In February, my colleague Liz Longo was featured as a webinar speaker for the National Association of Subrogation Professionals (NASP) on the topic “Medicare Advantage Plan Recoveries: Best Practices and Shifting Legal Tides.”  This topic has been evolving for more than 10 years as litigation and case law have disputed over the issue of whether the private cause of action for double damages under the Medicare Secondary Payer (“MSP”) Act provides Medicare Advantage (“MA”) Plans with the right to bring suit against primary payers.  The early rulings generally held that the secondary payer rights and recourses granted to the government under the MSP are different and do not apply to MA plans under the federal statute. As such, the only recourse available to MA Plans was to pursue reimbursement of those conditional payments through contract-based action in state courts.

The most significant hurdle is overcoming the fundamental misconception that MA Plans are private insurers.  In order to do so, MA Plans must be “all in” in the sense that they must adhere to all of the rules and regulations imposed upon an MA Plan. That being said, MA Plans must be sure to operate with caution in order to avoid compliance pitfalls.  As such, MA Plans must notify members of appeals rights, track grievances, maintain records of coverage investigations, and stay up-to-date on DX code directives in the CMS MSP Manual.

MA Plans must also utilize effective subrogation pursuit and recovery strategies.  For example, ICD-10 and ISO are very effective methods of leveraging technology for member outreach.  The MA Plan may also track chronic conditions or review MSP files made available monthly by CMS.  In doing so, MA Plans will address a primary concern, which is to avoid member abrasion during the identification and investigation processes.

If you would like to hear more about our point of view on MA Plan recoveries and best legal practices for subrogation, you can listen to our recorded webinar, available in its entirety for NASP members by clicking here.

As Q4 begins (could it be true?), my colleagues and I are busy preparing our 2016 wish lists and calculating the budgets to support them.  As an executive team, we’ll spend the next several weeks taking a hard look at our results for the year so far and make some tough decisions about our financial plan for the next year.

I bet your plan’s executives are in the same boat. They’re reviewing the year behind and planning for the year ahead. Where is the plan succeeding? Where is it falling short? Which new initiatives will make into the next year’s budget? Which will have to wait?

As the year comes to an end, what can your plan do to boost results for the current year or get a head start financially for 2016? Consider taking a look at Medicare Secondary Payer (MSP). CMS premiums have a direct impact on your bottom line and there’s a good chance that you’re not receiving the full premiums you’re owed. In fact, you may be getting shorted by millions of dollars in premiums due to MSP. And even if your plan is already validating open MSP records to ensure correct primacy, you still may not be seeing all the opportunities to restore premium revenue.

My team at Discovery Health Partners worked with 16 Medicare Advantage plans over the last two years to restore $86 million in underpaid premiums. Many of these plans already had teams on the ground validating other insurance and attempting to correct erroneous CMS eligibility information in hopes of receiving premium adjustments. Roadblocks standing in the way of their success range from lack of focused resources and insufficient follow-up to a limited view of open MSP records (hint: you should be looking at ALL open records).

Within a matter of only a few months, we were able to help these plans restore millions of dollars to their bottom lines. This includes $20 million for a 96,000-member MA plan and $32 million for a 550,000-member MA plan. Even a 38,000-member MA plan was able to restore $13.4 million. What would an additional $10 million or $20 million mean to your plan’s financial performance?

By our calculations, Medicare Advantage plans as a whole are missing $2 billion in premium revenue. As MA membership quadruples over the next seven years, the problem (or shall I say opportunity?) will only increase.

If you’d like to learn more about how MSP validation may be able to provide that financial uptick you need at the end of the year, please reach out to me at my email address below. I’d welcome the opportunity to talk about our proven best practices and our low-risk contingency-based MSP solution.

By now, you’ve discovered how valuable it can be for Medicare Advantage (MA) health plans to validate and correct member records to restore underpaid premiums due to Medicare Secondary Payer (MSP).

Many MA plans, however, overlook the necessity to address Prescription Drug (Part D) open records with MSP.

Here are four important reasons to address Prescription Drug as part of your MSP process:

1. To comply with regulation.  This is the top reason to maintain accurate member records for Rx eligibility. CMS puts the burden on MA Prescription Drug plans to validate open MSP/Rx records on file with CMS for its members. Having an active validation process satisfies this compliance requirement. Medicare Advantage plans do get audited – and if they can’t prove proper validation, hefty fines can result.  Be sure to manage your Rx validation with a software application that tracks history in case an audit is requested by CMS.
2. To keep eligibility information accurate. Yes, it’s a challenge to maintain accurate eligibility data for your members, but it’s even harder to catch up on a backlog of outdated records. We’ve seen plenty of garbage data stemming from a lack of oversight. Addressing Prescription Drug continuously with MSP is a best practice to ensure member records are actively managed, which can deliver many downstream benefits.
3. To pay Rx claims correctly.  With poor quality or insufficient data, claims can get stuck. With too many open records requiring validation, claims get paid slowly – or sometimes not at all. For example: in contrast to medical claims that require only one number for claims payment, Rx claims require four numbers: RXID, RX Group, RX PCN and RX Bin.  All too often, one or more of these numbers is missing, which holds up payment.  Other number mismatches or invalid record types also cause delays. But when Rx data is accurate and complete, claims get paid smoothly and swiftly.
4. To provide better member service.  When drug claims are held up, health plans aren’t reimbursed and members can get stuck with bills.  Sorting out these problems frustrates members, wastes time, and clogs health plan resources to investigate and fix the issue. When prescription drug claims are paid the way they should, everyone benefits. Plan Benefits Managers are more confident in their claims data, and members are satisfied with their prescription drug coverage.

To get started, evaluate your current MSP efforts. Is Prescription Drug covered in your MSP process? If not, why?

Our clients often cite bandwidth as a common issue.  To their relief, we assure them that we’ve got it handled. We verify accuracy, find missing pieces of information, and send updated eligibility data ongoing.  When it comes to Rx validation, we always advocate a proactive approach – it saves time and delivers a better outcome for all involved.

For more information, check out our Medicare Secondary Payer resource page for links to additional articles and insights about advanced MSP solutions.

When it comes to premiums, many Medicare Advantage (MA) plans are being underpaid because of incorrect Medicare Secondary Payer (MSP) adjustments.

It’s a known problem – Commercial plans mandatory Section 111 reporting creates instances of other coverage for a member. This flags the MA plan as the secondary payer for that member resulting in a negative MSP adjustment. Meanwhile, in some instances the MA plan could continue to pay the member’s claims as primary.

Though most MA plans have a process in place to attempt to correct the records and restore underpaid premiums, many don’t realize just how much it could be costing them. In many cases, efforts fall far short of what is possible. Would you be surprised to hear that a 30,000-member MA plan could restore more than $4 million in underpaid premiums? Or that a 50,000-member MA plan could restore more than $6.5 million? While individual plan results may vary depending on existing processes, proven results have been staggering.

Based on our work with several MA plans to validate MSP records and restore underpaid premiums, my colleagues and I have designed a simple calculator to determine how much a plan can restore on average:

• 4% of MA membership has open MSP records
• 50% of those records have premium restoration potential
• Each member typically has 15 months of premium that can be restored from initial validation
• The average monthly premium adjustment is $450 (this varies slightly by state)

If you’re not achieving these results, it’s probably because of hidden challenges inherent in the MSP process, which can stand in the way of maximizing revenue from MSP.

• Focused and skilled resources. Validating open MSP records and restoring the underpaid premiums is a time-consuming effort that requires focus and skill. And who is not resource constrained these days? If a plan does focus on identifying and restoring underpaid premiums, it’s lucky to have one or two people managing the effort as one of multiple aspects of their jobs.
• A narrow view of open records. If you focus only on open MSP records for actively enrolled members or examine only a portion of MSP records per member, you may miss many opportunities to restore premium dollars. Though members may be deactivated, don’t forget that you can restore premiums back to 72 months.
• Validation dead ends. When I say time-consuming effort, do you automatically think, “validation?” How many hours have been wasted trying to find the right telephone number or learn the right key pad options to get to the right person or department at another insurer to validate a member’s coverage? It’s inefficient, and when it doesn’t work, it leads to escalations, member outreach (abrasion), or dead ends.
• The long road to update CMS records.  Or maybe, when I say time-consuming effort you think, “CMS updates.” Whether you submit updates by batch file or ECRS Web, it takes time and requires resources skilled in the nuances of CMS systems. Success here is partially dependent on the completeness of information gathered during the validation effort. Also key is the method you choose to submit your updates. Hint: ECRS Web may require more time and focus at first, but it typically yields more acceptances after first submittal – up to 99.9%. Batch updates are known to have a 60% – 70% acceptance rate.

Whatever the size of your MA plan, it pays to actively look at open MSP records and premium restoration potential. If you want to learn more about how to evaluate your potential, improve your process, learn best practices, or enhance your team’s skills, we’ll be happy to talk you through it.

For more information…

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