CMS provides a comprehensive Readiness Checklist in October to be used as a self-assessment of your health plan’s ability to meet CMS requirements for the upcoming plan year. The Readiness Checklist includes many of the same critical requirements every year, but also includes new items based on concerns identified by CMS audits and new or revised regulations.
The CMS Readiness Checklist is not intended to be an exhaustive list of all of your requirements under the Medicare regulations. Why not take the time between the bid submission and AEP start to complete an internal readiness review and include last year’s CMS readiness checklist? An organization should prioritize operational areas before they dive head-first into AEP readiness activities.
Going through this activity now has major benefits:
CMS requirements are in place to protect Medicare members. Health plans have an opportunity to use this ‘readiness’ exercise to create visibility and transparency, identify risk, and craft remediation plans well in advance of the annual attestation. Health plans will increase profitability and STAR ratings when they implement efficient and effective processes geared toward a positive member experience.
Madena is available to provide support with development of the Readiness Checklist process, validation of business owners’ responses, and to assist with resolution of identified risks.
A member’s perception on whether a health plan ‘can get their billing right’ weighs heavily in their decision to stay a member of your plan. Incorrect or confusing invoices will be a primary driver of spikes into your call center. The two fundamental pieces to successful premium billing processes are: detailed invoicing and shortened timeframe from data pull to mailing. And, of course, you should never skip Reconciliation!
A clear invoice helps the member understand their current billing. Detail out LIS and LEP adjustments so that the member knows what the base premium is (that matches to the plan they enrolled in), and the adjustments impacting what they owe. Ensure that you have no more than four business days from the time the invoice file is generated to the time they are printed to help minimize a spike in call volume.
What should you be doing in those four business days? Premium Billing Validation and Reconciliation.
Lastly, don’t underestimate the value of feedback. Look at your Call Center call logs, grievances, and CTMs to identify member concerns and use that for premium billing improvements to drive higher member satisfaction.
Don’t have the tools or staffing for premium billing reconciliation? Madena has modular and highly affordable options to assist with your monthly premium billing reconciliation. Contact us to see how we can help.
On June 19th, CMS announced that the final audit protocols for the Medicare Parts C and D Program Audit and Timeliness Monitoring Data Requests were available on the CMS website. They can be downloaded here.
While the changes are not extensive, plans should review them and make the necessary system updates to ensure compliance.
Also make sure to pay close attention to Field Name and Length in all Record Layouts. Even though CMS announced in March they were reprioritizing Program Audits this year, they will be considering options for modifying the timing and scope of the 2020 program audits in order to complete them later this year.
As your plan is making the necessary updates to the Program Audit Record Layout, remember to add any necessary validation and timeliness checks to your file exports. This will ensure compliance and provide the necessary internal monitoring and auditing also required by CMS. If you have any questions, or need guidance on these activities, please contact us.
Below is a summary of the pertinent updates:
View/Download a PDF of the July 2020 Newsletter.