G&A alchemy

30 Pages·2015·1.89 MB·English

GRIEVANCES AND APPEALS (G&A)
ALCHEMY
Turning Complaints into Gold
REGAN PENNYPACKER
VICE PRESIDENT
GRIEVANCES AND APPEALS
Components of MA-PD Complaints
• Never welcome, often feared by the recipient.
• They stem from dissatisfaction and disagreement.
• Must haves: the right coordinators in place to address issues like a
pro, the right management to analyze and recommend
improvements, and empowered leadership to effectuate change.
• The bare minimum is no longer enough
• Solidifying the relationship with members
• Taking a cue from CMS feedback
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WHAT WE’RE GOING TO DISCUSS
• Fear of Complaints
• The Basics of Grievance and Appeal
Regulations
• What They’ve Said, What We’ve Seen
• CMS Conditions and the Effect on Star
Ratings
• Quality Service

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FEAR OF COMPLAINTS

• Why do we fear them?
• How do we change our
perception?
• Dealing with those who
complain - EXPLORE
• Building trust

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A COMPLAINT IS A GIFT
By Janelle Barlow and Claus Møller

• Misunderstanding of
complaints
• Complaining customers are
still engaging with us
• Think of it as description of a
business process that is not
working, such as:
Restrictive scripts
o
Procedural breakdowns
o
Insufficient onboarding
o
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QUESTIONS AND ANSWERS

• Standard time frame
• Quality of Care response
• Expedited time frame
• Grievance rights
communication
• CTM
• Lastly: Filing methods?
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HIGHLIGHTS OF G&A HISTORY
It’s not fashionable or trendy – it’s a classic
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PASSAGE OF TIME
History and Evolution of Regulations and Guidance
• 1997 – BBA
• 2001 – G&A regulations released
Distinguished from organization determinations and appeals.
o
Grievance procedures are separate and distinct from organization
determinations and appeal procedures, which address organization
determinations.
• 2003 – Chapter 13, Medicare Managed Care Manual (MMCM)
• 2003 – Medicare Modernization Act (MMA)
• 2004 – Four updates to Ch. 13
• 2005 – Part D audit guide released for review and comment
Guess what – little has changed
o
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PASSAGE OF TIME
History and Evolution of Regulations and Guidance

• 2006 – Significant Ch. 13 changes including change to Medicare
Advantage (MA), implementation of 30-day time frame; release of
Prescription Drug Benefit Manual (PDBM) Chapter 18
• 2006 – Audit guides available on the Health Plan Management
System (HPMS)
• 2007 – Chapter update
• 2008 – HPMS memo: Part D Appeals Requirements
Sponsors not meeting time frames
o
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PASSAGE OF TIME
History and Evolution of Regulations and Guidance

• Sept. 2010 – HPMS memo: Part D Compliance Issues –
Grievances, Coverage Determinations, and Appeals
Lack of adequate tracking systems resulting in missed adjudication time
o
frames
Failure to expedite coverage determination requests
o
Failure to properly classify and process grievances
o
Deficiencies in the area of Coverage Determinations, Appeals, and
o
Grievances (CDAG) may constitute a significant risk to Part D enrollees
to the extent such deficiencies result in denying prompt access to
medically necessary covered prescription drugs
• Nov. 2010 – HPMS memo: Reminders Related to Timely
Adjudication of CDA .. Two months later?

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