Episode: 336 |
Betsy Seals :
The Managed Care Industry:


Betsy Seals

The Managed Care Industry

Show Notes

Betsy Seals is a recognized leader in the managed care industry. She is the Co-Founder and Chief Operating Officer of Rebellis Group, where the members have decades of experience in health plan, pharmacy benefit manager, and government consulting experience.

In this episode, Betsy provides an overview of the managed care universe in the U.S.

Learn more about Rebellis Group at  https://www.rebellisgroup.com/

One weekly email with bonus materials and summaries of each new episode:

Will Bachman 00:01
Hello, and welcome to Unleashed the show that explores how to thrive as an independent professional. I’m your host Will Bachman. And I’m here today with Betsy seals, who is the principal and Chief Operating Officer and one of the co founders at rebellious group. And she’s going to tell us all about their work. Betsy is a nationally recognized leader in the managed care industry. Betsy, welcome to the show. Hi, well, thanks for having me. Okay, so my first question is, helped me understand what does managed care refer to.

Betsy Seals 00:40
So really anything that is either federally or state regulated is is what we mean by the term managed care. So for example, the best example on a national level is Medicare Advantage, which essentially takes the same federal dollars that are in you know, fee for service Medicare, and take those into the private sector. And really, with the idea of offering better benefits and a better product to Medicare Advantage beneficiaries, or to Medicare beneficiaries.

Will Bachman 01:07
Okay, so if I have just a regular private health insurance, we don’t call that managed care.

Betsy Seals 01:16
No, we typically call that commercial or ISP, or, you know, there’s probably a number of different names for for private health insurance.

Will Bachman 01:24
Okay. So for listeners that like me, I’m a listener, I guess, who maybe you haven’t yet reached the age where they’re really trying to study the different Medicare options. And there may be a little bit fuzzy on it. Explain to me in simple laypersons terms, what is Medicare Advantage?

Betsy Seals 01:45
Sure. So we’ll start with what is Medicare, right? Because then that’s going to feed into the question. Essentially, Medicare is the federal health insurance program that we all pay into all the way up until we are eligible, which typically happens when one is around 1/65 birthday, or in some circumstances related to certain disabilities at a younger age. And so at that point, all of that money that we’ve paid through all of our careers, is just put into the federal health care program turns into benefits, right, our Medicare benefits, and what we call fee for service Medicare is generally looks like the beneficiary paying 20% and Medicare paying the other 80. What Medicare Advantage Medicare Advantage is, is essentially private health insurance companies who have a contract with the federal government to take those same federal dollars and provide a better product, higher level of benefits, supplemental benefits, like transportation, over the counter drugs, a lot of different things that is not covered by Original Medicare, essentially managing those dollars in a more effective way to give the beneficiary a better product.

Will Bachman 02:56
So if I’ve turned 65, which is still a few years out, then how does it work? Do I have a choice? I can say no, no, I’ll just stick with basically plain old vanilla plain Medicare fee for service and I’ll pay 20% of anything? Or do I can go out and sign up with a Medicare Advantage plan. And then I have to pick which one of several providers that I want to sign up with, like, how does that work? How do I get into a Medicare Advantage? And then I have to sort of say, all of my benefits basically, will go to that insurance company, and they’ll provide me benefits, but I kind of relinquish my right for the fee for service, like how does it work?

Betsy Seals 03:35
Yeah, so when one is initially eligible for Medicare, they go and sign up, you know, Medicare Parts A and B. And then they essentially have a choice, right? They either are in fee for service Medicare, and they have a prescription drug plan on top of that for the Part D coverage. Or they can choose to join a Medicare Advantage plan, which typically has all of the benefits wrapped in one product, also referred to as part C. So it’s typically a, b, and D, all of your Medicare benefits within one product, and then managed under that product as well. And then for in terms of sorry, the next part of your question. I know we’re gonna so that piece out?

Will Bachman 04:20
Yeah, no, that’s right. I mean, it. We’re very casual here on the show. So so so I get to choose that and then all of the so if I pick a Medicare Advantage plan, then all of the dollars that I guess they just do they just get like a fixed amount of dollars from the federal government. Say, okay, Will Bachman he was going to get so many dollars, you know, on average of benefits. So all of those, just those dollars go straight to that healthcare company.

Betsy Seals 04:50
Yeah. So the payment around what those Medicare Advantage companies get is much more complicated than that. It has to do with their star ratings. That has to do with our risk adjustment, so a lot of pieces around how that company gets gets paid. What it turns into for the beneficiary is really a couple a couple really key things. One is a an out of out of pocket Max, very specific and regulated a co pays around different services. So you know exactly what you’re going to pay when you enroll in that Medicare Advantage plan, which by the way, we are in annual election Annual Enrollment Period right now, some marketing started on 10 one, and enrollment starts on 1015. So now is the time when all the beneficiaries are really reviewing their options. So that that’s how that looks from the beneficiaries perspective, in terms of what plan type, because there are a lot of different plan types. Just like in the commercial world, there are HMOs, there are p POS. And a beneficiary has choice. So typically, a Medicare beneficiary is either going to contact their local agent, sales agent, or they’re going to go to medicare.gov. And take a look in their zip code at what plans are available. And it really gives a great picture of the cost associated with those plans. You can input your prescriptions to see what you’re going to pay for each of those prescriptions. And really, that’s at least a way to do some due diligence and educate yourself on what new plans are in the market starting on 10. One, which will be live on one one next year.

Will Bachman 06:27
Okay, so sounds relatively complex to make this choice. And I and I guess it’s a good thing, that it’s not just a straight dollar per person, because that would drive the insurance companies to only recruit the really healthy 66 year olds, as opposed to the person with no pre existing conditions and so forth. So I guess they get paid more if the person is like a sicker person.

Betsy Seals 06:56
Yeah, so a couple things, what we call cherry picking, or, you know, targeting certain subsets of individuals based on their health status is prohibited by federal federal regulation. So we definitely are very careful not to do that in the Medicare Advantage world. We can’t ask any health screening type of questions when we’re enrolling beneficiaries. But that I will say that we know how those beneficiaries are managed, once they’re a part of the plan has a great deal to do with how successful that plan will be. You know, if you as an organization are really great at managing a diabetic population, you have a lot of different programs and outreach efforts and benefits to wrap around, you know, a specific disease state, you’re going to be much more healthy as an organization, then if you are enrolling beneficiaries with all sorts of different chronic conditions, and you’re not managing any of those appropriately or effectively. So the management of the beneficiary and those chronic conditions after the point of enrollment is absolutely critical for health plans. Success.

Will Bachman 08:01
Okay, great. So now I at least have a beginner’s knowledge of what managed care is. Tell me a little bit about the types of clients that your firm serves? Is it the mostly the for profit insurance companies that are running these Medicare Advantage programs? Or is it government? Or some some third choices? or all of the above?

Betsy Seals 08:25
Yeah, so probably the the real answer is all of the above. But I would say, our core client is a Medicare Advantage health plan, whether it’s for profit or not for profit. So that would be our kind of number, our core client. And then in addition to that, we essentially have clients in all different areas of the business. What we’ve noticed recently is a lot of different, for example, tech companies entering the space because there’s a lot of money to be made in healthcare, right. But just because you are successful on the tech side, and you have a great idea does not necessarily mean that you understand the Medicare Advantage or the managed care landscape, and certainly doesn’t mean that you understand all the nuances of the regulations, which apply equally to any type of technical solution. So more and more, as the industry has evolved, we have found ourselves working with those companies who have a really great idea of how to change healthcare or be innovative and healthcare space, but really don’t understand the landscape and don’t understand the regulations. So that’s been a lot of fun. The other the other place I’d say that we play is that there’s a lot of a lot of private equity firms really investing in the space now a lot going on in managed care Medicare Advantage specifically. And so doing due diligence or kind of providing advisory services to those PE firms has been a new piece of our business which has been a lot of fun as well.

Will Bachman 09:53
So beyond the due diligence for PE firms, could you give me some obviously sanitized But examples of of actual types of projects that your firm has done

Betsy Seals 10:07
for private equity or for an industry

Will Bachman 10:09
or for industry. Let’s start there.

Betsy Seals 10:11
Yeah, so let’s take the example of for our typical project for a Medicare Advantage company, right medic Medicare Advantage health plan. A typical project for us would be, for example, benefit administration testing on Part D. So we all get a new formulary starting one, one, we need to make sure that those benefits are tested that those those, you know, the beneficiary Mrs. Smith, when she goes into the pharmacy on the first of the year that she is going to get her prescription, and she is going to pay the right amount for that prescription. And a lot of work and effort goes in to making sure that that happens on one, one. So that would be a typical project for us performing a mock CMS audit, CMS audits these contractors each year, and you know, on a on a different cycle, but certain organizations are audited each year, and the outcome of those audits can mean you know, great you passed, you’re doing a good job, or they can mean that you’re being slapped with a fine or a sanction. And in the most egregious cases, contract termination. So they really, really mean a lot to these organizations and doing well in an audit and being prepared is very important. So we conduct a mock Audit Services to prepare our clients for that CMS audit. And we also conduct audit preparedness. So if they get their audit notice, and they would like assistance from you know, folks who have been through it a hundreds of times before to really help them do the audit. That would be another kind of typical project that that we would assist with.

Will Bachman 11:48
And tell me a little bit about what a mock audit does, and what an actual CMS audit would look like in practice.

Betsy Seals 12:00
Sure. So a CMS audit program audit looks at a couple of key areas, for example, compliance, program effectiveness, formulary, administration, coverage, terminations, appeals and grievances. So really, you know, based on back in the day, when I first started in the industry, CMS would come in and audit every single area of a health plan, pretty much they’ve really pared back their auditing to those areas that they view as having the most beneficiary impact. So for example, formulary administration, right is the beneficiary getting his or her prescriptions on time and paying the right amount. appeals and grievances does the beneficiary have access to his or her appeal rights. So those are really things that are there to protect the beneficiary and ensure that that beneficiary is has access to the benefits, and there are no barriers to care. So what our mock audit process does is really the exact same thing and process that CMS would follow, we’re going to provide the audit notice, we are going to provide the universe requests, we’re going to do everything in the same way that CMS would in order to give our clients that real experience, the dress rehearsal, if you will, prior to to the show, the only difference that we would have in our process is that along with conducting the mock audit, we also have our consulting hat on right, and be able to advise our clients. Okay, you guys did really great in this area. These are the recommendations we’d make to do perform well on a CMS audit in these areas. So really kind of wearing both hats of providing the real experience and then also providing recommendations along the way.

Will Bachman 13:46
And how do you and the and the CMS do for example, the the formulary administration, would they ask something like show us the last 100 times that a patient went to the pharmacist then what happened? Or and then they pull one at random and try to pull the thread or like what do they actually do?

Betsy Seals 14:10
There are a number of different pieces to the formulary administration. And to be honest, this is I’m not a pharmacist, I do not review those cases, I probably can’t answer exactly the process without looking it

Will Bachman 14:21
up, or pick a different one, a different part of the audit that you’re familiar. Yeah.

Betsy Seals 14:25
So for example, on compliance program effectiveness. One of the areas that is a newer area is what we call a tracer sample. So it’s exactly what you’ve said, right? We’re going to pick an issue, and then we’re going to dig into that issue to find out exactly what the organization did along the way. Did they did they do a root cause analysis? Did they have all the documentation in place in order to document their investigation and findings? Was there a corrective action put in place? What was the result of that? So really looking at a deep dive in how the organization is responding? issues is kind of at the crux of the way that CMS is, is auditing today?

Will Bachman 15:07
And how do you stay up to date with the latest and greatest of what the CMS is doing? Like, do you go and, you know, talk to people that have just been audited to say, What did they ask you this time? And, you know, how do you stay up up to date on that?

Betsy Seals 15:22
I think there’s a couple of different ways. Certainly, you know, I’ve been in the industry 18 years, and I think my first year in compliance, we were audited. And I’ve probably been involved in audits or audit remediation every year since then, I also worked as a CMS subcontractor performing program audits. So part of it is just that built on knowledge that we have from from performing and being involved in so many different audits. CMS does release an audit protocol each year. And they detail how they’ve modified their audit auditing protocol from the previous year. So that is certainly very important to you know, take that and ensure that we understand the edits and have the updated documents and all of that. CMS also does provide us with a number of different kind of reports around their findings, if they apply us money penalty, because of non compliance, those reports are all publicly available. So just really knowing where all the little pieces of information are to build on your, you know, historical knowledge, and really have the most up to date information that’s happening right now is kind of our job as consultants, right, to know where to look and to be the most up to date and knowledgeable on the process.

Will Bachman 16:42
Do effectively every managed care plan. Do one of these mock audits? Is it almost like a typically a CEO or just a board requirement that that you do one? Or is it just only a small percentage do I’m curious how commonly it’s, it’s, it’s done.

Betsy Seals 17:04
I wish that it were all Medicare Advantage organizations that did a mock audit. I think, unfortunately, with compliance, a lot of times organizations don’t place the importance that is needed and tell they go through an audit, and it doesn’t go well, or until they receive a notice of non compliance. Because unlike a lot of different areas, for example, risk adjustment, or stars, or PDE, reconciliation, a lot of the projects that we perform, are essentially going in and helping that client find money that’s being left on the table, right. And those types of projects are always going to be at the top of any CEOs list of things to get done. With compliance, you’re typically never finding money, what you’re doing is mitigating risk. And so often, it’s those CEOs who’ve really been in the industry for a while, or those compliance officers who have been in the industry for a while who understand the importance of preparing and of being compliant. Because if unless you’ve had air experience kind of an adverse event, because of non compliance, we’re really understanding the risk there is not easy. Can

Will Bachman 18:18
you share us any obviously, sanitized examples of things that you found that would have been like really bad if the CMS found it, and then the company was able to fix it, like any examples of things that were just like, totally non compliant. I,

Betsy Seals 18:37
there’s a number of examples that I could give you. But I, I will tell you that the things that we’ve seen, you know, in my 18 years and 14 years in consulting, have been almost things that you could never imagine, you know, closets full of unpaid claims. compliant. Oh, yeah. Oh, yeah. Lots of stack. claims that were unpaid compliance officers ripping up documentation in the ladies room. I mean, it’s it’s anything that you could imagine. We’ve seen it all. So never surprised. Never surprised anymore.

Will Bachman 19:14
That’s a classic. Oh, yeah. That’s our unpaid claims closet. That’s what we just throw the claims when we don’t feel like processing them. And when a golf that day, whatever,

Betsy Seals 19:24
yeah, Joe’s on leave. He can’t get through those this year, because poor people, he just think about these people who didn’t get their claim paid. Oh, my God. Yeah. So So, you know, as absurd as it sounds, really, you know, I started in customer service. So whenever I’m approaching these projects, and I think a lot of folks that are in that industry kind of started, you know, on the clinical side, with patients or on the pharmacy side with patients. I always have that voice of the beneficiary in my head. So the way that we approach our work is of course to help our clients, but also all of our goals in this industry. should be to serve the Medicare Advantage beneficiary. They are a vulnerable population. They’re either over age 65, with chronic conditions are under age 65 and disabled. And my personal perspective is if you’re going into Medicare Advantage, you have an obligation to, of course, do what’s right from a business perspective, but ultimately, to care for the beneficiary in the best way possible.

Will Bachman 20:25
Now, your firm has quite a impressive roster of talent. If you go on your website, you can click on I think team and see really impressive range. Tell us a little bit about the types of folks that you have on the team.

Betsy Seals 20:43
Yeah, so we have four owners on our team myself, and my background is in compliance and operations and consulting. Deborah Devereaux, who is co founder, and she is a pharmacist, and she has been in the managed care industry for years and a practicing pharmacist longer than that charlo Knight Lilly, who also kind of grew up in managed care, she’s worked for a number of large players has been a compliance officer for our Medicare Advantage plan. also worked in consulting for a number of years. April Fleming, who is also grew up in Medicare Advantage and managed care, also spent many years in consulting. But she’s kind of our technical wizard. I like to tell her because she also is very tech savvy, and has built a lot of products in the industry. So we really lean on her for that innovation perspective in terms of an idea and what’s possible.

Will Bachman 21:44
And then you have a bunch of, I think subcontractors that you have sort of as a pool of talent available to pull in to projects.

Betsy Seals 21:50
We do we have contractors as well as w two employees. And we the way we kind of structure our firm is that we have a person who corresponds to any area within a managed care or Medicare Advantage company. We have for example, pharmacists, who are expert in managed care. We have clinical Rn, and physicians who are experts in managed care. We have certified coders risk adjustment experts, compliance expert, so really, I like to tell our clients, anything that you could possibly need in met in the Medicare Advantage world, I have somebody who can help you with that.

Will Bachman 22:33
Fantastic. So Betsy, where can people go to find out more about your firm? Where would you like to point them?

Betsy Seals 22:41
rebellious group comm is our website. Also, we have a blog on our website, where we kind of provide key updates, as well as LinkedIn, our LinkedIn page. Excellent. And we will include that link in the show notes. So Betsy,

Will Bachman 22:57
thank you so much for joining today and teaching me about Medicare Advantage managed care type of work you do, and now I know where to go for a mock CMS audit. I was really great having you on the show. Absolutely. It’s great to be here. Thank you.

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