Part B Insider (Multispecialty) Coding Alert

CMS to Scrutinize VBID Participants

Published on Mon Nov 09, 2015

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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 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.