provider directory compliance - gormanhealthgroup.com · affordable care act (aca) is here to stay,...

REGAN PENNYPACKER

Senior Vice President, Compliance Solutions

ELLIE M. MARTIN

Senior Director, Provider Innovations

PROVIDER DIRECTORY COMPLIANCE

Copyright © 2017 Gorman Health Group, LLC2

PROVIDER DIRECTORY COMPLIANCE

Medicare Advantage (MA) Regulatory Requirements

• Where is Dr. Jones?

CMS Report and GHG Case Studies

Data Integrity and Downstream Impact on Plan Operations

MA Compliance Enforcement

Impact, Regulatory Guidance, and Enforcement on Other Government-Sponsored Health Plans

Preparing for Success and Best Practices

Questions & Answers


MA REGULATORY REQUIREMENTS

Where can I find the rules?

Medicare Managed Care Manual (MMCM), Chapter 4: Benefits and Beneficiary Protections

Medicare Advantage and 1876 Cost Plan Model Provider Directory

All References to the Provider Directory Best Practices in the Contract Year (CY) 2017 Final Call Letter

State-specific requirement(s), NCQA, URAC, and NAIC


CMS ONLINE PROVIDER

Directory Review Report

Background and Methods

Findings and Common Drivers of Deficiencies

Implications

Next Steps: Including CMS January 13 and January 17, 2017, Memos


ONLINE DIRECTORY COMPLIANCE

CMS MMCM, Chapter 4

Plans must outreach to providers on a quarterly basis to validate:

• Address

• Phone number

• Accepting/Not accepting members

• And any other element in the directory that affects access for a member

Finding the root cause of poor data integrity resulting in deficient directories and Health Services Delivery (HSD) tables

How to solve for X

Plans Must Solve for Both X and Y

X FACTOR Y FACTOR


GHG CASE STUDIESKEY POINTS

Directory Audit

Collaboration with Member Services Project

Assisting in the Aftermath


DOWNSTREAM IMPACT

Impact on Internal Health Plan Operations

Impact on External Vendors

Sales, AEP, Member Retention, and Member Experience?


PREPARING FOR SUCCESS

What Does Data Integrity Look Like?

Policies, Procedures, and Tools

Continual Auditing


WHAT DOES TRUE DATA INTEGRITY LOOK LIKE?

Data Integrity

Data Management

Data ValidationOperations

Crosswalks/ Validation


POLICIES, PROCEDURES, AND TOOLS, OH MY!

Contracting/Points of Entry

Credentialing

Configuration

Claims

Audit Cycle


BEST PRACTICES TO DATE

PLAN PROVIDER MEMBER

Baseline review of the provider data cycle

Establish a solid relationship with your providers

Set up a hotline for members to report inaccuracies in the directory

Initial Compliance Audit and repeat on a regular basis, up to and including how information is reported on your MA HSDs or other state-required network submissions

Incorporate penalties into the provider agreement or provider termination policies / hold a portion of payment until quarterly responses are complete

Potentially establish a “hold harmless” policy if the member sees a provider incorrectly listed in the provider directory for a period of time

Evaluate the tools and/or human resources to best fit your plan’s needs, size, and level of inaccuracies

Contact providers who have not submitted claims in a period of time such as 3-6 months and gage interest in continued participation\need

Work with your Sales and Marketing teams on how to mitigate member sales and retention


MA COMPLIANCE ENFORCEMENT

54 Sponsors Assessed and Provided a Weighted Deficiency Score

31 Notices of Non-Compliance

18 Warning Letters

3 Warning Letters with a Request for a Business Plan

January 13, 2017, Online Provider Directory Review Report


ADVERSE EFFECTS

Beneficiary Access and Performance Problems (BAPP) Measure

Past Performance

Additional Burden on Operations


Each Qualified Health Plan (QHP) issuer maintains a network that is sufficient in number and types of providers, including providers who specialize in mental health and substance abuse services, to assure all services will be accessible without unreasonable delay.

For plan years beginning on or after January 1, 2016, a QHP issuer must make its provider directory for a QHP available to the Exchange for publication online in accordance with guidance from Department of Health and Human Services (HHS) and to potential enrollees in hard copy upon request.

Network Adequacy Findings, Observations, and Recommendations – Plan issuer compliance review summary report

HHS proposed rule published February 17, 2017

NETWORK ADEQUACY IN QHP

45 CFR 156.230 – Network Adequacy Standards

https://www.federalregister.gov/documents/2017/02/17/2017-03027/patient-protection-and-affordable-care-act-market-stabilization


QHP AND MEDICAID ENFORCEMENT

Affordable Care Act (ACA) is here to stay, for now

November 2015: Insurers utilizing networks for their Exchange products that are significantly narrower than their regular PPO networks

January 2017: Conclusions find ineffective monitoring, inaccurate directories, provider volume considerably less than reported, and PCP panel sizes exceeded contractual limits


WHO IS GORMAN HEALTH GROUP?Gorman Health Group is the leading solutions and consulting firm

for government-sponsored health programs

Government ProgramsLeading enterprise of national consulting services and software solutions for payers and providers

Our MissionOur mission, as the industry’s most active professional services consultancy and provider of technology-based solutions, is to empower health plans and providers to deliver higher quality care to beneficiaries at lower costs, while serving as valued, trusted partners to government health agencies

Washington, DCHeadquartered in Washington, DC, with more than 200 staff and contractors nationwide with over 2,000 combined years of Government Programs experience

LeadershipDeep payer and provider knowledge coupled with Centers for Medicare & Medicaid Services (CMS) regulatory expertise

Privately OwnedFounded in 1996


Our clients have one-stop access to expert advice, guidance, and support, in every strategic and operational area for government-sponsored programs, across seven verticals.

CLINICALChanging how you approach Medical Management, Quality, and Star Ratings

PROVIDER INNOVATIONSSupporting network design and medical cost control implementation

OPERATIONSBringing excellence to every aspect of your implementation — from enrollment to claims payment

COMPLIANCEOffering guidance and support in every strategic and operational area to ensure alignment with CMS

PHARMACYLeading experts in Part D, Pharmacy Benefit Manager, formulary, and pharmacy programs

HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONSImplementing cross-functional risk adjustment programs for medical trend management and quality improvement

SALES, MARKETING & STRATEGYDriving profitable growth and member retention through strategic marketing, sales, and product development

BROAD SERVICES

18 Copyright © 2016 Gorman Health Group, LLC


Sentinel Elite™ is a module-based software solution designed to assist government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly

Valencia™ provides rigorous, compliant, and transparent workflow controls that ensure your operational processes — and the resulting payment — are as accurate as possible

OMT™ is a complete compliance toolkit that supports the complete organization by bringing a new level of transparency to performance monitoring, including the required oversight of delegated entities

CaseIQ™ not only captures all of the data points needed tocategorize, work, and report MA and Part D appeals and grievances, it also guides case processors through each case to minimize the risk of non-compliance due to user error

Gorman University™ provides training sessions on a variety of industry topics, each designed to meet the unique needs of your organization

The Insider provides in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization and the future of Medicare, Medicaid, and the Health Insurance Marketplace

Software solutions to stay compliant, maximize revenues and manage complex processes

PRODUCT SERVICES


Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health

Insurance Exchange opportunities. Since 1996, our unparalleled teams of subject matter experts, former health plan executives, and seasoned healthcare regulators have been providing

strategic, operational, financial, and clinical services to the industry across a full spectrum of business needs. Our mission is to empower health plans and providers, through a compliant,

member-centric focus, to deliver higher quality care to members at lower costs while serving as valued, trusted partners.

Further, our software solutions have continued to place efficient and compliant operations within our clients’ reach. Our Valencia™ software provides rigorous, compliant, and transparent

workflow controls that ensure your operational processes – and the resulting payment– are as accurate as possible. Sentinel Elite™ is our module-based software solution designed to assist

government managed care organizations onboard agents, provide training, manage ongoing oversight activities, and pay commissions effectively and compliantly. Our Online Monitoring Tool™

(OMT) is the complete Medicare Advantage and Part D compliance toolkit, designed to perform ongoing monitoring and auditing, manage regulatory notices, document corrective actions, and

streamline member material review. CaseIQ™ brings clarity to appeals and grievances and offers a new way to ensure your cases come to a compliant resolution. We also offer training courses

on a variety of industry topics designed to meet the unique needs of your organization through Gorman University™, and our exclusive daily digest, The Insider, provides in-depth analysis and

expert summaries of the most critical legislative and political activities impacting and shaping your organization.

Stay connected to industry news and gain perspective on how to navigate the latest issues by subscribing to our weekly newsletter, and follow us on LinkedIn, Facebook, and Twitter.

We are your partner in government-sponsored health programs.

T

E

T

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Ellie M, Martin

Senior Director, Provider Innovations

281-827-1916

[email protected]

Regan Pennypacker

Senior Vice President, Compliance

401-539-7489

[email protected]

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provider directory compliance - gormanhealthgroup.com · affordable care act (aca) is here to stay,...

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