It’s a Marathon – Not a Sprint

Plans will shortly be receiving the Readiness Checklist from CMS. At first glance it looks like just a bunch of boxes to check off and answering yes and no questions. Here’s the rub:

Starting to figure out whether or not you have 30 boxes of non-readiness to report to your Account Manager is not a good way to roll into 2015. The previous year’s readiness checklist should inform your priorities for the year’s operations. Your relevant questions are: Who and what department owns this? Do we have policies and procedures, business processes and reports for this? Have we had any CMS outlier notifications about this? Did we audit this? Anything that you answer as “not ready” is automatically a priority.

You can’t start being ready when the checklist arrives. Plans should be preparing to “be ready” all year long. For instance, here’s what has to be done for Coordination of Benefits readiness:

CMS expects health plans to establish/maintain systems and procedures for at least weekly COB data report/file processing by not only receiving COB information from various sources, but also applying the COB information to claim payment system(s). Health plans may not understand how to interpret the CMS COB file and use internal sources, such as enrollment forms, claims, provider services, and member services to identify other health information for COB. Health plans need to be able to clearly categorize the various types of records and perform distinct validation, outreach and processing for group coverage, non-group coverage, third party liability, federal/state programs, as well as charities.

The important step of validating the other health information from CMS and other internal sources is often overlooked and a critical step to maintaining COB information in CMS systems. Without this step, information is outdated causing incorrect claim processing, member abrasion and escalated issues. CMS expects that organizations utilize the Electronic Correspondence Referral System (ECRS) to send COB updates to CMS timely and accurately, but health plans often fail to work the ECRS response file rejections and update internal claim system COB flags or other coverage information. Readiness planning should include the final, most often overlooked, yet most vital step: Reconciliation. An effective reconciliation process will work all COB related reports including TrOOP Balance Transfer exception reports, COB error reports, reconcile enrollment, claim and pharmacy systems, as well as monitor claim payment accuracy and recovery of other liabilities.



The biggest risk health plans face in government programs is managing membership and financial data. With Gorman Health Group’s Valencia, you’ll always know where your membership and premium-related data is out of sync, thus eliminating missed revenue and inappropriate claims payments.. Learn more about how Valencia can help you >>

Save the Date for the Gorman Health Group 2015 Forum. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor, MD. Learn more about the event >>

Debra Devereaux
Debra Devereaux

Deb Devereaux is Senior Vice President of Pharmacy and Clinical Solutions at Gorman Health Group (GHG). In this role, she is responsible for leading a team of pharmacists and business analyst consultants with broad health plan, Centers for Medicare & Medicaid Services (CMS) and Pharmacy Benefit Manager (PBM) experience. Deb brings GHG clients more than eight years of Medicare Part D operations expertise. Read more

No Comments Yet

Leave a Reply

Your email address will not be published.