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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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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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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Four tips for balancing the effects of Medicare Secondary Payer

Medicare Secondary Payer (MSP) is a multi-pronged issue for Medicare Advantage plans. If plans aren’t monitoring the effects of MSP on medical and pharmacy claims as well as premiums from CMS, they could be hurting their bottom line—to the tune of millions of dollars. MSP also introduces compliance responsibilities that plans must regard or else face possible consequences.

This requires a balancing act to ensure primacy information is correct for members with other insurance and to verify that claims are paid and premiums are collected in accordance with the member’s primacy.  Plans should work to identify inaccurate primacy information and build processes that can help correct these errors so they can ensure accurate payments all around.

Let’s look further at each area.

Premium

It’s important to realize that CMS primacy information is not always correct. Medicare Advantage plans should be reviewing CMS information each month to verify primacy to identify underpaid premiums as well as overpaid premiums.

What’s your motivation to verify premium underpayments? Your bottom line! Underpaid premiums often cost health plans more than they realize, and, in fact, Discovery Health Partners has recovered more than $200 million in underpaid premiums for Medicare Advantage plans. When the MA plan moves from secondary payer to primary payer for a member, the plan can recoup underpaid premiums going back 72 months. This adds up quickly!

On the other hand, CMS mandates that plans repay premium overpayments within 60 days. Obviously, this is required to stay in compliance, so plans need to ensure they are checking for CMS overpayments as well.

As plans work to identify and correct primacy errors, we always advise them to do a root-cause analysis to determine why dollars were taken from the plan and identify the entity that “took” the dollars. For example, was it due to a Section 111 reporting issue? You can see this on a quarterly basis if you have constant flip-floppers (members for whom you already corrected primacy but who show up again later as secondary). This could indicate a problem on the commercial side of your own plan.

Once you identify the owner of the problem, you can work with them to make corrections. And you can prioritize the work by which entity or problem affected the most dollars for your plan.

Claims

The financial impact of incorrectly paid claims due to MSP is not as great as the premium impact, but it’s still a worthy effort to verify claims that can return dollars to your plan. As you know, primacy order determines how claims should be paid.

As you update primacy information based on a monthly review of CMS files, it’s important that MSP and claims specialists work closely together. As primacy order changes, claims specialists can make sure claims get adjusted and reviewed. They also should make sure that claims systems are updated in order to pay claims correctly to providers.

You also can recoup overpaid claims (claims that you paid as primary but should have paid as secondary). Usually, you can go back 12 or 18 months to adjust claims and recoup dollars—it depends on contracts with providers or state regulations—which can add up to millions of dollars. It seems that CMS is paying closer attention to how claims are paid and if they follow the order determined by the plan, so if you haven’t focused on this before, now is a good time to change that.

It’s important to look at the full picture across premiums and claims—if you’re getting a reduced premium and paying claims as primary, then it’s a double hit for your plan. If you can correct both, it’s an even bigger improvement to your bottom line.

Pharmacy

Part D plans have an obligation to verify primacy and ensure that member drug benefits are available to them when they need them. Plans that use a pharmacy benefits management firm (PBM) to manage pharmacy claims should be sure to share primacy updates with them and verify that they actually use that information. The PBM should pay claims based on recent verification on the medical side.

It helps to ask PBMs about their processes and how they use the information you give them. Ask them to map out the process so you can see that payments will be correct based on the information you share. Again, CMS is looking at this to ensure pharmacy claims are paid accurately.

Tips and tricks

If you’re uncertain about the performance of your MSP process, keep these tips in mind:

  1. Make it an ongoing process. Member primacy is constantly changing, so you have to keep on top of your monthly reviews.
  2. Check everything. As I said before, CMS may have inaccurate primacy information, so you have to double check that each month. Likewise, make sure your recovered premiums match your expectations each month—if you expect 60 months of premiums back, make sure you get the full 60 months.
  3. Assess. Get to root cause of errors and make sure updates get made.  For example, look for constant flip flops for indications such as Section 111 reporting problems. Also, review TRR 245 and 280s, which notify the plan of a member’s MSP status turning on and off. By reviewing and verifying the daily 245, you can avoid losing dollars instead of recouping after the premium has been reduced.
  4. Validate. Other insurers are your best source of validation information. Consider keeping a database of other insurer phone numbers to make research easier and faster. Use all the information available to you—member surveys, Section 111 responses, CMS reports, etc.

For more on this topic, view our on-demand webinar, Walking the line: balancing claims, premiums, and compliance for MA plans.

 

 

Discovery Health PartnersFour tips for balancing the effects of Medicare Secondary Payer
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MSP Validation momentum continues for Discovery with new wins in Q3

Blue Cross and Blue Shield plans headline new client roster

 

ITASCA, IL—October 24, 2017 – LaunchPoint division Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, added three Blue Cross and Blue Shield plans in Q3 to its growing roster of clients. More than 50 health plans, including 4 of the top 10 insurers, are Medicare Secondary Payer (MSP) Validation clients.

Honored two years in a row as a top 100-finalist in the Chicago Innovation Awards, MSP Validation helps Medicare Advantage plans recoup millions of dollars to their bottom lines by ensuring the accuracy of healthcare premiums paid by Centers for Medicare and Medicaid Services (CMS) for members with other health insurance. To date, Discovery has restored more than $200 million in underpaid premiums for its clients, including more than a dozen Blues plans.

MSP Validation analyzes plans’ open MSP records, validation of primacy, ECRS submissions, response monitoring, and premium reconciliation. The solution is typically delivered as an outsourced business process with Discovery experts managing the entire process on behalf of the client. It is often provided as a supplemental offering that complements clients’ existing efforts to help restore more. Clients can also subscribe to the service as cloud-based software to manage the MSP process in-house with their own staff. Many choose to take over ongoing maintenance after Discovery manages the initial restoration effort.

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience. We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.

 

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Discovery Health PartnersMSP Validation momentum continues for Discovery with new wins in Q3
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Webinar: Walking the line – balancing claims, premiums, and compliance for Medicare Advantage plans

Walking the line – balancing claims, premiums, and compliance for Medicare Advantage plans

The inter-connected relationship between MA compliance, claims, and revenue

As Medicare Advantage plans walk a tight line when ensuring optimal care, paying claims correctly, and meet regulatory standards, they must carefully consider the intertwining dependencies within their plans and with CMS, which can impact their ability to meet company goals while managing compliance.

Listen to Discovery Health Partners’ Medicare subject matter expert, Amy Cogsdill, as she discusses the delicate relationships between premium recovery, claims payments, and compliance for Medicare Advantage plans.

Please use the quick form on the right to access the webinar today.

Discovery Health PartnersWebinar: Walking the line – balancing claims, premiums, and compliance for Medicare Advantage plans
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Discovery MSP Validation achieves $200M in premium restorations

Milestone reflects accelerating momentum in new client growth

 

ITASCA, IL—August 29, 2017 – LaunchPoint division Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, has restored a record $200M in premium for its health plan clients through its MSP Validation solution. Honored two years in a row as a top 100 finalist in the Chicago Innovation Awards, MSP Validation helps Medicare Advantage plans recoup millions of dollars to their bottom lines by ensuring the accuracy of healthcare premiums paid by Centers for Medicare and Medicaid Services (CMS) for members with other health insurance.

“We can deliver significant premium restoration in a matter of months, which is continuing to drive strong interest in MSP Validation among health plans,” said Paul Vosters, Discovery president. “Few payment or revenue integrity solutions can boast of such a fast ROI,” he added. Discovery added five new clients in Q2 of 2017, covering in sum 346,000 Medicare Advantage members. New clients include such highly respected health plans as Tufts Health Plan, Geisinger Health Plan, and UCare. More than a dozen new MSP Validation clients have joined the Discovery client roster since the first of the year.

MSP Validation includes the analysis of open MSP records, validation of primacy, ECRS submissions, response monitoring, and premium reconciliation. The solution is typically delivered as an outsourced business process with Discovery experts managing the entire process on behalf of the client. It is often provided as a supplemental offering that complements clients’ existing efforts to help restore more. Clients can also subscribe to the service as cloud-based software to manage the MSP process in-house, with their own staff. Many choose to take over ongoing maintenance after Discovery manages the initial restoration effort.

 

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience. We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.

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Discovery Health PartnersDiscovery MSP Validation achieves $200M in premium restorations
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Discovery to speak at MedAdvantage Operational Finance Summit

Session by Discovery Health Partners’ Kathleen Cortez to set the stage for understanding payment integrity’s role and value

 

ITASCA, IL (July  11, 2017) –Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, will co-sponsor and speak at the Medicare Advantage Operational Finance Summit on July 18-19, 2017, in Chicago. Hosted by Healthcare Education Associates and RISE, the conference brings together Medicare Advantage executives from operations, compliance, membership, and other areas to discuss enrollment and membership operations, accounting and reconciliation, and comprehensive payment integrity.

Discovery Vice President of Operations Kathleen Cortez will kick off the payment integrity track with a discussion of the role and value of a comprehensive payment integrity program for the Medicare Advantage plan.  “Kathy does an excellent job helping stakeholders understand what payment integrity is, how it fits within the MedAdvantage plan, and what value it delivers,” said Paul Vosters, Discovery president.  Payment integrity addresses the accuracy of the transaction occurring between health payer and provider.  It ensures that the health claim is paid correctly—by the responsible party, for eligible members, according to contractual terms, not in error, and free of wasteful or abusive practices.

The session also includes a discussion of payment integrity best practices as gleaned from almost a decade of Discovery’s experience helping health plans manage such programs.

Discovery Health Partners is a member of RISE, the Resource Initiative and Society for Education, an organization dedicated to ongoing outreach and education for health plans and providers.  Discovery frequently speaks and exhibits at conferences managed by RISE affiliate Healthcare Education Associates.

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience.  We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.  More information about our solutions, including Coordination of BenefitsEligibilityMedicare Secondary Payer Validation, and Subrogation is available at https://www.discoveryhealthpartners.com.

 

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Discovery Health PartnersDiscovery to speak at MedAdvantage Operational Finance Summit
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Discovery Health Partners sustains momentum in Q1 with MSP wins

Strong business case and quick ROI keep demand strong with health plans of all sizes

 

ITASCA, IL (June 26, 2017) – LaunchPoint division Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, added 5 clients in Q1 of 2017 for its Medicare Secondary Payer (MSP) Validation solution. This strong success sustains the strong momentum of the last three years during which 35 health plans chose Discovery’s MSP Validation solution, representing a third of the Medicare Advantage market.

Discovery Health Partners, honored two years in a row as a top 100 finalist in the Chicago Innovation Awards, helps Medicare Advantage plans recoup millions of dollars to their bottom lines by ensuring the accuracy of healthcare premiums paid by Centers for Medicare and Medicaid Services (CMS) for members with other health insurance. In the last three years, Discovery has restored more than $150 million in underpaid premiums for its MSP Validation clients.

“Clients love this solution because the ROI can be realized in a matter of months,” said Paul Vosters, Discovery president. “While the larger plan has the most to gain given their larger member base, there is clear advantage for Medicare Advantage plans of any size,” he added. Q1 new clients include both small, mid-sized, and large Medicare Advantage plans, including Upper Peninsula Health Plan, PacificSource Health Plans, and one of the top 5 health plans in the U.S.

MSP Validation includes the analysis of open MSP records, validation of primacy, ECRS submissions, response monitoring, and premium reconciliation. The solution is typically delivered as an outsourced business process with Discovery experts managing the entire process on behalf of the client. It is often provided as a supplemental offering that complements clients’ existing efforts to help restore more. Clients can also subscribe to the service as cloud-based software to manage the MSP process in-house, with their own staff. Many choose to take over ongoing maintenance after Discovery manages the initial restoration effort.

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience. We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.

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Discovery Health PartnersDiscovery Health Partners sustains momentum in Q1 with MSP wins
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A second look at underpaid CMS premiums could restore millions

 

Premium loss due to Medicare Secondary Payer (MSP) has more impact on the financial bottom line of a Medicare Advantage (MA) plan than many people realize. Though MA plans are on the task – attempting to find and correct errors in member eligibility and CMS premium payments – most are still missing millions of dollars due to hidden challenges in the process.

For this reason, any plan could benefit from a supplemental “lookback” at their MSP files to ensure all the bases have been covered and premium revenue has been maximized. This simply means looking back through the plan’s MSP, MMR, and member eligibility files to look for cues that the MA plan is owed additional premium reimbursement for certain members, either because of inaccurate eligibility information or because of a process issue that was unable to correct eligibility information and restore the premium.

Why supplemental MSP Validation is necessary

The reasons that these cues may have been missed in a first pass are varied and often include:

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

Some of the most common reasons plans are unable to identify or restore underpaid premium are out of the control of the department that is managing MSP validation. Would you even know if your IT department is sending you incomplete data? What if you can’t 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 supplemental MSP Validation works

Typically, when a MA plan does a “lookback” across its full MSP file, it can expect to see a spike in premium restorations over an initial validation period of about 4 to 6 months, often bringing in millions of dollars in additional premium revenue.  Restorations will then taper off as the plan maintains a best practices MSP program.

Discovery Health Partners provides a supplemental MSP Validation solution that complements MA plans’ internal efforts by doing this lookback for them.  Again and again, we find that even though most of these plans are working diligently to identify eligibility issues and premium reductions due to MSP, every one of them had been underpaid more than they realized.

In fact, in the last three years, we have recovered $150 million in additional premium restoration opportunities across all of our MA clients. These include plans of all sizes and maturity levels:

  • 100,000-member New York area health plan – $24 million
  • 30,000-member Midwestern health plan – $16 million
  • 20,000-member regional plan – $2.1 million

The amount of potential restoration opportunity for a MA plan is a function of five parameters. The variability of these parameters among our clients has resulted in a premium recoupment range of $11 premium per MA member on the low end to $419 premium per MA member on the high end.

  • The number of identified indications of other insurance on file with CMS for the plan’s MA members
  • The percentage of inaccurate records successfully validated
  • The number of months of actual restoration opportunity there is for each incorrect record
  • Average monthly restoration amount
  • CMS acceptance rate of corrections submitted

Check out our newest infographic, which highlights the impressive results MA plans of all sizes have had with a supplemental MSP validation solution that complements their ongoing internal efforts.  You’ll see why using an outside firm to help with this lookback can yield additional premium recoupment at no risk to your plan.

Paul VostersA second look at underpaid CMS premiums could restore millions
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