Category: Uncategorized

As the dual eligible population grows, Dual Eligible Special Needs Plans (D-SNPs) are also experiencing tremendous growth across the country. CMS reports that as of February 2022, D-SNPs are operating in 45 states and have upwards of 3.8 million beneficiaries. The growth is primarily driven by these factors:

• Choice of Medicare Advantage over traditional Medicare due to benefits and population health flexibilities
• Provider understanding of these plan benefits, a common thread of some of the fastest growing new entrants
• Recent increased acceptance of managed care for this population
• State and federal attention on ways to better manage care for vulnerable Medicare beneficiaries
• State and federal policies that embrace well-run managed care, highlighting an opportunity for health plans with existing Medicaid lines of business that are considering expanding into Medicare offerings, including D-SNPs

While growth in D-SNPs is rapid, the offerings across states and health plans vary tremendously due to different requirements at the state level. For example, the differences between a non-fully integrated D-SNP and a fully integrated D-SNP (FIDE-SNP) determine whether Medicaid benefits are going to be fully intertwined and managed by the same managed care entity as the Medicare D-SNP covered services. Depending on which state(s) a plan is operating in, there could be a different paradigm to their approach such as Medicare-Medicare Plan (MMP) in states that opt in to running a three-way contract with CMS as part of the Financial Alignment initiative.

From a plan perspective, understanding what’s essential to the care model and adapting it to resource availability in each state requires having technology in place that enables flexibility. Depending on the state where a plan operates, there will be significant fluctuations in diversity which makes personalization and customization necessary to work in lockstep with state regulators. And regardless of the state, there’s also a certain amount of coordination as specified in state Medicaid agency contracts, such as specific protocols and population health interventions that are part of the CMS model of care proof.

Within the context of modern technology, care management technology is key to improving population health especially as it relates to the D-SNP population. HealthEdge’s GuidingCare is a next-generation technology platform that supports a health plan’s patient-centric model of care and is currently used in 29 states to help manage this complex population. These plans use GuidingCare service plans and script forms to meet the varying requirements in the different markets.

HealthEdge is fluent in the needs of state-sponsored programs serving the most vulnerable and high-risk populations. The GuidingCare platform integrates with both findhelp and Healthify to seamlessly connect members with services they need to address social determinants of health (SDOH) challenges. Plans that rely on GuidingCare can maximize coordination and member engagement for improved STAR ratings, better health outcomes, and increased member satisfaction.

Learn more about GuidingCare for Dual Eligible Special Needs Plans (D-SNP) here.

Within Medicare Advantage (MA), there are Special Needs Plans (SNP) with specialty cohorts that provide coverage for members who qualify for both Medicare and Medicaid. The membership for these Dually Eligible Special Needs Plans (D-SNP) include some of the most vulnerable populations in the United States who have medically complex needs and social risk factors. As a result, this beneficiary group has a higher spend profile due to their end-to-end care management requirements and population health strategies necessary to meet their complicated healthcare needs.

When D-SNPs were introduced in 2006, they were available in just seven states. In 2022, D-SNPs are offered in 43 states and Washington D.C. This year, two new states have joined those offering D-SNPs – Wyoming and South Dakota. As of 2021, the SNP Alliance reported 627 Dual-Eligible SNPs serving 3,133,448 beneficiaries. The growth trajectory for Medicare Advantage will continue more than ever before at any point in history. Combine this with increasing Medicaid enrollment and eligibility growth, and enrollment in dual eligible specialty plans will continue to surge.

While the D-SNP market grows, health plans need a way to help members navigate their complex population health needs. GuidingCare® supports care management and population health services with a 360-degree view of the member that incorporates social determinants of health data. Recent data from the Centers for Medicaid and Medicare (CMS) show that for the D-SNP eligible population:

• 41% have at least one mental health diagnosis
• 49% receive long-term care services and supports (LTSS)
• 60% have multiple chronic conditions

Health plans with Dual-Eligible members must stay compliant with changing regulations while serving this population with complex health needs. GuidingCare provides 280 evidence-based clinical and health status assessments available out-of-the-box or customizable. One in five Medicaid members are managed through GuidingCare, 29 states employ GuidingCare to help manage D-SNP populations, and 14 states use GuidingCare for LTSS.

This solution automatically delivers up-to-date Medicare and Medicaid policies and fee schedules, resulting in lower administrative costs, increased operational efficiency, and improved compliance. Not only does care management lower costs and improve health outcomes, but those plans that execute it well set themselves apart from the competition with improved Star ratings.

Learn more about GuidingCare for Dual Eligible Special Needs Plans (D-SNP) here.

As expected, the Biden administration extended the mid-April expiration of the Public Health Emergency (PHE) another 90 days, so the countdown again restarts for July 15. The stakes are high for many parties, even as many Americans are shedding their masks and moving on.

For some states, the pandemic influx of Medicaid members was the largest enrollment action they witnessed in the 50-year history of Medicaid. Industry experts and states are keeping a close eye on what happens next.

When the PHE expires, so does continuous coverage for Medicaid enrollees. Many will become ineligible or need to proactively re-enroll to stay covered. Some estimate as many as 15 million Americans could lose coverage or need a transition in coverage, such as to an Exchange plan.

The Biden administration has promised 60 days’ notice to state Medicaid programs before ending the PHE, so the administration could signal its intent in mid-May if July is the targeted end-date. Many states say they don’t have the time or resources to effectively discern eligibility, contact and re-enroll beneficiaries even at that. Some experts think Medicaid continuous coverage could be de-linked from the expiration of the PHE to accommodate these concerns.

Other impacts PHE expiration:

• Most beneficiaries in traditional Medicare will lose significant telehealth access unless they are in rural areas or participate in Medicare Advantage.
• Providers will lose substantial financial support. Major provider associations are pleading for more time. Providers say they face challenges in providing care postponed during the pandemic, and have supply chain disruptions and staffing problems.
• Popular telehealth flexibilities will continue at least five months beyond the end of the PHE, thanks to 2022 Congressional legislation.

There is mounting political pressure to end the PHE. Various emergency measures, such as those affecting skilled nursing facilities, are already winding down. Many policy experts expect the April renewal to be the last extension. If the PHE is extended yet again, the new date to watch will fall in mid-October.

In the ongoing struggle to achieve clarity around how Surprise Billing regulations will work, the Centers for Medicare and Medicaid (CMS) opened a Federal IDR Portal in late April to guide resolution of out-of-network rate disputes between payers and providers after direct negotiations fail. As the saying goes, “the devil is in the details.” This process represents the last resort for payers and providers if they can’t come to rate agreements on their own.

The portal reflects revised guidance independent arbiters can use in the Independent Dispute Resolution (IDR) process and what information they shall consider when choosing between two prices – one offered by the provider and one by the payer. The arbitration method is known as the “Major League Baseball” approach – both parties make offers and an independent arbiter determines which price prevails. The arbiter must choose one award without modification, so whichever number is chosen is final.

Some of the variables the independent arbiter must consider are:

• The Qualified Payment Amount (QPR) for the relevant service. In general, this is the median of the contracted rates, factoring in geography, specialty and inflation. The methodology for this was established in the CMS July 2021 interim final rules.
• Other credible information as submitted by either party that is not prohibited and is relevant to the offers made.
• IDR arbiters may also consider, for non air-ambulance services, the level of training and outcomes for the provider; the provider or facility market share; patient acuity and service complexity; the facility’s teaching status, case mix and scope of services; a demonstration of good faith or lack thereof in attempts to reach a contract.

Factors that the IDR must not consider include:

• “Usual and customary charges,” including when expressed as a percentage or share of same
• The amount that the provider would have billed were key rules (45 CFR 149.410, 149.420, and 149.440 as applicable) not applied.
• The reimbursement rates for most public payers, including Medicare, Medicaid, CHIP and TRICARE. The same rule applies as above for figures expressed as percentages or shares of those rates.

The rules are both similar and different for air ambulance services. In that case, additional variables an IDR arbiter may consider are the type of air ambulance vehicle and its level of clinical capability, and the population density at the point of pickup for the patient.

The IDR entity has 30 days to notify the involved parties in the dispute of their decision. The non-prevailing party must also cover the costs of the IDR services.

Note: Please reference the Independent Dispute Resolution link for complete guidance. This blog post is a partial summary and does not represent legal advice.

Healthcare is unique in so many ways – services are customized to each person, experience is impacted heavily by the provider, and quality of care is affected by your coverage. Paying for healthcare services is also unique. Where else do you go to a place of business for a service, pay a co-pay (or not) at the time of service, and then a few weeks later receive a bill outlining how much that service cost, how much your insurance will cover, and how much you’ll be paying out of pocket? And, woven throughout that whole scenario are rules and regulations that play a significant role in the calculation of what the health plan pays and what you pay.

These past few years, payers have been challenged more than ever to keep up with volatile market dynamics and comply with regulatory requirements. It’s not an easy feat to accomplish. The health insurance industry must comply with federal regulations from the Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid (CMS), as well as each state’s health departments. There’s the Medicare physician fee schedule adjusted by location and updated yearly, and the ever-evolving rules brought on by the pandemic, which in some cases were even changing on a weekly basis. And, with each new presidential administration, comes another new set of rules and regulations.

In these unique times, it’s critical to have technology in place that enables your organization to respond nimbly to rapidly changing regulatory mandates. Payers need to be able to ‘future proof’ their business and HealthEdge’s payment integrity solution, Source, is built for that purpose.

Source enables complete government compliance with first-pass payment accuracy. The unique two-week update cycle delivers all CMS and Medicaid regulatory updates automatically by a team of Medicaid and Medicare experts. Additionally, Source aims to streamline the workflow by removing the strain of manually loaded fee schedules.

One HealthEdge client, SummaCare, uses Source to manage regulatory updates and has realized significant process efficiencies saving their organization time and money. Join us for a more in-depth look at how Source helps SummaCare navigate the ever-changing regulatory cycles. Register for the upcoming AHIP webinar on May 5th.

Health plan payers receive hundreds of millions of claims each year. With such an inundation, it’s easy to understand how complicated and challenging payment processing can be. And when the slightest mistakes can cost you precious time and money, paying claims right the first time is imperative. Here are the top 5 biggest payment accuracy challenges and how to fix them.

1. Inaccurate claims

Processing claims is an arduous and complicated task for any health plan. Pricing varies by region, specialty, and provider group. Other considerations like member seasonal geolocation add to claim payment complexity. With the high volume of claims and their associated complexities, inaccuracies happen – and they occur more frequently when being processed manually. The importance of automation for first pass accurate claims is extremely important.

2. Inefficient processes

The payer world is constantly shifting, merging, and consolidating different organizations into one. When two organizations join, they often use different technology platforms that are not interoperable or don’t do the same task. In addition to the challenges of organization consolidation, many payer departments are definitively siloed, working in vacuums. Often, different technology vendors are leveraged across the organization for the same purpose – but serving different business lines. Implementing one technology platform for all lines of business supports a more efficient and streamlined organization.

3. Changing fee schedules and regulations

Fee schedules are updated every year and adjusted by region; healthcare regulations are impacted by presidential administrations and external factors – like a global pandemic. Since 2019, over 3,000 pieces of healthcare legislation have been introduced to Congress as listed on congress.gov. Ultimately, 25 of those were passed into law which may not seem like an impactful number, but when measuring the many ways in which one law can affect healthcare billing, those changes can be overwhelming to keep up with and efficiently navigate. Penalties for non-compliance can be very costly, so adopting a platform that automates the implementation of new regulations is essential in today’s healthcare environment.

4. Staying audit ready

The amount of tracking needed to perform and pass an audit at any time is daunting. Many payers know the pain felt when receiving an engagement letter from the Auditor-in-Charge at the Centers for Medicare and Medicaid (CMS). Beginning at that moment, the payer is responsible for filling out forms and providing appropriate documentation for CMS to conduct their audit. If anything is incomplete or amiss, the payer is at risk of failing the audit and incurring penalties. Technology that tracks all documentation needed for an audit and essentially creates an audit trail so that it’s ready whenever it’s needed, is an absolute game changer.

5. Flexible technology

Lastly, for too long many healthcare organizations have been using legacy technology that isn’t particularly flexible, interoperable, or transparent. The pandemic made it abundantly clear that organizations able to come out ahead during this time of great healthcare transformation are those embracing and investing in technology that delivers all three. Automation for efficiency is certainly important, but it’s only one piece of a technology puzzle that can really propel a payer to achieving or even exceeding business goals.

HealthEdge’s payment integrity solution, Source, was built to specifically address the burden of each of these challenges. Listen in to the May AHIP webinar on May 5th where SummaCare details how adopting Source enabled them to tackle these top five claims processing issues. Register now.