Topic: Brain Food

Spring Fever Focus: Grievances and Appeals

Regan Pennypacker

Spring is here, showing us all different signs of renewal.  It motivates us to clean out clutter, open those windows, and start the year fresh.  Audit season is also upon us, and people are taking a close, hard look at internal processes that surround grievances and appeals processing.  Findings in this area keep showing up, like that college grad that keeps popping in to visit his friends back on campus.  Just leave already, you’ve had your time!

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Medicaid Reimbursement Rates and the Future of the Program

Sunmi Janicek

A recent monumental decision by the Supreme Court was just passed, and it will define the way Medicaid providers will be reimbursed now and in the future.  Many Medicaid providers, including doctors, hospitals, and healthcare organizations, are already concerned with the low reimbursement rates, but now, due to the 5-4 vote by the Supreme Court, many will not have the right to push the states into increasing their payments.

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Reenergized After RISE…Now What?

Daniel Weinrieb

It’s the Wednesday after a jam-packed RISE conference, focused on “Best Practices and Actionable Tools for Improving Risk Adjustment and Achieving Exceptional Quality Performance.”

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Marry Data to Build Accurate Customer Profiles

Mary Kaye Thibert

Have you ever played “Pin the Tail on the Donkey” as a kid and found yourself laughing when you got completely turned around and totally missed the donkey? That’s what it’s like when blindly developing benefits, products, marketing, and sales strategies without understanding what your current and prospective customers look and think like – except there’s not a lot of laughing going on.

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Value-Based Care: HHS Sets Timeline for Transition

Elena Martin

The Health & Human Services Department (HHS) recently announced an accelerated time frame with regards to its efforts to transition the Medicare Fee-for-Service (FFS) payment system over to alternative reimbursement models. Not to be outdone and following on the heels of the HHS announcement where a private coalition of some of the nation’s largest healthcare systems and payers announced an initiative to move from FFS payments to so-called value-based payment by 2020. This coalition, called the Health Care Transformation Task Force, was proposed by Richard Gilfallin, a former Medicare official and Chief Executive of Trinity Health, a Catholic system that operates in 21 states.

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CMS Releases Part D Drugs and Formulary Requirements

Debra Devereaux

The long awaited revision to the Prescription Drug Benefit Manual Chapter 6 is hot off the press. Many of the changes have been published previously by CMS in Best Practice guidance or communicated in the course of CMS compliance audits. The changes include additions to the sections on Medically Accepted Indications, drugs purchased in another country, drugs covered under Medicare Part A or B, policy regarding formulary changes, updates to the description of covered commercially available combination products, and updates to existing policies with respect to utilization management

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Countdown to Final Submit

Regan Pennypacker

Today is the final day for current or potential plan sponsors to submit their Medicare Advantage and/or Part D application for a new contract or service area expansion (or service area expansion  for 1876 Cost Plans). By now, many of you have already hit final submit and are either celebrating or working on known deficiencies. Or, perhaps you are still waiting for documentation or a final quality check of your submission before you feel confident to submit. Here are a few of the things we learned this year along the way. Read more

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