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Insights from the MedHOK 2018 User Conference

Insights From The MedHOK 2018 User Conference

MedHOK held its 2018 User Conference earlier this month in St. Petersburg, Florida. The four-day affair featured a series of healthcare insight panels, as well as some fun time and collaboration between our great client plans.

For those who could not attend, in this post we summarize some of the key themes discussed during the User Conference and hope you will be able to make it next year:

Key Insights and Recommendations:

  • Private health plans continue to g
  • row, grow, grow! This is most prevalent in Medicare, but we expect Medicaid to continue to attract health plans.
  • The Centers for Medicare and Medicaid Service (CMS) wants to see more Special Needs Plans and Long-Term Care plans to control long-term care costs and control both Medicare and Medicaid.
  • There is a distinct shift coming from Utilization Management to Care Management and Quality. We see a Model of Care for Everyone emerging over time.
  • Given high costs and poor quality, pharmacy quality will take on a new focus. We strongly suggest that you integrate your medical and pharmacy approach.
  • Medicare is not slowing down regarding Compliance. They are increasing program audits and civil monetary penalties, and findings remain at high levels. In fact, CMS seems to be refining its strategy at every pass to hone in on new and increasingly complex areas.
  • There seems to be slight improvement in some of the audit areas that were most concerning in previous
    • findings:
    • Timeliness
    • Use of appropriate letter templates and appeal rights
    • Use of clear and concise verbiage in letters
    • Misclassification of cases
    • Consistent use of evidence-based criteria
    • Outreach
  • Keep close watch on your auto-forward and over-turn rates!
  • Implement the new enhanced outreach requirements if you have not done so already.
  • The MTM program remains a hot topic at CMS HQ.
  • Unless CMS backs away from restructuring after the comment period, universe layouts are changing again.
  • CMS can sometimes be very understanding if a plan practices strong disclosure (before and during an audit) and has good documentation, RCAs, and completed BIAs. Be transparent. Also, prepare year-round with mock universe runs, mock audits and other preparations for the increasing chance you will get an audit letter. In essence: Don’t be like that child who tries to hide the dent on the car after a fender bender.
  • Both Democrats and Republicans on Capitol Hill, as well as CMS, are ready to pounce on plans on overpayments. According to an HHS OIG report, Medicare Advantage and Part D represent the third-highest overpayment category for healthcare and fourth overall.
  • For Medicare financial reconciliation folks, expect the world to get more complex as RAPS is phased out in favor of EDPS, several payment models come into play over the next several years, and models become increasingly refined. Additionally, are you ready for RADV and the chance of an extrapolation penalty? That thud you just heard was the finance department passing out – I hope they are OK.
  • The Medicaid mega rule continues to be implemented and it will bring a rigorous compliance regime mirroring Medicare to Medicaid in all 50 states.
  • The Star program in Medicare has been a huge success and CMS continues to introduce increasingly complex measures that will challenge plans. We call these Comprehensive Management Measures and plans will need to build out bigger and better collaboration between pharmacy, UM, CM and quality in order to maintain high scores.
  • The statistics show a large gap in achieving high Star ratings and maintaining high Star ratings.
    While they have been around forever, there is a renewed focus on social determinants given that they can be as good or better predictors of health outcomes.
  • We are starting to see CMS get very adventurous in Medicare, and possibly in Medicaid, in the future! Just these past few years, we have seen the following out-of-the box thinking. So, get your thinking caps on and be bold!
    • Value Based Insurance Design
    • Molding benefits and services for those with multiple co-morbidities
    • Expanding allowable service offerings to non-health items and areas not traditionally covered by Medicare

Road Map:

  • Clients learned MedHOK is busy building the platform of the future to make sure our plans keep up with compliance trends and the changing healthcare landscape. Our focus is on Innovation, Compliance, Efficiency and Collaboration. Our major road map items hit the most important emerging areas of healthcare to ensure:
    • Plans meet the value-based demands of the future
    • Optimal efficiency in tight-margin times
    • Analytics to ensure plans can zero in on negative trends in compliance, productivity and operations.

Fun Time:

  • We dined at the Dali Museum (we took the Stairway to Heaven and saw Lincoln) and went on a dinner cruise (The Rum punched – and certified captains only please!).

Until Next Year!

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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