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- INOC | NOC for Data Center on Network Adequacy Test Submissions for Medicare-Medicaid Plans
- Raji on Obamacare Reinsurance and Risk Adjustment, Year One.
- Brian Krantz on What a Difference a Year Makes
- Gorman Health Group on Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight
- Liz Robinson on Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight
Topic: Part D
Today, most employees and employers in all organizations struggle to do more with less…not just health plans.
The pessimist complains about the wind. The optimist expects it to change. The realist adjusts the sail. -William A. Ward
Now that the smoke has cleared and the ink is dry on the formulary/transition and bid submissions, it’s okay for plans to breathe for a couple of weeks. Then—if you’re implementing a new Pharmacy Benefit Manager (PBM)—it’s time to roll up your sleeves and get started with conceptualizing and developing a road map for the next six months. It’s important to start early and work steadily to make decisions, create processes, and complete training. During this time, you must continue to partner with your current PBM to process claims, make coverage determinations, and oversee and monitor all the delegated functions according to the plan you have in place. With the new PBM, you have the opportunity to tweak some processes that perhaps weren’t working exactly as you had envisioned originally.
Some important points came out of the Centers for Medicare & Medicaid Services’ (CMS’) Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast; the presentations and videos of the event can be found here in CMS’ Event Archives. If you did not have a chance to attend or watch it live, please watch the videos for important changes pertaining to many aspects of the MA-PD program. Speakers addressed Part C and Part D call letter updates, policy and technical changes, Quality Improvement Project (QIP) and Chronic Care Improvement Program (CCIP) lessons learned and best practices, the new network management module, enrollment updates, and fraud, waste, and abuse (FWA).
An important paper recently released in the American Journal of Managed Care shattered the notion that care management can save money on high utilizers. The article reviewed recent studies of the effectiveness of health plan care management programs and found that, while many studies show significant savings, more rigorous studies concluded that savings were “limited or nonexistent.” Mind. Blown.
Nineteen years ago this week, I left the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS) and the Office of Managed Care, to launch what would become Gorman Health Group. Time has flown, the company has grown, and my backside sewn with hard lessons about our industry and government health programs. Here are 19 lessons I’ve learned in those 19 years. Read more
We just wrapped our best-ever Gorman Health Group 2015 Client Forum at National Harbor with over 200 of our closest clients and partners. There was both great and tough news, so here’s a few takeaways, including a couple stunners: Read more