Topic: Compliance

Complaints – Make Sure They Are the Gift that Keeps on Giving

Julie Billman

Have you ever received a gift you knew had value, but you just weren’t sure how to use it to its full potential? Complaints are very much like that. We need to change our view of complaints and consider them to be gifts from our members that need to be opened and cared for as the important pieces of information they are. Complaints are something we all wish would never be needed, but every health plan receives them. Our members have needs, and sometimes those needs don’t appear to our members to be met. In those instances, if we are lucky, the health plan receives the complaint. If we are not lucky, our members’ neighbors, acquaintances, doctors, or even worse ‒ regulators and congressional representatives’ ‒ receive the complaint.

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Meeting CMS Halfway: The 2016 Audit and Enforcement Conference

Regan Pennypacker

On June 16, the Centers for Medicare & Medicaid Services (CMS) held their third annual Medicare Advantage & Prescription Drug Audit and Enforcement Conference and Webcast. At the heart of this conference is the CMS Program Audit. Agency experts as well as Sponsor participants presented to an in-person and webcast audience on expectations, process enhancements, upcoming developments, and more.

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Medicare Program Audits – Four Things Operations Should Be Doing Today

Julie Billman

Do you think the Centers for Medicare & Medicaid Services (CMS) program audits are stressful? We often make it worse for ourselves than it already is. Imagine being in the audit webinar pulling up a case and having CMS say that case was to be excluded from the universes.  Instead of showing your department, processes, and system capabilities, CMS is getting the impression you don’t even know your data well enough to pull a correct universe. What can Operations departments do to get ready? Here are four things you can begin doing today to be ready: Read more

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Health Plans Need to Start Talking About Disparities in Care

John Gorman

On the heels of a recent groundbreaking RAND report on racial disparities in Medicare Advantage (MA), the US Department of Health & Human Services’ Office of Civil Rights (OCR) issued a regulation that requires serious attention in health plans participating in MA, Part D, Medicaid, and ObamaCare. It’s a game-changer in advancing health equity and reducing disparities.

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Medicare Marketing Guidelines Summary of Changes – Have They Left You Scratching Your Head?

Carrie Barker-Settles

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The Formulary Season

Debra Devereaux

It’s the formulary season, and you should be in the home stretch for your Health Plan Management System (HPMS) submission. What’s on the formulary and what changes were made to the formulary are among the top reasons why members either enroll in or disenroll from a health plan. Manufacturer price increases over the past two years and the number of high-cost specialty drugs released to market make formulary decisions and utilization increasingly difficult and significant to the health plan’s bottom line. With an average generic medication utilization rate of 80-85%, there is limited movement to improve. Some thoughts to consider:

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Why Do We Make Simple Things So Difficult?

Aaron Eaton

Time and time again, we encounter “the coolest workarounds” ever invented within the government programs space. Said a different way, we encounter staff who are stuck inventing ways to accomplish the regulatory burden upon their shoulders when they don’t have the right processes and tools to efficiently do their job. The manual effort and workarounds almost get the job done but ultimately leave the plan short of their end goal. This phenomenon is not just seen in one operational area but is commonly experienced across multiple disciplines within the health plan.

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