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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.

Bad data is estimated to cost the healthcare industry $314 billion annually and negatively impact an organization’s revenue by 10-25%. The claims payment structure is characterized by decentralized data and delayed pricing updates leaving plans scrambling to keep up with CMS and Medicaid policy changes and struggling to price Medicaid claims accurately.

Addressing this outsized demand on insurers and their technology partners requires getting control of your data. With annual stats like an expected Medicaid enrollment growth of 5.8% and a 9.5% claims payment error rate, technology that can make data more meaningful and actionable is the solution. Successful organizations have focused on three technology solutions to achieve consistent, accurate, and transparent payments:

• SaaS technologies
• Integrated ecosystems
• Centralized data

1. SaaS technologies

Challenge: Your traditional solution for first-pass accurate claims processing relies heavily on manual and infrequent data, and policy updates that are not aligned. Variability in pricing methodologies adds complexities to processing your claims.

Solution: A platform that delivers frequent updates to Medicaid baseline data with software as a service, so you’re always working with up-to-date prices and edits, preventing inaccuracies with real-time data. Because it’s in the cloud, no internal resources are required to deploy the changes. First-pass claims payment accuracy is increased dramatically – enabling your business teams to refocus on value-added activities.

2. Integrated ecosystems

Challenge: Multiple and different technology platforms across the organization impact the integrity of your data and the information exchange environment.

Solution: A unified platform that brings software, data, and service into a single workflow. Implementing one technology platform that delivers up-to-date regulatory data, claims pricing and editing, and real-time analytics tools gives your organization an edge over the competition. A single source of truth and a single point of accountability is a transformational approach for payers to make payments with total confidence and make business decisions with real intelligence.

3. Centralized data

Challenge: Your workflows and data are managed across multiple platforms that are not exchanging information in the same language, frequency, or format – wasting time and increasing the risk of errors.

Solution: A unified, cloud-hosted platform enables a single place to centrally update, maintain, and manage data with multiple entities. This automated approach reduces IT maintenance delays and delivers centralized, accurate data.

Source is HealthEdge’s prospective payment integrity solution, a cloud-based platform built to specifically address the burden of these challenges. Join our webinar on May 5 and learn how SummaCare modernized its processing and realized big savings. Register here.