Administrative

The Balanced Budget Act has resulted in a horrendous increase in administration costs. And worse still the BBA in real terms has significantly reduced the amount plans receive in premium revenue. We hope the politicians will see the error of their ways and address this situation.

Sadly, this is out of our control. However, we have developed low-cost solutions to assist plans in the following areas:

    • Reconciling payments with CMS.
    • Tracking and submitting encounter data.
    • Reducing the cost of submitting enrollments and disenrollments to CMS.
    • Ensuring financial compliance.
    • Reducing the administration costs of managing payments to providers.

All these services are designed with the goal of:

    • Reducing the need to invest in costly software development.
    • Ensuring plans maximize revenues.
    • Reducing the time/staffing levels required.

E*TRACK™
A modular system which manages Medicare+Choice enrollment, encounter data, accounts receivable and then some. E*TRACK™ consists of:

E*LOG™: Medicare Reconciliation Services
 Our reconciliation service, E*LOG™, is designed to assist plans simplify and speed up the reconciliation of payments received from CMS. It is a complete accounts receivable program and then some.

The service was designed to meet five key objectives:

    • Reduce staff costs,
    • Ensure a plan is maximizing revenues.
    • Ensure a plan is in full compliance with all CMS regulations for financial reporting.
    • Speed-up cash flow.
    • Provide actuaries with key data.

Current clients over a six month period have seen an average revenue increase of over 1.8% while simultaneously reducing staffing costs in this area by up to 50%.

More on E*LOG™.


E*ADMIN™: Transaction Reply Report Module/ Correspondence Module
A new module to the E*TRACK system designed to significantly reduce the administration cost of creating and sending monthly CMS correspondence, reconciling payments with CMS and meeting CMS enrollment/disenrollment regulatory requirements. A typical plan can anticipate saving around 60 hours in administration costs a month for every 10,000 members. The module incorporates the CMS Transaction Reply Report into E*LOG, PDM's financial reconciliation system. The result is a complete solution for plans to work the back-end of the enrollment/reconciliation process.

FEATURES:

  • Ability to edit batch letter lists before letter generation,
  • Generation of all appropriate confirmation letters out to accepted enrollees/disenrollees,
  • Generation of all appropriate rejection letters to rejected enrollees,
  • Generation of automatic disenrollment letters,
  • Generation of appropriate Status change letters,
  • Generation of discrepancy letters,
  • Automatically records and tracks all correspondence by member, thereby providing a complete audit trail, and
  • When used in conjunction with E*LOG, any plan adjustments that are made as a result of a CMS initiated action are written to the weekly transaction log for upload to the mainframe system.
  • Captures the Monthly Transaction/Reply Report from CMS.
  • Generates Pre-Distribution Lists of all Correspondence.
  • List of letter recipients by type and date.

FUNCTIONS:

  • Completely integrated with E*LOG;
  • Gives pop-up suggestions, applicable regulatory documentation, and instructions for different transaction types;
  • Automatic Letter Generation;
  • Automatic Notes entered into E*LOG; and
  • Audit Trails of all Correspondence.

E*DATA™: Encounter Data Reconciliation & Tracking
Critical to ensuring correct payment under risk adjustment is a plan’s ability to track, resubmit and reconcile claims. Without these capabilities a plan cannot determine whether all the claims are being included in the CMS premium calculation. This can result in a significant underpayment to the plan and to make matters even worse a potential compliance issue.

Plan Data Management has developed E*DATA™, a proprietary software system and ancillary services, to assist plans in four areas:

    • Reduce the need to invest in developing software.
    • Keep administration costs to a minimum.
    • Ensure the plan meets all BBA reporting requirements.
    • Maximize revenue under the BBA.

More on E*DATA™.

E*CAP™: Capitation Payment Service
E*CAP™ is a product developed at the specific request of some of our clients. Like many M+C plans, they pay their providers a percentage of CMS premium. These plans are under increasing pressure by their providers to reconcile CMS payments to the payments made to their provider organizations. The challenge is keeping track of CMS overpayments and underpayments and passing the correct amount on to the provider. Paying a percentage of either the CMS or Plan estimated premium without tracking discrepancies could result in significant over- or under-payments – which are sometimes difficult to recover.

E*CAP™ was developed to address this challenge. E*CAP™ will manage the capitation payment arrangements with providers on a monthly basis. An often long and arduous administration process.

In addition it will also ensure that when your plan goes through the annual settlement processes with your provider organizations you will be ready and able to determine what is due/to from the provider and have the reports to back up the numbers.

To conclude, your plan can be assured of not over or under paying providers and it can significantly reduce the administration cost of managing the capitation process.

More on E*CAP™.

E*STAT™: Enrollment & Disenrollment Services
E*STAT™, our new monthly enrollment and and disenrollment service, was developed to provide a LOW-cost alternative to developing software or using one of the existing services.

E*STAT™ provides M+C plans with the capability of checking member eligibility and then submitting enrollments and disenrollments to CMS electronically.

Plans can either use our remote data-entry screen to key in the required accretion/ deletion/correction transactions, or they can choose the option of sending us a batch file of all monthly transactions in a specified format. Within 24 hours, we will return two reports and/or data files to the plan with the following information:

    • Whether the new enrollment (transaction type 61) is eligible to enroll in a Medicare+Choice plan, and if not, why.
    • Whether the transaction passed all front-end edits, and if not, why.

All records passing eligibility requirements and front-end edits are then sent directly by PDM to the CMS Data Center GHP master file. The plan will receive a confirmation that the batch file was received and that all acceptable transactions were included. Our transmissions to CMS will be on a production schedule, so plans can make any necessary changes and resubmit to us before we submit to CMS.

After the transactions are processed through CMS’s GHP system, we will provide plans with a data file version of the McCoy Exception report when it becomes available.

More on E*STAT™.
E*PRO™: Enrollment & Disenrollment Services
A suite of three modules for identifying, researching and correcting the most common Special Status discrepancies: Working Aged, ESRD and Institutional.

E*WORK™ is an E*TRACK module which greatly simplifies and automates the process of identifying, researching and correcting Working Aged discrepancies, as well as tracking annual surveys.

E*ESRD™ is an E*TRACK module which greatly simplifies and automates the process of identifying, researching and correcting ESRD discrepancies.

E*INST™ is an E*TRACK module which greatly simplifies and automates the process of identifying, researching and correcting Institutional discrepancies, as well as performing monthly certification and submitting the 01 transactions to CMS.

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