Regulatory Compliance For A Competitive Advantage

So many regulations are intertwined; health plans cannot ignore the ones that may seem insignificant. Every year these smaller regulation changes get bigger.

For example, the industry has been talking about provider directories since the mid-80s, but change was still very slow. The inhibitors to having up-to-date provider directories often moved initiatives for standardizing and updating the processes to the bottom of the priority list. CMS now has the ability to substantially penalize payers whose provider directories are out of date or otherwise inaccurate to the tune of $25,000 per member!

One of the key requirements in the Interoperability Final Rule is the Provider Directory API. This rule, enforceable in July 2021, highlights the importance of accurate and timely information about network providers for Medicare Advantage and Managed Medicaid. Health Plans operating in the CMS markets must take steps to ensure their data and processes to deliver the data are working properly, not just to be compliant but also to remain competitive.

Medicaid Managed Care, in particular, is evolving rapidly. A few years ago, most Medicaid recipients stayed with a fee-for-service Medicaid; they were not pushed toward managed care. Many states now prefer managed care over fee-for-service, as it is lower in cost and also preferred by an increasing number of members, as it provides more options and flexibility.

Medicaid is very fluid. A health plan with a Medicaid line of business must stay in-tune with what CMS is doing and how it interfaces with its state’s specific regulations. In particular, the business processes for Managed Medicaid enrollment can seem overwhelming. Daily full enrollment files are sent by the state, which must be translated into enrollment records that retain a historical view of all changes made throughout.

This deluge of information requires technology that can handle extensive slicing and dicing of the data. The enrollment record changes can impact everything from the available benefits for the member to their primary care provider assignment and even the amount payable for a specific service.

The enrollment data is required by core processing systems and must be viewable and usable by the health plans to properly address questions and other inquiries. Furthermore, these changes are typically time-sensitive, requiring that daily files are processed quickly and accurately and sequentially.

Many regulations are intertwined, some in conflict, some furthering a “cause” or process. The mission of all is to benefit the members, and in most cases, there are benefits of compliance to the health plans.

For example, health plans that focused on getting an updated provider directory in their claims system and also available to members create a win-win scenario! Members and potential members have the most up-to-date information, and health plans are processing claims without the worry of mass adjustments (or penalties!) down the road.

Everyone benefits!

About the Author

Maggie Brown

Maggie Brown, Regulatory Compliance Manager

Maggie Brown has over 30 years of leadership experience in healthcare and insurance marketplace. Maggie transitioned from health plan management roles to implementing core business solutions for numerous health plans around the country. With the enactment of HIPAA, the Balanced Budget Act, and the Medicare Prescription Drug, Improvement and Modernization Act of 2003 she focused on how to ensure a health plan could implement key technology solutions, meeting the needs of their members, while being compliant in a rapidly changing regulatory environment. Maggie has led implementations for government programs at both new and established managed care companies. Maggie holds a Doctor of Religious Arts degree with a major in Pastoral Psychology.

Insights Q&A
What's In Your Medicare Advantage Toolbox?

Every year, Medicare beneficiaries can make new choices to purchase from among many competitive plans aimed at providing services and resources for better health. HealthEdge helps payers with Medicare lines of business to remain compliant and stay ahead of the competition. Learn more in this Q&A with Regulatory Compliance Manager Maggie Brown.

Medicare Advantage

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