The Bridge – Volume 6

Jennifer Young
Jennifer Young, Executive Vice President

What Is an Independent Certification for Enrollment and Premium Billing?

An Independent Certification is conducted by a third party (such as Madena), who performs an independent analysis of the accuracy of your health plan’s enrollment, premium billing, and reconciliation processes. Using our Membership SuiteTM software, we can load a simple membership and invoice extract to compare with CMS historical files. We utilize a systematic and iterative process to apply a comprehensive series of data algorithms, which will identify a listing of discrepancies between CMS and your data. Madena will deliver a detailed listing of outstanding discrepancies along with our summary analysis of any other data results that may suggest gaps within your enrollment and premium billing processing.

Our independent certification has been successfully used in a variety of ways: corrective action remediation, in support of the quarterly Enrollment & Payment Certification, or to confirm the completeness and accuracy of both vendor and home-grown solutions. Madena’s Independent Certification services offer an impressive return on investment, visibility and transparency into operations, and identification of potential compliance gaps before they become a problem.

Contact us for more information on how we can help your health plan become more efficient and profitable.

What Should Your Monthly Discrepancy Rate Be?

We often get asked this question. CMS generally establishes a threshold of error to be 4% or less. But do you want to create issues for 4% of your members? Membership discrepancies create 4x the cost to fix than to process right the first time. Think about how many hands an identified discrepancy can go through: compliance/CTM, call center, grievance, and enrollment staff. Your target should be .4% (yes, POINT 4). If your discrepancy rate is higher, this may indicate upstream errors that are not being caught timely. The stronger and more accurate your enrollment & TRR processing is, the less discrepancies you should have.

Don’t underestimate the value that call center logs, CTMs, and grievances can provide in helping to trend and identify root causes. You should also have escalation points through these mechanisms to treat every reported membership discrepancy (e.g. not enrolled, wrong plan, can’t get medication at point of sale) as immediate need for resolution. Putting effective reconciliation and resolution processes in place can reduce administrative costs and membership turn-over.

Do you have small gaps in your existing reconciliation? Our modular Membership SuiteTM reconciliation software allows you to buy only the function that you need to supplement your existing reconciliation solution.

View/Download a PDF of the June 2020 Newsletter.