Posts Tagged ‘Medicare’

Prescription Drug Plan (PDP) Technology & Services by Sun Knowledge

Wednesday, April 4th, 2012

Prescription Drug Plan (PDP) Technology & Services by Sun Knowledge

Sun Knowledge provide the following services to PDP sponsors, Medicare Advantage organizations that offer MA-PDs (including local HMO plans, local, PPOs, regional PPOs, and Private Fee-for-Service plans), organizations with Cost Plans under section 1876 of the Social Security Act, Employer Groups, and PACE organizations.

  • Enroll all eligible Medicare beneficiaries
  • Administer the Part D benefit including providing coverage for drugs included in a CMS-approved formulary, administering appropriate deductibles and co-payments, managing the benefit using appropriate pharmacy benefit managerial tools, making discounts for applicable name brand drugs available to eligible enrollees at the point of sale, and operating effective oversight of that benefit
  • Ensure that records are maintained in accordance with CMS rules and regulations and that both records and facilities are available for CMS inspection and audit
  • Process claims
  • Operate quality assurance, drug utilization review, and medication therapy management programs
  • Administer coverage determinations, grievances, exceptions, and an appeals process consistent with CMS requirements
  • Provide customer service to beneficiaries, including enrollment assistance, toll-free telephone customer service help, and education about the Part D benefits
  • Protect the privacy of beneficiaries and beneficiary-specific health information
  • Develop and/or maintain systems to support enrollment, provide claims-based data to CMS, coordinate benefits with secondary insurers (or primary insurers when Medicare is secondary) and support e-prescribing
  • Health Plan Management System (HPMS) Data Entry
  • Provide PDP / Claims Services for New Employer/Union-Only Group Waiver Plans (EGWPs)
  • Automatic Enrollment of Full-benefit Dual Eligible Individuals
  • System Access and Data Transmissions Support with CMS
  • Abides by all applicable Federal laws, regulations and CMS instructions
  • Performs adjudication and processing of pharmacy claims
  • Operates an enrollee grievance and appeals process
  • Performs customer service functionality
  • Performs enrollment processing
  • Complies with formulary guidance that is contained in the Prescription Drug Benefit Manual
  • Provides for an appropriate transition for new enrollees into Part D plans following the annual coordinated election period, newly eligible Medicare enrollees from other coverage, individuals who switch from one plan to another after the start of the contract year, and current enrollees remaining in the plan affected by formulary changes prescribed Part D drugs that are not on its formulary
  • Maintains policies and procedures to prevent over-utilization and under-utilization of prescribed medications
  • Maintains methods to ensure cost-effective drug utilization management via Step therapy; Prior authorization (PA); Tiered cost-sharing
  • Implements internal medication error identification and reduction systems
  • Implements a Medication Therapy Management (MTM) Program designed to ensure optimum therapeutic outcomes for targeted beneficiaries through improved medication use & for targeted beneficiaries, reduce the risk of adverse events, including adverse drug interactions
  • Has an appropriate MTM enrollment policy which enrolls targeted beneficiaries using an opt-out method of enrollment only
  • Has an appropriate MTM enrollment policy which targets beneficiaries for enrollment at least quarterly during each year
  • Supports and complies with electronic prescription standards relating to covered Part D drugs for Part D enrollees
  • Complies with the CMS Enrollment and Disenrollment Guidance documents that are provided on the
  • Complies with CMS operational guidance on Creditable Coverage and the Late Enrollment Penalty
  • Provides all current and newly enrolled individuals all required enrollment material and notices within the timeframes provided in the CMS PDP Enrollment and Disenrollment Guidance
  • Operates a process for enrolling Medicare beneficiaries in the PDP that includes: communicating with beneficiaries who are requesting enrollment in the PDP within timeframes specified by CMS, including requirements for initiating appropriate follow up with beneficiaries who submit incomplete enrollment requests; and making enrollments effective according to the effective date requirements associated with the enrollment period in which the enrollment is received
  • Accepts and processes voluntary disenrollment requests from beneficiaries, including providing all required notices and information to beneficiaries, communicating these requests to CMS, and establishing the disenrollment effective date according to the effective date requirements associated with the enrollment period in which the disenrollment request is received
  • Provides advanced notice to all enrollees in the event of a contract termination, describing the implications of the termination and alternatives for obtaining prescription drug coverage under Part D in accordance with Part 423 regulations and CMS non-renewal instructions
  • Implements policies and procedures (including appropriate notice and due process requirements) for optional involuntary disenrollment as permitted by CMS
  • Ensures that information necessary to access all plan benefits, such as an ID card, is provided to new enrollees prior to the enrollment effective date, or no later than 10 days after receipt of the enrollment request, according to the timeframes described in the PDP Enrollment and Disenrollment Guidance
  • Completes the reconciliation of all enrollment, membership and payment data, and submits requests for valid discrepancy corrections in compliance with the 45-day schedule to submit the monthly CEO certification of enrollment data for payment
  • Monitors and documents complaint resolutions for complaints attributed to their contracts in the CMS’ Complaint Tracking Module in accordance with CMS’ Standard Operating Procedures for Part D sponsors

Business Health check for organizations

Wednesday, December 1st, 2010

Whatever business one is associated with- be it information technology or insurance or health care- one can now easily and seamlessly gauge where one’s business stands and what curative measures one must adopt in order to whip it back into shape and make it grow. The market is thankfully swamped with numerous sophisticated tools that comprehensively and expeditiously perform health check-ups of businesses and help them hit the ground running again. Broadly speaking, a company’s business health boils down to its consumer base, working capital and IT systems.

In order to boost the sales of any product, it is essential for business owners to penetrate the awareness of their target customers, substantially gaining their trust and credibility. An effective, streamlined and integrated marketing action-plan can significantly bolster the brand reputation of any organization. In this age of globalization and IT, business owners are increasingly falling back upon smart, nimble web-marketing tools including search engine optimization, email marketing and Facebook as well Twitter market in order to build brand reputation and rope in prospective clients. However, for both smaller and bigger business organizations, conventional and age-old marketing tactics, including advertisement with renowned publications and distribution of marketing flyers as well as brochures, work just fine.

Working capital is crucial to the management of funds in any organization, as it reflects its ability to pay its debts or short-term liabilities on time. Successful and timely achievement of an organization’s long-term and short-term goals essentially reflects its sound business health and calls for effective working capital management. Poor liquidity or working capital can spell disaster on the health of a business, making it increasingly difficult for it to cope with its day-to-day expenses. Hence, it is of utmost importance to monitor and hold a vigil on an organization’s amount of working capital, including its accounts receivables and payables. Moreover, every organization must make a conscious effort to keep its working capital ratio as low as possible in order to maximize its profitability margins. A business owner must stay abreast of the latest trends of the target market and strictly avoid tying funds in fixed assets and stocks that are an anachronism now.

Due to absence of hindsight, business owners often miserably fail to judge the enormity of risks, associated with their businesses, hampering their growth in the process. Lack of smart action-plans to ward such risks off also contributes to the failure of businesses. This holds true for most SMEs (small and medium enterprises) that comprise the lion’s share of private sector enterprises in almost all the countries of the world. Failure to access modern, easy-to-use online tools accounts for the collapse of most of the businesses. What business owners do not realize is that they are just one click away from solving problems that need to be addressed immediately. There are certain integrated online tools such as Google Analytics, Omniture that can perfectly identify the reasons behind the sudden shift in traffic across the web. Web tools, including Alexa can work to the advantage of a company, giving it valuable information about its position in terms of web-traffic, traffic detail pages, related link pages and what people are primarily searching on the web. Alexa site audit, like webmaster tools, can crawl and analyze websites, giving in-depth visibility to search engines and insights into optimization, monetization and overall health status of business websites.

A business will jeopardize its own growth, if it loses sight of its consumer base. That is where a good PR campaign comes in handy. A business can flourish only when it accurately gauges the expectations and demands of its consumers. PR can do its tricks in different ways. Apart from traditional advertising, sales letters and face-to-face selling, well-executed PR tools can include press releases, guest columns, media interviews, workshops, seminars and public speaking engagements, which are highly instrumental in promoting and bettering the health of businesses.

Last but not the least, a small yet significant component of business health is Information Technology that handles all kinds of data, eventually paving the way for information. Infact, IT and business intelligence work hand in hand in order to accomplish all data related tasks that an organization is assigned with. IT is crucial to all the processes associated with Business Intelligence applications that primarily collect, preserve and extensively analyse business data. Infact, mission-critical BI applications can expertly churn out insightful information about new revenue generation opportunities from crude data they have at their disposal and target network expenditures at the most lucrative service areas. BI tools significantly slash unnecessary expenditures that business organizations stumble upon, improving their profitability margins and operational efficiency. BI is also effective in keeping a track of the performance levels of people across the entire organization, right from finance and HR to sales.

Working from Home and the Legal Issues that it Entails

Thursday, November 18th, 2010

Working from home is no cakewalk, these days. Since outsourcing is in
its full swing, many intricate international laws have come to the
fore, dictating and shaping the future of people, who primarily work
from home. Businesses of all shapes and sizes must stringently abide
by these laws, including taxation laws and laws pertaining to workers’
compensation, protection and insurance. Employees, working from home,
must be made aware of the pros and cons of their professions and the
onus of educating them about all the legal issues is on the
organizations they work for.

This section addresses various legal issues that people, working from
, essentially face. However, within the limited scope of this
article, it has not been possible for us to put each and every law
under the microscope. It does not matter, whether you are working for
a health BPO or are running your own business that specializes in
insurance analytics. The rules hold true for everyone. Hence, before
you commit to a profession, which involves working from home, you must
make a conscious effort to know all the laws, surrounding your
employment and their legal implications.

If you run your own business, you have to be accountable to the
government, reporting all kinds of income, generated in the process.
Businesses often have to contend with several liability issues, as is
the case with LLCs, with two or more owners. It is mandatory for these
LLCs to file an annual federal tax return form, even if they do not
generate any income. Whether you are running an LLC or a corporation,
each business, no matter which niche market it caters to, has its
unique set of issues, revolving and evolving around taxes. It is
important to seek the advice of a seasoned lawyer or accountant in
order to get a hang of your responsibilities as a business owner. You
can also conduct an independent research for self-education.
W2 employees are distinctly different from 1099 employees. Below is
the summation of the differences between the two:

If you are a W2 employee, working for a business, then, your wages are
taxable. Since every month, taxes are deducted from paycheck, you are
required to report the exact deductions at the end of the year.
Besides unemployment insurance, injury liability and other commonly
applied benefits, W2 employees are also entitled to 401K plans.
1099 employees are primarily contracted by businesses to work on their
assignments. These employees, embodying typical freelance or
contractual work, are required to separately report their earnings for
taxation. These employees are not entitled to any of the benefits,
otherwise, applicable to W2 employees.

Before taking the plunge, you must educate yourself about the legal
responsibilities in terms of taxes and reporting incomes. This
education will definitely come into play, when it comes to running an
independent business or hiring new staff. If you are an employee about
to be hired, it is of utmost importance to double-check with your
employer, whether you are to be hired as a W2 employee or as a 1099