Taking the Mystery out of the Appeals Stars Measures

Why are appeals measures part of the Star Ratings? The Centers for Medicare & Medicaid Services (CMS) uses plan performance in these measures as a proxy for determining whether plans are providing access to care for every member in an equitable, consistent and compliant manner. The Star Ratings are only one mechanism CMS uses to monitor appeals. In addition, the following activities ensure CMS has insight into and oversight of plan appeal processing:

1. Independent Review Entity (IRE) Medicare Managed Care Reconsideration Project to review untimely and denied appeals
   
   
2. Annual Timeliness Monitoring Project (TMP)
   
   
3. Annual Part C Reporting
   
   
4. Organization Determination, Appeals & Grievances (ODAG) Audit Protocols
   
   
5. Star Ratings which reflect two appeals measures: Plan Makes Timely Decisions about Appeals and Reviewing Appeals Decisions

The Stars appeals measures will continue to be quadruple weighted for one more Star Rating year. With such intense focus on HEDIS® and CAHPS® measures, Star leaders frequently have little insight into the mechanics of success for these operational measures.

For simplicity, I’ll refer to Plan Makes Timely Decisions about Appeals as Timeliness and Reviewing Appeals Decisions as Upholds since it refers to the percentage of the time the IRE upholds the plan’s denial decision.

Appeals measures and Star Ratings basics:

1. Only a subset of appeals is included in the calculated rates:
   
   
   1. Upheld initial denials
      
      
   2. Appeals that were not processed and forwarded to the IRE within regulatory timeframes.
      
      
2. The draft cut points CMS recently released in the Second Plan Preview reinforce their expectation that plans have stringent controls in place to ensure appropriate decisions as well as timely processing.
   
   
   1. 5-Star threshold for Timeliness = 98%
      
      
   2. 5-Star threshold for Upholds = 100%
      
      
3. The minimum denominator for inclusion in the Star ratings is 11 appeals resulting in little to no margin for error.
    
   1. Assuming a plan has 11 appeals in the denominator for timeliness, a single late case results in a drop of 2 Stars, from 5 to 3.
      
      
   2. Using the same scenario for upholds, a single overturn results in a 3-star drop, from 5 to 2 Stars.
      
      
4. Denials and untimely processing also influence the member experience and can result in lower CAHPS® scores, particularly in the Getting Needed Care and Getting Appointments and Care Quickly measures.

Regardless of whether the appeals measures are a part of the Stars calculation, there are foundational operational processes all plans should enact to ensure every member is receiving the care they need in a timely manner. Consider the fact that an appeal is the result of a long string of events that doesn’t just start with the initial denial.

Ask yourself these questions:

• Are your claims and authorization systems configured to match your approved bid/benefits?
• Does your Evidence of Coverage (EOC) clearly describe benefits and limitations?
• Are there procedures that currently require prior authorization that you’re approving a vast majority of the time? If so, consider removing the prior authorization requirement.
• Do you have open communication and coordination between the Appeals & Grievances (A&G) team and both Claims and Clinical Operations?
• Are you tracking and trending your appeals to identify potential issues?
• Are you applying your benefits consistently across all members and reviewing overturns to ensure all members with the same scenario can access services? If not, you are exposing the plan to a potential compliance risk.
• Are Customer Service, Provider Management/Network Operations, Clinical Operations, and A&G aligned and well-informed regarding benefits, authorizations, and payment rules?
• Are you monitoring your timeliness and uphold rates by line of business and CMS contract to ensure the rates you’re reporting are not diluted by overall performance?

The Bottom Line

A strong operational foundation that includes oversight and accountability is the key to success in the Stars appeals measures, but more importantly, it is the key to providing the right care, at the right time, in the right setting for your members to ensure healthy outcomes.

Healthmine is here to help. Reach out with any questions on how we can help you achieve your goals. Cherie.Shortridge@healthmine.com