Topic: Brain Food

Rewards and Incentives: Are We There Yet?

Betsy Seals

Yes, Medicare Advantage is finally catching up to the rest of the health care industry, and we are now permitted to offer enrollees Rewards and Incentives.

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A Christmas Wish List for Claims

Debra Devereaux

Here’s what I am wishing for all our health plan clients….an uneventful start to the 2015 Plan Year. By that I mean that all the prescription claims that should adjudicate without rejecting actually do, and the claims that should not pay, reject as expected. Either the beneficiary leaves the pharmacy with their medication or the pharmacist is alerted that there is a potential problem with the dose of the medication. Here are some of the issues that we have found from our reviews: Read more

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Federal study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act

Susan Roberts

Federal investigators said in a new report that large numbers of doctors who are listed as serving Medicaid patients are in reality, not available to treat them.

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Hepatitis C virus (HCV) and treatment with Sovaldi® (sofosbuvir)

Roxanne Newland

The medication Sovaldi® has revolutionized the way HCV is treated and at the same time has shocked health insurance payers and particularly Medicaid prescription drug budgets. With an estimated cost of $1000 or more per pill for a twelve (12) week course of treatment, the cost to treat one person can exceed $84,000.

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Medicare Secondary Payer – A Simple Process with a Big Impact

Christine Tobin

We’ve heard many organizations say, “We do MSP” or “MSP, it’s easy, we’ve got it covered”. MSP processing may not be rocket science but it’s a regulated process with steps that need to be executed correctly. The MSP transactions that your organization submits directly affect the monthly payment to your Plan and impact your financial reports. Your organization needs to have a confidence level that is equipped with the proper tools to be efficient and compliant, and most importantly feel confident that the financials related to MSP are accurate.

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Medicare and Exchange Risk Adjustment: Data Quality Matters

Janet Fina

Plans/Issuers participating in the Exchange may think they have dodged a bullet because HHS has stated payments will not be adjusted during the first two years of the program as a result of RADV audits. However, other remedies such as prosecution under the False Claims Act may still be applied to non-compliant issuers (health plans).

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Best Practices in Medicaid Claims Administration and Oversight

Mae Regalado

Every Medicaid operation needs high-performing claims administration. With strict medical loss ratios as required by healthcare reform, ongoing regulatory changes, timeliness, and payment accuracy relevant to provider pricing and benefit administration, covering operating costs poses significant challenges. Claims adjudication must be efficient and cost effective.

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