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.
read more

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
read more

3 bad habits that are good for healthcare subrogation

When it comes to getting better results from subrogation, forget everything you ever learned in kindergarten! Being unfair is…well, unfair; ignoring people is bad; and being pushy is rude.

But adopting a few “bad” habits actually can make your subrogation program stronger to drive better financial results and member feedback.

1. Be unfair

Not all subrogation cases are equal, so let’s not treat them that way. Some cases are worthy of more time and energy than others, so let’s find new and better ways to identify the right cases and use the most advanced methods to pursue them.

First, you have to be as certain as possible that a case has subrogation potential and this starts with the identification phase of your subrogation process.

For too long, the practice was to cast a wide net when looking for cases to subrogate. Anything that looked like a car accident or a slip-and-fall case ended up in the “verification” bucket. The problem with this “wide net” approach is that it funnels too many false positives into the process. Devoting time and resources to a case that has no recovery potential ties up your staff (which costs you time and money) and creates undue stress on members.

The last decade has seen advances in information science and technology that have allowed subrogators to more precisely identify cases that actually have third-party liability and can be expected to reach a settlement.

You can now mine claims data for details such as diagnosis codes and demographic data that signal a subrogatable case. In fact, ICD-10, which came out in 2015, has been beneficial for companies using data mining to zero in on claims with greater likelihood of having subrogation potential. Many health plans and vendors have adopted these techniques, which have allowed them to reduce false positives so they can use resources more efficiently and cost-effectively, while improving settlement ratios.

Recent years have seen the most aggressive health plans and vendors (including yours truly) begin to experiment with technologies that fall into the category of artificial intelligence, machine learning, and predictive analytics.

These emerging technologies allow us to build upon the improvements of the last decade by learning from subrogation results and automatically applying those learnings back into the case identification algorithms to become even more precise.

2. Ignore your members

Well, not really. But as you pursue the big business of subrogation for your health plan, keep an even bigger focus on your members’ experience. Remember that your members come first above all.

It has become clear to all of us in this business that we need to find more ways to verify the causes of injury and rely less on calling and mailing members repeatedly.  The first line of defense for your members is the identification process (described in #1 above), which allows you to more accurately identify cases that actually have third-party liability. With this smaller net, you minimize false positives, which as a matter of course, reduces unnecessary outreach to those members.

Additionally, you can take advantage of external liability databases and other third-party data services to augment your detection methods and further minimize member outreach. One use case for this type of service is medical malpractice and personal injury claims, which can be difficult to find using traditional data mining techniques. These techniques can shorten the lifecycle of subrogation cases by as much as 90 days, while minimizing member outreach.

3. Be pushy

The previous two subrogation bad habits lend themselves to the third, which is to be pushy. When we’re aggressive about accurately and quickly identifying and verifying subrogation cases, we increase our chances of not only reaching settlement more quickly, but also reaching a settlement that is agreeable to us and/or our clients.  How, you ask?

Prioritize cases

One way to get more aggressive is to prioritize cases by dollar values and “push” them to staff accordingly. Obviously, a case totaling $450,000 in claims demands more attention and resources than one totaling $4,000 in claims. Yet traditionally, all cases ended up in the same pile to be worked top to bottom. In subrogation, time is money.

The faster you act on a case, the better your chances of reaching a desirable settlement. But the faster cases pile up, and the more overwhelmed the team gets, the more this idea falls by the wayside.

Case management technologies can automatically drive prioritization methods throughout your subrogation process based on rules you define. As a result, you can get the timeliest and costliest cases pushed to the top.

Similarly, case management queues can assign specific cases to recovery specialists most suited to characteristics of the case. For example, if you can identify which team members are best at negotiating with difficult attorneys, then you can automatically push cases to those specialists.

Engage legal resources at the right time

Once you make it to the settlement phase of a subrogation case, it’s important to engage with your legal resources, whether internal or external, to aggressively pursue optimal recovery for the health plan.

Though settlement is typically the shortest phase in a subrogation case, it’s also the trickiest and most involved because it’s when you start talking about limited dollars available, you have to be articulate in legal arguments, you must have a strong understanding of the plan’s rights, and you must be able to aggressively negotiate to recoup dollars on behalf of the plan.

Subrogation lawyers and paralegals who are trained to manage these types of negotiations can navigate this complicated phase to quickly optimize your settlements.

Consider subrogation prepay cost avoidance

Health plans are showing a growing interest in identifying third-party liability before paying a claim. As health plans become increasingly adept at data integration for mining and analytics (either internally or through their vendors) they have more tools to inform pre-payment decisions.

If a plan is able to coordinate a third-party liability claim with a primary payer, it can avoid the cost without engaging in subrogation methods. Due to time constraints, pre-pay subrogation may prove to be more member intensive, requiring direct outreach to identify if there is another recovery source.

In the case of subrogation, as in most payment integrity functions, pre-pay cost avoidance has to be balanced with post-pay recovery. It’s never all or nothing. Even if the decision is to pay a claim because it appears that there is no liability or no other coverage available, the claim can be pended for potential post-pay subrogation.

Summary

Now is the time for subrogators to take a fresh look at the tools and techniques they use to identify, investigate, and settle third-party liability cases. Technology-enabled subrogation is the way to go, and fortunately for everyone, newer technologies are making it more possible than ever to narrow the focus on subrogatable cases, minimize member contact, shorten time to settlement, and maximize recoveries.

Learn more on our Subrogation resource page.

Heather Rodemann3 bad habits that are good for healthcare subrogation
read more

LaunchPoint, Discovery parent, named to Inc. 5000 list

Healthcare payer interest in payment and revenue integrity solutions drive sustained growth

 

ITASCA, IL (August 16, 2017) – LaunchPoint, a provider of cloud-based information-driven solutions for healthcare organizations and parent company of Discovery Health Partners and Ajilitee, today announced it has been named one of the fastest-growing private companies in the U.S. for the fourth year in a row, according to Inc. Magazine’s annual Inc. 5000 list. LaunchPoint’s three-year growth rate has earned it a place on the list since 2014, when it debuted at #100; 2016’s placement was #4719 among the fastest-growing private firms in the U.S. According to Inc. Magazine, only one in ten companies who have earned a spot on the Inc. 5000 list repeat that achievement four times.

“We’re honored to be part of the Inc. 5000 community for the fourth straight year and appreciate this recognition of our growth and marketplace success,” said Terrence M. Ryan, Chairman of the Board. “It is an exciting time to be in the healthcare industry, and we will continue to reach for exceptional standards of quality, client service, and results for our payment and revenue integrity clients.”

LaunchPoint serves more than 60 health plans nationwide through its Discovery Health Partners division, including five of the top ten health plans in the United States and 12 Blue Cross/Blue Shield plans. The company has added a dozen new clients year to date.

About LaunchPoint

LaunchPoint operates businesses that provide cloud-based information-driven solutions for healthcare organizations. Its two divisions are Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, and Ajilitee, a healthcare information and analytics consulting business. LaunchPoint has repeatedly been named a fast-growth technology innovator by Inc. 5000, which recognizes the country’s fastest growing companies; by Crain’s Chicago “Fast 50” list of fastest growing companies in the Chicagoland area; and as a finalist in the Chicago High-Tech Innovation Awards.

# # #

Discovery Health PartnersLaunchPoint, Discovery parent, named to Inc. 5000 list
read more

2017 TAHP Managed Care Conference & Trade Show

Date: October 23-25, 2017

Location: Houston, TX

Meet the Discovery Health Partners team at the Texas Association of Health Plans’ Managed Care Conference and Trade Show at the Marriot Marquis Houston. This year’s conference, “Connect. Innovate. Achieve.,” will feature a high-level roster of dynamic speakers who will be coming together to brainstorm and discuss ways to achieve greater value, affordability, transparency, and accessibility in health care.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Discovery Health Partners2017 TAHP Managed Care Conference & Trade Show
read more

Discovery Health Partners drives millions in recoveries and revenue optimization for Lovelace Health Plan

Analytics-based subrogation, COB and eligibility services improve health plan’s visibility, reporting and reduction of claims payment errors

ITASCA, IL (April 28, 2014) – Discovery Health Partners’ cost containment support for New Mexico-based Lovelace Health Plan has resulted in $16 million in recoveries and revenue optimization in two years, announced the company.

A mid-sized health plan, Lovelace has realized nearly $7 million in subrogation and COB recoveries working with Discovery Health Partners. These savings are the result of improved data mining, analytics, and modernized workflow available through Discovery Health Partners’ Intelligent Cost Containment Platform, which allows quick and accurate identification of cases for recovery.

By adding Medicare Secondary Payer (MSP) validation and premium restoration – a service that helps Medicare Advantage plans quickly and accurately validate MSP records, correct inaccurate records, and restore underpaid premium dollars – Lovelace has recovered an additional $7.1 million. A majority of these restorations were found within 120 days, with future revenue optimization forecast at $4.2 million annually.

“It’s a critical time for healthcare organizations to improve efficiency and performance. Discovery Health Partners’ reporting and analytics provided greater visibility into cases and trending. We also are impressed with how well their team partnered with ours,” said Karen Eskridge, Chief Operations Officer, Lovelace Health Plan. “Since working with Discovery Health Partners, we’ve pursued new savings, recovery and cost avoidance opportunities, improving our bottom line very quickly.”

Lovelace also engaged Discovery Health Partners for a Cost Containment Blueprint consulting engagement, which identified additional opportunities for cost savings and revenue generation.

“We look holistically at every health plan client’s cost containment program. Each has its own unique challenges and requirements, which our customized plans reflect,” said Paul Vosters, President and Chief Operating Officer, Discovery Health Partners. “Time and again, our clients say they value our flexible approach, partnership, and leading-edge case management and reporting tools.”

 

 

 

 

 

 

 

 

 

 

 

 

 

Discovery Health PartnersDiscovery Health Partners drives millions in recoveries and revenue optimization for Lovelace Health Plan
read more

Discovery drives millions in recoveries for Lovelace Health Plan

Analytics-based subrogation, COB and eligibility services improve health plan’s visibility, reporting and reduction of claims payment errors

ITASCA, IL (April 28, 2014) – Discovery Health Partners’ cost containment support for New Mexico-based Lovelace Health Plan has resulted in $16 million in recoveries and revenue optimization in two years, announced the company.

A mid-sized health plan, Lovelace has realized nearly $7 million in subrogation and COB recoveries working with Discovery Health Partners. These savings are the result of improved data mining, analytics, and modernized workflow available through Discovery Health Partners’ Intelligent Cost Containment Platform, which allows quick and accurate identification of cases for recovery.

By adding Medicare Secondary Payer (MSP) validation and premium restoration – a service that helps Medicare Advantage plans quickly and accurately validate MSP records, correct inaccurate records, and restore underpaid premium dollars – Lovelace has recovered an additional $7.1 million. A majority of these restorations were found within 120 days, with future revenue optimization forecast at $4.2 million annually.

“It’s a critical time for healthcare organizations to improve efficiency and performance. Discovery Health Partners’ reporting and analytics provided greater visibility into cases and trending. We also are impressed with how well their team partnered with ours,” said Karen Eskridge, Chief Operations Officer, Lovelace Health Plan. “Since working with Discovery Health Partners, we’ve pursued new savings, recovery and cost avoidance opportunities, improving our bottom line very quickly.”

Lovelace also engaged Discovery Health Partners for a Cost Containment Blueprint consulting engagement, which identified additional opportunities for cost savings and revenue generation.

“We look holistically at every health plan client’s cost containment program. Each has its own unique challenges and requirements, which our customized plans reflect,” said Paul Vosters, President and Chief Operating Officer, Discovery Health Partners. “Time and again, our clients say they value our flexible approach, partnership, and leading-edge case management and reporting tools.”

 

Additional information

To learn more about Discovery Health Partners and our solutions, please visit one of our resource pages or complete our contact request form to speak with a Business Development Director.

Press releases

Recent news

Search

Discovery Health PartnersDiscovery drives millions in recoveries for Lovelace Health Plan
read more