Verisys Presents at the 3rd Annual Medicare Advantage Leadership Innovations Forum in Phoenix, AZ
Medicare Advantage Plan Leaders Gather in Phoenix to Share Best Practices
Verisys presented at the Medicare Advantage Leadership Innovations Forum this week in Phoenix, AZ where leaders from the nation’s top MA plans gathered to share best practice strategies and results amidst the ever-evolving regulatory environment.
Jan Smith Reed, Verisys VP of Payer & Hospital Solutions, shared with the group the key points of understanding and navigating the CMS Final Rule, Program Integrity Enhancements to the Provider Enrollment Process (CMS-6058-FC). CMS Rule 6058 indirectly supports continuing efforts for increased patient satisfaction and outcomes while focusing directly to stop waste, fraud, and abuse in government-funded health care. Ms. Reed encouraged greater collaboration with the credentialing departments to assimilate the importance network providers and affiliates have on quality outcomes and patient satisfaction scores. She reiterated that expanded primary source data needs to be accessed to ensure the plans’ reputation is maintained, enrollment is protected, and to defend against targeted fraud, waste, and abuse.
CMS Rule 6058 expands CMS authority to deny or revoke enrollments and more broadly defines affiliates and disclosable events. The Rule sets goals to prevent providers and suppliers from circumventing program rules by coming back into the system under different names, has a greater focus on accuracy of addresses, identifies patterns of abusive ordering and certifying of services, and revokes providers and suppliers with outstanding debt to CMS.
What are Medicare Advantage Plans?
Medicare Advantage Plans, sometimes called “Part C” or “MA Plans,” are a type of Medicare health plan offered by private companies approved by Medicare to provide all of the Part A and Part B benefits. Most Medicare Advantage Plans also offer prescription drug coverage (Part D). By enrolling in a Medicare Advantage Plan, most Medicare services are covered through the plan, and Medicare services are not paid for by Original Medicare. Flexible and added benefits are also available through the MA plans. Below are the most common types of Medicare Advantage Plans:
- Health Maintenance Organization (HMO) Plans
- Preferred Provider Organization (PPO) Plans
- Private Fee-for-Service (PFFS) Plans
- Special Needs Plans (SNPs)
CMS Star Rating and HEDIS Used to Measure the Quality of Medicare Advantage Plans
Quality performance metrics such as CMS Star Ratings and HEDIS (Healthcare Effectiveness Data and Information Set) Measures can give consumers an objective indication of health care payer quality. The use of CMS Star Ratings and HEDIS allows the Medicare program to determine the quality of all Medicare-sponsored plans including Medicare Advantage and prescription drug MA plans. Commercial Medicare payers can leverage these quality metrics in order to position and market their health plans as ideal insurance options for beneficiaries. Standardized quality measures aggregate how well a payer has performed based on the regularity of services performed, improvements in patient health, and consumer satisfaction.
Challenges MA Plans Face in Improving Patient Outcomes
Patients need to be diligent at picking up their prescriptions, taking their medications, and proactively working toward a healthier lifestyle in order for the MA Plans to receive a good rating. Many beneficiaries are not doing these basic things but it’s not always due to neglect. There are a number of factors that make this challenging for patients. CMS is looking for ways to integrate flexible options to assist patients who fall into one or more of the social determinants of health, so they don’t decrease a payer’s rating because of circumstances that need to be addressed such as poverty, distance to medical care, and transportation. Some Medicare recipients don’t fill their prescriptions, thus they aren’t taking their medications, because they can’t afford the prescription, or they have to choose between buying food or paying for their meds. Payers can intervene in these instances by setting up meals-on-wheels or arranging for transportation to pick up the patient and drive them to medical appointments or to the pharmacy. Payers can also work with pharmacists and prescribers encouraging better communication with their patients about their situation to find out if there are hindrances to their success in implementing treatment.
How Verisys Assists Payers in Improving Patient Outcomes
By properly screening and monitoring providers, prescribers, and pharmacists, Verisys ensures fully credentialed individuals are working with patients. Patient safety and improved patient outcomes are far more likely to occur when providers who should not be in the network are identified and removed. Continuous monitoring of all the providers in your network, to ensure full compliance with CMS requirements, involves checking numerous state and federal primary sources on an ongoing basis.
Verisys has been aggregating provider data since 1992 and has the most comprehensive data set in the industry. Verisys’ data set FACIS® (Fraud Abuse Control Information System) is the number one trusted data platform and a nationally used database for screening and continuous monitoring against healthcare exclusions, debarments, disciplinary actions, and healthcare sanction screenings.
A FACIS search looks for results or potential matches from all federal data sources (OIG (OIG database verification), SAM (including SDN), FDA, DEA, TRICARE, FBI, U.S. DOJ, U.S. Treasury Dept., U.S. State Dept.) and all state-level Federal Healthcare Entitlement Program (FHEP) sources (State Medicaid Exclusions, State Contractor Disqualification/Debarment Lists, HEAT Task Force News, State Attorney General News, Federal District – Attorney General News, Medicare/Medicaid Opt-Out Lists).
Verisys will keep your network of providers, staff, and affiliates in full compliance with CMS regulations which contributes to greater patient safety, improved patient outcomes, higher Star Ratings and HEDIS results, and will mitigate the risk of fines and penalties due to noncompliance to CMS requirements.
|Written by Juliette Willard
Healthcare Communications Specialist
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