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Payer's Edge - Medicare Part D and Star Ratings

Blog: The Payer's Edge

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MEDICARE PART D APPEALS DETERMINATION AND YOUR PLAN’S STAR RATING

Your plan’s star rating has a significant effect on your bottom line. It’s a key way attract new enrollees, expand market share and increase revenue. And, as you may know, the factor that has one of the largest impacts on your star rating is your Medicare Part D determinations and redeterminations.

Let’s take a look at exactly what that star rating means to you and the link between the way your plan handles Part D determinations and how your plan rates.

On average a one-star rating improvement delivers[1]:

  • A year-over-year 8 to 12 percent increase in plan enrollment

  • An increase in revenue between 13.4 and 17.6 percent (when improving from a 3-star to 4-star rating)

  • A 9.5 percent higher likelihood to enroll

  • 134 percent more value to your members in extra benefits and more generous rebates (for improvements from 3 to 4-star)

  • An additional 5 percent quality bonus on top of the base rate (when going from 3 to 4-star)

And…

If your plan achieves a 5-star rating, you’re allowed to enroll members throughout the year – not just during the late fall annual election period – meaning more members, higher revenues and additional bonuses and rebates.

Beyond those benefits, the rebates you generate through a higher star rating allow your plan to be more creative when designing your benefits, providing you the ability to include enhanced benefits that would not have been cost effective at lower enrollment rates.

These enhanced benefits deliver a more stable population of enrollees with lower rates of disenrollment, further boosting your star rating – a cycle that spurs both enrollment and financial growth for plans which make their star rating a priority.

However, in order to maintain or boost your company’s star rating, CMS guidelines must be strictly adhered to .

  • For Part D Appeals Determinations, you have a 7 day time limit for standard appeals.

  • And, for the expedited process, you’re limited to just 72 hours.

If your plan is unable to make the turnaround time, you’re required to report it and your star rating will suffer.

As you can see, your plan’s Medicare Part D determinations and redeterminations constitute a significant role within your PDP/MAPD business with effects on your plan’s star ratings and your organization’s ongoing success.

That’s why AllMed is here for you, a partner you can trust to provide evidence-based, defensible determinations for Medicare Part D appeals all within a turnaround time you can depend on to meet CMS guidelines.

And, our quick turnaround time provides an added bonus of a positive impression on your plan’s members which translates into improved ratings in your CAHPS surveys, further boosting your star rating.

With AllMed, you can also rest assured that all of your determinations are handled by physicians specifically trained in Medicare Part D so you never have to worry about training our staff on Medicare policies and we can instead focus on your plan’s own policies and processes.

Our reviewers search out detailed information from the prescriber, previous determination and claims history to review your member’s complete medical record, ensuring our rationales are backed by evidence, protecting you from cases being overturned at the Federal IRE level.

Whether your plan needs year-round help or is facing seasonality issues (such as an influx of onboarding new members for upcoming plan year) processing reauthorizations, covering any month’s overflow, or medical director staffing, we can efficiently process your appeals determinations with clarity and totality to preserve, protect and boost your plan’s star rating. Reach out to AllMed today to discover how together we can help ensure your plan’s Medicare Part D success.

[1] Bajner, R, T Meinkow , E, et all. THE IMPACT OF STAR RATINGS ON RAPIDLY GROWING MEDICARE ADVANTAGE MARKET; Navigant; https://www.navigant.com/-/media/www/site/insights/healthcare/2018/medicareadvantageanalysis.pdf, accessed 9/26/18