Medicare Advantage Implementation – It’s All About Asking the Right Questions

The famous economist Paul Samuelson stated, “Good questions outrank easy answers.” That is true in most things that really matter in life. It is human nature to go with the obvious easy answer, but nothing is ever as easy as it seems. Think of the last time you started a new job or a new hobby, were there unexpected experiences? Was it harder or more complicated than you expected? What questions do you wish you would have asked before you embarked?

At Gorman Health Group, our consultants work with clients in the midst of all different kinds of implementations. They range from new systems, insourcing, or outsourcing to bring a new Medicare Advantage Prescription Drug (MA-PD) plan into existence. With all of those implementations, there are some key questions that have complicated answers. Here are a few high priority questions to ask before starting an implementation.

  1. When expanding into MA-PD, what makes this product different than our other product lines? We typically see health plans asking, “Where can we leverage what we have?” It is the natural, easy, and most cost-effective way to move forward, but it often ends up with the plan trying to fit a “square peg into a round hole.” You may spend less in the short term, but long-term lost productivity and compliance concerns generally become apparent shortly after implementation when there is no time to fix them. There is really no area of MA-PD that does not have unique requirements that impact processing, from the way you capture customer service calls to the tools used to make clinical decisions. Nothing in MA-PD is as easy as it seems.
  2. Do we have the right people included? No, I’m not talking about consultants, although I can vouch to the added benefit we bring. Do you have a mix of detailed, knowledgeable subject matter experts and decision-makers? What about people with compliance knowledge and experience? The unbalanced mix of people can set your implementation on the wrong trajectory.
  3. Where systems or vendors are involved, have we checked the right references? Health plans are generally well versed in asking for references from a current client and a past client. What about asking for a client that has gone through a Centers for Medicare & Medicaid Services (CMS) audit? Have you asked their clients about grievance levels related to system processes or vendor actions? Has your Compliance team spoken with the Compliance team at the vendor?
  4. Are we focused on just the short term, or including long-term goals? Implementation is hard work. It can be all encompassing and often time is being managed by people who have a “day job” within the organization. There are critical focuses that should be woven into the implementation such as:
    • Create Member Focused Processes – Making it easy on the health plan but hard on the members will not lead to successful growth.
    • Weave in Star Ratings Culture throughout the Organization – Everything within the organization that touches a member directly or indirectly impacts Medicare Star Ratings. Establishing this culture from the start is far easier than retrofitting it into the organization later.
    • Verify Setup of Critical Payment Processes – Making sure your risk adjustment and encounter data are accurate and robust is critical to a plan’s financial success. Medicare Secondary Payer is very different than the commercial process and can have significant financial impact on premium from CMS. Making sure you are processing claims for members on hospice accurately is easy to configure in your initial setup.  Recoveries after the fact can be challenging.

Don’t let the right answers to the wrong questions send you down a treacherous path. Whether you are implementing a new health plan, system, or product line, there will be challenges, even in the best of circumstances. How significant those challenges are to overcome is often determined by the questions asked or missed. Your success may come down to a set of serious questions with hard answers that, when implemented, get you exactly where you need to be.

At Gorman Health Group, we have been part of many service area expansions, system upgrades, and new product implementations. Regardless of where you are in the process, we can help your organization ask the right questions to cross the finish line. If you would like more information about support for a system conversion, expanding your service area, or implementing an MA-PD plan, please contact Gorman Health Group or email me directly at

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