Compliance

The Balanced Budget Act has significantly increased compliance requirements for plans, with the resulting likelihood of sanctions from CMS (or even more drastic measures) if they do not conform. Two key areas of concern are:

Reconciliation of premium revenue: The CFO or CEO now has to attest each month that the premium revenue received is correct. In addition to this, a plan must submit a list of all discrepancies to the regional CMS office each month.

Working Aged: Every year a plan must survey all members to determine their Working Aged status.

Plan Data Management has three services which address these issues (and then some):

Outlined below is a brief introduction to these services. They are designed to assist a plan to meet the CMS regulations under the BBA while simultaneously reducing administration costs.

E*LOG™

E*LOG™ was developed to assist plans identify, track and resolve discrepancies in payments from CMS. In addition to this, we built in additional features to address crucial compliance issues. Outlined below are key functional and reporting capabilities designed to assist a plan meet CMS financial compliance regulations.

FUNCTIONS:

  • Track discrepancies through resolution.
  • Date and user stamp all user comments and actions completed in the process of resolving a discrepancy.
  • Generate and track all applicable CMS correspondence.

REPORTS:

  • Financial reports for the CFO or CEO showing exact payments received and total discrepancies identified.
  • Discrepancy reports for the local CMS office.
  • Monthly discrepancy summary report by type.
  • Discrepancy report by type/member.
  • Cumulative analysis of discrepancies by member.
More on E*LOG™.
E*ADMIN™

This module creates and sends monthly CMS correspondence, reconcile payments with CMS and meets CMS enrollment/disenrollment regulatory requirements.

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.

Working Aged Management

Up until now this process has been relatively simple as only a small percentage of Medicare beneficiaries work (under 1% for most plans). However this is very likely to change with the new tax law that allows beneficiaries to work without impacting their social security payments. This we believe will significantly increase the number of cases, and unfortunately owing to the inaccuracy of some of the Federal Governments databases cause a significant increase in the number of discrepancies.

Plan Data Management now offers a program to manage the process. We conduct member surveys, monitor the monthly Membership Report, and resolve all discrepancies.

More on Working Aged Mangement.

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