Surviving CMS “Crackdowns” on Medicare Advantage Plans

A Modern Healthcare article today highlights the importance for MA plans to do a better job of managing their provider networks in terms of maintaining accurate directory information and ensuring availability for Medicare patients they’re covering (see the full article).

A properly organized and managed referral management system (like ReferWell’s, for example) provides not only significant savings on the total cost of care (on the order of $20–25 PMPM, according to numerous studies) but it also provides “soft dollar” benefits that may be equally significant:

  1. Because we are continuously updating providers’ location and contact information (as they update the system to make sure patients show up at the right place for each appointment), users have the logging and reporting to show that immediately.
  2. Because users can see the full information on all referrals (including attempted referrals that didn’t find a doctor) and their status, those users have real-time information on provider availability, response times to get appointments, and provider responsiveness in closing the loop across their network (including any ‘narrower network’ they create within the overall provider network).
  3. Based on the real-time information, users can proactively address any gaps they are seeing before a reviewer points them out, shortening the review (saving loads of staff time today spent researching these questions manually) and saving money on outside “secret shopper” campaigns and improving the results: a one-star improvement is estimated to be worth $40 Million in increased reimbursement from CMS, according to an executive at one MA plan!

So, in addition to all the other financial benefits, using an automated referral management system positions users to take on these types of reviews in the future and passing them with flying colors!

Written by ReferWell

ReferWell is a New York-area digital health company that leverages the referable moment — the point in time when a person is most ready to take action to improve their health — to improve access to care, increase health plans’ quality performance and reduce the total cost of care while improving the members’ experience and outcomes. ReferWell’s intuitive technology platform and skilled service team helps health plans and providers manage value and help more people get on, and stay on, their healthcare journey by providing an optimized provider search, making it easy to schedule appointments at the point of care to increase patient compliance, and providing a service component to ensure providers close the loop regardless of the EMR they use.

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