Draft Part C and Part D Appeals Guidance for Industry Comment

On October 1, 2018, the Centers for Medicare & Medicaid Services (CMS) released consolidated draft chapter guidance based on Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual.

CMS requests comment on the revisions, structure and format by close of business, Monday, October 22. In a new publication, I summarize notable revisions and provide suggestions and points to ponder based on my experience with this beneficiary-impacting area of plan operations.

Whether you are a new or experienced in your role – be it Compliance Officer, VP of Operations, Appeals Director – and whether you are at a plan sponsor or entity delegated to perform these functions, my summary provides key considerations to supplement your review.

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Crushing Deductibles Affect RI Families

Many employer group plans today have higher than normal deductibles. In my experience (and under past employment), benefit plans generally did not have an in network deductible, and my out-of-pocket costs included either copayments of flat dollar fees, or coinsurance, percentages of a total. Deductibles were saved for out of network benefits, and even then we were talking only $500 or $1000, on a generous plan. Nowadays, a family has to meet so many out of pocket costs.  I have two anecdotes to provide in this regard.

A family member experienced a glitch, and was not able to change her plan as of January 1 of this year. A new plan with a new deductible was in effect February 1.  Unfortunately, her out-of-pocket costs incurred in January do not offset her February plan with a new organization. She has filed appeals requesting exceptions, which hopefully will be approved because the Summary of Benefits and Coverage (SBC) has been arguably watered down to incompletion. This is a great difficulty for someone self-employed and raising a family.

A close friend has been helping her sister financially as she undergoes treatment for a serious illness. Her sister was diagnosed a few months ago, and has a plan your benefit which includes a $6000 deductible starting June 1. She works for a major pharmacy benefit manager in a warehouse position, and has so for years, but barely makes a living wage considering she is single, taking care of her disabled son as well as a granddaughter. My friend is self employed herself and is now hustling as best she can to help her sister pay participating physicians who are demanding cash upfront.

These anecdotes illustrate a couple examples of how our current system is causing great financial harm to working families. More refinement is needed to make sure people don’t delay care and providers do not refuse care due to cost.

Passed the Test!

This past week I completed and passed the exam to be a Certified Compliance & Ethics Professional, or CCEP. This certification is administered by the Compliance Certification Board.  Continued education is something I personally value and in all instances of my professional activities, it enhances not only my client work but also my decision-making as a manager of staff and as a board member of a health center. I recommend anyone in this field to pursue this or a similar certification.

In other news, 2018 seems to be flying by. I am keeping busy not only with career obligations but also with my volunteer efforts. We are seeking a new CEO for our health center, as our current leader is retiring. He has some pretty big shoes to fill, so if you know anyone with some HRSA experience and a penchant for New England living, don’t hesitate to send them my way. Really, is it almost March?

 

January Imperatives

A few thoughts during this quiet Sunday in a temperate January come to mind that I hope all readers consider:

  • Yes everyone has their feelings about the flu shot. I’m not here to preach about the vaccination as it’s a personal decision you make with your medical professional. However, as a human, it’s not only flu season we are dealing with but also a very miserable virus. It’s scary the number of reported casualties this season. If you or a family member is under the weather, get checked out. Here are some helpful tips on choosing the right setting for your medical care.
  • The first State of the Union Address delivered by President Trump will be this coming Tuesday, January 30. Anticipated themes include tax reform, border security, immigration, and the stock market. Tune in at 9PM Eastern.
  • On the local front, while Q4 2017 data is not finalized, I am hoping that accidental drug-related overdose deaths are on the decrease for our tiny state. Every live saved is a blessing and a gift that has slipped through another family’s fingers. Continue educating yourself and promoting recovery options for all.

Looking forward to a prosperous and healthy 2018 for everyone.

#OpioidEpidemic

My brother died of a Fentanyl overdose this year. Next year, he will be included in all the charts and bar graphs showing the thousands of overdose deaths. You won’t see his name, but I will see it, and so will his mother and father and brother, burned on every chart, graph, and state map.

The top story on my bookmarked news page earlier today  was about President Trump declaring the opioid crisis a Public Health Emergency. It is now a mere hours later and the headline is now regarding talks of a major pharmacy player that may potentially puchase the nation’s third largest health insurer. It seems to me this crisis is reduced to the fleeting hashtag level of awareness – here today, gone tomorrow.

According to the Centers for Disease Control and Prevention, an average of one hundred and seventy five people in the United States died every day last year due to overdose. One hundred and seventy five families devastated a day.

Stats and colorful maps are fantastic eye-catching tools to raise visibility, but we are all Davids and this crisis is the Goliath. When do we stop the bleeding? Who should be held accountable for immediate changes? In my work, it is all about identifying root causes and Corrective Action Plans. We create a Beneficiary Impact Analysis when there is the hint of risk to plan enrollees. When can the collective Davids join up and bring this epidemic to the ground? When will Goliath collapse?

I close this with a link to Virginia Recovery Foundation. These good people educate family members on how to get loved ones the help they need, and your donation will honor my brother. Or, please give to your local community resources.