Mega-Reg refers to the ruling on managed care that came out in April 25, 2016 this year. The aim of this ruling is to modernize managed care in Medicaid and Children’s Health Insurance Program (CHIP). The ruling represents administrations goal of improving quality of care, reducing spending, increasing transparency in Medicaid programs and enhance health outcomes. The ruling is 1400 pages long. Here is a quick synopsis of the top 5 implications of Meg-Reg
1. Impact of the Medicaid modernization efforts
A major portion of the medical establishment’s budget can be attributed to Medicaid in most states. As part of the modernization efforts, there is a concerted bid to shift away from fee for service systems to managed care systems. This objective of this is to curb waste and prevent fraud. A big part of these efforts is to put payment integrity systems in place within the establishments and states are pushing for this. Is your establishment geared up to do this?
2. Network adequacy standards
Medicaid can bring to bear incredible strain on network adequacy, especially if participation in the program witnesses a sudden escalation. On the other hand, states are pushing for increased transparency and validation. To keep the network coverage optimal and keep provides motivated to accept these members, payers will have to relook at how they contract with networks. To do this you need to:
o Identify the areas where your medical organization have service gaps, particularly in the emergency services department
o Allocate funds for bridging these gaps
The author credits the material in this article to whitepaper from Optum. Download the detailed whitepaper“Modernizing Medicaid today and tomorrow: Five implications of the Mega-Reg”.
3. Managing the new transparency rules
As part of the new rules, medical establishments are required to improve the transparency levels within their organizational hierarchies as they are expected to be more accountable. This could mean that there is additional stress in areas where the systems where already under duress. Accountability may take several forms- validating encounters, verifying reporting, data quality checks and more and all of these are going assume greater importance than before.
A good way to address this aspect is to categorize members into different rate- based groups, making it easy to designate and collect the appropriate premium payment from each group and each individual member of the group. The biggest challenge is to correctly identify and place various members into the right groups so that you have a standardized pricing plan that is logical and viable for your organization while also conforming to rules.
4. Dealing with withheld premiums
Many states withhold premiums if the medical organization is found to be falling short of quality standards. Metrics are used to quantify quality issues and enable accurate measurement. These can be earned back by the organization at a later date by improving metrics. However, it does have an adverse impact on the organization’s auto- enrollment and this is one issue that you will need to address.
5. Aligning with Mega-Reg quickly
Although many believe that a period of 30 days is adequate to bring systems up to speed with Mega-Reg, there is no clarity on this. A good approach may be to identify the priorities for your organization and focus on implementing those first. For example, if you feel that your organization could use some improvement in fraud prevention or wastage prevention areas, focus on these aspects of the Mega- Reg and bring them into the system first with viable solutions. The other aspects can be addressed once these critical problem areas have been addressed effectively.
In conclusion, it is imperative for organizations to take steps right away to ensure that they are geared to the new rules. The key takeaway is taking advantage of being the first mover. The first mover can engage with the state and help share what the future looks like.
The author credits the material in this article to whitepaper from Optum. Download the detailed whitepaper “ModernizingMedicaid today and tomorrow: Five implications of the Mega-Reg”.