The Role of Information Technology in Overcoming Challenges to MA, PBM Appeals and Grievances

Medicare Advantage plans and the pharmacy benefit managers with which they partner face ongoing challenges managing appeals and grievances. Health-care technology company leader Anil Kottoor writes about how information technologies provide solutions to common problems MA plans and PBMs face in tracking cases and coverage decisions and communicating information regarding coverage determination decisions. He advises that robust IT systems can help plans meet timeframes for cases and lessen the complexity of processing grievances and appeals.

Organizational Determinations and Appeals and Grievances (ODAG) and Coverage Determinations and Appeals/Grievances (CDAG) are some of the most significant challenge facing Medicare Advantage (MA) contractors today, according to the 2012 Centers for Medicare and Medicaid Services (CMS) Audit.

An important piece of the puzzle in terms of ensuring member satisfaction and providing appropriate care, MA health plans and their pharmacy benefit managers must successfully administer member appeals and grievances with minimal issues.

The CMS audit identified the following as the most frequent missteps:

• failure to follow national or local coverage determinations;
• failure to send proper denial notices/appeal rights;
• misclassifying organizational determinations/appeals as grievances;
• failure to effectuate overturns or approvals; and
• failure to auto-forward adverse reconsideration cases (including cases not adjudicated within the timeframe) to the independent review entity as required.

Addressing these weaknesses should be a priority for MA plans, as a number of performance standards are tied to plan responsiveness and member satisfaction. As such, failure to successfully manage the appeals and grievances process may negatively impact their rating under CMS’ Five Star Quality Rating System – and as a result, revenue. Yet, many do not have access to the systems necessary to properly track and manage these processes and as a result errors are made.

However, this will soon change. In fact, a recently released policy in the CMS 2014 Call Letter will increase the focus on oversight of delegated claims payment contractors, requiring that all MA Part D sponsors have real-time, direct access to the systems their delegates are using to adjudicate claims, process appeals and grievances and handle other critical functions.

Simply reviewing delegated claims payment contractors’ submitted reports for compliance will no longer be enough. In the call letter, CMS notes that it does not believe it is possible for a sponsor to fulfill its monitoring and performance obligations without access to systems that perform these and other critical functions. This statement holds some weight when compared to the 2012 audit results.

Challenges for Health Plans

The reality is that there are a number of complex steps that health plans must take in order to successfully comply with CMS’ requirements for grievance and appeals processing under Subpart M of the Medicare Advantage regulations.

For instance, health plans must provide written communication to enrollees about the procedures available to them at each stage in the grievance and appeals process. Thus, communications regarding the grievance process must take place at the time of enrollment, upon involuntary disenrollment initiated by the health plan, upon denial of an enrollee’s request for expedited review of an organization determination or appeal, upon an enrollee’s request, and annually thereafter.

Further complicating the process are the fulfillment timeframes that the health plans must meet, including notification via letters that also carry very strict requirements in terms of content and timeliness—a situation exacerbated by the varying timeframes between MA Part C (or Medicare fee-for-service Part B) and Part D pharmacy requests. This leaves ample room for error in determining which benefit the drug request falls under, which fulfillment timeframe is correct and ensuring communications are sent in a timely manner.

A third-party review must also be completed in a timely manner for certain levels of appeal, which means health plans must ensure communications are evaluated prior to distribution to the enrollee. Health plans must then demonstrate that they have addressed any comments from the review by showing that they have processed the claim within yet another regulated timeframe.

The problem is that many plans rely on primarily manual processes to manage timeframes and keep track of appeals and grievances. Information is entered into multiple databases where it sits until administrators are ready to address the case at hand, leaving the process open to human error and creating a situation where timeframes are often missed and letters not sent.

The Role of Technology

Due to the complexity of these processes, CMS suggests that health plans and their pharmacy benefit managers seek out robust and integrated technology platforms that utilize built-in alerts and reminders to support compliance. By effectively tracking cases against fulfillment timeframes and alerting users on an escalating basis, these tools streamline the process by which fulfillment timelines are applied and mitigate the risk of non-compliance.

Due to the complexity of these processes, many health plans and their pharmacy benefit managers are moving toward more robust and integrated technology platforms that utilize built-in alerts and reminders to support CMS compliance. By effectively tracking cases against fulfillment timeframes and alerting users on an escalating basis, these tools streamline the process by which fulfillment timelines are applied and mitigate the risk of non-compliance.

The best systems also provide a structured workflow that captures all key data elements needed for processing and tracking medical appeals and managing grievances across the organization. This mitigates the risk of human error and ensures that all cases are processed consistently, and that correspondence is triggered automatically and attached to the original case.

In some cases, these platforms will also automatically generate required letters and more accurately capture the date requests are received based on postmark.

Further, by identifying all authorization and/or claims that are part of the case, these tools ensure each is addressed and resolved. Real-time activity monitoring by management also enables a proactive approach to administering case load and compliance deadlines.

Finally, by robustly tracking the status of each component of a case, these tools also provide health plans with a complete audit trail and comprehensive documentation all in one place—streamlining audits and ensuring that all information is complete and accounted for.

When delegating Appeals and Grievances, it is important to seek out a delegated claims payment contractor that has these functions, and can easily allow the health plan to log into the delegate’s systems without added cost.

The reality is, without the tools necessary to track and manage appeals and grievances, many plans will struggle to comply with CMS regulations—a challenge that the organization has identified and corrected with its recently released regulation tied to appeals and grievances processing.