Medicare Compliance & Reimbursement

‘Secret shoppers’ are part of the federal government’s arsenal.

The new Value-Based Insurance Design (VBID) model for Medicare Advantage (MA) Plans appears to give plans a wide berth when redesigning benefits for targeted enrollees. But there are many safeguards in place, ensuring that the Centers for Medicare & Medicaid Services (CMS) will definitely be watching plans closely.

CMS has built into the model design a variety of protections for enrollees. Chiefly, MA Plans are not allowed to propose reductions in targeted enrollee benefits or increases in targeted cost-sharing amounts as VBID interventions. Also, MA Plans cannot discriminate against non-targeted populations, for example, by making changes to plan benefits in ways that decrease benefits to enrollees with non-targeted clinical conditions.

Additionally, CMS is layering several additional enrollee protections on top of those woven into the plan design, including:

• use of “secret shoppers” to ensure that plan marketing and sales representatives are not inappropriately citing plan participation in the VBID model;
• after-the-fact randomized or targeted auditing, to review plan compliance with CMS definitions of eligible target populations;
• a customized script for any calls to 1-800-MEDICARE related to the VBID model and a standardized process for following up on any enrollee complaints;
• an enrollee right to opt-out of the model, if they request to do so;
• a standardized process for receiving and reviewing any provider complaints related to the model;
• ongoing monitoring of incoming plan data, to ensure that there is no evidence of significant deterioration in enrollee outcomes or in enrollee satisfaction, or other adverse enrollee impacts; and
• ongoing monitoring of incoming plan data, to ensure there is no significant increase in coding intensity associated with plan participation in the model.