Topic: Brain Food

CMS 2015 Spring Conference

Regan Pennypacker

Some important points came out of the Centers for Medicare & Medicaid Services’ (CMS’) Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast; the presentations and videos of the event can be found here in CMS’ Event Archives.  If you did not have a chance to attend or watch it live, please watch the videos for important changes pertaining to many aspects of the MA-PD program.  Speakers addressed Part C and Part D call letter updates, policy and technical changes, Quality Improvement Project (QIP) and Chronic Care Improvement Program (CCIP) lessons learned and best practices, the new network management module, enrollment updates, and fraud, waste, and abuse (FWA).

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The Imminent Medicaid Mega-Reg is Gonna be “Epic”

John Gorman

For the last several weeks health policy nerds have been anxiously awaiting the release of the long-awaited Medicaid managed care proposed rule, the first from the Centers for Medicare and Medicaid Services (CMS) in 13 years. We’re coming to call it the “mega-reg” here.  Friday at the Congressional advisory MACPAC meeting, Commissioners were widely quoting  the term “epic” used by Jeff Myers, CEO of Medicaid Health Plans of America, in a recent National Journal article.

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You’re Doing it Wrong in Care Management

John Gorman

An important paper recently released in the American Journal of Managed Care shattered the notion that care management can save money on high utilizers. The article reviewed recent studies of the effectiveness of health plan care management programs and found that, while many studies show significant savings, more rigorous studies concluded that savings were “limited or nonexistent.”  Mind. Blown.

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19 Lessons from 19 Years

John Gorman

Nineteen years ago this week, I left the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS) and the Office of Managed Care, to launch what would become Gorman Health Group.  Time has flown, the company has grown, and my backside sewn with hard lessons about our industry and government health programs.  Here are 19 lessons I’ve learned in those 19 years. Read more

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Claims Leakage and the Path to Avoidance

Mae Regalado

All managed care organizations must operate a high-performing Claims Management. With strict medical loss ratios (MLR) as required by healthcare reform, timeliness provisions, payment accuracy, and constant regulatory requirement changes, covering operating costs pose significant challenges. Cost containment whereby eliminating excess, leakage and waste must be top priority.

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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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