To succeed in Medicare Advantage, plans must achieve higher quality and Star Ratings, surmount CMS and medical loss ratio (MLR) requirements, and develop member onboarding and retention capabilities, all while operating in a highly competitive market.GHG brings two decades of industry leading solutions and unparalleled experience to optimize your plan’s business models and best practices while increasing the overall quality of operations, ensuring your MA plan is positioned to make the most of the program’s opportunity.
For the millions of individuals experiencing a shift in coverage between Medicaid and Quality Health Plans (QHPs), continuity of care can help ensure sustained access to providers and ongoing courses of treatment during coverage transitions. Establishing policies of coordinated coverage between Managed Care Organizations (MCOs) for transitioning individuals is crucial in reducing coverage gaps. Medicaid health plans must be able to navigate through State and Federal regulations and work well with State agencies.
Get ready for the biggest coverage expansion since Medicare Part D. Health plans face the greatest challenges we’ve ever known in our industry while operating in a new line of business we’ve never imagined. At the same time, the “new normal” in government programs means opportunity abounds for health plans that prioritize quality and drive compliance measures. Health plans operating within the Exchanges must evolve from a culture of sales and marketing to a culture that is member-centric and more accountable with a greater sense of urgency.
Gorman Health Group’s deep expertise in the Government Programs space goes beyond the traditional health plan. We’ve helped Third Party Administrators refine operations for better service and performance, pharmaceutical manufacturers develop and execute strategies for managed markets, conducted market research and competitive analysis for new and veteran vendors in the space, developed system architecture and business rules for software companies and provided interim leadership and staffing to a variety of entities.
PBM management is especially critical given CMS’ focus on drug benefit-related issues, such as prescription drug event reporting and transition fills. Our team performs in-depth compliance assessments to evaluate PBM performance as a delegated entity. We’ll audit your team’s efforts to ensure that your PBM is accurately adjudicating claims on your client’s behalf and reporting accurately to CMS. We’ll evaluate the efficacy of your MTM programs and much more.
It’s not just about the ACO. In a few years, what it means to be a “payer” versus a “provider” will have changed forever. But not all will successfully make the transition. With our team of veteran executives from leading payers, providers, and regulatory agencies, we’re implementing new models of finance, leadership and clinical value as systems adapt to health reform.