GRIEVANCES AND APPEALS (G&A) ALCHEMY · Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare

GRIEVANCES AND APPEALS (G&A) ALCHEMY

Turning Complaints into Gold

REGAN PENNYPACKER VICE PRESIDENT

Copyright © 2015, Gorman Health Group, LLC

• Never welcome, often feared by the recipient. • They stem from dissatisfaction and disagreement. • Must haves: the right coordinators in place to address issues like a

pro, the right management to analyze and recommend improvements, and empowered leadership to effectuate change.

• The bare minimum is no longer enough • Solidifying the relationship with members • Taking a cue from CMS feedback

GRIEVANCES AND APPEALS Components of MA-PD Complaints

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• Fear of Complaints • The Basics of Grievance and Appeal

Regulations • What They’ve Said, What We’ve Seen • CMS Conditions and the Effect on Star

Ratings • Quality Service

WHAT WE’RE GOING TO DISCUSS

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• Why do we fear them? • How do we change our

perception? • Dealing with those who

complain - EXPLORE • Building trust

FEAR OF COMPLAINTS

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• Misunderstanding of complaints

• Complaining customers are still engaging with us

• Think of it as description of a business process that is not working, such as: o Restrictive scripts o Procedural breakdowns o Insufficient onboarding

A COMPLAINT IS A GIFT By Janelle Barlow and Claus Møller

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• Standard time frame • Quality of Care response • Expedited time frame • Grievance rights

communication • CTM • Lastly: Filing methods?

QUESTIONS AND ANSWERS

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HIGHLIGHTS OF G&A HISTORY It’s not fashionable or trendy – it’s a classic

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• 1997 – BBA • 2001 – G&A regulations released

o Distinguished from organization determinations and appeals. Grievance procedures are separate and distinct from organization determinations and appeal procedures, which address organization determinations.

• 2003 – Chapter 13, Medicare Managed Care Manual (MMCM) • 2003 – Medicare Modernization Act (MMA) • 2004 – Four updates to Ch. 13 • 2005 – Part D audit guide released for review and comment

o Guess what – little has changed

PASSAGE OF TIME History and Evolution of Regulations and Guidance

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• 2006 – Significant Ch. 13 changes including change to Medicare Advantage (MA), implementation of 30-day time frame; release of Prescription Drug Benefit Manual (PDBM) Chapter 18

• 2006 – Audit guides available on the Health Plan Management System (HPMS)

• 2007 – Chapter update • 2008 – HPMS memo: Part D Appeals Requirements

o Sponsors not meeting time frames


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• Sept. 2010 – HPMS memo: Part D Compliance Issues – Grievances, Coverage Determinations, and Appeals o Lack of adequate tracking systems resulting in missed adjudication time

frames o Failure to expedite coverage determination requests o Failure to properly classify and process grievances o Deficiencies in the area of Coverage Determinations, Appeals, and

Grievances (CDAG) may constitute a significant risk to Part D enrollees to the extent such deficiencies result in denying prompt access to medically necessary covered prescription drugs

• Nov. 2010 – HPMS memo: Reminders Related to Timely Adjudication of CDA .. Two months later?


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• 2012 – Ch. 13 refinements: Medical director, medical necessity decisions

• 2012 – First release of CMS Program Audit Protocols released as we know them today; include CDAG and Organization Determinations, Appeals, and Grievances (ODAG)…

• 2013 – CMS requires complaint form on plan websites to be prominently displayed

• 2013 – audit protocols include CDAG and ODAG… • 2014 – audit protocols include CDAG and ODAG… • 2015 – audit protocols include CDAG and ODAG…

PASSAGE OF TIME The more things change?

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WHAT CMS HAS SAID SO FAR

(A.K.A. what you’ve heard a million times already)

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• Grievance resolution letters failing to provide enrollees with written notice of their right to file with, and the contact information for, the Quality Improvement Organization (QIO);

• Sponsors providing inaccurate or incomplete information in grievance resolution letters;

• Sponsor failed to notify enrollees of the resolution of grievances within CMS-required timeframes;

• Failure to properly address and resolve grievances; • Mishandling of quality of care complaints; and • Misclassifying organization determinations or reconsiderations

as grievances.

THINGS WE HAVE OBSERVED If You Give Me a Minute, I’ll Think of Something to Complain About

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• CMS turning up the heat • Reiteration • CMS G&A training • Sanctions • Notices • CMPs

o Are all these related to complaints?

o YES!

CMS CONDITIONS AND EFFECT ON COMPLIANCE

Doctor, I keep getting notices of non-compliance when I’m non-compliant…

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STAR RATINGS/ COMPLIANCE CORRELATION

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• High correlation between Star Rating and “red flag” issues

• Review Complaints per 1,000 average and disenrollment rate

• Sub-3-Star plans on CMS “hit list” in 2015 o “Scarlet letter” on Medicare.gov o Letters to members o Plan terminations

Overall Stars Complaints/ 1,000

% Disenroll Annually

0.78 .23%

½ 0.29 .15%

0.32 .16%

½ 0.21 .13%

0.19 .08%

½ 0.11 .06%

0.13 .03%

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That’s an incredible statistic, showing the rapid effectiveness of Stars impacting the member experience at the plan level in just a couple years. Stars has truly become a game-changing indicator of quality across health plan functions. – JG, September 19, 2014

VOLUNTARY DISENROLLMENT September 2014 MedPAC

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Medicare Advantage demographics and enrollment patterns, Harrison and Zarabozo, 2014


• When members do not contact you • When members do contact you

o Some will agree o Some will not o Most will be neutral

• Consequences of this treatment

CALCULATING LOSSES

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• Outstanding service every time • Value that exceeds needs and expectations • Promise • Values

o Customer Focus o Accountability o Innovation o Excellence o Integrity o Respect o Compassion

• Vision: four cornerstones

COMMITMENT TO QUALITY

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1. Assisting members with problems is a clear priority in our company.

2. The way my department is organized makes it easy for employees to solve member problems quickly.

3. The way we are organized makes it easy for members to reach the right person or area when they have a problem or question.

4. Members experiencing problems can start the recovery process with one single contact. Our system doesn’t require the member to make multiple contacts to get resolution on an issue.

5. Customer Service knows what they can personally do to solve member problems.

6. We have an established process for collecting data in inquiries and grievances, analyzing their meaning, and making changes as warranted.

TRUE/FALSE EXERCISE

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DISCUSS

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GETTING TO QUALITY SERVICE

Tools – People – Processes

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• Tools at hand • Successes? Failures? Was the

system a cause of any findings identified in auditing and monitoring?

• Are you responding in time? • Are you providing the best,

most appropriate resolution possible?

TOOLS OF THE TRADE A Little Self-Assessment Never Hurt Anybody

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• Eye of the beholder • Have the right people in the right jobs

o Coordinators who are empowered and handle issues like a pro o Management to analyze and recommend improvements o Leadership that supports or effectuates changes needed o Long-term strategy

• How to communicate with internal and external customers effectively • Stand by your actions: Can you say you did all you could to

address?

PEOPLE PROVIDING QUALITY SERVICE People Do Business With People They Like

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• Ideal staffing scenario • Working with what’s in place?

How has that worked so far? • Case Coordinator • Quality Analyst • Auditors • Management • Directors • Change leaders

THE RIGHT STAFF Comprised of the necessary goals and behaviors

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• Frequent monitoring • Periodic audits • Trends: How many complaints

need to be filed before you call it a trend?

• Going to the source – member o During resolution o Post-resolution

• Uncomplicated procedures • Root cause analysis

QUALITY SERVICE: PROCESSES We Can Do This the Easy Way, or the Hard Way.

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ROOT CAUSE ANALYSIS Chief Alchemy Officer

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THE SIX PS

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Why did this member complain? What experience led them to this stage? Did we have a previous opportunity to resolve? What was in the organization’s control that did not meet the member’s expectations? Was the member respected? Listened to? Appreciated? Am I seeing this complaint as a gift?

SERVICE BASICS The Power of Customer-Centric Service

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Year Suspension Termination CMP CMP Total Total ACR 2008 2 1 0 0 3 of 3 2009 5 1 6 $125,750 2 of 12 2010 5 1 9 $834,970 7 of 15 2011 0 1 8 $431,000 0 of 9 2012 2 0 10 3,300,000 6 of 12 2013 3 1 11 1,131,505 5 of 15 2014 5 1 30 $4,925,150 30 of 36 2015* 1 0 10 $2,460,250 10 of 11

ACTIONS: COMPLAINT-RELATED

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Data based on when action imposed and not program audit year Source: CMS.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/Part-C-and-Part-D-Enforcement-Actions-.html *As of March 30, 2015


Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare managed care, Medicaid and Health Insurance Exchange opportunities. For nearly 20 years, our unparalleled teams of subject-matter experts, former health plan executives and seasoned health care regulators have been providing strategic, operational, financial, and clinical services to the industry, across a full spectrum of business needs. Further, our software solutions have continued to place efficient and compliant operations within our client’s reach. GHG offers software to solve problems not addressed by enterprise systems. Our Valencia™ software reconciles the capitation payment of more than six million Medicare beneficiaries and continues to support customers participating in the Health Insurance Exchanges. Nearly 3,000 compliance professionals use the Online Monitoring Tool™ (OMT), our complete Medicare Advantage and Part D compliance toolkit, while more than 45,000 brokers and sales agents are certified and credentialed using Sales Sentinel™. In addition, hundreds of health care professionals are trained each year using Gorman University™ training courses.

We are your partner in government-sponsored health programs

T

E

REGAN PENNYPACKER VICE PRESIDENT

(401) 743-0003

[email protected]

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GRIEVANCES AND APPEALS (G&A) ALCHEMY · Gorman Health Group, LLC (GHG) is a leading consulting and software solutions firm specializing in government health programs, including Medicare