Whether you are a new or existing Medicare plan, January is the best time to make sure your membership is accurate, digest any issues identified, and develop a process improvement plan.
Successful enrollment processing requires training, execution of established processes, and an ability to adjust as needed based on inventory and circumstance. A review of “lessons learned” during AEP is a critical look-back activity. In doing this internal evaluation, some areas to review include common problem areas:
If your AEP was highly successful, you can take the opportunity to perform end to end evaluations of your key processes. Effective
management of all enrollment responsibilities is the key to meeting CMS required timeliness standards and to address discrepancies
before an RPC submission is required. Are these functions working as well as they could be? Have you validated and confirmed the
efficacy of what you think is working well?
Madena is ready to assist with data analytics for independent validation of the accuracy and validity of your processes and technology.
Identifying discrepancies early in the year will reduce the negative impact on members, plan capitation payments, and grievance or
CTM complaints. Noncompliance can result in low STAR rating and corrective action plan by CMS.
Have you contracted with your Data Validation Contractor (DVC) for 2020?
CMS requires Medicare health plans to have an independent contractor in
place for annual reviews that will begin April 1st. Consider Madena for your
annual DVC. Contact us to learn more!
Medicare announced that complaints will be reported to health plans in
real time starting 1/18/2020. What modifications do you need to make
to your CTM process and reporting? How can you be more responsive to
CMS has confirmed the current daily email notification process for CTM
module will not change. The plans will receive emails only once a day.
The real-time email notifications will not be sent because it could
potentially lead to plans getting swamped by a deluge of emails
Let’s roll up our sleeves together and improve your member
Appeals & Grievance Summit 2020
Madena is a sponsor of the upcoming “Enhancing Appeals &
Grievances and Improving ODAG & CDAG Readiness” industry
event March 25-27, 2020. This conference will be packed with
information and opportunities to learn from other health plans
and industry experts. Don’t miss out on this event!
Madena contacts may use code H127MAD at registration to
receive 15% off the registration fee.
Did you know that we do one-time independent data analytics on
your membership to identify discrepancies that your internal or
vendor solutions are managing?
The independent data analytics that we performed in 2019 had a
100% success rate at identifying discrepancies that were not
found by our clients’ internal and vendor reconciliation software.
In October, CMS issued a memo regarding the 2020 Timeliness Monitoring Project
(TMP). As in previous years, CMS will be conducting an industry-wide monitoring
project by collecting data to evaluate the timeliness of processing Medicare Advantage
(Part C) organization determinations and reconsiderations and Medicare Prescription
Drug (Part D) coverage determinations and redeterminations.
The TMP will include a retrospective collection and review of 2019 data from Medicare
Part C and Part D sponsors with active contracts in both CY2019 and CY2020. CMS will
be conducting this collection in three waves, with the first wave of letters requesting
data being issued in January 2020.
Like the collection for program audits, universe submissions should include data
processed in-house and by all First Tier, Downstream, and Related entities (FDRs). In
addition, all universes will be submitted at the Parent Organization level; therefore, one
universe submission may include data for multiple contracts.
Madena can help in a number of ways:
Being aware of the issues within your data is critical. If the data submitted to CMS lacks validity, reliability, or indicates a data integrity issue, this can impact Star Ratings by designating an automatic 1 Star for all measures that use this data. We can help prevent this outcome.
Here’s the updated PCUG version 13.3.
LEP Amount Annual Change – Make sure to update your systems with the 2020 LEP amounts for members that have LEP. The LEP
amounts for members that pay premium directly to you was received on the December CMS LEP Detail Report and for members that
pay premium via SSA/RRB use the January CMS MPWR Report.
Madena BPO Services – providing scalable staffing solutions for us to help your company achieve optimal operational efficiency,
profitability and member satisfaction.
View/download a PDF of the January 2020 newsletter.