Topic: Compliance

The Good, the Bad and the Ugly in Medicare Advantage

John Gorman

In the last two weeks there’s been good, bad and ugly news for Medicare Advantage (MA) plans.  On one hand, the program has never been stronger and quality metrics are surging in the right direction; on the other, the industry is sucking it up on following the rules of its biggest customer, the Centers for Medicare and Medicaid Services (CMS).

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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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They Still Don’t Like It

Debra Devereaux

In the October 8, 2014 memo entitled “Contract Year 2014 Part D Formulary Administration Analysis (FAA)”, CMS reiterates their concern with the accuracy of formulary coding. For the April 2013 analysis, 9 out of 88 (10.2 %) plan sponsors were found to have failed FAA, meaning that greater than 20% of the sampled rejects were determined to be inappropriate. The parameters for the 2014 FAA are: Read more

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Another Flood of Good News for Medicare Advantage

John Gorman

Last week the Centers for Medicare and Medicaid Services (CMS) did its annual data dump for the 2015 Medicare Advantage (MA) and Prescription Drug Plan (PDP) bids.  Even with MA plans sailing into the worst rate environment in over 15 years, the data offered another flood of good news for the industry.

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Bombshells from MedPAC on Medicare Advantage Retention

John Gorman

The Medicare Payment Advisory Commission (MedPAC ), the nonpartisan blue-chip Congressional uber-nerds on our favorite entitlement program, met this week and the staff report presented a couple bombshells on retention rates in Medicare Advantage (MA).

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CMS’s Star Ratings Firing Squad Gets Squirt Guns

John Gorman

Last week, in a surprise move, the Centers for Medicare and Medicaid Services (CMS) reversed its threat to terminate all Medicare Advantage and Part D health plans with 3 or fewer Stars for more than 3 consecutive years.  Roughly a dozen health plans were lined up in front of the firing squad as an example to the industry for months — and then CMS issued squirt guns to the executioners. 

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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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