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The Voice of Julie Billman
One of the best things about being a consultant is that we get to meet a lot of really great people who are passionate about what they do and the members they serve. At Gorman Health Group, our projects span a wide range of activities – from implementing new programs to mitigating production, quality, and compliance concerns. Working with our clients, we see some of the common issues that plague the industry and a variety of best practices. In you attended the Gorman Health Group 2018 Forum in April of this year, you heard a variety of our most common projects and critical findings. If you weren’t able to attend, below are a few of the highlights from that event. As these are common projects and findings, you may want to take a look within your organization to determine if these might be potential issues for your plan. Read more
I am in the midst of helping to sell a family member’s house. The house was recently remodeled and looks amazing in the realtor posting. An offer came in for full asking price, and we are now in the inspection phase of the process. This is where things get real. The buyers have an “options clause,” which is an opportunity to walk away from the sale if things aren’t as they expected. One of the inspections showed some foundation damage that if not fixed will result in the sale falling through – and for good reason, as the buyers want a house in good working order.
I live in the Northeast, and we are once again in the midst of a nor’easter. It is this time of year when I consider moving south. The only way to keep on top of this volume of snow removal is to regularly clear driveways and sidewalks. Some snow is a very heavy lift, and some is very light and easy to shovel—and so it is with working through some of our common Medicare Advantage (MA) operational issues. Our experiences with clients cover a wide range of projects: we complete operational assessments, financial reviews, operational trainings, and policy and procedure (P&P) reviews. Throughout our projects, we see some common themes that cause health plans to trip. Some take more effort to resolve, but some are light lifts.
The Centers for Medicare & Medicaid Services (CMS) Advance Notice and Call Letter included additional reminders to plans about managing Qualified Medicare Beneficiaries (QMBs). A QMB is a dual-eligible beneficiary who does not have full Medicaid. Instead, that individual has Medicare cost-sharing subsidies by the state Medicaid program for Part A and B covered deductibles and coinsurances. When a QMB member is part of a Medicare Advantage (MA) plan, it becomes the MA plan’s responsibility to ensure providers do not balance bill the member for the plan deductibles and cost sharing for Medicare-covered services provided by the MA plan.
I fly often, and it gives me comfort knowing my pilot completes a pre-flight checklist. I often see the pilot out on the tarmac walking around the plane giving it a quick inspection. It is a demonstration he/she takes our safety seriously.
When you think of the ideal strategic partner, what words come to mind to describe them? For me, those terms are honesty, integrity, value-add, vision, and an understanding of my needs. These are the same things that members are expecting from us when they choose our health plan to provide their health insurance. As we start 2018, all of our staff have the opportunity to prove our commitment and demonstrate our health plan’s core values to enhance our members’ experiences. As you enter into 2018, here are some reminders of critical components to support your members in 2018. Read more
It’s the Annual Election Period (AEP) for Medicare Advantage (MA), and like many health plans, those of us in the industry are often busy. Family members on Medicare are often asking about changes or concerns about their health plan. When I checked in with my father, he indicated he needed to change his MA plan because he owed a $36,000 hospital bill he felt should be covered by his health plan. I thought he was confused until I saw his Explanation of Benefits (EOB), and it did have a $36,000 denial for a hospitalization. The denial message indicated, “You may owe this amount. You will be billed by your provider.”