Topic: Brain Food

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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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 are integral to helping prospective enrollees understand the benefits of your Plans, and  play an important part in the retention of your current members. Having a strong proactive Member Call Center is crucial in today’s environment. Test your call center – see if they pass the test. A proactive Member Service Call Center Department should at a minimum, do all of the following: Read more

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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 Medicare & Medicaid Services (CMS) is approaching the program audit and audit validation process. The most notable trend this year is continued push back of responsibility onto the Organization. In recent sanction reports, CMS states that it will require the Organization “to hire an independent auditor to conduct validation in all operation areas cited in this notice and to provide a validation report to CMS.” In addition, CMS presenters at the CMS Fall Conference, which took place on September 11, 2014, stated that “The onus of correction overall is on the sponsor. Therefore, CMS this year will not request universes to conduct sample testing unless the sponsor is unable to demonstrate through its presentation and from the responses to CMS questions, that it has not corrected the findings.”

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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 of buzz surrounding the upcoming release of an updated Medicaid Managed Care regulation. Per CMS officials speaking at the conference, the last update was 12 years ago!

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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 expansion by the states.  To date, only 27 have, and I see little optimism for more than a handful to do so anytime soon.

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NY Times article reiterates compliance trends in Medicare Advantage

Betsy Seals

As many of you have already read, the NY Times ran a scathing article on October 12th titled “U.S. Finds Many Errors in Medicare Health Plans” shining a light on serious Compliance issues we’ve all been aware of over the past several years. Is the continued lack of non-compliance really news to anyone in the industry? Most certainly not – we have all been tracking the continued issues of non-compliance, increased CMS Compliance actions, and have read the audit reports posted on the CMS website. What the NY Times article did was remind us that the compliance trends in Medicare Advantage are a serious matter which should not be taken lightly.

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Exchange 2014 Data Submission Due April 30,2015

Janet Fina

As we wind down on our inaugural year with Health Insurance Exchanges (HIX), we have seen plans using a variety of approaches in their Risk Adjustment data reporting efforts. Some continue to use the same approaches used for their Medicare programs (chart reviews, provider outreach, in-home assessments, etc). Some have not even begun any retrospective, prospective or quality programs because they don’t know where to begin. What is the right approach? Probably somewhere in the middle.

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