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Topic: Brain Food
As a seasoned veteran in healthcare operations I’ve seen firsthand the progression of data utilization by health plans. Despite decades of growth we’re not there yet.
Is it Groundhog Day or does this memo say the same thing as last year? Nope you’re not imagining things – In CMS’ Memo titled “Common Conditions, Improvement Strategies, and Best Practices based on 2013 Program Audit Reviews” that was released on August 27th, CMS outlines again the industry pitfalls and best practices around common areas of noncompliance identified as a result of CMS Program Audits. You may be saying to yourself “some of this looks familiar” well – you’re right.
September 4th was final submission day for Marketplace plans but some worried health plans were asking “what ifs” about their last submission for network access. These plans have re-submitted network updates after two CMS rejections that required correction for failing reasonable access. They have three consecutive wrong guesses on whatever standards CMS believes they have not met. They want to know what happens if CMS doesn’t approve their network access plan. Of course, they are still asking what standards need to be met.
For many, the medical loss ratio (MLR) is the ratio of the health plan’s incurred medical claims to the total premiums earned. However under the Affordable Care Act and for government health programs, the MLR is the ratio of medical claims plus quality improvement costs divided by earned premiums minus federal and state taxes and fees and payments in lieu of taxes.
As expected, CMS has been sending correction notices to health plans about their networks. Also, as expected, some plans have received a second rejection of their response to the first rejection. Now, time is limited since final corrections are due by September 4. Health plans are asking CMS to give them some idea about how to meet CMS expectations.
If you are a veteran of Medicare Risk Adjustment reporting, you are probably in high gear planning or implementing year end programs to optimize 2014 and 2015 revenue. But is the same old approach you used last year the right approach for this year? Or maybe you are new to Medicare Risk Adjustment or Commercial Risk Adjustment reporting and not quite sure of what programs you should be doing this time of year.
With the release of the 2015 Marketing Guidelines, CMS made a few key updates to the Outbound Enrollment Verification (OEV) Process. One of the most significant updates is that CMS now allows organizations to complete the OEV process via direct mail or email (if the beneficiary opted-in for email). This change actually provides significant opportunity for organizations. The way we see it, organizations will now need to choose one of two paths. The first path is to continue using outbound telephone calls to fulfill the CMS requirement. If your organization has developed and implemented an effective OEV process, by all means continue with this process. However, if you’re thinking “why would we continue the current process when our OEV process has been riddled with issues of non-compliance?” Well, we agree.