The healthcare landscape is constantly evolving and Medicare health plan administrators are facing a wave of new regulatory requirements that significantly impact their operations. 

These changes are designed to enhance transparency, equity, and compliance, ensuring enrollees receive high-quality care consistent with Medicare’s evolving standards. 

For Medicare Advantage Organizations (MAOs), the path forward requires careful alignment with the latest rules to avoid penalties while ensuring enrollees are well-served.

Key Health Plan Areas Most Affected By Recent Medicare Compliance Changes

Health plans are facing significant regulatory changes, particularly in the areas of configuration, product and enrollment, appeals and grievances, claims, and data analytics.

Configuration processes now require greater transparency, annual reviews, and alignment with clinical guidelines to ensure timely access to care. 

New rules impact product offerings, prior authorizations, and culturally competent enrollment, while appeals and claims processes must adhere to stricter timelines and documentation requirements. Additionally, data privacy, cybersecurity, and reporting standards have been heightened to ensure compliance across the board. 

These updates are designed to improve care quality and protect enrollees while holding health plans accountable.

Let’s dive into the specific changes in requirements to be aware of.

Configuration Is The Most Impacted With Nine New Regulatory Requirements

Configuration processes are the most affected, with nine new regulatory requirements now governing how MAOs manage coverage, emphasizing transparency and alignment with Medicare standards.

1. Adherence to Coverage Determinations: MAOs are required to align with updated local and national coverage determinations, ensuring that all coverage decisions meet Medicare standards.
2. Transparency of Coverage Criteria: Health plans must make internal coverage criteria publicly accessible, ensuring that enrollees and providers understand how coverage decisions are made.
3. Compliance with Post-Claim Audits: Post-claim audits are subject to updated regulations, meaning that plans must ensure all claim-related activities meet Medicare standards.
4. Timely Access to Care: Configuration processes must guarantee timely access to care, which is critical to maintaining high-quality service for enrollees.
5. Documentation of Clinical Criteria: Detailed documentation and justification must be maintained for any clinical criteria not covered by traditional Medicare, ensuring transparency and compliance with regulatory standards.
6. Annual Review of Prior Authorizations: MAOs are now required to review and potentially revise prior authorizations on an annual basis to ensure they align with current guidelines and clinical needs.
7. Transparent Configuration Processes: Health plans must ensure that configuration processes are transparent, especially concerning coverage criteria and authorizations.
8. Alignment with Clinical Guidelines: Utilization management processes must be clearly aligned with clinical guidelines to ensure that decisions are medically appropriate.
9. Communication with CMS: All configuration changes must be communicated to the Centers for Medicare & Medicaid Services (CMS) through a defined process to avoid non-compliance penalties.

These updates reflect the increasing emphasis on consistency, transparency, and timeliness, which is vital for ensuring that enrollees receive the care they need without unnecessary delays or confusion.

Product And Enrollment Each Have Five New Regulatory Requirements

The regulatory updates extend into product and enrollment areas, with five new requirements that health plans must address.

Product

1. Prior Authorization Policies: New prior authorization policies have been implemented for specific products to ensure that medical necessity is met, balancing access without imposing undue restrictions.
2. Formulary Flexibility: MAOs are now allowed greater flexibility in formularies, particularly concerning generics and biological products, making it easier to offer cost-effective alternatives.
3. Agent/Broker Monitoring: There are enhanced monitoring requirements for agent and broker activities to ensure they comply with Medicare’s marketing rules.
4. Supplemental Benefits: Updated protocols for offering supplemental benefits have been introduced, aligning these benefits with Medicare’s overall objectives.
5. Consistency Across Products: Internal coverage criteria must be consistent across all products offered by MAOs, promoting fairness and reducing confusion among enrollees.

Enrollment

1. Special Enrollment Periods (SEPs): Expanded SEP rules provide more opportunities for enrollees to switch plans under specific conditions, giving them greater flexibility.
2. Culturally Competent Enrollment: Health plans are now required to implement culturally competent enrollment procedures, ensuring that diverse populations receive appropriate and effective guidance and support.
3. Telephone Enrollment: Stricter guidelines govern telephone enrollments, ensuring that all enrollees fully understand the plan they are signing up for.
4. Fraud Prevention: Enhanced scrutiny is required during the enrollment process to prevent fraud, protecting both the plan and the enrollees.
5. Documentation Requirements: New documentation requirements ensure that all enrollment activities are properly recorded, providing an audit trail for compliance and fraud prevention.

These updates highlight the importance of maintaining robust, transparent, and culturally sensitive enrollment practices, ensuring that beneficiaries are well-informed and protected during the enrollment process.

Appeals And Grievances, Claims, And Data Analytics Each Have Four New Regulatory Requirements

The appeals and grievances process is essential to ensuring that beneficiaries’ concerns are addressed swiftly and effectively. 

Appeals & Grievances

1. Stricter Timelines: Appeals must now be resolved within more stringent timelines, ensuring faster resolutions and improved beneficiary satisfaction.
2. Detailed Documentation: All grievance cases must be documented in greater detail, ensuring that all issues are properly addressed and reported.
3. Mandatory Training: Staff members handling appeals must undergo mandatory training to stay current with the latest regulatory requirements.
4. Reporting Standards: New reporting standards for appeals outcomes have been introduced, ensuring greater transparency and accountability in the process.

Claims

1. Processing Standards: New standards for claims processing require alignment with traditional Medicare, ensuring consistency in the way claims are handled.
2. Post-Claim Audits: Updated guidelines govern post-claim audits, ensuring that claims are compliant with Medicare rules.
3. Handling of Rejected Claims: Stricter compliance rules now apply to the handling of rejected claims, ensuring that beneficiaries are not unfairly denied coverage.
4. Transparency in Claims Reviews: Enhanced transparency is required in the claims review process, allowing beneficiaries to clearly understand the rationale behind approvals or denials.

Data Analytics

1. Enhanced Reporting Requirements: Reporting requirements have been enhanced to ensure that health plans submit more accurate and comprehensive data.
2. Analytics for Compliance Monitoring: The use of data analytics in monitoring compliance is now mandated, ensuring that plans are staying within regulatory guidelines.
3. Data Privacy and Security: New guidelines for data privacy and security are in place, ensuring that enrollee information is protected.
4. Clinical Integration: Stricter standards require that data analytics be integrated with clinical processes to enhance the quality of care delivered.

These changes ensure that beneficiaries don’t face extended delays when disputing coverage decisions, contributing to a more responsive and patient-centered system.

Customer Service, Fulfillment, IT, And Utilization Management Each Have Two New Regulatory Changes

In addition to the core areas of configuration, claims, and data analytics, several other key aspects of Medicare health plan administration are undergoing regulatory updates.

Customer Service

1. Handling Inquiries: New rules govern how customer service representatives handle inquiries, ensuring that enrollees receive clear, consistent, and accurate information about their benefits.
2. Mandatory Training: Customer service representatives are now required to undergo mandatory training to ensure they are fully equipped to assist enrollees and remain compliant with Medicare’s standards.

Fulfillment

1. Stricter Controls on Materials: Stricter controls have been introduced over plan-related materials distribution to ensure that enrollees receive accurate and timely information.
2. Enhanced Monitoring: Enhanced monitoring procedures are now required to prevent errors and delays in material distribution, ensuring that all enrollee communications are prompt and error-free.

IT 

1. Cybersecurity Requirements: New cybersecurity regulations have been introduced to safeguard enrollee data, requiring health plans to implement advanced data protection protocols.
2. Regular IT Audits: Health plans must conduct regular audits of their IT systems to ensure compliance with the latest cybersecurity requirements and to safeguard against breaches.

Utilization Management

1. Annual Policy Review: The Utilization Management Committee must review all policies on an annual basis to ensure that they are in line with current guidelines and consistent with traditional Medicare standards.
2. Stricter Guidelines for Prior Authorization: New guidelines have been introduced for prior authorization processes to ensure that decisions are medically necessary and consistent across the board.

By implementing these new standards, health plans can improve customer interactions, safeguard sensitive data, and ensure that care decisions are both consistent and medically necessary.

Reporting Requirements Have Become More Stringent

Health plan reporting requirements have become significantly more stringent, with a heightened focus on accuracy, timeliness, and comprehensive documentation. Plans are now obligated to submit more detailed reports covering a wide range of metrics, ensuring that all aspects of compliance and enrollee care are thoroughly documented.

These enhanced reporting standards are designed to increase transparency, providing CMS with a clearer and more detailed picture of health plan performance. Failure to meet these new requirements could result in penalties, making it crucial for plans to prioritize timely and precise data submission.

Ensuring Compliance and Quality Care 

These regulatory changes reflect CMS’s commitment to enhancing transparency, equity, and quality across all aspects of Medicare Advantage and Part D plans. For plan administrators, this means thoroughly reviewing and implementing these changes to remain compliant while improving the overall experience for enrollees.

These regulatory changes are designed to ensure that enrollees receive the highest standard of care, fully aligned with Medicare’s continuously evolving requirements. Through greater transparency, data-driven processes, and heightened compliance measures, MAOs can successfully navigate these updates, protecting their organization and the individuals they serve.

Get expert guidance to navigate the complex and ever-changing regulatory requirements facing Medicare Advantage Organizations. 

Our expert consultants leverage our AxisConnect™ suite of services to provide extensive health plan consulting to unlock your organization’s full potential. Our seasoned team collaborates with you in areas like regulatory affairs, technology, and operational efficiency to ensure you meet all requirements. Connect with our team today.

 

Author:

Kelly Thao

Sr. Compliance Analyst

HealthAxis

In July, the Centers for Medicare & Medicaid Services (CMS) introduced two pivotal updates that health plan administrators need to be aware of to maintain compliance with the latest regulations.

This blog will cover the essential changes and updates for:

• Medicare Prescription Payment Plan (M3P): Final Part Two Guidance
• Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

As you review these updates, it’s important to remember the significant impact that non-compliance can have on your organization, including financial and reputational risks.

 

M3P Final Part Two Guidance: Key Updates Health Plan Administrators Need to Know

As part of the ongoing implementation of the Inflation Reduction Act of 2022, CMS continues to refine the M3P program. This initiative, which marks a transformative shift in the Medicare Part D landscape, was designed to provide enrollees with more manageable prescription drug costs.

While M3P presents substantial benefits for Medicare beneficiaries, it also requires health plans to navigate a new set of operational challenges.

The Final Part Two Guidance, released on July 16, 2024, builds upon the Final Part One Guidance from earlier this year. It focuses on critical areas such as outreach and education, pharmacy processes, and additional operational requirements that will be vital for the successful rollout of M3P in 2025.

Below are the key updates that health plan administrators need to be aware of as they prepare for the program’s first year.

Section 10: $0 Due at Point of Prescription Pickup

Part D plans with $0 cost-sharing for all drugs are not required to offer the payment plan. This is due to the fact that the primary purpose of payment plans is to assist with managing significant out-of-pocket expenses. This adds additional pressure on health plans to modernize and replace outdated or legacy technologies to remain current.

If there are no costs to share, or all drugs are free under the plan, the need for healthcare billing compliance for a payment plan becomes redundant.

Section 30.1.1: No More Bundling of Member Materials Required

Part D sponsors can send election request forms separately from the membership ID card mailing. This update no longer requires Part D sponsors to bundle request forms with other materials.

It leads to greater administrative efficiency, an improved member experience, and avoiding delays or issues with membership ID cards and other materials by being able to send out election requests promptly and independently.

Section 30.2.2.2: More Flexibility in Attracting New Members

Sponsors can develop their own outreach strategies for identifying enrollees likely to benefit. This allows sponsors to customize their approaches to outreach based on their unique enrollee populations and plan characteristics.

It also helps plans make data-driven decisions that come from identifying patterns and trends among enrollees.

Section 30.3: Health Plans Must Hone Communications About Member Rights

Specific content requirements for communication materials regarding program participation and termination are required. This update mandates that health plans must provide enrollees with all the necessary information to better understand their rights, benefits, and any changes to their plan.

This enhanced transparency improves Medicare compliance guidelines and increases member understanding. Yet, it requires health plans to rethink the information they provide to their members and how it’s presented.

Section 50.1: Aligning Medicare and Medigap Payments

This update includes clarifications on handling supplemental coverage affecting patient pay amounts. This helps ensure that beneficiaries are not overcharged as it correctly coordinates payments between Medicare and Medigap supplemental insurers.

Section 50.3.1: Changes in How Pharmacies Interact with Billing Systems

Long-term care pharmacies must provide the benefit notice during the billing process instead of before dispensing medication.

Previous to these new regulatory changes, long-term care pharmacies were required to provide a benefit notice before dispensing medication. Now, they must provide notice during the billing process instead. While this is intended to streamline operations and reduce confusion, it may require a substantial retooling of pharmacies billing systems.

Critical Tech Focus: Core Admin System Modernization

For health plans managing M3P, technology modernization is a crucial area of focus. Upgrading core administrative processing systems (CAPS) is essential to handle the program’s complex billing and enrollment requirements effectively.

Key areas of modernization should include:

• Enhancements to claims adjudication processes
• Adjustments to billing systems for managing monthly installment payments
• Improved data exchanges with pharmacies to accurately track out-of-pocket expenses

By prioritizing these tech upgrades, health plans can ensure they meet M3P requirements efficiently, maintaining compliance and delivering a seamless experience for both the plan and its enrollees.

Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance: Key Updates Health Plan Administrators Need to Know

Medicare health plans, including Medicare Advantage (MA) plans such as HMOs, PPOs, Medical Savings Accounts, and others, operate under strict regulatory frameworks to ensure that enrollee grievances, organization determinations, and appeals are processed fairly and efficiently. These processes are governed by the MA regulations outlined in 42 CFR Part 422,Subpart M.

On July 19, 2024, CMS released an HPMS memo detailing significant updates to the Parts C & D Enrollee Grievance, Organization/Coverage Determination, and Appeals Guidance. These updates, which include revisions to terminology and align with existing regulations under 42 CFR § 422.566(d), are crucial for health plans to implement immediately to remain compliant. Below are the key updates that health plan administrators need to understand and integrate into their operations.

These Key Updates Are Effective Immediately

Physician Review

One of the major updates requires that all denials of coverage that’s based on a medical necessity must be reviewed by a healthcare professional with relevant expertise. This ensures decisions made are clinically sound and adds another layer of protection for enrollees, ensuring that their access to care isn’t restricted by administrative or non-expert reviews. This means health plans must have qualified professionals available to review these denials, and might require the additional training or hiring of specialists which could ultimately increase operational costs.

Representation

CMS has new clarifications on who can act as a representative for enrollees. Part of their focus on greater transparency and quality delivery of care, enrollee representatives must now ensure that enrollees are fully aware of their rights to appoint someone to represent them and the processes involved in doing so. This is designed to help eliminate misunderstandings and give enrollees the support they need, particularly in complex claims such as appeals or grievances. Health plans may need to revise their training materials for customer service representativesand update their documentation to meet this new regulatory requirement.

Terminology Changes To Grievance and Appeal Processes

Terminology related to the filing and handling of grievances, particularly those that concern quality of care, are designed to streamline processes and maintain consistency across the Medicare provider industry. Standardizing the language and procedures will make the grievance process more accessible and understandable for enrollees. This necessitates revisions to internal procedures, training the staff on new terminologies to use and an updating of all materials provided to enrollees.

Prior Authorization

Clarified processes and enrollee rights regarding plan approval requests are now mandatory, ensuring that enrollees are fully informed of their right to appeal a prior authorization denial and the timelines within which they must do so.

Like this change, much of the new regulatory requirements are designed to improve transparency and timeliness to avoid delays in necessary care. Health plans must refine their prior authorization processes, update systems to track authorizations more effectively, and provide clear communication to enrollees about their rights and options.

Notifications

CMS has further specified who can request initial determinations and notification requirements, including whether a service is covered, and how they are required to notify enrollees of these decisions. This requires health plans to ensure that their notification processes are robust and compliant with these new regulations, which could require better automation of certain notifications.

Dismissal of Requests

Conditions for dismissing initial determination or appeal requests have been redefined in order to prevent the unnecessary processing of invalid or incomplete requests which will help streamline the appeals process. Health plans will likely need to update their internal review procedures and provide further staff training to better identify cases were a dismissal is Appropriate.

Critical Operational Focus: Medical Necessity Denial Reviews

One operational area that health plans should closely examine to ensure compliance with the July 2024 updates is the review and processing of denials based on medical necessity.

Specifically, health plans need to ensure that their procedures for denial reviews involve a

relevant healthcare professional as mandated by the updated guidance.

• Risk of Non-Compliance: Failure to have denials reviewed by an appropriate healthcare professional could lead to non-compliance, resulting in potential penalties and challenges in appeals.
• Process Alignment: Health plans should assess and possibly enhance their current workflows to ensure that every denial of coverage based on medical necessity is properly reviewed by a qualified healthcare provider, as per the updated CMS guidelines.
• Training and Documentation: Staff should be adequately trained on these new requirements, and health plans must document these processes to provide evidence of compliance during audits or when grievances and appeals arise.

By prioritizing the operational process around medical necessity denials, health plans can mitigate the risk of non-compliance and ensure smoother handling of grievances and appeals under the updated guidance. For those seeking immediate expert guidance to navigate these changes, tapping into consulting support can be a crucial step in ensuring your organization is set up for success.

The Only Constant in Medicare Compliance is Change

The recent CMS updates underscore the dynamic nature of the Medicare landscape. Health plans must stay informed and adapt their operations to ensure ongoing compliance. These changes, particularly those related to M3P and grievance handling, require careful attention and strategic planning.

HealthAxis understands the challenges health plans face in navigating this complex regulatory environment. With our deep expertise in Medicare compliance and a proven track record of success, we offer comprehensive solutions to help you thrive.

Let us help you navigate these changes confidently. Contact us today to learn more about how HealthAxis can support your organization.

 

Author:

Kelly Thao

Sr. Compliance Analyst

HealthAxis

In the healthcare industry, the regulatory landscape is constantly evolving, and healthcare payers continually struggle to stay up to date.

The problem? Organizations are developing tools to mitigate healthcare regulatory compliance risks as they happen.

What can set you apart from other health plans is to be proactive by identifying the risk early and developing a mitigation strategy to address the problems before they even occur.

So, how can you do this? It’s simple.

You need to develop an effective plan that allows for flexibility in addressing regulatory changes by creating continual awareness and developing a culture of corporate compliance embraced by the highest to the lowest levels of employees.

In this article, you will learn how developing and implementing a healthcare corporate compliance program can give you a competitive advantage over competitors that fail to take action to ensure corporate compliance is woven into the fabric of the organization and culture.

This is achieved by affirming the organization has implemented preventive measures to reduce any potential compliance risk.

But first, let’s discuss what regulatory compliance is.

What is Healthcare Regulatory Compliance?

Regulatory compliance is a set of processes and controls that support your organization’s corporate compliance program and establishes a culture with an expectation that all employees exhibit strict adherence to the policy and regulations.

For instance, regulations involve issues such as the safety of those you serve, access to healthcare services, healthcare provider and facility relationships, patient privacy, and government reimbursement.

• Health Insurance Portability and Accountability Act (HIPAA)
• Anti-Kickback Statute and Stark Law
• The Health Information Technology for Economic and Clinical Health (HITECH) Act
• Affordable Care Act (ACA)

Furthermore, regulatory compliance for plans, payers, and other healthcare organizations requires a high level of knowledge and understanding of the regulations, policy, execution, and precision in delivering healthcare services.

Why Does it Matter?

Reputational risk can occur in various ways and result in organizational and financial damages, including loss of business and brand value. Additionally, financial, civil, and criminal fines can be assessed against an organization if the Centers for Medicare & Medicaid Services (CMS) determines a healthcare organization has violated the regulations.

For example, CMS may penalize payers when a provider does not have accurate information, like out-of-date directories.

An additional requirement under development and review within the Interoperability Final Rule is the payer-to-payer data exchange. The rule states that health plans in the CMS market must ensure accurate and timely information.

Healthcare organizations cannot miss a single directive, even when it seems minor. This is where a robust corporate compliance plan can easily demonstrate an ethical and responsible approach to being a good steward of federal and state healthcare dollars.

Benefits of a Healthcare Regulatory Compliance Plan

While some may see corporate compliance as a barrier to business development and growth of an organization, an effective corporate compliance plan can be a competitive edge.

Increase Member Satisfaction

CMS requires the completion of annual surveys by Medicare Advantage members to determine their level of satisfaction. Plans that make compliance a priority should lead to more satisfied customers, which can help in determining the plan’s CMS Star Ratings.

These ratings can affect and determine your reimbursement rates, expansion, and growth, justifying why health plans must allocate resources to compliance and make it a priority.

Additionally, when potential members consider new health plans, they often see your ratings as a determining factor. Therefore, improving your star ratings can attract and increase the number of new members.

Speaking of attracting new members, that brings us to our next benefit.

Attract & Retain Members

With social media and the internet at your members’ fingertips, they will research your online presence. If they identify any reported corporate compliance or regulatory issues, it may sway them toward your competition.

Additionally, following compliance regulations often leads to better quality care for your members. Your members will trust you more and appreciate their improved experience; and in return, be more likely to retain their membership and share with their friends and family, which can provide organic growth for your organization.

Provide Better Service

Think of regulatory compliance as an incentive to provide a better experience to your members. Corporate compliance creates transparency in your organization and improves the quality of your data and additional protections for your client and member records.

When information is shared freely with your members and their providers, you can ensure they receive better care that is medically necessary and improves health outcomes.

Avoid Legal Issues

As you already know, following HIPAA regulations and protecting patient privacy is required by federal and state law, which means you are responsible for securing any data you transmit or have stored.

When you create and implement processes to ensure you follow laws and protect your members’ privacy, you will confirm your organization remains in compliance with the U.S. Department of Health and Human Services (HHS) requirements.

Barriers to Compliance

While your compliance & ethics team is a champion of adhering to regulations, your entire organization is responsible for maintaining compliance.

Unfortunately, some common barriers include:

• Ineffective leadership
• Unmotivated staff
• Lack of appropriate resources
• Lack of training & education

Here’s how to solve these roadblocks.

Lead By Example

As cliche as it may sound, it is true. When you display compliant and ethical behavior during your day-to-day interactions with your team, they tend to follow the modeled behavior, becoming a habit.

Motivate Team Members with Rewards

Simply announcing new processes and corporate compliance goals is not always enough to motivate individuals to adopt the values and change behavior. Publicly praising and rewarding employees for taking steps to prevent corporate compliance errors reinforces compliant and ethical behavior.

Provide Resources to Properly Implement Programs

Even when both leaders and employees are on the same page, team members may lack the resources or capabilities to address compliance conflicts. Give your team the knowledge and technology to enact your compliance plan.

Administer Proper Training & Education

Your compliance & ethics team is charged with developing training that educates and empowers individuals to understand and identify potential compliance issues before they occur.

Now, it is time to build your plan.

7 Key Elements of an Effective Corporate Compliance Plan

Medicare Advantage plans must follow CMS requirements for an effective corporate compliance program.

According to CMS, an effective corporate compliance program must include all of the following 7 elements:

1. Written Policies, Procedures, & Standards of Conduct

Companies must have written documentation that explains their commitment to comply with federal and state requirements.

This documentation provides employees with guidance and standards of conduct for compliance-related issues and opportunities for improvement that employees must abide by to remain a participant in federal and state healthcare programs.

Written documentation ensures that employees are aware of the company’s compliance policies and procedures and assists in preventing potential compliance problems.

2. Chief Compliance Officer, Corporate Compliance Committee & High-Level Oversight

CMS requires the Chief Compliance Officer (CCO) to maintain independence from business operations to avoid self-policing, which can create a conflict of interest. Enforcing this standard means the CCO’s responsibilities cannot include conducting or overseeing daily operational functions.

The Corporate Compliance Committee should consist of senior management and departmental managers with decision-making capacity who participate in quarterly meetings.

The Committee’s primary purpose is to oversee the compliance and ethics programs, such as training, risk assessment, and Corrective Action Plans implementation.

3. Effective Training & Education

Here’s a fact: You should always develop and institute regular, effective education and training programs for all associates and first-tier, downstream, and related entities (FDRs). This is a key responsibility of your CCO.

Your Compliance & Ethics Program should also incorporate training into its daily educational programming to ensure compliance with ethical standards.

Next, all employees should complete training on topics, such as compliance, HIPAA, fraud, waste, and abuse prevention. These materials should be reviewed annually and updated whenever there are regulatory changes, new policies, or guidance. The Compliance & Ethics Department tracks the training completion, content quality, and participation timeliness.

4. Strong Lines of Communication

Your CCO should maintain a virtual open-door practice and be easily accessible to all employees. The CCO should also offer several communication options, such as in-person meetings or email.

Build an environment where all associates feel comfortable approaching the CCO with questions or concerns. You can achieve this by creating a safe space for confidential and anonymous reporting of suspected compliance violations.

5. Well-Publicized Disciplinary Standards

Next, your disciplinary standards should set the guidelines for when an employee or FDR commits any acts of non-compliance. Disciplinary actions should be consistently applied and imposed fairly and equitably.

Special consideration may apply, depending on the severity of the offense and the level of harm to Medicare beneficiaries, which may require immediate action up to the suspension or termination of employment or contract.

6. Set Up Routine Monitoring, Auditing, & Identification of Compliance Risks

Through audit work plans, monitoring activities, and other sources for identifying potential risks, your Compliance & Ethics team should perform regular monitoring and auditing of operational activities to ensure compliance with federal and state standards.

Conduct an annual risk assessment to determine the highest risk areas and develop an audit work plan accordingly.

Upon completion of these activities, any corrective action requirements can be identified, where applicable, and reporting can then be provided to the Corporate Compliance Committee.

7. Create a System for Prompt Response to Compliance Issues

Once a compliance issue is reported, initiate a timely investigation. You must determine which regulatory requirements were violated, the cause and intent of individuals or departments involved, and the scope and severity of the violation.

Information on the outcome of the investigation must then be provided to the reporting individual if disclosed and to the Corporate Compliance Committee. If necessary, a performance improvement plan, corrective action plan, or other disciplinary action is recommended.

Although completion of any corrective actions is typically handled by management in the affected area, Compliance & Ethics should oversee these actions.

Set Your Corporate Compliance Plan in Stone with HealthAxis

Ready to transform your corporate compliance plan? Work with an organization that takes corporate compliance as seriously as you do.

“HealthAxis is committed to conducting business with the utmost integrity and in accordance with all laws and regulations. We have built our honorable reputation and exceptional culture through our employees’ unwavering principles and upholding our core values.” Robert Nolan, Chief Compliance Officer.

Our Chief Compliance Officer, Rob Nolan is involved in the day-to-day operations of the corporate compliance program and is responsible for developing and implementing education and training programs for all associates and related entities.

At HealthAxis, our Compliance and Ethics Program provides our clients with operational guidance and safeguards against fraud, waste, and abuse.

With the right technology partner on your side, your organization can navigate the ever-changing regulatory landscape without risk. Request a demo today to see our solutions in action!

Since the passage of the Affordable Care Act, the adoption of the value-based care model has been increasing in popularity among healthcare organizations, government officials, and especially among Medicaid and Medicare.

As more and more organizations begin implementing it, they are experiencing improvements in efficiency, profits, and patient outcomes.

In this article, we will discuss:

• What is value-based care?
• How is value-based care different from fee-for-service?
• What are the benefits of value-based care?
• How healthcare organizations can make the transition to value-based care seamlessly.
• Different ways payers can help providers along the value-based care continuum.
• How to improve your value-based care with cutting-edge technology solutions.

Let’s dive in!

What Is Value-Based Care, and How Is It Different From Fee-For-Service

Value-based care (VBC) is a reimbursement model in the healthcare industry where providers are paid based on patient health and satisfaction outcomes.

In contrast, in fee-for-service (FFS) models, providers are paid based on each service performed. FFS focuses on quantity over quality, and VBC centers around the quality of care, efficiency, and smarter spending.

For example, in FFS, payers pay providers for every visit, test, medication, MRI, and the like, conceivably encouraging providers to drag out care to make more money.

FFS providers get paid for treating people when they are sick, whereas value-based care providers get paid for keeping their patients healthy.

6 Benefits of Value-Based Care

Value-based care encourages payers, providers, and health plans to be innovative and work together to improve the quality of care they provide to their patients.

1. Lowered Costs

Patients

First, let’s examine the reduced costs for patients. One of the best features of value-based care is the focus on preventative measures to keep patients healthy. One way to accomplish this is through measurement based care, which utilizes data to improve patient outcomes.

A hidden bonus is that preventative care is often more affordable than more pervasive treatments once the patient is sick. It also leads to quicker recovery and lessens doctor visits and treatments.

Payers

Additionally, value-based care lowers costs for payers and increases efficiency by supporting bundled payments that cover the complexities of the patient’s care.

Not only that, but payers gain stronger cost control when paying for patients’ services. Improved quality of care leads to better outcomes which ultimately reduces spending. Accordingly, payers disperse less money for the services used by their patients.

2. Enhanced Quality of Care & Patient Satisfaction

With metrics and ratings based on customer satisfaction, every employee concentrates on providing the highest quality of service and placing the patient first.

When healthcare organizations focus less on pushing treatments and tests to make money, they can provide quality care.

Value-based care emphasizes treating the whole person, not just remedying the presenting illness. This practice leaves the patient feeling much healthier and satisfied with their treatment.

3. Reduced Risk for Payers

Another benefit of VBC for payers is that it reduces risk. Both payers and providers have a stake in the outcome and work together to keep costs low and deliver quality care.

When adopting the two-sided risk models, providers accept accountability if they exceed their budget or miss revenue goals. They must compensate payers for a portion of the losses.

4. Improve Coordination

When everyone has the same goal of providing quality care to the patient, everyone is on the same team. Without the friction from fee-for-service models, operations are more efficient, and processes move faster.

With value-based care, incentives and technology help improve coordinated care.

Transactions are packaged together, diminishing the time spent going back and forth. It also decreases the paperwork between payers and providers, denoting fewer lost documents.

This brings us to benefit number five.

5. Decreased Administration Burden

With VBC, payers can save time, money, and energy by managing paperwork and other tedious administration tasks.

Through bundling the entire care plan, payments and paperwork are consolidated- unlike fee-for-service, which produces a high volume of paperwork with individual treatment visits.

6. Healthier Community

Prevention is one of the pillars of value-based care. It is achieved by focusing on dietary and lifestyle changes to help stop complications from conditions, such as diabetes, from developing.

Diabetes is one of the leading drivers of healthcare costs and about 37 million Americans live with diabetes, with even more having prediabetes.

A doctor who adheres to a value-based approach would prescribe a prediabetic patient a healthy diet plan, an exercise program, and also look at the psychological aspects.

If this method takes hold, it can help reduce the number of people in America who develop diabetes. Plus, by similarly scrutinizing other conditions, the result can be a healthier community.

 

Even though value-based care was introduced in 2006, successful adoption and implementation are still rare. Here are a few ways to help your chances of success.

3 Ways Healthcare Organizations Can Transition Seamlessly to Value-Based Care

Now that you understand why you should begin transitioning to value-based care models, here are three tips to make the switch easier.

1. Create Efficient Data Sharing Between Providers and Payers

As you know, HIPPA prohibits sharing patient data unless it is for treatment or payment. When a payer and provider work together around VBC, they must change their data use agreement.

Payers need to share back costs and utilization information with providers quickly and efficiently. Otherwise, it can lead to problems for the providers, such as not knowing their financial gains and losses.

Improving Data Sharing

Payers often base their data on claims systems that may post a paid claim several days to a month after the delivered treatment, leading to delays in data sharing.

However, when the provider can share their clinical data with payers, they can integrate that information with their claims data, creating a more efficient process.

For the two to thrive, they need to share data quickly and transparently.

Speed and transparency between the payer and provider are the keys to shaping a fluid process and advancing performance and quality of care.

2. Health Plans Need To Provide Data

Another addressable area requiring examination and development is the arrangement between healthcare plans and healthcare providers.

For providers to be proactive in their patients’ health, health plans need to provide actionable analytics reporting to the providers. This data should contain a comprehensive view of the patient and their claims.

This information benefits not only providers and their patients, but also health plans. The full-patient picture can provide a competitive edge, drive innovation, and influence the roadmap to develop new member benefits and plans.

3. Implement High-Quality Technology

To keep up with the requirements of a value-based care model, modern and cutting-edge technology is a must. Legacy systems often lack flexibility, complex coding, or automation to give healthcare plans the ability to shift to VBC.

Having the capability to configure all plans and automatically respond to any changes in regulation is essential for providing quality VBC.

How Payers Can Help Providers With the Value-Based Care Continuum

To achieve success, payers must help providers transition to a value-based care continuum when entering a new contract. The models involved in value-based care are very different from fee-for-service. Shifting them into a simpler but similar model may be the best course of action.

Additionally, there are other steps payers can take to help support providers as they maneuver towards value-based care.

Offering Payment Support

Providers are required to pay transformation costs such as:

• Coordination costs
• Practice transformation costs
• Other expenses

To help offset or cover part of the provider’s cost, a payer can offer a payment per member or a performance bonus. Also, paying them upfront can help move them along easier.

During the early stages, it is also important for payers to be understanding of growing pains and not judge providers too harshly during these early transformation stages and instead base payments on growth.

Then, as they evolve, the payment models can, too.

Implementing Technical Support

Financial isn’t the only support payers can offer providers. Technical backing is also essential to flourish. They will need data and insights during the early stages to address shortcomings and migrate faster.

For instance, furnishing them with online tools or reports helps them discern how they stack up amongst their peers. Then they can identify where they are performing poorly and overspending.

Additionally, payers can provide them with data and reports to help them form strategies to improve their performance.

Transforming Primary Care

A primary care practice initially created based on a fee-for-service model will need support transitioning to meet performance metrics.

The way they deliver care must align with the new value-based payment models. While it is the providers’ responsibility, a payer can help by providing metrics centered around patient-centered utilization to guide them.

Do More Research

Some areas that could benefit from more research are:

• Incentives quantities
• Provider movement in the value-based care continuum
• Assessing successful practices’ strategies

Data can tell a story. When you dig into the research of what has worked for others,
the analysis can lay out a blueprint for success.

Improve Your Value-Based Care With High-Quality Solutions

When payers, health plans, and providers work together, they can provide the best possible patient outcomes. Value-based care allows healthcare organizations to improve their quality of care while saving money.

But for the process to be seamless, without any delays or inaccuracies in data when sharing amongst each other, you need a high-quality system.

You need a system that can help you manage your claims, third-party data integrations, and improve workflows.

HealthAxis’ solutions provide the flexibility to configure the most elaborate contracts, provider reimbursement fee models, and payment arrangements needed for a value-based care structure.

Our end-user configuration makes it easy to build complex arrangements and helps automate the process to improve operational efficiency and lower costs. In addition, you are equipped with data and actionable analytics to support your reporting, cost tracking, and quality measurements.

Forge successful, value-based outcomes and refine member services with Healthaxis’ powerful HxOne solution.

Does your plan suffer from high costs due to workflow inefficiencies? Does your staff struggle with providing quality services and care to patients?

This may be due to outdated workflow management processes.

While the world continues to advance, discovering new technologies to better day-to-day life, many health plans and payers still remain in the past with respect to healthcare administration.

In this article, we will explain

• The importance of healthcare workflow management
• How you can use technology to optimize workflows for healthcare payers and plans
• Examples of developing healthcare workflows with technology

Let’s dive in.

The Importance of Health Plan Workflow Management

Optimizing workflows is all about identifying inefficiencies and fixing them. By correcting these procedures, healthcare professionals can spend less time on tedious tasks and more time delivering quality services and care to patients.

Streamlining workflows helps your organization reduce errors, ensure compliance with regulations, and improve your quality of care. From there you are able to produce successful value-based outcomes and refine member services.

If you are a business owner or manager you need to make sure you are providing your staff with the resources required to optimize workflow processes. This means keeping your organization up to date with the latest technology available.

Medicare Advantage (MA) Plans Need Streamlined Workflows

If you are a Medicare Advantage Health Insurance Plan you know how important it is to have a high star rating. It can be what sets you apart from other plans and ensures potential enrolees that you deliver quality plans.

The Centers for Medicare and Medicaid Services (CMS) is a trusted source so getting a high star rating from them can highly influence enrollees. To ensure you get your desired scores your organization needs a medical and benefits management technology.

How Technology Can Optimize Workflow Processes for Healthcare Payers and Plans

Technology investment can optimize workflow processes by:

• Progressing patient care
• Enhancing coordination
• Streamlining documentation procedures
• Boosting communications
• Reducing tedious and redundant tasks

Now, let’s detail the different steps you can take when using new technology to optimize your workflows.

Update Communication Throughout Your Organization

Outdated communication operations like following up on unanswered calls or playing phone tag with providers wastes a lot of personnel time.

Modernizing to hi-tech, automated communications can alleviate inaccurate information and increase timely member outreach. If your team improperly handles calls or doesn’t reply promptly to a member, it can adversely affect patient engagement rates and star ratings.

By automating the repetitive tasks, the team is free to handle the more pressing matters at hand. Using technology can result in quicker response times, higher member satisfaction, error elimination, boosted staff morale, and overall cost savings.

Remove Wasteful Paper Processes

Practices that involve paper such as patient files are another drain on resources where technology can assist. Staff can spend countless hours chasing down paperwork and files.

By replacing as many paper operations as possible with new tech, you can save time and money, and reduce manual errors.

Crucial information can be lost or misfiled with paper documentation, causing payments, patient claims, and eligibility information to fall through the cracks. Cloud-based portals, member platforms, and computerized documentation systems all advance workflows. Allowing staff to work securely throughout all departments with all types of devices, wherever they are.

Utilize Automation to Save Time

Automation allows for the elimination of some tedious manual tasks saving time for performing quality care. One-third to one-half of administration costs are from billing and payment transactions between providers and payers.

By automating, mundane and repetitive tasks, your staff is able to dedicate their time and energy toward more crucial functions. A payer claims process is the perfect operation where automation can play an important role and make a sizable impact on staff and capital.

Dealing with third-party payers can consume an enormous amount of your staff’s time. There are many repetitive tasks and every payer has their own set of requirements. A healthcare platform can help automate many mundane steps and ensure more efficient and accurate billing.

Adopt A.I. to Strengthen Operations

As A.I.’s capabilities and benefits become more recognized, more industries have adopted it in their daily operations. The American Medical Association (AMA) shared ways that they believe A.I. can improve workflows.

For example, payers can use A.I. for automating and collecting data to streamline workflows in eligibility and benefit verification.

It can advance:

• Point-of-care learning – reduces wasted time looking for research
• Reporting – removes manual data-collection
• Documentation – creates efficient patient documentation

Health care professionals are adopting A.I., and it is becoming imperative for your business to keep up.

Enhance Analytics to Uncover Inefficiencies

Technology allows you to consolidate and analyze data to pinpoint areas for improvement or needed action.

With a tech-forward healthcare system, you can obtain dynamic metrics, alerts, and reports. Your team can monitor performance, analyze key performance indicators, and compare them to performance benchmarks. Then, you can turn this data into integrated and actionable insights in record time.

The use of technology for analytics can help lower costs, become more compliant with regulations, detect fraud, enhance quality of care, and streamline your operations.

Revamp Your Operations with HealthAxis Solutions

By adopting cloud-based technology into your day-to-day practices, you can refine your workflow processes. From the first point of contact with your patient to sending them the final bill, every aspect can run smoothly with healthcare tech.

Seeking to advance your healthcare business? HxOne allows you to manage your analytics, technology, and day-to-day operations in order to provide quality care to your members and reduce your costs.

Through our tech-enabled services, you can provide enhanced customer service, adapt quickly, and offer new products to members, all while reducing your overall risk.

Request a demo today to learn how HealthAxis can develop your workflow and streamline your operations.