What health plans need to know about Medicare Advantage financial reconciliation

Health plans must reconcile their Bid Pricing Tool (BPT) values against auditable material such as corporate financials or bid-level operational detail. This white paper discusses key considerations that can factor into this required reconciliation for Medicare Advantage (MA) and Medicare Part D (PD) plans that file bids with the Centers for Medicare and Medicaid Services (CMS). The paper discusses drivers of variation between financials and BPT values and structural differences between bid and financial data. Topics also include the impact of runout and completion, paid date tracking in claims data, Part B prescription claims, and CMS settlements. The paper also touches upon CMS related party rules, and revenue and risk score runout adjustments. Understanding and correctly explaining the differences between bid and financial values can help health plans ensure their bid values are correct and appropriate. This will also prepare plans to answer CMS desk review questions efficiently, as well as address bid and financial audit questions as they arise.