Introducing CASE – Your pathway to improving reconciliation of enrollment data

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Madena is pleased to introduce CASE, a reconciliation and certification process focusing on the enrollment aspect of Medicare compliance to provide a thorough independent assessment of the reconciliation results of MAPDs.

CASE was created by leveraging over a dozen years’ of collective Medicare enrollment experience to provide an effective scorecard to improve and enhance the reconciliation process for MAPDs. It contains robust business logic to evaluate a plan’s enrollment records against CMS’ enrollment data to provide a clear, comprehensive and actionable report in the following manner:-

Compare – We will evaluate 100% of your current enrollment data, going back two years, against CMS’ authoritative data source – the MMRs to ensure it matches CMS’ records in key enrollment/disenrollment areas affecting member benefits and plan remuneration.

Analyze – We analyze and identify all of the variances and discrepancies found by CASE and compare those to the results of your own enrollment reconciliation process and MARx.

Score – A monthly compliance scorecard is provided at the end of every review cycle. Enrollment reconciliation results are graded using a pre-determined set of criteria to identify the effectiveness of your processes in key enrollment areas providing you with a more accurate view of your compliance with CMS’ enrollment standards.

Enhance – Getting a list of discrepancies quantifies the problem but does little to help organizations resolve the issues. Our approach provides actionable information to specifically help resolve the problems identified and get you to where you want to be. Our reconciliation data is presented in human readable form to help interpret how the results co-relate with policies and procedures, how it impacts your organization and what to do about it.

According to Denyse Wise, Madena’s President, “Medicare enrollment is a complicated process governed by strict government compliance requirements. Although CMS requires Medicare plans to implement effective reconciliation programs, my experience with MAPDs from our consulting work and as the former Program Director of the RPC shows that despite annual audits and quality assurance checks, far too many Medicare Advantage plans are still not catching all the valid discrepancies in Enrollment Data each year. Moreover, they are usually unaware of it until much later in time when they end up spending a great deal of resources tracking down potential compliance liabilities.”

Non-compliance resulting from even a small number of enrollment discrepancies may have a negative impact on your overall members’ experience by denial of benefits, service delays, limiting member’s choice of healthcare practitioners, and adding impediments to receiving quality care. Failure to correct and resolve these issues in a timely fashion may also result in monetary fines or disciplinary actions.

With the Annual Enrollment Period nearly upon us, the launch of CASE is especially timely in bringing an effective process and a fresh set of eyes to support your Enrollment Reconciliation Process. While you focus on managing the spike in enrollment volume and member experience, we focus on ensuring your Reconciliation Process is catching all ensuing discrepancies within the 45-day Certification Process per CMS guidelines.

Webinar: LIS/BAE Best Practices for Part D Sponsors

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Thursday, June 13. 2:00pm – 3:30pm EST (Note date change)

Are you ready to become an LIS/BAE expert and stop making the same mistakes that have become commonplace in the industry?

Inevitably we have all run into similar challenges surrounding Low-Income Subsidy (LIS) and Best Available Evidence (BAE) Polices and Programs. CMS guidelines on this program can be vague and confusing, and those problems are often compounded by the disparity in the eligibility rules for the 50 different states. Moreover, 30% of the submissions for LIS Status Updates sent to the RPC are currently being rejected, creating costly headaches for your organization and your members.

In response to these present circumstances, Denyse will be conducting a specialized training Webinar based on 5 years of experience overseeing and developing CMS’ LIS Deeming review process as the RPC Program Director.

The information you can expect to gain from this one-hour training session includes:

  • A breakdown of LIS/BAE policy and how a member qualifies for LIS (including little-known tips on CMS’ expectations on valid BAE)
  • Understanding the differences between LIS Eligibility and LIS Deeming
  • A behind-the-scenes look at the RPC Review Process for LIS Status Updates (including a walkthrough of various case-studies on commonly rejected LIS submissions and how to avoid the same mistakes)
  • Subsidy Eligibility, Determinations/Redeterminations and the role your organization plays in them
  • How to navigate through different State Medicaid Systems and Aid Codes
  • Other tips and best practices on BAE to effectively comply with Policy


Following the training, there will be a 30-minute Q&A for the live event to get personalized guidance on the challenges your team is encountering under current LIS/BAE policies and guidelines.

All registrants will receive a copy of the recorded webinar, so if you are unable to attend the live event, please register to obtain a copy of this valuable training for your organization.

Click this link to register now

(Contact us for discounts on group pricing)

Note : Payment for the webinar is through Paypal services. If you prefer credit card payment, please choose the ‘Pay with a Credit or Debit card’ option in the paypal screen. 

Post-AEP season

in Articles by Denyse Wise Leave a comment

Medicare Form

Two months have past since the AEP cutoff and I’m wondering how everyone is managing with their annual Reconciliation Review and Retroactive Adjustment work? This is something I would often wonder about every year for the last six years as the Program Director of the Retroactive Processing Contract (RPC). I would wait week after week from January through April until the discrepancies came in to analyze, process, and report back to CMS. Now I am here in the MAPD community in a new capacity and can come right out and ask: How is everyone doing with their Post-AEP Reconciliation Review?

Over the years, I’ve seen tremendous improvement in the overall performance of each organization’s enrollment operation for AEP since 2008. Organizations are more equipped to handle growth and volume through more efficient systems and trained personnel. The MARx Redesign and Modernization project of 2011 enabled organizations to submit more retroactive adjustments directly to CMS for faster processing. These combined efforts reduced the number of retroactive submissions to the RPC by more than half since 2008. A remarkable achievement!

However, the areas organizations continue to struggle with during Post-AEP season are exception cases. These include cases that fall outside CMS or RPC Guidance, special enrollment clean-up projects, and interpreting CMS policy and MARx system requirements. The reasons behind these commonplace struggles are usually a result of having unique cases that cannot be clearly covered in written guidance, internal systems issues and human error. Regardless of the reason, these issues can leave organizations struggling to resolve hundreds and sometimes thousands of discrepant cases to comply with CMS regulations, avoid Regional Office Approvals, receive timely accurate payments and achieve the highest level of member satisfaction possible.

To kick-off this new journey of bridging Medicare enrollment operations, we are offering our first webinar on Post-AEP Reconciliation and Retroactive Adjustment Processing. This webinar will provide organizations with valuable information on how to organize their discrepancies to ensure the highest level of compliancy and results. We will discuss when to submit directly to MARx for CCM processing versus when to submit to the RPC for Category 2. We will provide valuable tools and information on identifying cases not to submit to MARx to ensure compliancy with your Enrollment Data Validation (EDV) Review. We will share tips on how to prepare your retroactive cases for the RPC to avoid rejections and improve your retroactive enrollment performance. 

The webinar will be aired February 26th at 2:00pm EST.  To register for our webinar please click on the link below.  All registrants will receive a copy of the recorded webinar so even if you are unable to attend the webinar live, still register by February 26th to obtain your copy of the training.  If for some reason you miss the cut-off, contact us at for further instructions on how to obtain a copy.

Please join us on the 26th and let us know how you’re doing with the 2013 Post-AEP Reconciliation Review.  I’m excited to reconnect with everyone and eager to help again! 

Of course always feel free to drop us a note anytime to share any other enrollment issues or questions you may have.  Talk soon! 

Madena is live!

in Articles by Denyse Wise Leave a comment

Madena Solutions

After months of consideration, I decided to leave the RPC team in mid January and start my own Medicare Enrollment Consulting practice.  This was not an easy decision for many reasons, but felt like the right decision.  I had the distinct privilege of working with talented and deeply passionate people at Reed, Central Office, the Regional Offices and the MAPD Organizations.  Working with CMS and the organizations to better understand the enrollment needs and challenges that exist between the two has become a personal passion of mine since I started this work.   After having worked so closely with CMS Central Office for the past 6 years and gaining a solid understanding of their expectations and standards, I’ve chosen to dedicate my work and practice to helping the MAPD community improve their enrollment operations to meet those standards.  After contributing to the success of reducing the number of retroactive submissions and improving the RPC Turn-Around-Time; I realized the other ways in which I could support the organizations achieve much greater success in meeting CMS’ enrollment standards was best served by leaving the RPC to provide more focused services.

Coupled with my partner’s talents and skills, Madena will serve MAPD organizations directly to deliver personalized consulting services to help bridge the gap between their operations and CMS’ operations.

We are excited to be launching this consulting practice together and look forward to working directly with all of you in this coming year!  

Hope to see you soon!

Best wishes,