The Bridge – Volume 3

Provider Directory and Data Accuracy

Because members rely on provider directories to locate an in-network provider, inaccuracies could pose a significant access-to-care barrier. As a result, CMS can, and does, issue compliance actions as a result of directory inaccuracies.

Earlier this year CMS announced the use of the National Plan and Provider Enumeration System (NPPES) to help increase the accuracy of directories
and reduce the burden of directory preparation for providers and plans.

National Plan and Provider Enumeration System (NPPES):

  • Is available to virtually every provider in the U.S.
  • Is available to all in an application programming interface (API) format.
  • Has core data elements for directories.
  • Is free to both plans and providers.
  • Was recently updated so providers can enter multiple addresses and the date they certified that data.
What Should Plans and Providers Do?

Plans should communicate with network providers on why and how to use NPPES to update their data with the addresses where they see patients on a regular basis. Then, plans should review their data against NPPES and make updates accordingly. The NPPES database is available for download and also is periodically available as a change file, making updates easier. Providers should use NPPES to review, update, and certify their data.

What Will CMS Do?

CMS will begin provider directory reviews in May 2020. The focus will be on PCP, Oncologists, Cardiologists, and Ophthalmologists with data accuracy as the focus. CMS will no longer be reviewing if providers are accepting new patients. Further, with the focus on data accuracy, it is no longer a requirement for quarterly calls to providers. This makes using NPPES even more beneficial.

Upcoming Events

Appeals & Grievance Summit 2020

The Enhancing Appeals & Grievances and Improving ODAG & CDAG Readiness conference has been rescheduled. This industry event was originally scheduled for March 25-27, 2020 at the AC Hotel in Downtown Nashville and has been changed to June 8-10, 2020 at the same venue.

Madena will still be presenting the Wednesday morning session, Universe Production: Combining the Operational and Compliance Perspectives to Optimize Accuracy and Effectiveness.

If you have a room booked at the AC Hotel, please contact them directly at 615-514-2500 to change your reservation. If you’ve booked at the Margaritaville Hotel, please call 877-505-7223.

Service Spotlight

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

Madena Membership Suite™ EDV Module – Create EDV packets to ensure streamlined submission of data from EDV worksheets and supporting documentation. Meet monthly Medicare audit requirements and track audit success or failure to implement internal coaching and process improvement.

Madena Membership SuiteRPC Module – Reduce errors and RPC rejections by the systematic creation of archivable RPC packets, cover letter, and submission sheets. Upload FDRs to close out items or identify rejections requiring resubmission. Generate RPC reporting to allow inventory management, oversight, and to identify trends

Madena & Industry News

Leverage EDV for Process Improvement

The Enrollment Data Validation (EDV) provides a monthly random sampling of transactions submitted to CMS and actions taken by health plans via MARx UI. This is a great opportunity to identify people, process, and system improvements, but is often untapped by Medicare health plans.

The EDV volume and quick turnaround time are the biggest barriers to not using the issues identified for process improvements. Fluctuation in volume of EDV packets requested by the RPC can be anywhere from 5 to 100 or more from month to month based on the number of transactions submitted by the health plan to CMS. During the 7-day turnaround time frame, your staff is focused on getting the EDV packets created and out the door.

We suggest the following approach:

  • Take the time to establish an EDV process that will identify, capture, and trend all errors.
  • Use the RPC EDV schedule and incorporate it into your department calendar to ensure that EDV processing begins the day EDV is posted in eRpt and the submission deadline is met.
  • Use a tracking tool such as the Membership Suite™ EDV module to assign, track, audit, and submit all EDV packets by deadline.
  • Create sample verbiage to be used on the EDV worksheets for efficient and consistent EDV packets.
  • Design an EDV audit checklist to document accuracy of EDV packets and the processing of transactions (such as election period and application received/date submitted).
  • Provide a summary of EDV packets indicating identified errors and process improvements needed to avoid recurrence.

Our team would be happy to set up a demo of our EDV Module or provide BPO services for your monthly EDV.

Contact us to discuss how we can help your plan maximize your data and efficiency.

March Recon – Avoid CAT 3 Submission

Monthly Reconciliation is an opportunity to confirm that the health plan systems correctly reflect the member information and is in sync with CMS’ system MARx. When discrepancies are identified quickly, updates can be made with minimal impact to members and health plan capitation. Discrepancies that linger over several months will cause member abrasion, a barrier to accessing benefits.

CMS monitors RPC Category (CAT) 2 & 3 submissions and considers health plans with high volumes to be “outliers.” These outlier plans will be investigated by CMS Account Managers to identify the root causes associated with the increased volume. Note that entitlement reinstatements are the result of a CMS action, not the health plan. Therefore, it is important to track root cause for all RPC submissions.

CMS’ expectation is that health plans have zero Category 3 submissions.

March Reconciliation is the last chance to avoid CAT 3 submissions for January 2020 enrollments that require correction. Make sure to closely review all of the January effective date enrollment discrepancies identified from the MMR to determine if retro-action is required. If so, the RPC packets can be submitted as a CAT 2 as long as uploaded by 3/31/2020.

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