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Tackling the Top Challenges faced by Medicare Advantage Organizations in Managing Mandatory CMS Materials

BY Sohail Malik

Medicare Advantage is the fastest growing business segment in the Healthcare insurance industry in the United States.

According to a recent report by KFF, Medicare spending is expected to double in the next 10 years with similar growth expected in Medicare membership. According to the Centers for Medicare and Medicaid (CMS), one in three Medicare enrollees selects a private Medicare Advantage plan.

This growing market segment represents a big opportunity for Medicare Advantage Organizations (MAOs) that are prepared to take advantage of it. That said, many are challenged to meet the rigorous demands presented by the regulatory controls and requirements surrounding CMS-mandated customer plan materials such as the Annual Notice of Change, Evidence of Coverage, Summary of Benefit, and related materials.

Medicare Advantage Organizations key challenges

In a recent poll conducted by Messagepoint and World Congress Events, MAOs identified the following challenges in managing these materials:

  • Missed deadlines & late submissions – Due to the complexity of making the annual changes required by CMS, responding to last-minute changes by CMS and the pressure on employees to pull through
  • Employee burnout – Due to long hours spent over the summer responding to CMS model and data change requirements
  • Document quality challenges (Leading to errata, fines, rework) – Issues with compliance with CMS models and inconsistencies between plan submissions are extremely common
  • High costs – Various approaches do not support economies of scale – as the number of plans grow, costs grow at the same rate
  • Work effort impedes business scalability – Depending on the approach, the amount of work required to manage the documents prevents organizations from moving forward with the expansion of plan offerings

These issues are directly impacted by the approach leveraged to manage these complex, regulated documents.

Document Management Approaches Directly Impact Success:

MAOs typically rely on one of three approaches to manage their documents.

Approach 1 – Manual methods.

It isn’t uncommon for MAOs to rely on manual approaches to create each plan document individually, leveraging copy-paste, manual edits and even MS Word-based mail merges. This approach is fraught with issues that relate to the heavy reliance on manual work being completed by individual employees. Errors, missed deadlines, burnout, and scaling issues are rampant for organizations choosing this approach. Organizations have one lever to grow their business or improve success rates when using this approach and that is to “throw more people at the problem”. Not only is this an ineffective and costly approach, but it also doesn’t allow for economies of scale as an MAO grows its plans to serve new market segments.

Approach 2 – Outsourcing.

It is also not uncommon for an MAO to pass this work to external vendors to complete. MAOs are then reliant on vendors who often still complete much of the work manually introducing many of the same issues with the internal manual approach. Of course, the additional cost of having to rely on the vendor for every little change and click charges only add to the cost and help to limit scalability.

Approach 3 – Adoption of Document Generation Software.

Many MAOs have started to leverage software offerings to address the challenge of document generation.   Many of these products can provide some efficiencies, but the level to which they improve processes varies widely. The vast majority of these tools provide a blank starting point for the MAOs, forcing them to implement complex CMS models, plan data, business rules, translations, and 508 compliance requirements.

How to address the challenges:

Because success is so strongly tied to the management approaches applied to the creation and management of these documents, MAOs must search for solutions that address the key challenges that are holding their business back.

MAOs should look for software solutions that provide the following capabilities:

  • Cloud-based – Leveraging a browser-based solution that is hosted by your vendor greatly reduces the cost and management requirements of your organization. These solutions should be accessible from anywhere your team works via a Web browser.
  • Pre-built documents – Pre-built documents that provide the CMS layouts and latest model content, and complex CMS rules per the latest regulations as a starting point for both English and Spanish versions of your plans. Pre-built documents with the CMS changes also remove the yearly uncertainty and is a key contributor to enabling organizations to have more time for QA and ultimately – finish their work early.
  • PBP data integration – By leveraging your existing PBP data, you can rest assured that your plan documents will match bid submissions and you will be able to generate fully compliant CMS outputs immediately.
  • Advanced content sharing – By using a system that enables you to centrally manage plan content as content objects separate from layouts rather than as individual documents create efficiencies creating and maintaining multiple plans. This approach not only prevents you from making the same changes to individual documents repeatedly, but it also enables you to respond quickly to last-minute changes that are always challenging and streamline QA processes. These capabilities should also allow you to customize content & messaging for different business segments.
  • Collaboration – Ensure your system allows multiple users to be able to work on chapters, sections, benefits simultaneously during editing, review & approvals.
  • Support for multiple document types – Content that is required to build out core CMS compliance materials is also leveraged for additional document types. Platforms should both enable content sharing and support for multiple document types where benefit information can be automatically driven by the centralized data & business logic.
  • Automatic 508 Compliance – 508 compliance should be automatic so that when you generate the output, it is 508c compliant across multiple languages and also generates dynamic large print versions of your content.
  • Rigorous QA processes – Accuracy is vital and it’s essential to have both change management tracking and QA capabilities that support and simplify the process. Key capabilities to look for include the ability to do side by side comparison of differences between two versions of a document, add annotations and identify defects.

Leveraging a solution with these capabilities enables MAO teams to finish early, with less stress, and higher quality easily navigating the annual changes from CMS and expanding their plan offerings.

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