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The Truven Health Blog


The latest healthcare topics from a trusted, proven, and unbiased source.


The 2016 Cost-Sharing Reduction Reconciliation Submission Deadline Has Passed – Are You Ready for Next Year?


By Marie Bowker/Monday, June 5, 2017

Under the Affordable Care Act (ACA), issuers of qualified health plans must offer cost-sharing variations of their plans, to provide options with reduced out-of-pocket expenses to eligible enrollees. The Centers for Medicare & Medicaid Services (CMS) advances funds to insurers monthly during the benefit year to offset these costs, followed by the requisite annual reconciliation.

Now that the June 2nd deadline for submitting 2016 cost-sharing reduction (CSR) reconciliations has passed, it’s important for health plans to evaluate their submission processes and decide whether they’ll need help reconciling subsidies for 2017.

Though it is unclear whether subsidies will continue -- given the uncertainty of healthcare reform and the push to eliminate the program -- America’s Health Insurance Plans (AHIP), the American Medical Association, the American Hospital Association, and a number of other business and healthcare organizations support continuing the program. In fact, several issued a joint statement calling for at least a two-year commitment to funding ACA CSR payments, and they want to see the money included in a congressional spending bill. As of this writing, CMS continues to provide CSR payments to health plans, and plans will be required to reconcile payments at the close of the 2017 benefit year.

Why you should start planning now for 2017

The CSR requirements are integral to the affordability of individual plans on the federally facilitated state marketplaces (the Marketplace), and essential for an issuer’s ability to control plan premiums. It’s vital for health plans to ensure that their advanced payments are reconciled accurately.  The law requires that health plans:

  • Utilize the Standard method (re-adjudication of 100 percent of claims) for the 2017 benefit year (as opposed to the earlier Simplified option)
  • Reconcile all advance payments and actual subsidies at the end of the year

In addition to being a complex compliance task, CSR reconciliation also carries much financial risk. According to CMS, more than half of enrollees in plans sold in the Marketplace choose CSR plans,* which means there could be a significant financial impact on health plans if subsidies aren’t reported correctly. Health plans need to reconcile accurately to be assured they receive any additional funds CMS may owe them or to return funds to CMS if their expenses were less than projected.

Health plans: If you struggled with your 2016 submissions or are worried about implementing the now-required Standard method for 2017, it’s time to select a partner for this task. Implementing the more complicated Standard method takes time, and there’s too much money at stake to be anything less than fully prepared and compliant. Contact us today for more information.

Marie Bowker, Senior Client Executive
Bryan Briegel, Healthcare Reform Solutions Strategist

* Centers for Medicare and Medicaid Services, “March 31, 2016 Effectuated Enrollment Snapshot” (CMS, June 30, 2016).




Care Management Analytics — Building a Strategy for Impact


By Truven Staff/Tuesday, May 9, 2017

 

An effective care management program is important for more than improving health plan member health. It is also a strategic capability for plans looking for ways to contain costs and differentiate their offerings to attract and retain employer groups in today’s competitive environment. But developing a robust analytics strategy for care management that scales as your needs change is no easy task, and health plans are feeling the pressure now that employers are demanding greater accountability regarding their care management programs.

An effective strategy can help you:

●       Stratify Members - Segment data into healthy, at-risk and chronic condition populations for appropriate intervention and member outreach

●       Identify Actionable Interventions - Deliver insights that allow your care management stakeholders to focus efforts on members who will receive the most benefit from engagement

●       Evaluate Programs - Understand the clinical, behavioral and financial impacts of care management programs and identify improvements for program design

Learn More About Care Management Analytics on May 24

On May 24, Senior Consulting Scientists John Azzolini and Kevin Ruane will host a webinar that focuses on strategies for building a strong analytics foundation to strengthen care management programs.

At session, attendees will learn about the:

●       Attributes of robust care management analytics

●       Hallmarks of intuitive reports

●       Benefits of embedding advanced analytics

●       Next chapter of care management analytics

Register for the event to learn more about care management.


Four Analytic Trends for Health Plans in 2017


By Truven Staff/Wednesday, March 29, 2017

 

In the rapidly evolving healthcare landscape, health plans are recognizing the value of leveraging their vast data warehouses to help define their business models. But, without a strong analytics tool, many organizations may miss critical opportunities to excel against their competitors. We offer our view of four trends facing health plans this year, and how they can use analytics to help achieve better results:

Strategic and operational leaders need fast access to reliable information. But as information needs and data sources expand, health plans may become more challenged to quickly and accurately analyze their vast amounts of data. Embedding robust enterprise analytics solutions directly in the data warehouse environment may enable IT and analytics teams to deliver greater value more quickly to business users.

With increasing price transparency throughout healthcare, savvy patients may “shop” providers to find more cost-effective options for treatments. This, in turn, may drive down costs and force health plans to reevaluate contracts and renegotiate prices. Analytic solutions can help you gain greater insight into your data and determine a better route to profitability.

It’s no longer enough to have the right team in place to foster success. Organizations should also seek on cross-team collaboration - particularly when it comes to deriving value from data. A comprehensive analytics platform may offer teams from IT and Informatics to Care Management and Actuarial Underwriting the tools they need to collaborate for maximum productivity.

While health plans are collecting data in large quantities, they may not see a clear path to extract important insights. At the same time, these organizations are putting more emphasis on social determinants as a forecaster for medical issues. Predictive analytic solutions may provide health plans with better ability to take a deep look at data and create models for cost risks among different populations.

Leverage the power of Portable Analytics from Truven Health Analytics to get deeper into your data and provide valuable insights that could help make the difference in your business this year. Contact us to learn more about Portable Analytics and its applications for your organization.

 

Source: Analytics Magazine, 2016


Health Plans: Choose Your Initial Validation Audit Vendor Wisely


By Anita Nair Hartman/Tuesday, March 21, 2017


For health plans, the time to select an initial validation audit (IVA) vendor is drawing near. Selecting a qualified vendor should be a thoughtful and informed process. If the audit shows a plan’s EDGE data are not valid and have risk score-impacting errors, the Centers for Medicare & Medicaid Services (CMS) may act to scale down the plan’s premium risk transfer payments, which may incur negative results for the plan’s financial performance. As a CMS-accepted IVA entity, we’ve been partnering with health plans to meet this requirement since the law was implemented.

CMS developed IVA requirements to help ensure that accurate and complete membership and risk adjustment information is submitted by health plans to the EDGE servers for eventual payment transfer calculations. According to the regulations, qualified commercial health plans must have an independent auditor with certified coders review medical records for 200 random members (or less if the Finite Population Analysis applies to the issuer) selected by CMS and must validate the enrollment and the diagnosis codes submitted. The deadline to select a vendor for this year is April 28, 2017.

 Medical records review is a critical part of the validation process, so health plans should consider experience and certification when selecting a vendor. Some other important qualities to look for in an IVA vendor are:

●      Deep knowledge of ACA regulations. A vendor should have a history of monitoring, evaluating, and influencing the changing ACA requirements.

●      Data, analytics, and auditing experience. A long history analyzing large claims databases and auditing healthcare claims, and prior experience with CMS-mandated reporting, are critical experiences.

●      Experience with EDGE servers. To efficiently audit EDGE data, the vendor needs experience with EDGE data format and content, and in processing large amounts of data.

●      Risk and reinsurance expertise. Look for an auditor with experience with risk models.

●      Flexible approach. This is not a completely straightforward process. Every health plan is different, and your vendor should be able to implement a solution to meet a health plan’s specific needs.

●      Certified coders. This one is straightforward. By law, the coders must be certified by the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC).

●      An IVA Approved by CMS. Plans must choose from a list of CMS-accepted entities.

Selecting an experienced and qualified partner to support the IVA will help give health plans peace of mind in managing the IVA requirements. If complying with CMS’s EDGE server requirements is taxing your organization’s resources, it’s time to consider partnering with a qualified EDGE server administrator, and IVA vendor, so you can get back to the business of offering quality health care. Contact us to learn more.

Anita Nair-Hartman, Senior Vice President, Payer Strategy and Business Operations
Bryan Briegel, Healthcare Reform Solutions Specialist


The Effects of Telecommuting Intensity on Employee Health

Chosen as AJHP Editor’s Pick for 2016


By Truven Staff/Friday, March 10, 2017

 

The number of employees who take advantage of telecommuting has increased substantially in recent years - especially with the improvements in technology and the increasing demand for more flexible work schedules. The Effects of Telecommuting Intensity on Employee Health, recently chosen as Editor’s Pick for 2016 by the American Journal of Health Promotion (AJHP), highlights how the employees at Prudential Financial, a company with a long history in promoting work flexibility are affected by telecommuting - specifically in relation to their overall health.

Over a two-year period, Prudential Financial, in partnership with Truven Health Analytics®, IBM Watson Health™ analyzed the amount of time employees spent telecommuting and what potential health risks arose because of it, including depression, stress, poor nutrition, physical inactivity, tobacco use, alcohol abuse, and obesity.

The research suggested that telecommuters had a lower risk of developing many medical ailments, including obesity, alcohol abuse, physical inactivity, and tobacco use. The study also found evidence that employees who engage in a small number of telecommuting hours were less likely to develop depression. While the study provided some evidence to suggest that flexibility with telecommuting has health benefits, maintaining some level of in-office work may help to strengthen spiritual and social health.

 Download the full study here.

 


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