Medicare compliance

It’s Time to Make your 2021 CMS Star Ratings Better Than Ever

The Centers for Medicare and Medicaid Services plans to release its 2020 Star Ratings in October. Whether you received four or five stars or lower, the clock is ticking if you want to have a positive impact on your health plan’s rating next year. 

It takes time to ensure your health plan is doing everything it can to ensure a four or five star rating. It’s a challenging task, but it’s feasible. An experienced Medicare plan consultant like the team at Tier 1 Pharmacy Consulting can help you prepare for rating season – and ensure the best outcome possible. 

What are Star Ratings? 

Most Medicare Part D and Medicare Advantage plans understand the importance of Star Ratings. The ratings are put out annually by the Centers for Medicare and Medicaid Services to give beneficiaries a look at the quality of the health plan before they sign up. Star Ratings focus on aspects of high-quality care within the control of the plan. They provide a complete, accurate, reliable, and valid picture of a program. Star Ratings also are used for compliance and monitoring, and measure aspects of a plan that are relevant and important to beneficiaries. CMS looks to NCQA, PQA and others for measure concept development, endorsement, and specifications.

Star Ratings are displayed on the Medicare Plan Finder – which recently got a huge facelift – so seniors may consider both quality and cost in their enrollment decisions. In other words, Star Ratings are very important.

Here are a few tips going into 2021. 

If it’s broken, fix it – with help. If your  health plan has been using the same tactics year after year and not seeing a ratings increase, it’s time to change your strategy. Look at your data, measure it, and seek an outside consultant to give you an objective picture as well as an action plan moving forward. 

Capture the right data. Many plans fail to earn four stars because they don’t capture HEDIS, PDE, and other important information. It takes time, and health plans have enough going on during a busy fourth quarter. Hire someone to look at issues and resolve them for you – before it’s too late. 

Invest in CAHPS. CAHPS are weighed more heavily now, making up a huge portion of the overall Star Rating. Make sure your CAHPS performance is as strong as your HEDIS investment. If you need, look for someone who can help make sure your CAHPS performance is solid.

Find a Star Ratings expert. As we mentioned in the three previous tips, there’s a lot of work to be done and a lot at stake. Why risk earning a low Star Rating due to lack of time, expertise, oversight, experience, or knowledge? The right consultant can make the difference between one and three stars and beyond.

The Time is Now 

If you didn’t achieve four stars this year, you have time to improve and influence your 2021 ratings with the right strategy, data, and attention to detail. It’s important that you review your current performance figures and use the right resources moving forward. 

If you earned four stars this year – congratulations! However, now is not the time to sit back and relax. Star Ratings is a competitive process, and the health plans who get top billing have already started taking steps to ensure the same if not better performance next year. 

Get Started 

Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2021 that will help your health plan improve its performance and achieve your goals.

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be complicated or overwhelming. It’s important that you earn the highest rating possible.

A four or five star rating is within your reach for 2021. We can help you get there.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

CMS to audit Medicare Advantage plans in response to overbilling

The Centers for Medicare and Medicaid Services (CMS) is at the center of a controversy that could affect health plans across the country. 

Last week, national news outlets – including National Public Radio – reported that CMS is proposing a series of new audits designed to take back $1 billion of the $30 billion the government says health insurers have overcharged Medicare in the last three years. CMS’ goal is to recoup some of that money by 2020. With the new year just five months away, the government could move full steam ahead with its plan – and health plans should be prepared. 

Some background, as noted in the NPR story and others: 

Some Medicare Advantage plans, the government says, have tried to boost their revenues by billing Medicare more than necessary. These plans have done so by stretching the truth on how much medical care their elderly patients need. Or, plans have charged Medicare for treating illnesses and conditions they can’t prove their members have truly been diagnosed with. 

With 22 million seniors – that’s one in three men and women over the age of 65 – on Medicare, the  problem is nothing new. In fact, CMS has known about inflated billing practices for several years; the agency has long considered auditing plans before to address billing dishonesty and mistakes but before had always backed off. 

Meanwhile, the U.S. Department of Health and Human Services Inspector General’s Office has kicked off  its own round of nationwide Medicare Advantage audits of health plans billing practices.

The scrutiny is growing. 

The insurance industry, for its part, is highly critical, arguing CMS audits are unfair and have the potential to negatively impact seniors’ medical care. 

“If adopted in its current form, [the audits] could have a detrimental impact” on all Medicare Advantage plans and “affect the ability of plans to deliver high quality care,” Insurer Cigna Corp. wrote in a May financial filing. 

If CMS proceeds with the audits, the penalties are unclear for health plans who are accused of overbilling Medicare. 

It’s important to be ready at all times for an audit – especially if your health plan has faced CMS oversight in the past. Being prepared will help plans identify and respond to potential gaps and address them as quickly as possible. The normal audit process is extensive, so one can imagine this latest round of audits will be in-depth at best. Plans are going to need help – and that’s where Tier 1 Pharmacy Consulting can help. 

We provide support and consultation for all types of audits. We can review data to ensure accuracy with file layout requirements, interpret data to identify potential issues, craft responses and create corrective action plans. Even for the kind of audits that are forthcoming. 

With experience in more than a dozen audits and a handful of mock audits, Tier 1 can find solutions to get you through the process and avoid fines if at all possible. 

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.

New CMS Rules to Increase Transparency and Lower Drug Costs

The Centers for Medicare and Medicaid Services (CMS) recently published a final rule intended to increase transparency and lower drug prices. This announcement has been in the works since CMS first posted their proposal in November 2018. Now that the final ruling has arrived, it’s important for health plans to understand what’s changed and how the rule may affect their business. Tier 1 is available to consult with health plans about these important updates. In the meantime, here’s a brief look at what this final rule means for health plans and the health care industry more generally.

What Does the Final Rule Mean for Your Health Plan?

If you’ve been following along with this blog, this topic will already be familiar to you—we’ve been keeping you posted about its various updates since the proposal was first announced. Published on May 23, the CMS’s final rule is formally entitled, “Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses.” As the title suggests, the amendments within the final rule pertain to both Part C (Medicare Advantage program) and Part D (Prescription Drug Benefit program) regulations. The amendments aim to help health plans negotiate for lower drug prices and reduce out-of-pocket costs for enrollees of Part C and Part D programs. The CMS ruling achieves this aim by improving regulatory frameworks and facilitating the development of products that meet patient needs while also reducing their fees. Health plans only want the best for their members—and reducing patients’ out of pocket costs help minimize the expenditures of Part C and Part D programs.

What Does the Final Rule Say that Your Health Plan Needs to Know?

On the same day they published their final rule, CMS posted a helpful fact-sheet outlining significant changes that your health plan needs to consider moving forward. Key takeaways include:

  • Part D policy relating to six classes of drugs has now been codified.
  • Part D plans are now required to adopt one or more electronic Real Time Benefit Tools that have the capability to inform prescribers when lower-cost therapies are available under their drug benefit.
  • Policy is now being finalized that would allow Medicare Advantage plans to implement step therapy for Part B drugs as a recognized utilization management tool.
  • CMS will now require Part D plans to inform members of drug price increases and lower-cost therapeutic alternatives in their Explanation of Benefits.
  • A new prohibition against gag clauses in pharmacy contracts now restricts Part D sponsors from prohibiting or penalizing a pharmacy from disclosing a lower cash price to an enrollee.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

Drop us a note at info@tieronepc.com. Let’s get connected.

Should my health plan outsource or handle CMS compliance in-house?

Why You Should Outsource Your Health Plan Headaches

Benjamin Franklin once said nothing in this world is certain except death and taxes. In twenty-first century America, this quote could be updated with a refrain: Nothing is certain except death, taxes, and the labyrinthine nature of our healthcare system.

Right now, the United States is in a state of flux when it comes to health care compliance. As lawmakers move towards different ends of the spectrum when it comes to how health care should be managed in this country, and by whom, health plans are often left to muddle through endlessly complex and quickly-changing rules and regulations. Changes occur so quickly in the health care space that it can seem like the Centers for Medicare and Medicaid Services are throwing out new regulations by the day. How can health plans keep up with the pace while also focusing on their clients’ needs and meeting their bottom line?

The answer is simple: by partnering with Tier 1 Pharmacy Consulting, health plans free up hours in their workday and save their employees time and countless headaches. CMS audits, guidelines, regulations, and changes to all of the above can be confusing. Outsource the work to us and your health plans will never have to worry about important business decisions falling through the cracks – possibly costing thousands of dollars and years of scrutiny.

Pharmacy Benefits Don’t Have To Be Complicated

At Tier 1, our goal is simple: Offer our health plan customers strategic, cost-saving solutions that boost the plan’s overall value and help its members by proving high-quality care. The way we go above and beyond that goal is just as simple: We offer a full suite of services designed specifically to save health plans both time and money.

Is your health plan well-versed on CMS’s 2019 update to the agency’s audit program? Every year, the CMS conducts thousands of audits, from BID audits to Formulary Administration audits, Transition Monitoring Program analysis, Data Validation audits and more. For some health plans, it would take a year just to work through the 2019 update, let alone take measures to prepare for the audits that may come along at any time. Tier 1 helps hundreds of plans a year by taking the grunt-work out of audit preparation: by outsourcing audit woes to Tier 1, health plans not only save time and money, but also greatly reduce their chances of paying fines due to accidental oversight.

Audits are just one example of what Tier 1 can offer health plans to make their schedules lighter and more able to innovate in other ways. We also help health plans to get answers to compliance questions more efficiently by acting as a liaison between them and pharmacy benefit managers. If your health plan has ever had questions about something as deceptively simple as website management or as straightforwardly complex as finding a new pharmacy benefit manager altogether, let Tier 1 help: we have the expertise and the insight needed to help health plans and PBMs get on the same page fast.

Reach Out Now and See What’s Possible

What would your health plan do if they didn’t have to worry about the endless complexities of CMS rules and PBM issues? It’s time to start thinking big. Hire Tier 1 Pharmacy Consulting today and start to see what’s possible for the future of your health plan.

Get in touch.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.


Think it’s Too Early for 2020 CMS Star Ratings? Think Again

The Centers for Medicare and Medicaid Services released its 2019 Star Ratings last month – which already has some health plans thinking about 2020.

If it seems far off, it’s really not. That’s because it takes time to ensure your health plan is doing everything it can to ensure a four or five star rating. It’s a challenging task, but it’s feasible.

Star Ratings are put out by CMS to give Medicare and Medicaid beneficiaries some insight into the quality of the health plan before they sign up.

Among other things, Star Ratings:

– Measure aspects of a plan that are relevant and important to beneficiaries. CMS looks to NCQA, PQA and others for measure concept development, endorsement and specifications.

– Focus on aspects of high-quality care within the control of the plan.

– Provide a complete, accurate, reliable, and valid picture of a health plan. Star Ratings also are used for compliance and monitoring.

Star Ratings are displayed on the on Medicare Plan Finder (MPF) so beneficiaries may consider both quality and cost in enrollment decisions. The Affordable Care Act established CMS’s Star Ratings as the basis of Quality Bonus Payments to MA plans. Beneficiaries can join a five star plan at any time through a special enrollment period.

How can you work to receive a higher rating in 2020? Let the team at Tier 1 Pharmacy Consulting help. We are experts in Medicare compliance.

Tier 1 Pharmacy Consulting can work with your staff so everyone understands his or her responsibilities and how to successfully tackle them. We can help you develop a Star Ratings plan for 2020 that will help your health plan improve its performance and achieve goals.

Tier 1 also will help you sort out conflicting messaging, outdated information, missing information, records and measures evaluated by CMS for its Star Ratings program. With us, you can rest assured that making changes doesn’t have to be scary. It’s necessary to get you the best rating possible. We will make sure your vendors are on board, too, supporting your efforts and all of the needs of the Star Ratings plan.

A four or five star rating is within your reach for 2020. We can help you get there.

About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.

Don’t Forget: The Medicare Provider and Pharmacy Deadline is Oct. 15

Is your health plan’s Medicare Provider and Pharmacy Directory up-to-date? If not, keep reading.

The federal Centers for Medicare and Medicaid Services requires health plans to provide their members with a Provider and Pharmacy Directory, both print and online. That way, when men and women enroll in Medicare they have immediate access to lists of providers and pharmacies.

Current and ongoing Medicare beneficiaries are entitled to a new directory if they need one.

As time goes on and plans, provider and pharmacies change, CMS requires plans to ensure their directories are accurate and updated every year. The deadline this year is October 15th.

 The task is more challenging than it seems. In addition to including new and/or different providers and pharmacies, health plans should, among other things:

  • Include an index of all providers and pharmacies
  • Make sure their online directories contain the same information CMS requires for print directories
  • Ensure that when plans are made aware of a change that their directories are updated within 30 days.
  • Make their online and print directories easy to read and understand
  • Ensure phone numbers are toll-free and include a toll-free TTY/TDD number and days and hours of operation
  • Include language as indicated in CMS instructions throughout the directory
  • Include a link on printed materials for members to go online if desired
  • Include general pharmacy information after general provider information and before provider listing requirements begin
  • Make sure copy in the directories is written in a way that complies with suggested reading levels
  • Format directories to make information easy for both English speaking and non-English speaking beneficiaries to read and understand whenever possible
  • Format sections, charts, tables and text to fit on a single page, or enter a blank return before right aligning with clear indication that the item continues to the next page. For example: (This section is continued on the next page)
  • Break up large blocks of plan-customized text into short paragraphs or bulleted lists and give a couple of plan-specific examples
  • Spell out an acronym or abbreviation before its first use in a document or on a page; i.e., low income subsidy (LIS)
  • Use universal symbols and/or commonly-understood pictorials
  • Consider using regionally appropriate terms or common dialects
  • Consider producing translated models in large print
  • If desired, provide subdirectories by specialty or geographic area to enrollees if it states that the complete directory will be provided to enrollees upon request. Subdirectories must be consistent with requirements outlined in the Medicare Managed Care Manual, the Medicare Prescription Drug Benefit Manual and the Provider and Pharmacy Directories Requirements subsection in the introduction to each state’s specific marketing guidance.

And that’s just a handful of the rules and guidelines required for the guide. You also need to make sure it’s been proofread and is grammatically correct.

It’s a huge undertaking. Many health plans don’t have the time or the right personnel in place to handle the huge task of updating the guide, especially when it comes to the pharmacy portion.

Tier 1 Pharmacy Consulting can help. We are experts in the Medicare Provider and Pharmacy Directory as well as overall Medicare marketing regulations and policy writing. We can interpret the CMS model document and use the right variables to customize it to health plans so that it is correct and remains within the right framework.

Tier 1 can help you stay compliant at all times, so you can focus on running your health plan.

 About Tier 1 

Tier 1 Pharmacy Consulting is a Denver, Colorado-based pharmacy benefit consulting firm offering customized services to healthcare plans that offer prescription drug benefits. Whether your health plan is big or small, Tier 1 offers strategic, cost-saving solutions that boost the plan’s overall value and help its members by providing high quality care.

Tier 1’s founder is a clinical pharmacist with more than a decade of experience in pharmacy benefit management. We are passionate about collaborating and developing effective strategies to improve health plan outcomes.

Tier 1 offers health plans a new perspective on how to manage their pharmacy benefit. Our team is made up of experts who strive to make effective plans even stronger and fill in any gaps due to a lack of time or resources.

We’re here for you. Drop us a note at info@tieronepc.com and let’s get connected.