Category Archives: Compliance3 Keys to a Successful Compliance Program
Complying with state and federal rules and regulations is a challenging endeavor. It requires health plans to manage a slew of different processes and resources. Missteps pose risks that could result in compliance violations, fines and a drop on CMS’s Five Star Quality Ratings.
Some of the most difficult areas to manage, from a compliance standpoint, include staying abreast of CMS updates and other regulatory requirements, producing error-free member marketing materials, and proper investigations management.
To get a handle on these biggest compliance challenges, health plans can start by mastering the three keys to a successful compliance program:
Category Archives: ComplianceHow to Avoid FDR Oversight Issues in a CMS CPE Audit
First Tier, Downstream or Related Entity (FDR) Oversight continues to be a hot topic for the Centers for Medicare and Medicaid Services (CMS) and plan sponsors. CMS auditors annually find deficiencies in FDR oversight and monitoring activities in program audits, with poor oversight of FDRs trending as a common condition in yearly audits.
Many plan sponsors consider an FDR as a risk only if a problem materializes. This is a mistake. All FDRs are operational and compliance risks. The extent of the risk exists in the type of functions the FDR performs, potential and actual member impact, and FDR issues.
Category Archives: Compliance6 Traits of a Great Consulting Partner
In the world of Medicare and Medicaid, choosing a consulting partner to help streamline your health plan’s operations can be tricky. While a company or individual may be well-versed in best practices for project management or operational efficiency, they may not understand the unique requirements of the payer market – making them less than effective at addressing your needs.
With that in mind, below are six traits to look for when choosing a consulting partner to work with your health plan: Read more »
Category Archives: Compliance3 Ways your Health Plan is Overspending – And How to Stop
Health plans today are feeling more pressure than ever before to do more with less. With increased scrutiny from The Centers for Medicare and Medicaid Services (CMS) and decreased budgets, leadership is constantly looking for ways to save money. Doing so might be easier than you think.
Below are three ways that health plans are overspending, and how they can stop: Read more »
Category Archives: ComplianceErrors in ANOCs and EOCs could cost up to $55 per affected enrollee
Over the last several years, The Centers for Medicare and Medicaid Services (CMS) has taken an increasingly tough stance on health plans that distribute Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents with unclear and/or inaccurate benefit information.
CMS is no longer sending health plans warnings for these errors; they are imposing civil money penalties (CMPs) for thousands of dollars that health plans must pay. For instance, CMS recently imposed a CMP in the amount of $132,000 to a health plan for failing to provide accurate benefit information to 2,400 enrollees in its Contract Year (CY) 2017 ANOC and EOC documents. For larger health plans, fines can quickly add up to millions of dollars.
CMS’s reasoning behind these fines is that if members receive inaccurate information related to premiums, deductibles and co-pays, they may enroll in a plan under false expectations. Read more »
Category Archives: ComplianceDocument Accuracy Assessment helps identify errors before CMS
The creation of your Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC) document is a very challenging process and can be a strain on already over-taxed resources. Ensuring the accuracy of these documents is extremely important, as CMS has taken an increasingly tough stance on plans that distribute documents with unclear and/or inaccurate benefit information.
If you’re like most health plans, you could use a few extra set of eyes to review your final materials to ensure accuracy.
Backed by our team of model document experts, our Document Accuracy Assessment services can identify inconsistencies and errors in your plan documents that could negatively impact members and cause CMS to take action against your plan. Cody’s Document Accuracy Assessment service allows you time to self-report these errors before CMS’ Oct. 31 deadline for self-reporting. Read more »
Category Archives: ComplianceCodySoft® Adds Part C and Part D Reporting Feature
CodySoft® has added a new feature to its Investigations Module®, making it easier for health plans to pull their Part C and Part D reports on plan oversight of agents.
Even though the Centers for Medicare & Medicaid Services (CMS) no longer requires this report in the annual Part C and D reports, health plans cannot afford to be lax in their reporting and monitoring of the sales force and marketing activities. The regional CMS office can require health plans to submit this report at any time.
Category Archives: ComplianceIndustry Alert: Iowa Senator Calls for Greater Scrutiny of MA Plans
Kaiser Health News recently published an article about Senator Chuck Grassley (R-Iowa) asking federal health officials to tighten scrutiny of private Medicare Advantage (MA) health plans. His request comes amid ongoing concern that insurers over-bill the government by billions of dollars every year.
In mid-April, Grassley wrote a letter to Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma, citing an article that alleged billing discrepancies. He has asked CMS officials to explain why they failed to collect nearly $125 million in potential overcharges identified at five Medicare Advantage plans audited in a single year.
Category Archives: ComplianceThe Pros and Cons of Updating Last Year’s AEP Materials vs. Using CMS’s Model Docs
The Centers for Medicare & Medicaid Services (CMS) will release its 2018 Model Documents for Annual Enrollment Period (AEP) materials any day. When it does, health plans will face the same question they face year after year – do we start fresh using this year’s Model Documents or update last year’s materials?
With Annual Notice of Changes (ANOC) averaging around 25 pages and Evidence of Coverage (EOC) documents averaging around 250-300 pages, getting AEP materials into members’ hands by September 30 means there is no time to waste. Generally speaking, using CMS’s Model Docs carries less risk; however, having to construct new documents from the CMS model every year is extremely labor-intensive.
The past several years, CMS’s Model Documents have been composed of roughly 90% boilerplate text that has varied little each year. With the exception of insurers that are consolidating plans or creating new ones, most annual changes to benefits, copays and other aspects of coverage are relatively minor. This may make updating last year’s materials an attractive approach when compared to the thought of using CMS’s model. On the flip side, there also are significant reasons using previous years’ documents might not be the best method.
It’s critically important to understand the following pros and cons when considering whether to update last year’s AEP materials or use CMS’s model docs.
Category Archives: ComplianceBest Practices for Language beyond the CMS Model Language
The Centers for Medicare and Medicaid Services (CMS) templates for the Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC) contain extensive model language that is required and must be used by every insurer. However, there are also numerous places in these documents where health plans have latitude and flexibility to use their own language to describe benefits, cost-sharing, coverage limits and so forth. These areas provide significant opportunities for health plans to better communicate with their members, and thereby positively impact the member’s experience.