustration and anxiety, all of which contribute to grievances.

The Centers for Medicare & Medicaid Services (CMS) began call-center monitoring for timeliness and accessibility in 2015 and has continued since. The call center of an MAO is the first encounter between existing, as well as prospective members, and the health plan. Experiences with the call center can leave long-lasting impressions with the members, which can impact the annual CAHPS[1] survey.

Managers of call centers need to collect data to evaluate agents’ performances and assess if process improvements are needed. However, collecting and analyzing data — as well as giving feedback to the staff — are time-consuming.

Member experience heavily weighted for STAR measures

Member experience will have a weight factor of four for STAR measures beginning 2023 and thereafter. This is an increase from two for 2022.

Although there are seven member experience measures — or 25% of the MA performance measures — on a weight-adjusted basis, member experience measures could account for more than 50% of the rating. As such, member experiences with a health plan take on additional significance in STAR performance.

STAR measures will be competitive

2022 was an outstanding year for STAR performances. Of the 471 MAPD[2] contracts, more than two-thirds (or 68.36%) were rated 4-STAR and above, compared to less than half of the 400 MAPD contracts (or 48.5%) in 2021.

The average rating in 2022 is 4.37 compared to 4.06 in 2021, which slightly dipped from 4.16 in 2020. A variety of factors, including actions taken by CMS, accounted for this spectacular showing. Going forward, reaching for the STARs will be competitive and challenging.

Expanded scope of Healthcare compliance oversight by CMS 

Call Center is one of several areas being monitored remotely by CMS. Between January and May 2021, most MAOs went through at least two to three monitoring routines with CMS: Part D Improper Payment Measure (IPM), Part B covered drugs administered through the use of a DME (e.g., a nebulizer, external or implantable pump), potentially duplicate payments under Part D for targeted drugs that are “always” considered to be ESRD-related (end-stage renal disease) when furnished to an ESRD patient and Transition Requirement Audit. These remote audits are additional to the one-third financial audit and program audit between July and October. Results of these audits have financial consequences for MAOs including the one-third financial audits. It is worth the effort to be prepared in advance for these oversight exercises.

New CMS Program audit protocol in 2022

In 2022, CMS will implement the new audit protocol 10717 for both Part C and D programs, as well as Medicare-Medicaid Plans (MMPs). There are fewer universes to submit due to consolidation of the tables. For instance, CDAG (Coverage Determinations, Appeals and Grievances) requires seven tables instead of 13, ODAG (Organization Determinations, Appeals and Grievances) requires six instead of 13, and SARAG (Service Authorization Requests, Appeals, and Grievances) requires five instead of 11. While it is good news to have fewer universes to submit, there will be a new learning curve for the data preparation team (or IT) to extract and populate the data in the new format correctly to avoid IDS (Invalid Data Submission) citations.

Read more- 2022 Program Audit Protocol Changes

Special applications can lift the burden of Healthcare Organization’s compliance monitoring

Healthcare organization’s compliance monitoring and internal audits are time consuming, and require dedicated staff to effectively and efficiently conduct the tasks while maintaining reliability. When human resources are in short supply, MAOs should consider other options to facilitate these necessary functions, instead of continuing with manual computation and tabulation, even with the help of Excel. The benefits of using specially designed software or applications to support monitoring and audits are multiple:

  1. Once the tool is deployed and used routinely, the MAO is always ready for audits, internal and external.
  2. Taking the load off IT and functional staff – the less preparation work and manual processing, the more ready they are to conduct regular monitoring.
  3. Monitoring/audit results are available faster with the help of software than manual processing. Feedback for the functional areas also comes more quickly for corrective action, if needed, thereby mitigating potential audit risks.
  4. Applications are scalable. Once the staff is trained to use the tool, scope of the monitoring can be expanded from limited sampling; for large data sets, statistical samples may be too onerous for manual review and tools can do the heavy lifting.
  5. Data can be scrubbed with help from the software, taking the load off the IT team. 

Inovaare has been providing healthcare organizations with quality services that help them comply with Medicare regulations since 2008. We can work with your organization to create a comprehensive plan that helps ensure you are following all the right steps and complying with all regulatory guidelines for all functional areas:

  • Formulary administration
  • Part C and D coverage determinations
  • Call Center
  • Appeals and Grievances

Give us a call today to explore how we may be able to support your needs and support your healthcare organization’s compliance processes. It is never too early to begin planning for your upcoming audits.