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Automating the preparation of CMS-compliant Medicare marketing materials

Nick Romano, Co-Founder and Chief Executive Officer, Prinova

The Medicare Advantage program has proven to be a very popular choice for qualified Medicare participants over the past decade and this trend is very likely to continue. More than 17 million, or 31 percent, of the rapidly growing group of Medicare recipients have chosen to enroll in Medicare Advantage plans offered by private payers. Competition is increasing among payers as they position to expand into new markets to capture a larger share of this growing population and the associated program funding. As a result, an individual participant has more plans to choose from than in previous years, which has transformed open enrollment into a highly competitive feeding frenzy among payers. 

Entering new markets and attracting new participants requires the Medicare Advantage Organization (MAO) to issue accurate and compliant marketing materials to participants in the service areas where they sell their plans.  Doing so in a timely manner presents challenges for those who are reliant on highly manual material preparation processes. The pressure to prepare updated materials between bid submission, desk review, benchmarks, and print production is exacerbated by manual preparation techniques. As a result, ensuring compliance with the federally mandated requirements for plan communications such as the Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) can be an arduous, time-consuming and costly process without the necessary content automation technology.

The stakes are high

The compliance challenges are clear:

  • Penalties for non-compliance
    • $25,000 per incident
  • Manual effort can be intensive and expensive
    • Determining the necessary changes across all versions takes significant time
    • Implementing manual changes across versions extends time-to-market and increases the risk of error
    • Mitigating risk from manual efforts requires resources, time, and money
  • Cost of rejection
    • If prepared versions are rejected by CMS or internal subject matter expert (SME) reviews, the manual process must start all over again, incurring additional costs and impeding time-to-market

For all of these reasons, content automation and change management control is a significant hurdle for payers trying to get the required communications to market each year. In addition to potential financial penalties, the MAO’s “Star Rating” can be negatively affected by inaccuracies in the information sent or by missing the required delivery dates mandated by CMS for communications.

Look to the cloud

One strategy for improving the process of creating CMS mandated communications is to leverage cloud-based Software-as-a-Service (SaaS) technologies that are designed to integrate with existing systems and technologies for both print and digital channels to accelerate the delivery of compliant and responsive customer communications while ensuring the protection of member private health information (PHI).

A commonly raised concern about adopting a cloud-based approach of this kind is security. However, a hybrid-cloud model can solve this concern by enabling users to manage content and rules in the cloud while member PHI remains behind an insurer’s firewall.

With this approach, model content and plan data can come together within a central content and rules platform to automatically update and generate versioned plan materials. Data extracted from the Plan Benefit Package (PBP), or another single source of truth, can be used as the input source to the process, significantly reducing the potential for human error.

Building content management, rule management and version management capabilities into the platform provides points of control and the ability to quickly and easily manage year-over-year changes. Non-technical users can make changes to bracketed content and rules quickly and easily without needing to involve IT. These changes can then automatically update one plan or propagate to many affected plan versions.

CMS approved models are built into the SaaS platform and updated each year according to CMS guidance. This eliminates the need for internal labor resources to manually support this activity. Year-over-year model updates can also be archived in the system.

Integrating workflow and user management in this way with SaaS technologies will enhance collaboration between internal and external stakeholders. When combined with version control and the management of different plan variations, users have a central view of the status of plan information throughout the lifecycle of the process. Editing content will not require any programming or specialized IT resources. Rather, a collaborative, self-service ecosystem can be created in which business users are able to access easy-to-use, web-based editing tools to enter or change communication content. On-demand proofing and approvals will further simplify the process and speed time-to-market while ensuring the right information is released to production.

In addition to streamlining the production and management of complex content assembly documents such as contracts, ANOCs and EOCs, SaaS technologies can apply the same concepts to welcome packages, forms, letter correspondence, ID cards, monthly and annual health statements and other communications that are part of the member services communications lifecycle.

Employing SaaS technologies to simplify the process of producing CMS mandated plan communications will deliver continual benefits to health insurers with every open enrollment cycle. With every efficiency realized, the risk of penalties as well as operating costs will be less and the opportunities to differentiate from the competition and enhance the customer experience will be improved.