Improving health outcomes at CMS

Maximus Eligibility Appeals Operations Support (EAOS) Technology and Operations Solution: Improving health outcomes for the American public at the Centers for Medicare & Medicaid Services (CMS)

The Centers for Medicare & Medicaid Services, CMS, provides health coverage to more than 100 million people through Medicare, Medicaid, the Children’s Health Insurance Program, and the Health Insurance Marketplace. Under the Patient Protection and Affordable Care Act, the CMS directs the eligibility appeals process, which includes operating a resolutions process for appeals in accordance with the strict application of well-defined government procedures.

Within a complex support services structure, CMS also manages the review of appeal requests and supporting documentation, coordinating data collection with appellants, general case management for the state and federal exchanges, writing summaries as well as providing recommendations to federal employees, where applicable. CMS implements training to ensure staff remain current on relevant laws, policies and guidelines.

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Services provided

  • Operations: Intake, adjudication, effectuation, call center, correspondence
  • Policy: Legal research/analysis, compliance, complex appeals, SOP development
  • Information Technology: Operations, security, development, helpdesk, reporting
  • Support: Quality, Training, PMO, Finance

Success achieved

  • Increased online submission rate to 80%
  • Simplified submission process with an eRFI
  • Reduced hearing case volume by 71%
  • Decreased issuing hearing decisions to within one business day

Streamlining complex processes to innovate IT infrastructure

Challenge

The appeals process is daunting for most consumers and CMS faces numerous challenges when working to improve the eligibility determinations process. Appellants most often need their coverage as soon as possible. There is a substantial hearing  case backlog that adversely effects the length of the adjudication and finalization of an appeal decision, often resulting in a delay of correct coverage determination.

If the consumer disagrees with their eligibility determination and initiates an appeal, the agency’s objective is to have a process in place that helps appellants navigate the appeals process with ease. In essence, they want to ensure a positive customer experience. To accomplish an enhanced customer experience, CMS required a proven technology and services solution organization to simplify the process for consumers through an Eligibility Appeals Operations Support (EAOS) program. Turning to Maximus and our extensive experience in accelerating digital transformation and modernizing IT systems, CMS set forth on its mission to assist Marketplace Consumers in reaching appropriate eligibility determination status both successfully and efficiently.

Approach

For the Eligibility Appeals Operations Support, EAOS program, Maximus leveraged industry leading emerging technologies and advanced analytics capabilities along with application development and modernization. By being the first ever program to build the solution environment in the CMS Cloud, Maximus was able to utilize CMS tools allowing for rapid application modernization and development efficiencies.

With a holistic focus on innovating the CMS information technology infrastructure, Maximus was able to provide an integrated suite of operations support services that met all the agency’s technical, utilization and security standards. Maximus’s innovative approach was successful not only because of our established level and length of trust with CMS, but also our ability to accomplish transformative program mission objectives including:

  • Development of a first of its kind environment built entirely in the CMS Cloud.
  • Utilization of CMS tools including Jira and CMS Virtual Private Cloud (VPC).
  • Delivery of 100% SAFe Agile Scaling Methodologies that aligned the organization around important objectives.
  • Migration to a full stack development resource pool to manage both front-end and back-end domains.
  • Focus on Human Centered Design and the relentless pursuit of a creative solution.
  • Adherence to important 508 Compliance requirements allowing full accessibility to any user.

Results

The Maximus team provided technology solutions and services that enhanced the intake, adjudication, hearing support, effectuation, call center operations, mailroom and correspondence activities, quality control, training, and finance tasks critical for an effective appeals case management solution. The program support improved the overall consumer experience with the CMS by:

  • Creating a simplified online appeal submission process in addition to the mail and fax receipt methods. Today, 80% of appeals are received online resulting in faster processing times, and ease of use for appellants.
  • Streamlining the adjudication processes so cases can be resolved prior to the hearing phase.
  • Enabling real time hearing selection and confirmation with the Hearings Call Center.
  • Developed an eRFI process for appellants to submit supporting documentation digitally.

Through a strategic collaboration with the CMS, Maximus delivered support for all functions in the operation of the appeals process associated with the federal and state-bases exchanges under the Affordable Care Act including both operations and digital tasks. As a trusted technology and service solutions partner, Maximus is proud to support the advancement and elevation of the nation’s public health.