Health Language Blog

CMS Audits Raise the Bar on Patient Communication

Posted on 10/25/16

Why payers need to engage consumer-friendly strategies nowClinical-Documentation-Outpatient-Claims.jpg

Two converging trends are moving patient communication strategies front and center for today’s payers: Consumers are demanding greater control of their healthcare decisions; and regulatory movements are requiring better patient experiences.

The equation is simple. When consumers understand both the clinical and financial side of care delivery, they are equipped to make better decisions, ultimately leading to better outcomes and lower costs. Yet recent industry activity suggests that a notable gap still exists between the language that clinicians and payers use and what patients understand.

It’s no secret that the Centers for Medicare and Medicaid Services (CMS) has ramped up Medicare Advantage audit activity in recent years. Recent headlines placed heavy hitters such as Humana, Cigna, and Health Net in the spotlight when audits resulted in cumulative financial penalties in excess of $3.5 million and a temporary suspension from marketing to future Medicare enrollees.

The bottom-line impact of these audits is turning heads across the industry and moving a number of the identified deficiencies to the top of the C-Suite’s priority list. Notably, one key shortcoming marked for non-compliance relates to effective communication between health plans and consumers. In an excerpt from a letter temporarily suspending a large payer from marketing and selling new Medicare plans, CMS stated the following:

  1. Denial letters for Part C organization determinations, Part D coverage determinations and appeals did not include adequate rationales, contained incorrect/incomplete information specific to denials, or were written in a manner not easily understandable by beneficiaries. As a result, enrollees and/or providers received incorrect denial letters and enrollees did not have adequate information concerning the requirements for coverage. This is in violation of 42 C.F.R. §§ 422.568(d), 423.568(g), 423.572(c)(2), and 423.590(g); IOM Pub. 100-16 Medicare Managed Care Manual, Chapter 13, Section 40.2.2; and IOM Pub. 100-18 Medicare Prescription Drug Manual, Chapter 18, Sections 40.3.4, 50.5.1, 70.9.1, and 70.9.3.[i]

Communication strategies matter. In fact, they are explicitly outlined by CMS as a requirement for health plans providing services to Medicare patients.

In light of these developments, payers need to take action now to improve communication and the quality of what they’re communicating to members. The reality is that consumers don’t understand the codified language and medical jargon used to describe care in denial letters, explanations of benefits (EOBs), and claims data. Thus, external communications must be decoded to a patient-friendly format.

The right strategy begins with a terminology management platform to support use of consumer-friendly descriptions alongside industry codes within automated patient billing documents. For instance, while a typical claim might designate a Sprain of tibiofibular ligament of left ankle, an accompanying consumer-friendly description would simply read Ankle sprain.

The Health Language platform offers a Consumer Friendly Descriptions content set covering more than 100,000 codes used for diagnoses and procedure billing. The content set is designed to translate claims data into consumable language for consumers through simple one-sentence or two-sentence descriptions. In addition, our implementation team helps organizations and health IT vendors integrate this needed content into existing applications.

Use of consumer-friendly content is an important step on the road to better patient engagement and experience. Learn more about our Consumer Friendly Descriptions here.

[i] U.S. Department of Health and Human Services. “Notice of Imposition of Immediate Intermediate Sanctions (Suspension of Enrollment and Marketing) for Medicare Advantage-Prescription Drug and Prescription Drug Plan.” January 21, 2016.  Accessed at

Topics: patient engagement, Consumer Friendly Descriptions, CMS

About the Author

Brian Diaz is the Senior Director of Strategy, Health Language, part of Wolters Kluwer, Health. Brian has over 17+ years of leading product and marketing teams for SaaS-based healthcare companies focused on interoperability, data quality, and diagnostic imaging. Brian has a computer engineering degree with the University of Minnesota.