Topic: Brain Food

The 2015 Ratings are In: Have the Stars Aligned?

Melissa Smith

The Centers for Medicare & Medicaid Services (CMS) has released the 2015 Medicare Advantage Star Ratings, and the Stars seem to be aligning with CMS’ goals of the Star Ratings program.  For the 40% of Medicare Advantage plans earning at least 4 Stars this year, and thus qualifying for Quality Bonus Payments, these newly-released Star Ratings illustrate the value of health plans’ investments in clinical innovation and quality improvement within Medicare Advantage product offerings.

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Marketplaces – Your Stars are coming

Steve Balcerzak

The Centers for Medicare & Medicaid Services (CMS) has been aggressively working in the background to establish the Star Ratings program for the Marketplaces, thus consumers will have their first quality information by 2017.  Selecting a Marketplace health plan will no longer be based only on price or provider.  As such, quality ratings will have a bearing on market share.

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It’s a Marathon – Not a Sprint

Debra Devereaux

Plans will shortly be receiving the Readiness Checklist from CMS. At first glance it looks like just a bunch of boxes to check off and answering yes and no questions. Here’s the rub:

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Important strategies for a plan’s medical management team

Peg Novak

It wasn’t too long ago that the clinical staff and practitioners in the medical management arena of health plans only focused on the quality and continuity of care with their members. These objectives were very important, and should continue to be the focus of any medical management team. However, in more recent times, it has become just as important for the clinical areas of health plans to become aware of the costs of care they incur and to become involved in the control of those costs.

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Data the Silent Killer

Glenn Ellerbe

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.

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Groundhog Day: CMS Issues Best Practice Memo Related to Common Audit Findings

Betsy Seals

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.

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Passing Marketplace Reasonableness – One More Chance

Steve Balcerzak

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.

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