MMP - Creating a Marriage of Medicare & Medicaid operations · in every strategic and operational...

CREATING A MARRIAGE OF MEDICARE & MEDICAID OPERATIONS

MMP financial demonstration plans framework for success in aligning Medicare and Medicaid Operations within your organization.

JENNIFER YOUNG SENIOR CONSULTANT

Copyright © 2015, Gorman Health Group, LLC

Government Programs Leading enterprise of national consulting services and software solutions for payers and providers.

Our Mission

Our mission, as the industry’s most active professional services consultancy and provider of technology-based solutions, is to empower health plans and providers to deliver higher quality care to beneficiaries at lower costs, while serving as valued, trusted partners to government health agencies.

Washington, DC

Headquartered in Washington, DC with more than 200 staff and contractors nationwide with over 2,000 combined years of Government Programs experience.

Leadership

Deep payer and provider knowledge coupled with Centers for Medicare & Medicaid Services (CMS) regulatory expertise.

Privately Owned

Founded in 1996

Gorman Health Group is the leading solutions and consulting firm for government-sponsored health programs.

WHO IS GORMAN HEALTH GROUP?

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Our clients have one-stop access to expert advice, guidance, and support, in every strategic and operational area for government-sponsored programs, across seven verticals.

CLINICAL Changing how you approach Medical Management, Quality and Stars

PROVIDER INNOVATIONS Supporting network design and medical cost control implementation

OPERATIONS Bringing excellence to every aspect of your implementation from enrollment to claims payment

COMPLIANCE Offering guidance and support in every strategic and operational area to ensure alignment with CMS

PHARMACY Leading experts in Part D, PBM, formulary and pharmacy programs

HEALTHCARE ANALYTICS & RISK ADJUSTMENT SOLUTIONS Implementing cross-functional risk adjustment programs for medical trend management and quality improvement

STRATEGY & GROWTH Leading experts in Marketing, Sales and Strategy development that create short and long-term profitable growth

BROAD SERVICES

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Dedicated to assisting Medicaid Managed Care Organizations achieve strategic, operational and quality goals across five verticals.

CLINICAL Blending medical and pharmacy to improve care coordination, outreach and utilization management to meet the complex needs of your membership.

STRATEGIC POSITIONING Analyzing and evaluating organizational adaptability, and readiness for change in new policy and population management environments.

QUALITY PROGRAM OVERSIGHT Guidance and support to achieve the results your members and regulators expect while attaining compliance with State and Federal rules.

FINANCIAL ALIGNMENT Providing health economic solutions for the needs of the Medicaid population including long-term care, behavioral health, and chronic condition management.

OPERATIONS Creative solutions to maximize cost effectiveness, and deliver lasting results from eligibility to provider contract management, and claims.

MEDICAID SERVICES

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• Where we are today • How and what to evaluate in your current organization • Identifying and merging best practices and resources • Creating the framework: CMS' expectations and taking the first

steps • Performing the stress test • Start today with a strategic vision to further align your LOBs

AGENDA

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WHERE WE ARE TODAY

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• To the member it is one seamless policy – a marriage of Medicare & Medicaid o One PCP and provider network o One ID card and benefit set o Rich benefits with low out of pocket costs

• To the health plan – o Coordinated operations and administration o Many states have a deep focus on self-directed

quality care that improves the lives of enrollees. This requires strong care management and quality programs, which is a challenge with passively enrolled low income enrollees.

o Many states continue to require dual reporting to state and CMS with dual capitation streams

MEDICARE/MEDICAID PLANS The future of Dual eligible health care?

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Medicare

Medicaid


SOUNDS EASY ENOUGH…

What is the catch?

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• Medical management costs will increase • Inefficiencies that exist in your

organization will create further inefficiencies

• Operations must be a lean, mean administrative machine o People o Processes o Technology

EVALUATING YOUR CURRENT ORG Avoid the ‘catch’

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EVALUATING YOUR CURRENT ORG Operational areas of focus

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Capability Assessment PEOPLE Work Force Planning Skills & Gaps Roles and Responsibilities PROCESS Consistency Standardization Business Requirements & Design Process Maps Policies and Procedures (P&Ps) Desk Level Procedures (DLPs) Quality Review

TECHNOLOGY

Configuration Test Data Analytics Data Management Information Management Key Performance Indicators Measurement &

Monitoring Managed Care Systems

MIL

E-D

EEP

MILE-WIDE


• Enrollment & Reconciliation o Coordination and

communication with state o IT and Operations processing

of state files o Reconciliation, reconciliation,

reconciliation – people, process and tools

• Call center o Are CTMs tied to unresolved

calls? o Call metrics met? o Staff have necessary tools?

• Claim payment o Misdirected claims o Claims timeliness o Inventory management o Proper reimbursement

methodologies • Appeals and grievance

o What is delegated? o Monitoring, reporting and

oversight? o Own the resolution of

grievances related to enrollment and eligibility

EVALUATING YOUR CURRENT ORG Where to start?

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• Know and understand the differences of Federal vs. State requirements – the differences and similarities in the requirements should be evident in your people (training, documentation resources), the processes and your technology

• Ensure that contractual obligations are captured within all core operational areas, systems configuration and transactional activities

• Develop a strategy for comprehensive quality control and oversight activities

• Continue to define and redefine policies and procedures and data management, including consistency within each product

• Implement processes that monitor end-to-end MA and MMC operations at the execution and functional level

BEST PRACTICES It is critical to identify and merge organizational best practices

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• Your operations must perform all functions under Medicare Managed Care reconciliation except those delegated to the state (Chapter 2). o Confirm the state is managing TRC codes related to enrollment and

associated member correspondence, including OOA o Create a process around the remaining TRC codes (e.g. LIS and

associated member correspondence) o MMPs must still perform reconciliation, and monthly enrollment and

payment attestation

CREATING THE FRAMEWORK Around CMS’ expectations

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People

Performance Metics

Process

Technology

CREATING THE FRAMEWORK Around CMS’ expectations

Call center must know when to refer the member to the state • Eligibility issues, plan

changes, address changes • Appeals and Grievances

are managed internally • Documentation of all

inquiries and referrals to the state

• Members who get tossed around = CTMs

• Coordination and communication with the state

• Scripts, job aids and resource information

Claims payments • No COB with

Medicare/Medicaid • COB requirements with

other insurers still in play • No changes to MSP

process

Appeals and grievance • Not delegated to the state • Own the resolution of

grievances related to enrollment and eligibility

• ODAG/CDAG audit readiness

Compliance • Own it. Now and always. • And don’t forget those

FDRs


• Readiness assessment is a starting point

• Include other, unchanged, compliance requirements

• Use your evaluation of operations: o Gap analysis o Risk assessment

• Create a prioritized set of recommendations that will serve as an action plan to execute operational and systems improvements.

PERFORM THE STRESS TEST Before you launch:

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• Prioritize key processes based on the value of people, process and technology. o For each priority process develop a view of the

current state based on assessments, using detailed process maps and analysis to help identify major gaps.

o Work together with a cross-functional client team to define a series of principles that will guide improved opportunities of the future state of each operational process, end-to-end, along with the roadmap to recommended future state, near and long term, that will lead to cost savings and improved services.

o Need help? Call Gorman Health Group.

INTO THE FUTURE Creating a strategic vision of continuous improvement and alignment

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Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance Exchange opportunities. For nearly 20 years, our unparalleled teams of subject-matter experts, former health plan executives and seasoned health care regulators have been providing strategic, operational, financial, and clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and compliant operations within our client’s reach. GHG offers software to solve problems not addressed by enterprise systems. Our Valencia™ software reconciles the capitation payment of more than six million Medicare beneficiaries and continues to support customers participating in the Health Insurance Exchanges. Nearly 3,000 compliance professionals use the Online Monitoring Tool™ (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 45,000 brokers and sales agents are certified and credentialed using Sales Sentinel™. In addition, hundreds of health care professionals are trained each year using Gorman University™ training courses.

We are your partner in government-sponsored health programs

T

E

JENNIFER YOUNG, MBA Senior Consultant

240.483.6289

[email protected]

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