Infocrossing’s Contract with CMS Helps Medicare Advantage and Medicare Part D Plans with Enrolling Members and Reconciling Payments from CMS | Article

retired man with medicareThe Medicare world changed in 2006 with the Medicare Modernization Act; the idea was to make it easier for beneficiaries to enroll in managed care. “But Congress also added more rules and complexities,” according to Charlie Johnson, Director of Operations for Infocrossing Healthcare Services, Inc. “Every time the program changes, plans find it very difficult to comply in many cases because of the new challenges.”

Johnson says “one of the biggest challenges” Medicare plans face today is successfully enrolling their members. Johnson says the processes set up by the Centers for Medicare and Medicaid Services (CMS) are not always easy to understand and use. Many of the plans struggle to successfully enroll their members using the processes provided.

Outsourcing this process can help the plans. “Most of our customers’ (plans) can’t do this by themselves. They need to outsource these processes to ensure that they are in compliance with CMS rules to successfully enroll their members,” says the Infocrossing executive.

Infocrossing’s Special Contract with CMS

Infocrossing has had a special contract with CMS for the last 19 years. CMS provides Infocrossing with an extract of the Medicare Beneficiary Database (MBD). This MBD file contains the demographic data for every person in the US who is currently eligible for Medicare or Medicaid benefits.

Infocrossing Healthcare Services uses this proprietary information to validate its plans data for correctness and accuracy. Using this process results in cleaner, more accurate data, which boosts the acceptance rate of the enrollment transactions the plans submit to CMS.

Currently, Infocrossing Healthcare Services is the only organization in the country with this contract, giving it access to the MBD data. UUNet also had a contract but withdrew in 2000. Johnson says CMS plans to award two other contracts to other firms this year. Until then, Infocrossing remains the sole supplier authorized to use this information.

Plans that don’t outsource to Infocrossing can submit data to CMS on their own at no cost, of course. Because the plans do not have access to the beneficiary information contained in the MBD, the enrollment transactions they submit to CMS are difficult to validate and may not be accurate. This makes them subject to high rejection rates.

The plans use the weekly and/or monthly Transaction Reply Report (TRR) to determine the success or failure of their attempt to enroll a beneficiary into their plans. Frequently a plan will not know if CMA has successfully processed a beneficiary until many days after the fact.

Most important, he says Infocrossing can greatly improve the success rate of enrollment transactions it submits to CMS. “Our Web-based, automated enrollment transaction submission process provides immediate verification of the accuracy of the data in each enrollment transaction,” explains Johnson.

Outsourcing’s advantage: the Medicare plans can concentrate more on delivering healthcare and prescription drug services to their members, knowing that the supplier’s process to enroll its members is efficient and accurate, reports Johnson. The successful enrollment of members ensures member satisfaction and increased revenue for the Medicare plan.

Automating the Enrollment Process

Infocrossing’s automated, Web-based processes allow the plans to enter all the requisite information online or through batch. The Web allows them to receive real-time responses. “It takes about two seconds,” reports Johnson.

Plans can also choose to batch their files and upload them at the Web site or use an automated FTP process. “Some large plans send us batch files every 15 minutes,” says Johnson; the process generates a response file, which it returns to the plan within minutes.

Meeting hard-and-fast CMS deadlines is another outsourcing advantage. Each month CMS has a cut-off date. Medicare plans submitting data on their own might experience a lag in acceptance. This can become a problem because the Medicare plan is liable for a member’s expenses from the effective date on the application date. It’s possible that the plan will not receive a reimbursement until the next month, which can affect its cash flow. Then, they have to retroactively enroll the member, which is “an administrative headache,” says Johnson.

Johnson says outsourcing allows Infocrossing’s plans to reduce their overhead because they now need fewer resources to handle the enrollment process.

The supplier uses the same procedures to disenroll members. In 2006 Infocrossing submitted approximately three million transactions to CMS.

Johnson says Infocrossing is able to provide its buyers with more demographic data than they can garner on their own due to their access to the MBD extract provided by CMS. It can provide additional demographic information such as date of birth, gender, etc. The data will list the applicant’s six prior elections. “Our reports give the plans a snapshot of applicants’ past activity,” he explains.

Payment Reconciliation

One of the most critical processes that plans must have to be compliant with CMS and ensure proper payment is the reconciliation of payments from CMS. Infocrossing provides its plans with both a Part C (Medicare Advantage) and Part D (prescription drugs) payment reconciliation process. Infocrossing’s payment reconciliation processes compare a plan’s data with CMS’s data. Discrepancies in the data maintained by the plan and by CMS can often result in incorrect payments from CMS. In today’s ever-changing world, the data maintained by the plan or CMS can often be incorrect. Johnson says faulty data can often result in incorrect reimbursements. Additionally, plans must attest to the accuracy of their data and that they are making satisfactory efforts to maintain accurate data.

When Infocrossing’s software identifies a discrepancy, the plan then researches the discrepancy to determine if the error is in the plan’s or CMS’s data. If the error is at CMS, the plan can request a retroactive payment based on the correction of the data. Once the correction is made, plans receive a payment adjustment via the Monthly Membership Report (MMR). Then the software processes the adjustment and applies the change to the proper months to keep the plan’s accounting accurate.

“This is a cash-flow management product. Our plans know every month if they are receiving accurate and full payment for each member of their plan,” says Johnson.

A lot has changed since Johnson started handling Medicare Managed Care processing working for a division of Litton Industries. Northrup Grumman sold the division to Acxiom before it bought Litton. Infocrossing purchased the division in April 2005.

The new rules and complexities of the new Medicare program have driven many companies to outsource, according to Johnson. While declining to give percentages, he says revenue has quadrupled since the new rules became law. “We’ve had an extremely good 2006 and 2007,” he remarks.

Lessons from the Outsourcing Journal:

  • Healthcare plans serving the Medicare market have two important challenges: successfully enrolling their members and making sure their reimbursements are accurate. Outsourcing eases both pain points because suppliers can use technology to mitigate them.
  • Currently Infocrossing is the only supplier that has a contract with the Centers for Medicare and Medicaid Services (CMS) to receive an extract of the Medicare Beneficiary Database (MBD). Infocrossing can compare data from its plans to the MBD data to detect errors. This improves the enrollment process significantly.
  • Technology makes a cumbersome process like enrollment easier. Infocrossing plans can use the Web to submit individual or batch enrollments. Infocrossing streamlines the enrollment process. The benefit: the successful enrollment of beneficiaries into a plan ensures member satisfaction and timely payments from CMS.
  • Outsourcing allows Infocrossing’s plans to reduce their overhead because they now need fewer resources to handle the enrollment and payment reconciliation process.

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