Four Common Operational Pitfalls in Medicare Advantage

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.

Here are four common pitfalls that can bury your operations team if you don’t get in front of them:

  1. Failure to Update Actions and P&Ps Due to Guidance Change: The Centers for Medicare & Medicaid Services (CMS) released two major changes in recent years for organization determinations, appeals, and grievances. The first one is that plans no longer need to submit dismissals to the Independent Review Entity. The second change involves updating what constitutes adequate outreach for missing information. We still see these incorrectly listed in P&Ps and not implemented within organizations.
  2. Accepting Medicare Secondary Payer (MSP) Information with No Research: Not managing your MSP members. MSP impacts both premium received and payment of claims. If you don’t have processes in place to validate each MSP-designated member and either correct discrepancies with the Coordination of Benefits Contractor or set up your system to pay secondary, that mismatch is costing your plan money.
  3. Paying Hospice- and Non-Hospice-Related Claims for Members Electing Medicare Hospice: Not having a tie between your claims system and hospice determinations. Hospice services are a carve-out for MA. Typically, hospice providers don’t bill for hospice-related services. Other providers may bill you for Medicare-covered non-hospice-related services on a primary basis without having the provider bill Fee-for-Service Medicare first. If your system is paying for those services, you are paying too much.
  4. Not Managing Out-of-Area or Return Mail Processes: Return mail is the bane of many health plans. It often sits in boxes in someone’s cubicle and may be worked if free time is available. That is fine until you have a person who moved out of the area requiring care. Then you have a situation that is difficult to manage and not in the member’s best interest. Taking time to manage return mail and out-of-area members is an important way to maintain compliance and protect both health plan and member interests.

In busy times, how do we stay ahead of all the changes and mountains of work? Just like clearing the snow, we need to plow through these issues to improve our health plan and member outcomes.

To learn more about the common health plan concerns we see routinely in our projects, join us at our annual Gorman Health Group 2018 Forum, April 25-26, at Red Rock Resort in Las Vegas. Download our agenda here.

During this year’s information-packed two days, our elite team of experts, operators, clients, and partners will help you figure out what matters and what doesn’t. We will share proven tactics to cut costs, increase member satisfaction, and manage and drive sustainable growth.

The preferred room rate expires on Monday, March 23, 2018. Register now >>




Gorman Health Group’s summary and analysis of the 2019 Advance Notice and Draft Call Letter for Medicare Advantage and Part D is now available. Download now

Registration is open for the Gorman Health Group 2018 Forum, April 25-26, 2018, at the Red Rock Resort ideally located near the Red Rock Canyon in Las Vegas. Download our agenda here.

Want to stay up to date on policy and regulation changes? The Insider is GHG’s exclusive intelligence briefing, providing in-depth analysis and expert summaries of the most critical legislative and political activities impacting and shaping your organization. Read our full press release >>

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