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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eBook: Restoring millions for your Medicare Advantage plan

eBook: Restoring millions for your Medicare Advantage plan

Correctly paid Medicare Advantage premiums are a critical source of revenue for many health plans

Unlock the hidden value in your data to identify root causes of errors and collect the full value of premiums owed to your plan.

Download our eBook and find out how a Premium Restoration strategy can help you:

  • Identify members with premium restoration potential
  • Improve process efficiencies
  • Monitor the financial impact
  • Maintain ongoing premium restoration activities

Discovery Health PartnerseBook: Restoring millions for your Medicare Advantage plan
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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.

Jeffrey 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.
Jeffrey MartinESRD: Finding and restoring underpaid CMS premiums in five steps
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A year in review: top blogs from 2019

The new year is upon us and with it comes a new decade. It has been a decade of transformation for healthcare with regulatory changes, health system consolidation, healthcare consumerism, and new technologies that have forever changed the industry. 2019 has been a time of change and growth for Discovery Health Partners as well. Here are highlights from our most popular blogs of 2019 to remind you what we’ve been up to all year.

3 bad habits that are good for subrogation

In February, we talked about the three “bad habits” that can lead to successful subrogation: be unfair, ignore your members, and be pushy. In any other scenario, these tactics can get you into trouble. But for subrogation, being unfair requires that you not treat all cases equally. Ignoring your members is all about avoiding member abrasion. And being pushy involves aggressively identifying and verifying subrogation cases. Altogether, these tactics help improve the opportunity for quick and fair settlement of subrogation cases.

Why Medicare Advantage plans may be losing money on members with ESRD

In March, we featured a post about the challenges Medicare Advantage plans face with members with end-stage renal disease (ESRD). Though ESRD afflicts fewer than 100,000 people nationwide, the disease requires lifelong care—and a disproportionate percentage of medical expense. The blog discusses the gap in CMS premiums for ESRD members and what Medicare Advantage plans can do to better identify them.

It’s challenging to identify and restore underpaid ESRD premiums. Here’s how to solve that

Another popular blog continued the ESRD discussion, highlighting a systematic approach Medicare Advantage plans can take to restore ESRD premiums. This includes automating the process of sifting through data to identify potentially underpaid premiums and maximizing the 84 months that CMS allows plans to identify, investigate, and restore premiums. The blog identifies five key components of an effective ESRD program: analytics, investigation, remediation, restoration, and monitoring.

Subrogation: 3 ways SaaS can help

In July, we returned to the topic of subrogation with a discussion of how software-as-a-service applications can help. Plans are finding that combining SaaS applications with in-house expertise creates a more effective, data-driven approach for finding and validating subrogation recovery opportunities. Specifically, you can: 1) make in-house recovery more efficient and insightful; 2) gain accessible, easy-to-use, scalable, and secure solutions; and 3) do more at a lower cost.

Stay tuned to our blog for more insights on these topics and to see what 2020 has in store. You can also get the latest industry and Discovery updates by following us on LinkedIn and Twitter. Are you interested in learning how Discovery Health Partners can support your organization? Contact us today!

Discovery Health PartnersA year in review: top blogs from 2019
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It’s challenging to identify and restore underpaid ESRD premiums. Here’s how to solve that.

Why it’s a challenge to identify and restore underpaid ESRD premiums

In her recent blog, Why Medicare Advantage plans may be losing money on members with ESRD, my colleague Lyndsay Deckert addressed the challenges MA plans face with receiving accurate premiums from CMS for members with end-stage renal disease (ESRD). I’ll pick up from Lyndsay’s information and delve more deeply into how Medicare Advantage plans can restore underpaid ESRD premiums.

Health plans miss out on millions in premium revenue that can be traced back to missing or inaccurate CMS data about ESRD statuses for MA members. To address this, many plans have developed processes for identifying and correcting inaccurate data, restoring underpaid premiums, and ensuring they collect the correct premiums going forward for their members with ESRD. However, ESRD premium restoration is a complex process that requires combing through multiple data sources to identify potential premium gaps and working through providers to correct ESRD-related patient information. This process is painstaking and requires tenacity.

ESRD reporting is (mostly) out of your control

The first challenge is sifting through data in CMS Monthly Membership Reports (MMRs), plan eligibility files, and claims data to find any potentially underpaid premiums. The clues may be hidden in various, disparate data sources. To make sense of these clues, it helps to have an automated process to bring all these data sources together and use optimized analytical queries to find anomalies in the data. This is in your control.

What’s not in your control is updating the potential missing flags once you’ve identified them. Plans must work with providers who are often pressed for time and resources and are subject to human error. One simple mistake can prevent CMS from restoring a patient’s ESRD status in the member data. This omission can take years to uncover and can cost the health plan millions in the meantime.

Plans can take control of ESRD restoration with systematic approach and patience

CMS allows health plans to identify, investigate, and restore up to 84 months of underpaid premiums for members with ESRD. However, it’s the plan’s responsibility to identify those ESRD members and to ensure their data is validated and corrected according to CMS guidelines.

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.

Here are 5 components of an effective ESRD premium restoration program that plans should look for:

Analytics—Comb through vast amounts of MMR, eligibility, and claims data going as far back as 84 months and identify likely ESRD members that require further investigation

Investigation—Determine the root-cause issues for each ESRD member that’s identified and the right process for addressing the issues with the appropriate submitting authorities

Remediation—Use the right method of outreach and coordinate with dialysis centers, CMS, or other third parties to ensure that information is corrected and updates are confirmed

Restoration—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

Monitoring—Ensure that each identified ESRD member status continues to be reported accurately and that correct premiums continue to be paid

With a systematic approach, time, and patience, plans can gain control of ESRD member statuses and restore underpaid premiums.

Kevin McDonaldIt’s challenging to identify and restore underpaid ESRD premiums. Here’s how to solve that.
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Infographic: ESRD has a major impact on Medicare Advantage financials

ESRD has a major impact on Medicare Advantage financials

Additional ESRD Premium Restoration resources

For more information, please visit our ESRD Premium Restoration resource page or complete the contact form on the right to speak with a Business Development Associate.

Discovery Health PartnersInfographic: ESRD has a major impact on Medicare Advantage financials
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Why Medicare Advantage plans may be losing money on members with ESRD

MA plans may be operating at a deficit for some members with ESRD diagnoses

Among the Medicare Advantage (MA) population, roughly half of a percent of members have a costly disease known as ESRD, or end-stage renal disease. Though this accounts for just under 100,000 people nationwide, the disease requires expensive, life-long care, which results in a disproportionate percentage of medical expense. For this reason, MA plans must ensure they know who these members are and verify that the premiums they’re receiving from The Centers for Medicare and Medicaid Services (CMS) are correct.

The 21st Century Cures Act (CURES; P.L. 114-255) will allow Medicare-eligible individuals with existing ESRD to enroll in Medicare Part C plans beginning in 2021[i]. With this significant change and as MA plans grow in popularity among older Americans, plans can expect to see an increase in their members with ESRD. To help manage this change, plans must focus on maximizing their financial performance so they can continue to remain competitive and offer enhanced benefits and care for their members.

And when it comes to covering the cost of care for members with ESRD, if CMS isn’t correctly paying these members’ premiums, then plans begin to operate at a deficit for these members. They pay the high cost of care, including ongoing dialysis treatments, but they do not receive the revenue to cover those costs. Over time, this adds up to millions in lost revenue for plans.

Higher CMS premiums should cover higher cost of care

CMS pays MA plans a significantly higher premium for each member with ESRD to help cover the higher costs of their expensive long-term treatment and care. The difference between a base monthly premium for a healthy member and a member with ESRD is roughly $6,000.

Because most members with ESRD are affected by a variety of additional health factors that affect their CMS premiums to the MA plan, the actual monthly loss per member can exceed $7,000. You can see how, when those premiums go unpaid, this adds up quickly for a single member and why, for such a small population, the deficit can grow exponentially across the whole population. Considering nationwide MA membership, this represents as much as $600 million in lost ESRD revenue opportunity industry-wide.

ESRD diagnoses go unnoticed

You may wonder how CMS might be overlooking ESRD statuses. The reasons range from clerical errors to eligibility issues to technology problems. Sometimes it’s just a matter of a delay before CMS begins paying the premiums. In any case, it’s incumbent on the health plan to find these errors and work to correct them so they can recoup underpaid premiums.

Like with premiums for Medicare Secondary Payer (MSP), CMS allows health plans to recover underpaid ESRD premiums 84 months in arrears. All MA plans should examine their populations to identify any missed ESRD statuses and corresponding premium errors. They can work through CMS and providers to identify why the errors happened, correct the problems, and restore underpaid premiums.

Is my plan losing out on ESRD revenue?

Possibly. Unfortunately, ESRD premium gaps are difficult to manage because of the reliance on third-party providers such as dialysis centers.

The bottom line is that ESRD patients may not get flagged in CMS data. And since plans don’t have ready access to the information used in ESRD treatment and reporting, they may not even be aware of a member’s diagnosis until months or years into their treatment, after they have already missed out on millions in premiums.

We work with a number of MA plans to find missing ESRD flags and restore underpaid premiums for those members.  We’ve consistently identified millions of dollars in underpaid premiums for plans with more than 100,000 members. And even though some of these plans already successfully identified missing ESRD flags, we uncovered even more.

Learn more about restoring underpaid premiums for members with ESRD.

[i] https://fas.org/sgp/crs/misc/R45290.pdf

Lyndsay DeckertWhy Medicare Advantage plans may be losing money on members with ESRD
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Webinar: Restoring underpaid CMS premiums for members with ESRD

Restoring underpaid CMS premiums for members with ESRD

What you can expect from this webinar

The process of identifying and restoring underpaid ESRD premiums is time-consuming and complex. This can stand in the way of maximizing the premiums you deserve for your membership with ESRD. View this on-demand webinar to learn:

  • Why CMS premiums for ESRD can go unreported and underpaid
  • The challenges involved in identifying underpaid premiums for MA members with ESRD
  • The challenges involved in restoring premiums
  • Discovery’s solution to help MA plans find and restore additional premiums

Use the quick form on the right to view the webinar on-demand.

Discovery Health PartnersWebinar: Restoring underpaid CMS premiums for members with ESRD
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