The Foundation Stone of Solid Medicare Implementation

Home repair becomes far more complex when something is out of square. Everything is more difficult, and work-arounds become standard. That is why a foundation stone is so important in construction – it is the first stone set, and all other stones will be built around it. Making sure it is in perfect alignment is critical. Implementing a Medicare Advantage (MA) or Prescription Drug Plan (PDP) requires the same precision. If you don’t start with things perfectly aligned, you will always be fighting a battle to keep things straight, compliant, and productive.

What is the key to a successful implementation? It is the practical application and real-world knowledge of the current MA and PDP requirements. Knowledge is critical, just as a foundation stone is critical, but it is the practical placement of the stone in the right location that gives it the ability to maintain the integrity of the structure.

Many health plans have experience with implementing new products or lines of business. They anticipate MA and PDP will be an extension of this experience. They start the project and subsequently realize it is like putting a round peg in a square hole and have to rethink the project – hopefully before too much rework is needed.

At Gorman Health Group, we typically have multiple implementation and service area expansion projects in process. That ongoing effort allows us to refine the process and guide health plans around the pitfalls that can result in a cracked foundation. Here are four level-setting steps to ensure your MA and PDP foundation stone is sound:

  1. Set expectations this new product is not like existing lines of business: Design the business requirements uniquely, and don’t complete them based on existing processes or other lines of business. Once the business requirements are completed, you can determine if there are synergies or processes that can be modified. Many health plans spend valuable time and money trying to modify existing processes only to find out they will not satisfy the requirements and are neither compliant nor efficient. Implementing an MA plan or PDP is expensive, and rework rapidly inflates these costs.
  2. Understanding of the regulatory environment: The Centers for Medicare & Medicaid Services (CMS) is rigorous in its oversight. The truth is, CMS believes there are enough plans in the market, and beneficiaries don’t need any more plan options. That allows CMS to take swift and sure action when regulations are broken. CMS actively works to weed out low performers. This is not always seen in other government or commercial lines of business. Plans should review the Part C and Part D Enforcements Action Page ( to understand the rigor applied and cost of non-compliance. There are lots of rules and regulations – CMS has 21 MA manuals and 18 PDP manuals. CMS also releases hundreds of Health Plan Management System (HPMS) memos on updates to regulation and guidance each year and expects plans to understand and comply with them all.
  3. Hire or contract with knowledgeable people: An organization needs people who understand the current MA and PDP business. Original Medicare knowledge or Medicaid knowledge, while valuable to an organization, won’t adequately give you what you need to set up MA and PDP programs. People with MA and PDP experience may be costly, but they will save you money in the long run as you set the foundation of your new program.
  4. Involve front-line staff: There are two events that allow individuals to gain the most knowledge about MA and PDP: implementations and audits. Implementations allow people to understand the information from the start and the “why” behind the actions. Audits allow people to see how the government views health plan actions and potential non-compliance. A health plan may have an implementation group to support the efforts, but not developing subject matter experts (SMEs) within each functional area during implementation would be a lost opportunity.

Every year, new health plans enter the MA and PDP business. It’s a big undertaking and a lot of work. Some plans thrive while others flounder. Protect your investment by setting your foundation stone securely in place to support ongoing growth for years to come in your Medicare line of business.

Gorman Health Group has a full spectrum of SMEs for MA plans and PDPs. We work with health plans on a daily basis on everything from implementations to program assessments and audit support and remediation. This keeps us current and relevant. Our experienced Operations team can work with you to set up strategic, efficient, and knowledgeable operations as you implement or grow your Medicare line of business. Contact us via this link to our website, or you can email me at to help you set up a firm foundation.



On Thursday, February 9, from 2-3 pm ET, join John Gorman and colleagues Olga Walther, Senior Legislative & Policy Advisor, and Leslie Mullins, Senior Consultant, as they provide a hard-hitting analysis of critical areas addressed in the document, including CMS’ changes to risk adjustment and encounter data, Star Ratings, Benefit Parameters and Bid Requirements, Part D Utilization Review, and more. Register now >>

The Gorman Health Group 2017 Forum Conference Brochure and Preliminary Agenda Is Now Available! Download it now to see the topics we have in store for you at this year’s event. Register now for the Gorman Health Group 2017 Forum, April 26-27, 2017, at the JW Marriott New Orleans.

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