The Client

Health insurance carrier that serves ~4 million members with: Quality, Managed Care Health Plans (including Medicaid, Medicare) LongTerm Services and Supports (LTSS), Behavioral Health, and Pharmacy Benefit Management Services.

The Challenge

CMS Audit identified several Corrective Action Plans (CAPs) and the carrier saw a decrease in CMS Star ratings around Member Complaints and Health Plan Performance, Health Plan Customer Service, Drug Plan Customer Service and Member Complaints and Drug Plan Performance.

The Solution

Garnet River developed a Regulatory Matrix for each functional area and performed an analysis to identify the functional area processes where the carrier was not in compliance with defined CMS Standards and Regulations. Approximately 75 findings were identified with proposed solutions. For example:

• Modifications to be made to the systems customer service workflow and benefit configuration to automate appeals and grievances process steps and streamline cross-functional area communications.

• Developed oversight tools to better manage RX vendor processes, modified outbound file layout to decrease processing error ratios, and identified additional service level agreements to hold RX vendor more accountable.

• Implementation of an ongoing quality assurance program in accordance to CMS standards and regulations for all functional areas.

The Impact

All CAPs were mitigated and approved by CMS and the plans CMS Star Rating has increased by 1 point in most categories allowing them to have an overall star rating of 4.5.