The Bridge – Volume 1

AEP Is Over – Now What?

Whether you are a new or existing Medicare plan, January is the best time to make sure your membership is accurate, digest any issues identified, and develop a process improvement plan.

Successful enrollment processing requires training, execution of established processes, and an ability to adjust as needed based on inventory and circumstance. A review of “lessons learned” during AEP is a critical look-back activity. In doing this internal evaluation, some areas to review include common problem areas:

  • Timely submission of applications by agents/brokers.
  • Electronic application loading process from multiple sources.
  • Inventory fluctuations and delay in processing paper and faxed applications.
  • Failure to download and process OEC enrollment file accurately.
  • Monitoring and processing of Fallout/Error reports to identify any issues with loading of applications from all sources, including the exports/integration with downstream claim payment systems.

If your AEP was highly successful, you can take the opportunity to perform end to end evaluations of your key processes. Effective
management of all enrollment responsibilities is the key to meeting CMS required timeliness standards and to address discrepancies
before an RPC submission is required. Are these functions working as well as they could be? Have you validated and confirmed the
efficacy of what you think is working well?

  • TRC processing and automation processes for updates to systems and generation of member correspondence.
  • Accurate LEP gap determination, letter trigger, and submission to CMS.
  • OEV letter trigger and timeliness.
  • OOA identification, research, tracking, letter trigger, and disenrollment based on CMS guidance.
  • Accuracy and completeness of the data capture needed for the CMS Part C & D Reporting specifications.
  • Premium billing accuracy, including premium payment method, OSB premium change transactions, LEP amount, LIS subsidy amounts, and billing notices.
  • Application of the CMS Plan Data Due or cutoff, current calendar month (CCM) processing, and election period/effective dates by staff and systems.

Madena is ready to assist with data analytics for independent validation of the accuracy and validity of your processes and technology.
Identifying discrepancies early in the year will reduce the negative impact on members, plan capitation payments, and grievance or
CTM complaints. Noncompliance can result in low STAR rating and corrective action plan by CMS.

Data Validation Audits Are Around the Corner!

Have you contracted with your Data Validation Contractor (DVC) for 2020?

CMS requires Medicare health plans to have an independent contractor in
place for annual reviews that will begin April 1st. Consider Madena for your
annual DVC. Contact us to learn more!

Are You Ready for Real Time CTM?

Medicare announced that complaints will be reported to health plans in
real time starting 1/18/2020. What modifications do you need to make
to your CTM process and reporting? How can you be more responsive to
members’ complaints?

CMS has confirmed the current daily email notification process for CTM
module will not change. The plans will receive emails only once a day.
The real-time email notifications will not be sent because it could
potentially lead to plans getting swamped by a deluge of emails
Let’s roll up our sleeves together and improve your member

Upcoming Events

Appeals & Grievance Summit 2020

Madena is a sponsor of the upcoming “Enhancing Appeals &
Grievances and Improving ODAG & CDAG Readiness” industry
event March 25-27, 2020. This conference will be packed with
information and opportunities to learn from other health plans
and industry experts. Don’t miss out on this event!

Madena contacts may use code H127MAD at registration to
receive 15% off the registration fee.

Service Spotlight

Did you know that we do one-time independent data analytics on
your membership to identify discrepancies that your internal or
vendor solutions are managing?

The independent data analytics that we performed in 2019 had a
100% success rate at identifying discrepancies that were not
found by our clients’ internal and vendor reconciliation software.

Explore our Data Analytics resources

Get ready for CMS Timeliness Monitoring Project

In October, CMS issued a memo regarding the 2020 Timeliness Monitoring Project
(TMP). As in previous years, CMS will be conducting an industry-wide monitoring
project by collecting data to evaluate the timeliness of processing Medicare Advantage
(Part C) organization determinations and reconsiderations and Medicare Prescription
Drug (Part D) coverage determinations and redeterminations.

The TMP will include a retrospective collection and review of 2019 data from Medicare
Part C and Part D sponsors with active contracts in both CY2019 and CY2020. CMS will
be conducting this collection in three waves, with the first wave of letters requesting
data being issued in January 2020.

Like the collection for program audits, universe submissions should include data
processed in-house and by all First Tier, Downstream, and Related entities (FDRs). In
addition, all universes will be submitted at the Parent Organization level; therefore, one
universe submission may include data for multiple contracts.

Madena can help in a number of ways:

  • Assist in working with your FDRs on understanding the universes and data extraction.
  • Evaluate your processes and systems to trace the validity and completeness of the data universes.
  • Perform systems data mapping and reviews to assist with universe preparation.
  • Evaluate universes for adherence to instructions and identify data integrity issues.
  • Conduct mock webinars for data accuracy and correction of problems BEFORE a CMS review.

Being aware of the issues within your data is critical. If the data submitted to CMS lacks validity, reliability, or indicates a data integrity issue, this can impact Star Ratings by designating an automatic 1 Star for all measures that use this data. We can help prevent this outcome.

Madena & Industry News

Here’s the updated PCUG version 13.3.

LEP Amount Annual Change – Make sure to update your systems with the 2020 LEP amounts for members that have LEP. The LEP
amounts for members that pay premium directly to you was received on the December CMS LEP Detail Report and for members that
pay premium via SSA/RRB use the January CMS MPWR Report.

Madena BPO Services – providing scalable staffing solutions for us to help your company achieve optimal operational efficiency,
profitability and member satisfaction.

View/download a PDF of the January 2020 newsletter.

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