Introducing CASE – Your pathway to improving reconciliation of enrollment data

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.

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