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    How to effectively manage Medicare enrollments

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    Most Medicare Advantage and Part D sponsors share a common goal: make Medicare a more profitable line of business. To help alleviate some of the challenges associated with enrollment practices, consider the following tips:

    1. Establish pre-enrollment procedures

    Establish a pre-enrollment process and identify staff responsible for verifying the enrollment application for accuracy and completeness. The pre-enrollment team should understand requirements for all transaction types for enrollments, disenrollments, benefit package changes, and member changes based on the plan design.

    Do not submit missing or invalid data to the Centers for Medicare and Medicaid (CMS). A good enrollment system will allow the user to stage the application until all required documentation is received and will prevent transactions from passing to CMS without proper requirements.

    2. Minimize eligibility issues

    Reduce the number of rejected transactions by CMS by predetermining the beneficiary's eligibility for Medicare and Part D. Eligibility inquiries can help validate the beneficiary's demographic information, status, and eligibility information to allow the plan to enroll the beneficiary properly.

    At the start of the Annual Election Period (AEP), CMS made additional data available for plans, such as Low Income Subsidy (LIS) levels, Part D Eligibility Date and past coverage periods. This data provides benefits that include: establishing the member billing with the appropriate LIS level; computing when a beneficiary's Initial Election Period (IEP) ends; and determining creditable prescription drug coverage.

    3. Submit early and often

    Submit transactions to CMS more frequently—either daily or weekly. CMS now requires submission of completed enrollments within 14 calendar days of receipt of the complete enrollment request. Early submission of enrollments also helps plans decrease turnaround time for issuing member ID cards, and members benefit from being able to obtain prescription drugs at the pharmacy.

    By submitting transactions early, plans can also maximize member enrollment and payments by giving staff ample time to resolve rejected transactions. If your plan misses the CMS cutoff, you are still required to submit the transaction within 14 days. In 2008, this date will shorten to seven calendar days.

    4. Correct data discrepancies during enrollment

    Plans risk losing 10% to 15% of revenues from incorrect enrollment data. Once the plan begins to correct a discrepancy, it can take several months to complete the correction and request retroactive payments from CMS.

    Organizations have a small window to notify CMS of requests for corrections. Plans must submit requests for corrections and supporting documentation to IntegriGuard within 45 days of the date the report becomes available to the plan. The certification for each month's data will be due to CMS within 45 days of the date the reports become available for that month's data.

    For a jump-start on the 45-day requirement, data discrepancies should be identified during enrollment. Compare plan data against CMS data. Staff can record and analyze discrepancies to determine if the plan data or CMS date is incorrect. Certain types of discrepancies require the plan to contact the beneficiary to resolve name, date of birth, gender, or living status discrepancies with the Social Security Administration.

    5. Reconcile transactions

    Plans should monitor and track the status of all submitted transactions to CMS and all response files from CMS. To obtain a status of submitted transactions, review CMS's Weekly and Monthly Transaction Reply Reports (TRRs) on a monthly basis. Plans that automate or outsource this process may significantly improve administration costs due to the volume of transactions.

    6. Use payment reconciliation tools

    Plans should reconcile all payments types for Part C and/or Part D to ensure compliance with CMS procedures and determine if they may have been underpaid. In developing the wherewithal to reconcile payments, plans can opt for one of two approaches: internal IT infrastructure and processing or contracted services from an external vendor. The current trend is toward contracted services for reasons, such as operating efficiency and return on investment.

    7. Eliminate 4Rx gaps

    The 4Rx data is critical to allow your members to realize the benefits of Medicare Part D coverage. In 2006, CMS received complaints from Medicare beneficiaries who were unable to realize Prescription Drug benefits at the pharmacy due to missing 4Rx data.

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