How the ESRD process works. And why it sometimes doesn’t.

Medicare Advantage plans don’t typically have a large population of members with End-Stage Renal Disease (ESRD). In our work with dozens of plans, we see about 5% of members with ESRD, a condition where there is permanent and almost complete loss of kidney function.

These few members, however, can have a big impact on a plan’s financial health if the Centers for Medicare and Medicaid (CMS) are underpaying premiums for these members. And especially if CMS has been underpaying for a length of time.

The average cost to treat a patient with ESRD can run well over $60,000 a year because members may require dialysis several times a week. To offset this higher cost of care, CMS typically pays health plans a premium of $7,100 for managing members with ESRD, compared to a premium of $815 for non-ESRD members. When you multiply the gap between non-ESRD premiums and ESRD premiums year over year, having the wrong ESRD status for a member can be quite costly to your plan.

Ongoing inaccuracies can mean that your plan is losing out on millions of dollars

Determining the cause of the error is time-consuming—and can be complicated—for health plans.


When you multiply the gap between non-ESRD premiums and ESRD premiums year over year, having the wrong status for your ESRD members can cost your plan millions.


Let’s take a look at how the ESRD process ideally works:

  1. The ESRD patient visits a dialysis clinic for treatment.
  2. The dialysis clinic or submitting authority fills out form 2728 (completely and accurately) and submits this to CMS through CROWNWeb, the data-management system that allows Medicare-certified dialysis facilities to safely submit facility and patient data to CMS.
  3. CMS is alerted to the patient’s ESRD status—and an ESRD indicator flag is turned on that will adjust the premium for that patient.
  4. Your plan then receives a higher premium for covering these patients.

In some situations, however, the process breaks down:

  • Members have ESRD diagnoses that your plan never knew about
  • The dialysis clinic or provider doesn’t complete the 2728 form or sends incomplete or incorrect forms
  • The clinic saves the form in CROWNWeb but doesn’t hit “submit”
  • Flag are temporarily turned off and not turned back on—for example, because the member went to hospice for a period of time
  • CMS fails to set the flag or had inaccurate dialysis start dates

Discovery is adept at navigating these complex processes and restoring premiums

Discovery can help your plan identify members with missing ESRD statuses and work to correct the errors at the source—by working directly with the submitting provider and CMS.

To begin our restoration process, we use the plan’s historical claims data and multiple data sources to identify claims diagnosis patterns. We look at the detailed membership files to see if that ESRD flag is present. If it’s not, we reach out directly to the dialysis center and, if needed, get the 2728 form resubmitted properly.

This can sometimes prove challenging as the dialysis center’s main focus is on patient care and not necessarily on ensuring the 2728 form has been completed accurately and submitted through CROWNWeb appropriately. So, our team will explain the importance of following CMS guidelines and will work with the dialysis center from start to finish to ensure the form is accurately re-submitted through CROWNWeb. We also coordinate with CMS to make sure that flag gets turned for the appropriate timeframe. Finally, we track the CMS Monthly Membership Report (MMR) updates and continuously monitor MMRs to ensure the flags remain on, as necessary.

Let us start reviewing your records

Discovery Health Partners can help find value for any size health plan, utilizing an 84-month non-intrusive lookback that restores actual premium dollars based on corrected ESRD flags. Plus, based on corrected ESRD flags, our lookback work ensures that future premiums are paid accurately for members with ESRD.

Learn more about Discovery’s ESRD Premium Restoration solution.

Alex ProjanskyHow the ESRD process works. And why it sometimes doesn’t.
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End-Stage Renal Disease (ESRD) FAQs

We recently talked about the need for Medicare Advantage plans to ensure that premium dollars coming in from the Centers for Medicare and Medicaid Services (CMS) are accurate. As with Medicare Secondary Payer, Medicare Advantage plans are losing out on premium dollars from members with End-Stage Renal Disease (ESRD).

Members with End-Stage Renal Disease account for a disproportionate amount of medical expenses. Experience shows that health plans are underpaid an average of $50,000 in CMS premiums for each misidentified or inappropriately documented ESRD member. Correcting inaccuracies and ensuring accurate submissions to CMS help plans restore millions in underpaid premium dollars. Here are answers to a few frequently asked questions about End-Stage Renal Disease validation:

What is End-Stage Renal Disease (ESRD)?

End-Stage Renal Disease, also known as ESRD, is a condition in which there is permanent and almost complete loss of kidney function. Some of these patients are treated by dialysis or kidney transplant. If members are flagged appropriately with the Centers for Medicare and Medicaid Services (CMS), the Medicare Advantage plan will receive the appropriate premium amount to pay for their care.

The challenge with ESRD members is that it is up to dialysis providers to submit appropriate documentation to CMS for members with ESRD. The plan has no control over this. Dialysis clinics can be difficult to work with due to high turnover and a lack of motivation to ensure accuracy.

What is the financial impact of ESRD to Medicare Advantage plans?

Medicare Advantage plans pay the full cost of ESRD claims, regardless of the amount of premium dollars received from CMS. For the sake of comparison, the average Medicare Advantage premium is $815. The average ESRD premium is $7,100. Multiply the difference over multiple members and multiple months, and the financial impact becomes significant.

What are common reasons that ESRD status is missed?

There are three areas where ESRD status is missed and where recovery opportunities exist. First, there may be members with ESRD diagnoses that the plan never knew about. Second, the member may have been flagged with ESRD at one point in time, but the flag was turned off and never turned back on. This may happen in a scenario in which the member went to hospice for a period of time. Lastly, the ESRD dates might not line up. CMS may not have paid the ESRD premium for the first few months of dialysis treatment.

What does ESRD validation entail?

When looking to ensure accurate premiums for ESRD members, the plan needs to first verify where it might recoup premiums due to missing ESRD flags. Once those members have been identified, the plan will want to ensure the complete and accurate submission of required documentation to CMS. Plans can recoup ESRD premiums for the previous 84 months.

Some Medicare Advantage plans find that they lack the resources to focus on ESRD validation or lack continuity due to multiple points of ownership throughout the organization. And the process of identifying members, gathering and correcting documentation, and working with dialysis clinics can be time-consuming and overwhelming. In these cases, the plan is wise to work with an ESRD validation vendor.

What do I need to consider when partnering with an ESRD validation vendor?

There are several factors to consider when evaluating ESRD validation partners. Most important is making sure the vendor has experience in the process and has developed proven best practices with measurable results.

Analytics plays a key role. The ideal partner will have developed advanced analytics and strong proprietary algorithms to find eligible members. Also important are established relationships with dialysis centers across the country and best practices developed with CMS over time.

In addition, the partner will manage the entire process from start to finish, requiring minimal to no involvement from the plan. The vendor will use proprietary analytics to identify members with the highest propensity of inaccurate ESRD statuses, perform subject matter expert review, work with dialysis clinics to correct data inaccuracies, submit accurate reports to CMS, and monitor the submission and acceptance process.

Lastly, the vendor will offer complete transparency by tracking, reconciling, and reporting on the progress of ESRD efforts and resulting financial outcomes.

 

Contact us today for more information about how Discovery Health Partners can improve your ESRD validation and premium restoration programs.

Discovery Health PartnersEnd-Stage Renal Disease (ESRD) FAQs
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Medicare Secondary Payer (MSP) FAQs

Today’s Medicare Advantage plans must manage payment integrity from two angles. First, they must ensure claims payments are accurate. And they must make sure that premium dollars coming in from the Centers for Medicare and Medicaid Services (CMS) are accurate. However, inaccurate member eligibility data often results in Medicare Advantage plans receiving fewer premium dollars than they’re owed.

Medicare Secondary Payer Validation is a key factor in quickly and accurately confirming CMS records, correcting inaccuracies, and restoring millions in underpaid premium dollars. Here are answers to a few frequently asked questions about Medicare Secondary Payer Validation.

What is Medicare Secondary Payer?

Medicare Secondary Payer, also known as MSP, is a term used by Medicare when another payer is primary, establishing that Medicare is the secondary payer. This applies to both Part C medical coverage and Part D prescription drug coverage. In both cases, the Medicare Advantage plan is paid a per-member monthly premium by CMS to administer the plan.

What is the financial impact of Medicare Secondary Payer to Medicare Advantage plans?

Premiums paid by the Centers for Medicare and Medicaid Services to Medicare Advantage plans are reduced 82% per month when other primary medical coverage exists. CMS puts the burden on Medicare Advantage plans to prove when they deserve primary premiums, and many plans don’t realize how much revenue they lose in underpaid premiums. The good news is that the Centers for Medicare and Medicaid Services allows Medicare Advantage plans to recover premiums from the previous 84 months.

Identifying inaccuracies in the CMS Common Working File is like looking for a needle in a haystack. How can this be more effective and efficient?

Finding inaccuracies and identifying primacy changes requires the right mix of data modeling, sophisticated tracking, and workflow technology. The key is to focus only on those records that have the greatest potential to negatively affect premiums.

Beyond identifying inaccurate records, how complex is the process?

There are several challenges and complexities in MSP validation. The plan may lack a dedicated or specialized team to focus on the problem, or there may be multiple points of ownership throughout the organization (e.g., claims and finance).

The validation process itself is complicated and time-consuming. It requires finding and contacting the other insurance provider, capturing and sharing validation data, and communicating with CMS to get the record corrected. Due to this inherent complexity, premium restoration is often delayed.

What do I need to consider when partnering with a Medicare Secondary Payer validation vendor?

Since MSP validation can have such a significant financial impact for Medicare Advantage plans, finding a Medicare Secondary Payer validation partner is wise. There are several factors to consider. Most important is making sure the vendor has expertise in the process.

In addition, the ideal partner will manage the entire process from start to finish, requiring minimal to no involvement from the plan. Rather than providing leads and stopping there, the vendor will make updates directly to the CMS source file and then monitor and report on the results.

The partner will back this up with the right mix of data modeling, sophisticated tracking, and workflow technology. The right validation vendor will also provide complete financial transparency and insight, helping to track, monitor, and reconcile the financial impact.

Lastly, the vendor will fill gaps in the Medicare Secondary Payer validation process, aligning the organization, simplifying compliance, bringing focus to validation activities—and providing measurable value.

 

Contact us today for more information about how Discovery Health Partners can improve your Medicare Secondary Payer validation and premium restoration.

Discovery Health PartnersMedicare Secondary Payer (MSP) FAQs
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Award-winning Discovery employee proves that small acts of accountability make a big impact

When a company sets hefty goals to deliver profound client value and create highly engaged employees, it’s not enough to communicate those goals to everyone. To be transformational, every single employee must be 100% committed to contributing to the company’s goals. 

Discovery has invested in a comprehensive accountability model based on the concept that when people take personal ownership of the company’s goals and accept responsibility for their own performance, they work at a higher level to ensure their own success AND the company’s overall success. 

Working with the culture management firm Partners in Leadership, Discovery has built a culture of accountability by sponsoring training workshops and holding weekly small-group huddles that let employees work on the four best practices of accountability—recognizing when there are gaps in execution, fully and personally owning responsibilities and aligning them to the company’s key results, creatively and collaboratively working on solutions, and actively executing on the solution while building an environment of trust.

“As I like to say, accountability is every Discovery employee’s best friend,” says Phil Garrison, VP of Human Resources at Discovery and the executive sponsor of the company’s accountability program. “For each of us at Discovery, the principles of accountability give us easy-to-use tools to improve our individual work performance, share honest feedback with each other, and contribute very directly to the company’s overall goals.  The concepts are so foundational, they can even benefit us in our personal relationships.”

Discovery has integrated the model into many aspects of the company’s processes, onboarding, and expectations, and accountability is a cornerstone of the company’s culture. The company’s new Accountability in Action award is one example.

Each quarter, this award recognizes Discovery employees who demonstrate they have a stake in the company and go above and beyond to contribute to the company’s key results by living the “what else can I do?” attitude.

The first-ever recipient of Discovery’s new Accountability in Action award is Beverly Orwig, an MSP Recovery Specialist who has been with Discovery less than a year. 

Beverly received the award—which includes a cash reward, an extra day off with pay, and other perks—for a small gesture done consistently at a challenging time for her team. When COVID-19 hit, Beverly recognized that the pandemic was causing a lot of stress for her coworkers and they were struggling to keep a positive mindset. She asked herself what else she could do to stand out, to make a difference. Beverly took it upon herself to start each morning by posting a positive message to motivate her team, help them push through the challenges, and hit their goals. Focusing on how the team was reacting to the new environment caused by COVID-19, Beverly knew that it can be very hard for people to stay engaged, stay aligned to company goals, and maintain a connection with the team. Beverly’s positive communication among the team members promoted the understanding that the team had the ability and would be able overcome obstacles.

Commenting on receiving the award, Beverly says, “I was beaming—winning made such an impact on me! It made me realize that one individual employee can make such a big difference in the company. This company empowers me every day. It’s what makes Discovery who we are—everyone pushing each other to continue the momentum, to move forward in the same direction.”

Beverly credits her supervisor Shawn Daniels with inspiring her and driving her motivation. “I never want to disappoint him,” Beverly explains. “When he sets a goal for me, well, I’m going to push to overachieve that goal. He takes a personal interest in me and my success and is consistently available to help me.”

Beverly feels she is succeeding at Discovery because of the tools and transparency that the company provides. “Discovery gives me all the tools I need and empowers me to do my job every day,” she says. If I don’t know something, there’s transparent management all the way up to the top to get questions answered. It doesn’t get better than that.” 

“I want to be here…I want to come here every day. How many people can say that? I love coming to work every day.”

When she’s not demonstrating accountability at work, Beverly is a murder-mystery bookworm; enjoys Blues, jazz, and swing music; and spends weekends baking and cooking great dishes.


Discovery has built a culture of accountability throughout the company and created a quarterly award to recognize employees that have a stake in the company and go above and beyond by living the “what else can I do?” attitude.

Congratulations to Q1 2020 Accountability in Action award runners-up!

Christine Garcia, Accountability in Action award runner-up
“Christine works to get the issues fixed rather than come up with temporary solutions. She is in constant contact and responds within minutes, often working late to make sure issues are resolved.”
Chad identified ways that Discovery’s platform could better support the business. He immediately took ownership and spearheaded the development of an app in record time—in addition to his day job.

If you’d like to learn more about the steps to accountability and building this kind of culture at your organization, we recommend the book The Oz Principle.

Discovery Health PartnersAward-winning Discovery employee proves that small acts of accountability make a big impact
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Industry voices—ensuring premium revenue accuracy during COVID-19

FierceHealthPayer features an article by Jeff Martin, Vice President of Eligibility Operations at Discovery Health Partners. The article highlights the importance of making sure MA plans receive the revenue they deserve in order to ensure a stable financial picture during the COVID-19 pandemic.

Click here to read the full article.

Jeff MartinIndustry voices—ensuring premium revenue accuracy during COVID-19
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Protecting payment integrity through client-centered support

Unexpected events like the COVID-19 pandemic make it increasingly difficult for health plans to manage costs and ensure payment integrity. We recently sat down with Monica Frederick, Vice President, Account Management for Discovery Health Partners, to discuss how Discovery’s people and account management approach contribute to our clients’ success.

You’re a newer member of the Discovery Account Management Team. Can you share your experience prior to Discovery?

Over the past 20 years, I’ve held numerous sales and business development positions to support healthcare organizations in bringing new patient care modalities to the market. My experience on the medical side gives me insight into how managed care organizations can strengthen their payment integrity efforts so they can better manage costs and continue to focus on member care.

What makes Discovery a successful team and what are we doing differently to support our clients’ success?

Discovery has built a solid reputation for providing value to health plans by helping to solve their payment integrity challenges. We owe our success to our exceptional people and culture of accountability. Every employee across the organization understands the importance of their role and how they contribute to our clients’ success. And I see the whole organization working tirelessly to anticipate customers’ needs and earn their trust.

Communication is a big part of our approach to account management at Discovery. We talk to clients frequently in person and virtually, and we also conduct client surveys to hear directly from our clients on how we’re doing and how we can continue to provide profound value to our clients’ organizations.

Through this hands-on approach, we’ve learned that we do many things right. Clients especially appreciate how we advise them to determine the best course of action for their operations and provide timely follow-up to address their concerns. This valuable feedback also helps us identify opportunities where we can improve our processes and solutions to better meet clients’ needs.

In addition, we have a Client Council that brings together individuals across our client base whose voices influence the future of our business. We host in-person and virtual meetings with our Client Council to deepen relationships and understand what clients need to be successful. These meetings not only provide clients with valuable networking opportunities, but also offers clients opportunities to share insights and best practices with other health plan leaders and drive future innovations.

What is Discovery’s approach to account management, and how do we drive value throughout the entire engagement with a client?

Our approach is flexible to meet each client’s unique needs, but it always starts with earning their trust, by getting to know them and understanding their business operations. We listen closely to their concerns and create a plan that addresses their challenges and aligns with their strategy and priorities.

When clients join Discovery, we put together an implementation team with the right skills and specific expertise to ensure a smooth, accurate, and efficient implementation. Our approach is flexible and can wrap around or come behind existing vendors and processes already in place. Discovery’s multi-disciplinary teams work collaboratively and our experts evaluate each client individually. There is no one-size-fits-all approach.

Once implementation is completed, an internal hand-off to the Account Management team occurs and all unique attributes and needs for each client are discussed in detail. A dedicated account manager takes the lead to provide guidance and manage day-to-day activities and communicate the status of ongoing projects every step of the way. We don’t just hand over reports; we take time to meet regularly with clients to review their information in a way that’s meaningful so we can make recommendations for improvements and achieve their desired results.

What are some of the ways Discovery helps health plans address unexpected payment integrity challenges like the COVID-19 pandemic?

COVID-19 is unlike any event the healthcare industry has seen in modern times, thus health plans are faced with challenges they could not have imagined just a few months ago. Not only do health plans need to ensure their members receive the care they need and support their providers, health plans must also keep up with individual states’ mandates regarding “non-essential” claims processes and review of COVID-19 related claims. At the same time, they are struggling with reallocating resources to support critical COVID-19 initiatives while managing the shift to a remote workforce.

Discovery is proactively reaching out to clients to make recommendations, based on their business, to help protect premium revenue, pick up productivity shortfalls as needed, and help them protect their workforce. We continue to work diligently on behalf of clients as an extension of their teams to ensure they get the right information to support the continuity of their operations.

Discovery went remote with payment integrity operations over a year ago, so we’re in a great position to help support our clients business during the pandemic. Discovery views challenges as an opportunity to learn from individual clients’ needs. As COVID-19 plays out, we will continue to partner with clients to make sure we are supporting them and their challenges are addressed in a timely manner.

 

Find out how Discovery Health Partners can help contribute to your payment integrity success in 2020. Contact us today!

Monica FrederickProtecting payment integrity through client-centered support
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Enhancing premium restoration in four steps

Today, more than 22 million seniors and people with disabilities choose a Medicare Advantage plan, and enrollment is projected to increase to an all-time high of 24.4 million this year1. Do you have insight into how much revenue your plan might be losing in underpaid premiums?

Ensuring accurate premium payments for your Medicare Advantage members requires the right people, processes, and technology to identify your potential for premium restoration. It all starts with data. By integrating data sources and viewing eligibility data holistically, you can easily identify members with the greatest propensity for inaccuracy: those requiring Medicare Secondary Payer (MSP) validation and those diagnosed with end-stage renal disease (ESRD).

Here are four steps you can take to capture underpaid premiums:

#1: Identify members with premium restoration potential

The undisputed first step in capturing underpaid premiums is identifying those members with premium restoration potential. Our experience shows that an average of 4% of Medicare Advantage members have open MSP records, and 50% of those records have premium restoration potential. By identifying members with MSP or ESRD, your plan can ensure those members are accounted for in MMRs and in payments from CMS.

#2: Improve process efficiencies

When analyzing open MSP and ESRD occurrences, your plan needs to identify and prioritize those that require investigation. By allocating scarce resources to the activities that will have the greatest impact on the bottom line, you can ensure that dollars and staff time are spent wisely and efficiently.

#3: Monitor the financial impact

As premium restoration becomes more complex and when resources are limited, sophisticated monitoring is needed to achieve the results your plan expects. With a proactive approach to monitoring premium restorations, you will want to forecast how many dollars will be added to the premium check, uncover whether you have received every month of restored premiums, and maintain an audit trail to validate the outcomes and steps taken to correct inaccuracies.

#4: Maintain ongoing premium restoration activities

Given the impact it can have on your bottom line, the premium restoration process must be maintained on an ongoing basis. By ensuring payment accuracy throughout the year, you can capitalize on significant revenue opportunities month after month, year after year.

Discovery’s data analytics combined with our deep understanding of CMS eligibility rules can help your plan unlock the hidden value in your data and collect the full value of premiums owed.

Discovery Health PartnersEnhancing premium restoration in four steps
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Restoring Medicare premium revenue during COVID-19

Medicare Advantage enrollment and the number of confirmed COVID-19 cases are on the rise. According to the Centers for Disease Control and Prevention (CDC), older adults and individuals who have health conditions like heart, lung, or kidney disease may be at a higher risk for complications.

Your Medicare Advantage plan relies on the Centers for Medicare and Medicaid (CMS) for information regarding other health insurance and certain health conditions. When this information contains errors, it affects your bottom line. For many Medicare Advantage plans, the losses can be more than they realize.

What can your Medicare Advantage plan do to maximize its financial performance during these challenging times?

You can begin to recover the premium dollars owed to your health plan by performing a retrospective review of eligibility data. Going back seven years, you can review your monthly membership report (MMR) files to look for indications that the health plan is owed additional premium reimbursement for certain members.

What are the top reasons for missed premium restoration cues?

There are several cues that a plan may miss when it comes to premium restoration:

  • Incomplete data aggregation from the plan’s IT department
  • Inaccurate member questionnaire data
  • Section 111 reporting inaccuracies by commercial plans
  • Inability to completely or accurately validate a member’s other insurance
  • ECRS Web rejections that should actually result in premium reimbursements

Finding the causes of these missed cues can be difficult. Would you even know if your IT department is sending you incomplete data? What if you cannot get another insurer to validate eligibility information for a member? If CMS denies a seemingly legitimate eligibility update, do you know how to overturn that?

How Discovery can help

Discovery Health Partners can strengthen your premium integrity efforts by taking a closer look at Medicare Secondary Payer (MSP) validation and members with end-stage renal disease (ESRD). A recent analysis by S&P Global Ratings states that COVID-19 will end up costing U.S. health insurers more than $90 billion in medical claims.1 More than ever, it is important for plans to chart a course for transformative action that not only protects their premium revenue but also protects their workforce. With more individuals working from home and being allocated to support critical COVID-19 initiatives, Discovery is ready to continue working diligently on behalf of our health plan clients to identify eligibility issues and premium reductions.

We have helped clients restore millions with our Medicare Secondary Payer Validation solution:

  • $2.1 million for a 20,000-member regional plan
  • $16 million for a 30,000-member Midwest plan
  • $5.7 million for a 200,000-member Blues plan

In addition, our ESRD Premium Restoration solution has helped clients restore:

  • $6.5 million for a 160,000-member Medicare Advantage plan across a two-year engagement
  • $4 million for a 230,000-member Medicare Advantage plan seven months after implementation
  • $3 million for a 100,000-member Medicare Advantage plan in 12 months

The amount of potential restoration opportunity is a function of four parameters:

  1. Successful validation of inaccurate records
  2. Number of months of restoration opportunity for each incorrect record
  3. Average monthly restoration amount
  4. CMS acceptance rate of corrections submitted

Contact Discovery Health Partners today to find out how we can help you with your premium restoration efforts as your health plan navigates the impact of COVID-19.

Access the latest COVID-19 information and guidelines from CMS.

Jeff MartinRestoring Medicare premium revenue during COVID-19
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ESRD: Finding and restoring underpaid CMS premiums in five steps

Medicare Advantage (MA) enrollment is on the rise, helping to boost health plans’ annual profits to $35.7 billion in 2019.1 These enrollment increases are expected to continue in 2020, so it’s critical to make sure CMS properly pays you for all your MA members.

Especially when it comes to members with end-stage renal disease (ESRD), the final stage of chronic kidney disease that requires patients to undergo costly dialysis or kidney transplants. Members with ESRD account for a disproportionate amount of medical expenses. Experience shows that health plans are underpaid an average of $60,000 in CMS premiums for each misidentified or inappropriately documented ESRD member. Without a strategy to identify these members, your MA plan could be missing out on millions of additional premium dollars from CMS.

CMS allows health plans to identify, investigate, and restore up to 84 months of underpaid premiums for members with ESRD. Your plan maintains responsibility for identifying those ESRD members and ensuring data is validated and corrected according to CMS guidelines. It can be a challenge to sift through CMS monthly membership reports (MMRs), plan eligibility files, and claims data to find any potentially underpaid premiums.

However, with a systematic approach, plans can gain control of ESRD member statuses and restore underpaid premiums. Let’s look at five ways you can take control of your ESRD premiums.

#1: Explore the hidden value in your data

Your data is critical to restoring underpaid ESRD premiums. Potential missing flags can be hidden in various, disparate data sources and take years to uncover. You will want to dedicate resources and analytics to bring these data sources together and surface anomalies. By regularly combing through MMR, eligibility, and claims data going as far back as 84 months, you can identify likely ESRD members that require further investigation.

#2: Investigate cases that show opportunity

After using your data to identify possible opportunities for ESRD premium restoration, you will want to investigate each case to determine what funds may be owed to you. With the right investigation process, you can determine the root-cause issues for each ESRD member you identified. Then outline the right process you need to follow to address the issues with the appropriate submitting authorities.

#3: Remediate the case

Once you have properly investigated the possible ESRD case, you will want to use that information in your remediation efforts. Your investigation will have uncovered the root cause of the problem, inaccurate or incomplete submissions, and any inconsistencies in the data. In your remediation efforts, you will use the right method of outreach and coordinate with dialysis centers, CMS, or other third parties to ensure the information is corrected and updates are confirmed.

#4: Restore underpaid premiums

Your investigation and remediation efforts will have given you the information you need to seek premium restoration. At this point, you will have corrected the information and submitted it to CMS for restoration. As soon as that has been done, you will want to diligently track and reconcile restored premiums and monitor future premiums for accuracy for as long as it takes to make sure revenue is fully realized.

#5: Monitor premiums

After you have worked to restore premiums, you will want to continue to ensure that all ESRD members are identified. Whether you review data on a monthly basis or do a health check twice a year, you will want to ensure that identified ESRD member statuses continue to be reported accurately and that correct premiums continue to be paid.

Plans that take a systematic approach to analyzing and reconciling their ESRD membership can successfully restore underpaid premiums and ensure accurate premium payments going forward. Many plans find that partnering with an experienced ESRD premium restoration vendor to focus on the things outside the plan’s control can help maximize results.

 

Contact Discovery Health Partners today to find out how we can help you restore underpaid premiums for members with ESRD.

Fierce Healthcare, “Health insurers’ profits topped $35B last year. Medicare Advantage is the common thread,” February 24, 2020.
Jeff MartinESRD: Finding and restoring underpaid CMS premiums in five steps
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Fixing payment integrity at the source

“New year, new me.” Seems like we hear this at the beginning of every year and hold on to the promise of moving on from the past and setting new goals for the future. Likewise, healthcare organizations are kicking off 2020 by charting new paths to address old problems and expanding into new initiatives to stay ahead of the competition.

Priorities such as increasing member satisfaction, provider relationships, and regulatory compliance remain top of mind for many health plans, which makes it a good time to take a fresh look at your payment integrity strategies and resources. Now is the time to evaluate how well your plan is maximizing recovery opportunities, improving cost avoidance strategies, and exploring premium restoration possibilities. To do this, you need to start at the source of your payment integrity challenges: eligibility data.

The impact of eligibility errors

It’s a known fact that improper payments abound in healthcare, many of which stem from eligibility errors made as a result of multiple data sources, outdated technology, manual processes, and members with other insurance coverage. When eligibility errors occur, they affect many payment integrity areas such as coordination of benefits (COB), subrogation, and Medicare secondary payer (MSP) validation. Failing to address these issues leads to incorrectly paid claims, improper reimbursements, or claims that shouldn’t be paid at all—costing your plan millions.

According to Gartner, billions of dollars are spent every year in improper claims payments across commercial, Medicare, and Medicaid lines of business. Gartner research states, “Payer CIOs must get proactive and leapfrog current performance by focusing on prospective payment integrity capabilities.” With this in mind, what can you do to strengthen your payment integrity approach?1

Identify inaccurate eligibility data

When taking a close look at eligibility data, your plan will want to determine which claims may have been paid incorrectly as a result of inaccuracies. We estimate that 20% of a plan’s membership will have other insurance, and of that 20%, the other insurance will be primary 17.5% of the time. For a 200,000-member plan, this represents nearly $5.4 million in incorrectly paid claims. When statistics like this are uncovered, the plan quickly realizes how important it is to keep its eligibility data in check.

Determine a cost-avoidance strategy

Avoiding improper payments is a core tenet of any payment integrity strategy. Accurate and trusted eligibility data plays a key role. We estimate that the same 200,000-member plan could save over $13.4 million by avoiding incorrect payments. With the right cost avoidance strategies founded on accurate eligibility data, the plan stands to see a significant impact to its bottom line.

Look beyond dollars and cents

When evaluating your payment integrity strategy, you will want to think beyond dollars and cents. Quality eligibility data will have a positive effect on administrative efficiency, member satisfaction, and provider relations.

By avoiding improper payments in the first place, you avoid the need to rebill, saving you and your staff valuable time and energy that might be channeled toward other payment integrity initiatives.

Member satisfaction is a key priority for any health plan. In fact, the member experience drives performance on CAHPS (Consumer Assessment of Healthcare Providers and Systems), which is a key driver of Star ratings. Eligibility data drives a diverse number of systems and processes including registration, enrollment, care provision, wellness, and customer care. All of these areas influence your members’ experiences with your plan.

Lastly, providers depend on prompt, accurate payment. When claims are denied as a result of recurrent eligibility issues, payer-provider relationships already burdened by administrative complexity are further strained. Ensuring accurate eligibility data and determinations not only improves efficiencies, it also helps to accelerate reimbursements, greatly improving relationships and alignment.

Consider a connected payment integrity approach

Given the effect that eligibility data can have on payments, you will want to consider a connected payment integrity approach and address any gaps in your technology. Often, challenges arise from multiple sources of data, conflicting or inaccurate data, data integration challenges, manual workflows, multiple reporting systems, and more. By creating a technology environment that can support connected payment integrity functions (e.g., claims recovery, subrogation, and COB), business managers and IT can come together in their thinking and create a single, trusted source of eligibility data.

 

Contact Discovery Health Partners today to find out how we can support your payment integrity initiatives in 2020 and beyond.

1Gartner, “U.S. Healthcare Payer CIOs Must Adopt Prospective Payment Integrity to Thwart Improper Claims Payment and Fraud,” February 13, 2018.
Jeff MartinFixing payment integrity at the source
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