Topic: Compliance

Go-to-Market – No Department Left Behind

Charro Knight-Lilly

Although the next Annual Election Period (AEP) is a ways off, now is the time to start thinking about product development and overall strategy. In most organizations, the start of the “Go-to-Market” (GTM) strategy discussions begins with the C-Suite, Product Development, and Sales and Marketing.  This keen group of professionals works sequestered and siloed for a period of time and then, voilà, they emerge with the lifeline of the health plan’s benefits and strategy in their hands.

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Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight

Regan Pennypacker

There is no shortage of concern when it comes to awareness of first tier, downstream and related entity (FDR) oversight. In fact, during a recent webinar hosted by John Gorman, Executive Chairman at GHG, and Betsy Seals, Chief Consulting Officer at GHG, on “The Top 10 Things Killing Your Organization”, we shared survey results showing the number one Compliance Program risk, from a health plan’s perspective, is FDR oversight.

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Industry Ducks Bullets in 2016 Medicare Advantage Rate Proposal

John Gorman

Friday, February 20th after close of business, the Centers for Medicare and Medicaid Services (CMS), released its 2016 Advance Notice of Medicare Advantage Payment, known affectionately as “the call letter.”

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Risk Adjustment Data Validation (RADV) Audits Just Got Real

John Gorman

Last night the second-largest Medicare Advantage plan in the country, Humana, filed an SEC document detailing a US Department of Justice investigation into the company’s risk adjustment coding and data collection practices.  The investigation is an extension of a 2010 physician-led whistleblower action under the False Claims Act.  The company has over 3.2 million Medicare Advantage members.

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CMS Releases the 2015 Audit Protocol: Critical Next Steps to Avoid Becoming A Casualty of Reasonable Expectations

Betsy Seals

On February 12th, CMS released the 2015 Audit Protocol. The question on everyone’s mind is – what does this mean for 2015? Well, it means a few things. Outlined below are some of the most impactful changes, as well as the “why” behind the change, and the trends that continue to emerge.

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Countdown to Final Submit

Regan Pennypacker

Today is the final day for current or potential plan sponsors to submit their Medicare Advantage and/or Part D application for a new contract or service area expansion (or service area expansion  for 1876 Cost Plans). By now, many of you have already hit final submit and are either celebrating or working on known deficiencies. Or, perhaps you are still waiting for documentation or a final quality check of your submission before you feel confident to submit. Here are a few of the things we learned this year along the way. Read more

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In 2015 a Slap on the Wrist Can Be the Kiss of Death

John Gorman

It is truth that in the second term of Democratic administrations, scores get settled between Washington regulators and business partners of the Federal government.  2015 will be no different for our favorite agency, the Centers for Medicare & Medicaid Services (CMS).  It’s already on a pace for 2015 to be the toughest year ever in enforcement actions against Medicare Advantage plans.  And generally speaking, the regulatory bar is rising faster than anyone imagined.  Consider: Read more

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