The Key to Meeting CMS Regulations

For health care payers that offer Medicare, Medicaid and hybrid government-sponsored plans, the regulations established by the Centers for Medicare and Medicaid Services (CMS) present significant challenges when it comes to creating customer communications that are compliant. For example, when generating printed correspondence, health plans are required to follow strict CMS models that define how and where to format information on the page. Organizations not meeting the demands of this regulatory document face steep financial penalties. According to the PPACA, health care payers and plan administrators who fail to deliver compliant summaries of benefits and coverage (SBCs) can face a $1,000 penalty per violation.

Many health plans have been audited in order to ensure that SBCs are being completed. According to Chuck Whitford, consultant at JRG advisors, “In 2013, more than 70 percent of audits resulted in fines or other corrective action. The most common triggers are participant complaints and incomplete or inconsistent information.”

The SBC Workflow Presents a Challenge

While the penalties imposed by the CMS for noncompliance with published models and delivery dates can be costly, the risk of penalties isn’t the only burden. Since regulatory oversight was established long before the availability of today’s modern technologies, most health insurers employ predominantly manual workflows for updating CMS models. These workflows have been adapted and have grown more complicated over time, which continues to add to even more “manual process overhead” that inhibits efficiencies.

Because of the critical nature of the content in each document sent to the insured and the associated risks that come with errors, many organizations assign a full-time document owner to a specific model or document type. These are staff members that have expertise in the regulations that apply to their model and hold the responsibility for updating the templates, testing all of the possible versions, confirming the physical page layout is correct and securing timely CMS approval.

The amount of manual resources needed to prepare even one model version can be extremely large. For example, it may take an insurer approximately 40 hours to update one model version, with hundreds or even thousands of versions of the same document needing updating. Add to that the time needed for the approval cycle. If CMS rejects the model, the update process starts over for every affected version. With hundreds of documents under management, each with potentially hundreds of versions, the costs are exponential as insurers allocate more and more resources to ensure compliance within mandated time frames.

In many cases, payers also face hard dollar costs associated with using outside creative agencies and print service providers to complete the process, in addition to the costs of assigning dedicated internal resources responsible for ensuring CMS updates are accurate and on schedule.

For payers facing these pain points, the need to improve processes extends well beyond compliance itself. It is a matter of staying competitive and, for some, remaining in business.  In fact, according to a recent Reuters survey, some health insurers are expecting member growth in the 20 to 100 percent range during open enrollment. They report having doubled or even tripled staffing in order to handle applicants.  This translates to a need for improved internal operations to remain competitive.

Identifying Workflow Bottlenecks

With these time and cost considerations, streamlining workflows becomes a priority.  Common workflow scenarios that create bottlenecks include:

• Thousands of model plans and versions maintained and edited as individual files
• Substantial amounts of duplicate content that is not shared between versions
• Incorporating updates from both external agencies as well as plan data from internal systems
• Manual, page-by-page formatting
• Manually proofing individual versions against guidelines and source data
• Errors resulting in the above causing rejections that restart the process

Eliminating the complexity caused by the foregoing manual processes, individual file structures, need for agency coordination and duplication of content has the potential to deliver immense process improvements.  This can be accomplished through automating these workflows.

Four Considerations When Optimizing and Automating Workflows

Here are questions insurers should ask when automating workflows for CMS-regulated communications to achieve bottom-line improvements that will save time, money and, most importantly, increase the accuracy of the content:

1. Can I generate all model versions from one master template without manual formatting?

2. Can I centralize content and manage it within a content management system, rather than embedding it in each version?

3. Can I set business rules to dynamically assemble the content for each version and format the physical pages for precise adherence to CMS regulations?

4. Can I transition the management of updates completely to business users without requiring support from IT that might slow the process down?

The right automated workflow replaces time-consuming, error-prone and expensive manual activities with accurate, preset processes. Dynamic formatting can replace manual layout methods, eliminating the need for outside agencies or dedicated internal staff for this process. Centralization will streamline management, add control and provide visibility into the workflow process and can significantly reduce costs.  This improves time-to-market as well.

Most important, automating previously manual processes for CMS-regulated communications ensures that customers receive timely, compliant and effective communications, which will enhance customer experience and loyalty.