Agenda

WELCOME & OPENING REMARKS: HOW TO MAXIMIZE YOUR VIRTUAL CONFERENCE EXPERIENCE

EXAMINING RECENT CMS GUIDANCE AND ODAG & CDAG UPDATES

This session will examine changes to CMS guidance regarding Part C and Part D appeals and grievances, including the implications for Part C/D reporting and the ODAG and CDAG audit protocols.

YOU GET THE CMS PROGRAM AUDIT NOTICE – DON’T PANIC

The general themes of the presentation are what to do when you get the CMS Program Audit Notice and what to expect if you have to conduct an Independent Validation Audit (IVA). For the Program Audit Notice section, I will discuss, at a high level, the timeline of the audit including engagement; submissions; field work; and reporting.  These items reflect what is in the CMS Program Audit Guidance. I will provide an overview of what to expect if there are findings in the audit which cause the health plan to have to conduct an IVA. Finally, I will share some best practices and lessons learned.

CONVERTING COMPLAINTS TO OPPORTUNITIES WITH THE POWER OF AI

Right and timely resolution of appeals and grievances (A&G) motivates members to stay with the Plan and enables compliance for the Plan. The session will demystify how payers can unleash the potential of artificial intelligence to convert complaints into opportunities with minimum disruption and boost customer satisfaction.

Key takeaways:

1. Explore the power of AI in transforming A&G processes
2. Learn how technology can be enabled to do it right "1st time"
3. Get inspired by the success of a Blue payer with Virtusa’s A&G solution

Virtual Networking Break

HOW TO IMPROVE WORKFLOW IN THE A&G PROCESS

The speakers will review requirements for an A&G system, while maintaining compliance, prioritization, timeliness and efficiencies.

• Identify criteria when evaluating an A&G system and/or processes
• Role based access
• Case classification due dates
• Automated assignments and reminders
• Tracking and automating correspondence
• Ability to add attachments for case documentation
• Producing reports; standard, custom, CMS reporting and universe creation
• Ability to create audit trail for all transactions

DEVELOPING OPERATIONAL EFFICIENCIES WITH A COMPLIANCE MINDSET

UPMC Health Plan has implemented best industry practices which involve:

• Weekly report monitoring to identify cases at risk of non-compliance
• Weekly compliance meetings with other areas of the health plan to identify potential compliance risks and if needed remediation and/or process improvements
• Monthly dashboards which reflect case completion, timeliness, with root causes provided for any late cases to identify trends
• Monthly universe submissions to our internal Medicare Compliance team
• Monthly quality audit review and remediation
• Monthly one on one’s with staff to review quality, review any concerns, and discuss trends
• Monthly process narrative updates, workflows, and tip sheets
• Quarterly audits with our internal Medicare Compliance team to ensure audit readiness
• Quarterly Notice of Non-Compliance training
• Yearly policy and procedure updates

Virtual Lunch Break in the Exhibit Hall

DRIVING STAR RATING SUCCESS THROUGH COMPLAINT ANALYSIS

The speaker will:

• Examine how root cause analysis of 1-800-Medicare CTM complaints and grievances can have impact on overall member experience
• Discuss the continuous improvement cycle needed in order to maintain complaints about the health plan STAR metrics and beyond
• Establish and discuss best practices for documentation and complaint casework handling to drive stellar performance
• Discuss how creation of feedback loops for complaint data can drive learning and coaching processes within the organization

BEST PRACTICES IN GRIEVANCE CLASSIFICATION

In order to combat the misclassification of grievances, CHRISTUS Health Plan has incorporated the following best practices to be utilized on a case-by-case basis.

• Categorization of grievance – examples – quality of care, benefit design, timely response, interpersonal aspect of care, barriers to access
• Oversight workgroups-weekly collaboration between customer service department and complaints, appeals, and grievance
• Department delegated member call center oversight and monitoring reviews with PBM
• Internal auditing and reporting

A&G BEST PRACTICES – GOING BEYOND REGULATORY COMPLIANCE

The speaker will share best practices based on his health plan’s experience with CMS. In some instances, an exclusive focus on regulatory compliance is not enough. For example, Medicare Advantage plans have 30 days for working grievances, but CMS expects that members who urgently need a drug or service receive a decision sooner. The health plan needs to have a process in place to identify these high-priority cases. Other examples include ensuring that all areas within a health plan that have contact with members receive training on A&G processes and conducting initial evaluations of potential grievances.

Virtual Networking Break

BEST PRACTICES IN ADDRESSING QUALITY OF CARE GRIEVANCES

Understanding the complexity of quality of care grievances is a key element to a successful grievance and appeals department. I will be discussing best practices to manage this type of grievances to ensure success in regulatory audits.

• Importance of properly identifying and investigating quality of care grievances
• How to meet regulatory requirements while providing adequate resolutions to members
• The new way of investigating quality of care grievances and regulatory agencies expectations
• Investigations and audits

ENRICH ENROLLEE EXPERIENCE AND LOWER OPERATING COSTS: COMPLIANCE-DRIVEN AUTOMATION IS HERE

After this presentation, attendees will:

• Discover A&G innovations in the market today
• Gain insight regarding how A&G operations can efficiently achieve CMS objectives
• Explore the future of mobile, AI and RPA A&G technologies

Virtual Networking Reception in the Exhibit Hall

Close of Conference