Every year on December 12th, the world unites in celebration of Universal Health Coverage Day (UHC Day). This official United Nations-designated day serves as a potent reminder of the critical need for strong, equitable, and resilient health systems accessible to all, regardless of background or financial means. It also marks the anniversary of a pivotal moment in global health history: the 2012 unanimous endorsement of UHC by the United Nations (UN) as a cornerstone of international development.

A Right, Not a Privilege: The Origins of UHC Day

The concept of UHC finds its roots in the 1946 World Health Organization (WHO) Constitution, which enshrines health as a fundamental human right and pledges to ensure the highest attainable level of health for all. UHC embodies the aspiration that everyone, everywhere, can access quality healthcare services when and where they need them, without facing financial hardship.

This vision has been further cemented by its inclusion as a key target in the United Nations Sustainable Development Goals (SDGs), specifically SDG 3.8: Achieve universal health coverage and access to essential healthcare services for all. UHC’s significance extends beyond healthcare, contributing to social inclusion, gender equality, poverty eradication, economic growth, and, ultimately, human dignity.

Time for Action: The 2023 UHC Day Theme

The theme for UHC Day 2023, Health for All: Time for Action, calls for immediate and tangible steps to get progress towards UHC back on track. Following the renewed global commitment to UHC at the UN High-Level Meeting on September 21st, 2023, it’s time to move beyond promises and into concrete action.

This means urging our leaders to enact policies that guarantee equitable access to essential health services, without financial barriers. It means ensuring good health and well-being are not a privilege for the few, but a right for all.

The urgency of action is amplified by the sobering reality that, according to the UN’s official page on UHC Day:

• Half the world’s population still lacks access to essential health services.
• 2 billion people face financial hardship due to out-of-pocket health expenses, including 344 million living in extreme poverty.
• Since the launch of the SDGs in 2015, progress towards UHC has stalled, even before the COVID-19 pandemic.
• The pandemic has further set countries back on their UHC journey, while also highlighting its crucial importance.

Building a Healthier Future: A Collective Call to Action

This UHC Day, let’s not just celebrate the vision; let’s commit to making it a reality. We can achieve this by:

• Holding our leaders accountable for enacting UHC-aligned policies.
• Supporting organizations working to strengthen health systems and promote access to healthcare.
• Raising awareness about the importance of UHC and advocating for its implementation.
• Sharing our own experiences and stories to amplify the call for health for all.

Remember, UHC is not just a goal; it’s a promise. By working together, across sectors and borders, we can build a future where everyone, everywhere, has the opportunity to live a healthy and fulfilling life.

To learn more and take action, visit the official UHC Day website: https://universalhealthcoverageday.org/

To celebrate Corporate Compliance & Ethics Week 2023, we’ve shared resources that highlight our dedication to data privacy and security, as well as expert insights on healthcare claims processing compliance challenges and fostering a culture of compliance. Join us as we recap these invaluable resources.

Our Commitment to Compliance and Accountability

Our dedication to safeguarding Protected Health Information (PHI) and provider data is unwavering. We’ve established a robust and secure ecosystem, exceeding both state and federal compliance requirements. Our commitment extends to our employees and subcontracted service providers, ensuring ethical and compliant behavior.

Watch Chief Compliance Officer Robert Nolan share our commitment to data privacy and security, and how we protect confidential information for our clients and their members.

Top 5 Compliance Challenges in Healthcare Claims Processing and How to Address Them

Healthcare claims processing is a complex landscape with compliance at its core. Neglecting it can lead to penalties and reputational damage. Our Chief Compliance Officer, Robert Nolan, shares expert insights in our latest blog, “Top 5 Compliance Challenges in Healthcare Claims Processing and How to Address Them.”

1. Timely Claim Handling
2. Required Notices and Disclosures
3. Payments per Policy Provisions and Coverages
4. Fraud and Abuse
5. HIPAA Compliance

Read the full blog for Robert’s valuable guidance on overcoming the top 5 challenges.

How Can Companies Foster a Culture of Compliance?

Watch the video below to hear from HealthAxis’s Chief Compliance Officer, Robert Nolan as he shares his insights on how companies can foster a culture of compliance, highlighting the importance of leadership, communication, training, and a speak-up culture.

 

Meet the HealthAxis Compliance Team

As we commemorate Corporate Compliance & Ethics Week, we’re shining the spotlight on the dedicated members of our compliance team, whose combined 90+ years of experience and commitment ensure that HealthAxis operates with the highest standards of integrity and ethics. Together, they make sure HealthAxis upholds unwavering ethics and maintains the highest standards of compliance. Thank you for your commitment and dedication!

 

Navigating Compliance for Seamless Operations

As we conclude Corporate Compliance & Ethics Week, we invite you to partner with HealthAxis to ensure seamless operations and unwavering compliance. Our robust Compliance and Ethics Program provides comprehensive operational guidance and safeguards against fraud and abuse, helping you navigate the ever-changing regulatory landscape with confidence.

HealthAxis’s CAPS technology and TPA services provide a comprehensive solution for all of your healthcare claims processing needs. We can help you to streamline your operations, improve efficiency, and reduce costs.

Schedule a discovery call today to witness the benefits of our proprietary CAPS technology, AxisCore^™, and modern BPaaS/BPO capabilities, AxisConnect^™. Together, we can foster a healthcare ecosystem that prioritizes patient privacy, ethical practices, and seamless operations.

As Medicare Advantage (MA) open enrollment is currently in full swing, it’s the ideal time to circle back and delve deeper into the substantial changes outlined in the 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F).¹ These changes, rooted in a resolute commitment to equity and enhanced healthcare access, are designed to safeguard beneficiaries, bolster quality measures, and promote health equity among all Medicare recipients.

In part one of this two-part blog, we examined the key changes to utilization management, marketing requirements, the Star Rating Program, and CMS’s efforts to advance health equity. In this second part, we’ll continue to explore the key provisions of the final rule and the impact on payers.

Behavioral Health Accessibility: Enhancing Support

The CMS final rule includes several changes to ensure that enrollees have timely access to the behavioral health care they need, including:

• Expanding network standards and telehealth credit eligibility to clinical psychologists and licensed clinical social workers
• Adding behavioral health services to general access to services standards
• Codifying standards for appointment wait times for primary care and behavioral health services
• Clarifying that emergency behavioral health services must not be subject to prior authorization
• Requiring MA health plans to notify enrollees when their behavioral health or primary care providers are dropped midyear from networks
• Requiring MA organizations to establish care coordination programs that include behavioral health services

These new requirements could be challenging for payers to implement, particularly smaller payers with limited resources. Payers may need to invest in new systems, such as network management, prior authorization, and care coordination systems, to comply with the new requirements. Additionally, they may have to expand their networks to include more behavioral health providers to enhance enrollees’ access to behavioral healthcare.

Implementation of Certain Provisions of the Consolidated Appropriations Act, 2021 and the Inflation Reduction Act of 2022

The Consolidated Appropriations Act (CAA) of 2021 (Division B, Section 118) makes the Limited Income Newly Eligible Transition (LI NET) Program permanent. The LI NET Program provides immediate and retroactive Part D coverage for eligible low-income beneficiaries who do not yet have prescription drug coverage. This change will ensure that low-income individuals can access affordable prescription drug coverage as soon as they become eligible for Medicare Part D.

Beginning January 1, 2024, the Inflation Reduction Act of 2022 (IRA) [Section 13531(a)(1)(A)] expands eligibility for the full low-income subsidy (LIS) benefit (also known as “Extra Help”) to individuals with incomes up to 150% of the federal poverty level. This change will provide the full low-income subsidy to those who currently qualify for the partial subsidy, improving access to affordable prescription drug coverage for approximately 300,000 low-income individuals with Medicare.

These changes will impact payers in several ways. First, the permanent extension of the LI NET Program and the expansion of eligibility for the full LIS benefit will increase enrollees receiving subsidies for their prescription drug coverage. This could lead to increased costs for payers.

• However, payers can mitigate these costs by taking several steps, including:
• Investing in utilization management tools and services ensures enrollees receive the most appropriate and cost-effective care.
• Leveraging data analytics to identify and address trends in their claims data that could lead to increased costs.
• Implementing performance improvement initiatives to improve the quality and efficiency of their operations.
• Developing and implementing strategies to attract and retain low-income enrollees.

Implementation of Certain Provisions of the Bipartisan Budget Act of 2018 and the CAA of 2021

The final rule finalizes several changes to the Medicare Part C and D programs stemming from the Bipartisan Budget Act (BBA) of 2018 (Public Law 115-391), the CAA of 2021, and the Inflation Reduction Act (IRA) of 2022 (Section 13531).

Key changes include:

• Expanded access to supplemental benefits: MA plans can now offer a wider range of supplemental benefits, such as transportation and meals.
• Promoted value-based care: MA plans are encouraged to adopt payment models that reward providers for delivering high-quality care at a lower cost.
• Protected beneficiaries from high out-of-pocket costs: MA enrollees have capped out-of-pocket costs in Part C and Part D.
• Capped the annual increase in the base beneficiary premium for Medicare Part D at 6%.
• Provided a $3,200 annual out-of-pocket cap for insulin.

The changes will significantly impact payers, requiring them to adapt their business models and partner with providers to improve the quality and efficiency of care delivery. However, the changes also offer opportunities for payers to serve more enrollees and expand their offerings.

Navigating the CMS Final Rule Changes

The CMS final rule updates for 2024 will significantly impact payers, but they also present an opportunity to transform healthcare delivery. At HealthAxis, we are committed to helping payers navigate these changes and emerge stronger than ever.

Schedule a discovery call today to learn how HealthAxis can help you transform your health plan operations with our cutting-edge CAPS technology, modern BPaaS/BPO capabilities, and industry expertise.

Source:
1. Fact sheet 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F), CMS

With the annual Medicare Advantage (MA) open enrollment well underway (October 15^th  – December 7^th each year), it’s the perfect time to revisit the significant changes outlined in the Centers for Medicare & Medicaid Services (CMS) 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F).¹ With a strong emphasis on equity and access to healthcare, these adjustments aim to protect beneficiaries, strengthen quality measures, and advance health equity for all Medicare recipients.

In this two-part blog post, we’ll explore the key provisions of the final rule and their implications for healthcare payers.

Utilization Management Requirements: Ensuring Timely Access to Care:

To ensure that beneficiaries have timely access and continuity of care, the CMS final rule includes various utilization management (UM) requirements changes. These changes include requiring:

• MA plans must comply with national coverage determinations (NCDs), local coverage determinations (LCDs), and general coverage and benefit conditions included in Traditional Medicare regulations to ensure that people with MA receive access to the same medically necessary care they would receive in Traditional Medicare.
• Coordinated care plan prior authorization policies may only be used to confirm the presence of diagnoses or other medical criteria and/or ensure that an item or service is medically necessary.
• Coordinated care plans to provide a minimum 90-day transition period when an enrollee currently undergoing treatment switches to a new MA plan, during which the new MA plan may not require prior authorization for the active course of treatment.
• All MA plans to establish a utilization management committee to review policies annually and ensure consistency with Traditional Medicare’s national and local coverage decisions and guidelines.
• Approval of a prior authorization request for a course of treatment must be valid for as long as medically reasonable and necessary to avoid disruptions in care by applicable coverage criteria, the patient’s medical history, and the treating provider’s recommendation.

These changes could create challenges for payers, as they may need to invest in new technologies and services, such as clinical decision support systems and automated prior authorization systems, to comply with the new UM requirements and improve the timeliness of care for their enrollees.

In addition to investing in new technology, payers can mitigate the challenges of the new UM requirements by communicating with providers and monitoring and evaluating their performance. By working with providers to understand the new requirements and tracking how long it takes to get prior authorization approvals, payers can identify and address any areas of improvement.

Marketing Requirements: Protecting Beneficiaries

The CMS final rule includes changes to marketing requirements to protect beneficiaries from misleading or confusing information and ensure they can make informed decisions about their coverage. These changes include:

• Prohibiting ads that do not mention a specific plan name and use words and imagery that may confuse beneficiaries or use language or Medicare logos in a way that is misleading, confusing, or misrepresents the plan.
• Ensuring that Medicare recipients receive accurate information about Medicare coverage and know how to access accurate information from other available sources.

These new marketing requirements could make it more difficult for payers to reach potential enrollees. Payers may need to revise their marketing materials and strategies to comply with the new requirements. They may also need to invest in new training for their marketing staff.

Star Rating Program Improvements: Strengthening Quality

In pursuit of elevated quality standards and greater equity, the Medicare Star Rating Program updates encompass:

• Finalizing a health equity index (HEI) reward, beginning with the 2027 Star Ratings, to further encourage MA and Part D plans to improve care for enrollees with certain social risk factors.
• Reducing the weight of patient experience/complaints and access measures to further align with other CMS quality programs and the current CMS Quality Strategy.
• Removing Star Rating measures and removing the 60 percent rule is part of the adjustment for extreme and uncontrollable circumstances.

These new Star Rating Program changes could make it more difficult for payers to achieve high Star Ratings. However, they will also help ensure that plans focus on the most important quality measures. Payers may need to adjust their quality improvement strategies to comply with the new Star Rating Program requirements. They may also need to invest in new data collection and analysis capabilities to track their performance on the new measures.

Advancing Health Equity

To ensure that all beneficiaries have access to high-quality care, MA and Part D programs are required to implement changes to advance health equity. These modifications include:

• Clarifying current rules and expanding the example list of populations that MA organizations must provide services in a culturally competent manner.
• Finalizing requirements for MA organizations to develop and maintain procedures to offer digital health education to enrollees to improve access to medically necessary covered telehealth benefits.
• Enhancing current best practices by requiring MA organizations to include providers’ cultural and linguistic capabilities in provider directories.
• Requiring that MA organizations’ quality improvement programs include efforts to reduce disparities.

The new health equity requirements will significantly impact payers, affecting costs, operations, and staffing levels, and aid in payer-provider collaborations. Compliance may necessitate investment in digital health education, cultural competency training for providers, provider directories, and new data collection/reporting systems to track social risk factors and health outcomes. Payers must also update quality improvement programs to address care disparities, potentially requiring the development of new interventions and progress tracking.

Navigating the CMS Final Rule Changes

Stay tuned for part two, where we will continue to look at key provisions in the CMS final rule and how they will impact payers. Together, we can navigate these changes and delivering the care that Medicare beneficiaries deserve. All while upholding the standards of affordability and quality in healthcare services.

Schedule a discovery call today to learn how HealthAxis can help you transform your health plan operations with our cutting-edge CAPS technology, modern BPaaS/BPO capabilities, and industry expertise.

Source:
1. Fact sheet 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F), CMS

 

In today’s rapidly evolving healthcare landscape, payers face numerous challenges in delivering efficient and effective services to their members. One significant barrier is the presence of legacy CAPS that impede payer transformation and hinder interoperability with other systems.

Watch this clip to hear from HealthAxis’s Senior Vice President of Product Management, Lisa Hebert, as she delves into the challenges posed by legacy CAPS and highlights how HealthAxis is leading the way in breaking down these barriers for payer transformation.

Ready to transform your health plan operations? Schedule a discovery call today –

https://healthaxis.com/request-a-demo

In healthcare claims processing, compliance with regulations and policies is crucial. Payers and providers must ensure that claims are processed in a timely manner, that notices and disclosures are provided, and that payments are made per policy provisions and coverages. Failure to comply can result in legal and financial penalties and reputational damage. In 2021, the Federal Government received $1.7B from healthcare fraud settlements related to drug and medical device manufacturers, durable medical equipment, home health and managed care providers, hospitals, pharmacies, hospice organization and physicians.

In addition to the recoveries, many of these actions were the result of whistleblowers who were a party to 351 settlements and judgments. In total, since 1986, there have been $72B recovered under the False Claims Act which protects taxpayers’ dollars, not just limited to healthcare fraud.

Here are the top 5 compliance challenges in healthcare claims processing and how to address them:

1. Timely Claim Handling

Timely claim handling is essential to members and providers. It includes prompt, smooth/efficient intake, accurate amounts, and timely payments. While payments are made to providers, if there becomes an issue with timeliness or accuracy, providers miss filing deadlines and could miss payments potentially resulting in provider abrasion, they may stop accepting your plan, or even take legal action. All of which negatively impacts your members, causing dissatisfaction. Timely claim handling is more than just providing quick responses/payments to members’ claims. This is an end-to-end process that encompasses a smooth intake, the accuracy and completeness of the claims handling and getting payments to the provider as expeditiously as possible.

To ensure providers can meet timeframes, and get paid with ease, having a smooth intake process means they have a variety of methods to get the claim to the processing center. When it gets to the center, it is important to review claims as quickly as a possible. Promptly responding to a claim that contains errors or omissions may prevent further delays or even claim denials. Therefore, insurers and healthcare providers must ensure that their claims processing systems are equipped to handle claims accurately and efficiently. In many cases, Payers and providers have regulated timelines to follow, but even when not regulated, they should establish clear timelines for processing claims. These performance goals for processing claims, such as the maximum time allowed for claim review, processing, and payment will help to promote consistency and transparency in the claims-handling process. Additionally, reporting to the health plan on claims timelines and notices to providers and members should be provided regarding the status of their claims. This will help to improve member satisfaction, reduce inquiries, and minimize the likelihood of unwarranted appeals and disputes.

Automation and technology can also streamline the claims process, reducing the likelihood of delays. For instance, automated claims review systems can help identify and flag incomplete or inaccurate claims before they are sent for processing. This can reduce the number of claims that require manual review, improving efficiency and reducing the likelihood of errors. Ensuring payments are drafted and EOPs (explanation of payments) are timely provided are crucial.

2. Required Notices and Disclosures

Under federal and state laws, payers and providers must provide specific notices and disclosures to members and payers are required to provide certain notices to providers too. These include notices of privacy practices (NPPs), explanation of benefits (EOBs), explanation of payments (EOPs), and appeals information. It is essential for health plans to comply with these requirements to ensure that members are informed about their rights and have access to the information they need to make informed decisions about their healthcare and providers have the information needed to treat their patients and get paid.

Health plans or their third-party administrators should include policies and procedures for providing notices and disclosures, regular training, and education for staff on the importance of compliance, and regular audits to ensure that notices and disclosures are being provided promptly and accurately. It is also important for healthcare organizations to stay current with changes in laws and regulations related to required notices and disclosures and to adjust their department programs accordingly.

Furthermore, payers should prioritize clear and effective communication with members regarding their healthcare information. This can include making sure that members are aware of their right to receive NPPs and EOBs and providing these documents in a language that the patient can understand. Healthcare organizations should also have systems in place to address member questions and concerns related to their notices and disclosures.

3. Payments per Policy Provisions and Coverages

Payments for healthcare services must be made per policy provisions and coverages. Failure to do so can result in overpayments, underpayments, affect STAR ratings or government programs enrollment algorithms, and possibly result in legal action.

To address this issue, healthcare insurers should establish clear policies and procedures for payment processing and ensure that they are followed consistently. Regular audits can also help identify and correct payment errors.

Ensuring that payments for healthcare services are made in accordance with the latest fee schedules and coverage eligibility is crucial to avoid overpayments, underpayments, and interest or penalty payments. Inaccurate or inconsistent payment processing can result in financial losses and harm the reputation of healthcare payers and providers.

Organizations should include clear policies and procedures for payment processing. These policies outline the specific procedures for calculating and processing payments and provide guidance on using specific billing codes and documentation requirements. It is also important to ensure that policies and procedures are followed consistently across all departments and staff members.

In addition to establishing policies and procedures, regular audits can help identify and correct payment errors. Healthplans and their third-party administrators undergo internal and external audits that are conducted periodically and sometimes spontaneously to ensure that payment processing is carried out correctly and that staff members adhere to established policies and procedures. Errors or discrepancies should be addressed promptly to avoid potential legal or financial repercussions.

4. Fraud and Abuse

Healthcare claims are a primary source of fraud and abuse. Fraud is defined as any intentional deception or misrepresentation resulting in financial gain. At the same time, abuse refers to actions that are inconsistent with sound healthcare practices and may result in unnecessary costs to patients or government programs. These can include a range of activities such as billing for services not provided, upcoding (billing for a more expensive service than was provided), kickbacks, and overutilization of services.

Effective compliance and ethics programs should guide and support employees in identifying and preventing fraud and abuse. This is accomplished through training and educating staff on compliance requirements and ethical standards regularly. It could also include monitoring and auditing of claims processing activities to identify any irregularities or potential fraud.

In addition, payers must be vigilant in their oversight of third-party vendors, such as billing companies and outside consultants, to ensure they comply with regulations and ethical standards. This may involve conducting due diligence before engaging with third-party vendors, establishing clear contractual expectations, and monitoring their activities closely.

Overall, preventing fraud and abuse requires a comprehensive and proactive approach involving all healthcare claims processing ecosystem stakeholders. By prioritizing compliance and ethics and investing in effective monitoring and oversight, healthcare insurers can reduce the risk of financial losses, government program contracts, and reputational damage while ensuring members’ highest quality of care.

5. HIPAA Compliance

The Health Insurance Portability and Accountability Act (HIPAA) is a federal law enacted in 1996 to protect member privacy and ensure the security of their health information. HIPAA establishes national standards for the protection of individually identifiable health information, known as protected health information (PHI), and requires healthcare providers and insurers to comply with these standards.

Compliance with HIPAA is mandatory for payers and providers, as failure to comply can result in significant legal and financial penalties. The Department of Health and Human Services Office for Civil Rights (OCR) is responsible for enforcing HIPAA regulations and fines can range from $100 to $50,000 per violation, with a maximum penalty of $1.5 million per year for each violation.

Payers should have compliance programs that ensure member health information protection. These programs should include policies and procedures for collecting, using, and disclosing PHI, training, and education for staff on HIPAA regulations and best practices for protecting member privacy, and logging and disclosing infractions.

HIPAA compliance also includes regular risk assessments to identify potential vulnerabilities in the handling of PHI and establish measures to mitigate those risks. Finally, insurers should have a system for reporting and investigating potential HIPAA violations to ensure prompt corrective action.

Navigating Healthcare Compliance Challenges: Harnessing Technology and Expertise

Compliance is essential in healthcare claims processing. By addressing these top 5 compliance challenges, healthcare payers can avoid legal and financial penalties, protect members’ privacy, and ensure accurate and timely payment for services, while maintaining their government program contracts, and retain members and providers.

Overall, technology has revolutionized healthcare compliance by providing tools to improve efficiency, accuracy, and accountability. As technology continues to advance, it is likely that healthcare compliance will further benefit from innovations that address emerging challenges and regulatory changes.

Please note that compliance risks and opportunities may have, evolved, or new challenges may have emerged recently, so it is critical to stay informed about the latest regulations and industry trends to effectively address compliance challenges in the healthcare sector.

At HealthAxis, our Compliance and Ethics Program provides operational guidance and safeguards against fraud and abuse, helping to ensure compliance with regulations and policies. With the right technology partner on your side, your organization can navigate the ever-changing regulatory landscape without risk.

Schedule a discovery call today to see our proprietary core administrative processing solution (CAPS) technology and modern BPaaS/BPO capabilities in action.

Author:

Robert Nolan
Chief Compliance Officer
HealthAxis