Exchanges – Risk Adjustment – Ladies and Gentlemen, Start Your Engines

Steve Balcerzak

Seriously, the first question is, “what do you have under the hood for risk adjustment in your health plan?” If you’re running a stock claims engine that merely matches up with your enrollment file for CMS Edge Server processing, and you don’t have a risk adjustment operation, you may be breathing fumes from your competitors. Now, for health plans accustomed to competing against each other, we have a new type of competition. Further, it’s not just plans on the Exchanges, it’s all health plans on or off the Exchanges. Up to now, health plans have been competing for market share on the basis of premiums, benefits or brand; but with Exchange risk adjustment, competition takes on new meaning. You can gain or lose dollars. Some plans will transfer dollars to competitors on the market share they painstakingly managed to enroll. Ouch!

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A Bad Couple Weeks for ObamaCare

John Gorman

It’s been a bad couple weeks for ObamaCare.  It started with a Republican gorilla-stomp in the midterms, a …

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The Importance of a Proactive Call Center

Mary Kaye Thibert

During the AEP we know how critical a role our Member Services team plays. During this time, they …

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CMS Validation Process: The Silver Lining

Betsy Seals

We’ve seen quite a few changes over the past few years in the way that the Centers for …

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CMS Initiates New Program to Support Care Coordination Among ACOs

John Nimsky

Many of you are aware of the recently published Centers for Medicare & Medicaid Services (CMS) Affordable Care …

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12 Years in the Making – Rules Guiding Medicaid Managed Care are Getting a Makeover

Aaron Eaton

At the Medicaid Health Plans of America (MHPA) meeting last week in Washington, DC, there was a lot …

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Little Reason for Optimism in Red State Medicaid Expansion

John Gorman

For months several Wall Street analysts and others have predicted near-total adoption of the Affordable Care Act’s Medicaid …

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