The Voice of Elena Martin

Elena Martin

About Elena Martin

Elena Martin is a Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development. Read more

CMS Announces Changes to the Network Review Process for Medicare Advantage Organizations

Elena Martin

As anticipated, the Office of Management and Budget (OMB) approved the Centers for Medicare & Medicaid Services’ (CMS’) move to network adequacy reviews on a three-year cycle, unless there is a triggering event that would reset the timing of a Medicare Advantage Organization’s triennial review.

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Provider Network Management New Year’s Resolutions for 2018

Elena Martin

Many of you and your teams are in the frantic, end-of-year trenches renegotiating current provider agreements or working on contracting new providers for a service area expansion, and it is easy to lose sight of all the changes swirling around the provider network arena. As we head into 2018, we would encourage you to incorporate these three key items into your Provider Network Management Department’s performance appraisal goals.

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Three-Year Network Adequacy Review for Medicare Advantage Plans

Elena Martin

If the Centers for Medicare & Medicaid Services (CMS) knocked on your door today, would you be ready to submit a compliant provider network within 60 days? CMS estimates the proposed three-year network adequacy review for Medicare Advantage (MA) plans would mean just that for approximately 304 MA plans for calendar year 2019.

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New Challenges in Network Development

Elena Martin

The summer sun is shining and vacation season is in full swing! While our Health Plan Network and Product teams are taking a few deep breaths after application and bid filing deadlines, we cannot rest on our laurels for very long. Summer is the best time to start planning your next service area expansion (SAE) or even your first step into the Medicare Advantage (MA) world. Maybe you are an established MA plan evaluating where to expand your geographic footprint. Maybe you are a Medicaid plan looking to expand into the Managed Long Term Services and Supports (MLTSS) arena and are wondering what it would take to have a Dual Eligible Special Needs Plan (D-SNP) so many of the MLTSS Requests for Proposal (RFPs) are expecting; or maybe you are an Accountable Care Organization looking to leverage your infrastructure and enter the payer world. Now is the perfect time to start planning for your 2018 and 2019 network needs. Regardless of the size and scope of the organization, your plan’s network adequacy and accessibility is a cornerstone of any new initiative. And, Plans need to be even more vigilant in managing their largest asset

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Network Exceptions: Why Coordination Between Provider Network Operations & Compliance is Key

Elena Martin

As we approach the holiday weekend, health plan Network and Product teams alike are breathing a sigh of relief after the fireworks that came along with this year’s network exception process, application, and bid filing deadlines.

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Top Challenges in Provider Data Management

Elena Martin

While health plan provider directory inaccuracies have been at the forefront of the news, regulatory agencies, and consumer protection agencies, the directories are only the tip of the iceberg in how difficult provider data management is for health plans. Plans continue to gather information on providers in a multitude of ways and from a variety of functional areas, continue to create conflicting repositories of provider data, and thus continue to face the painstaking and almost always manual validation of provider information.

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The Importance of Accurate Provider Data and Network Adequacy

Elena Martin

For almost two years, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data integrity is at the forefront of the initiatives enforced by government mandates, and provider data has topped the list of areas that not only need the most improvement, but the most oversight, correction, and, potentially, sanction. As we saw with the CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. By moving the online directory guidance in the Medicare Managed Care Manual from Chapter 3 (Marketing) to Chapter 4 (Beneficiary Protections), CMS has solidified the fact it is no longer acceptable to have inaccuracies in an area key for members to evaluate their health plan choices and find access to care. CMS released its first “Online Provider Directory Review Report” in January 2017 and followed up on January 17, 2017, with a CMS Memo on Provider Directory Policy Updates.

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