Topic: Prospective Evaluations

Government Sends Stark Reminders that Insurers’ Biggest Customer is Still the Regulator

John Gorman

Since we opened our doors 19 years ago, we’ve preached to health insurers to think of the government as your business partner.  This week, we got several reminders that insurers’ biggest customers — Medicare, Medicaid, and ObamaCare — are still the regulator.  As business conditions improve for health plans across these business lines, government expectations are rising, and scores are about to get settled, as they always are in the second term of a Democratic administration.

Read more

Leave a comment | Share | |

Takeaways from Accountable Physician Groups’ Annual Summit

John Gorman

Twice a year I get the honor of speaking to the California Association of Physician Groups’ (CAPG) annual summit and DC policy meeting.  CAPG represents accountable, capitated physician groups, and now has members in 39 states.  They’re always among my favorite speeches given how sophisticated the audiences are.  Here’s a few takeaways from my talk last week on “The Future of Government Programs”: Read more

Leave a comment | Share | |

You’re Doing it Wrong in Care Management

John Gorman

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.

Read more

Leave a comment | Share | |

Gorman Health Group Client Forum Takeaways: Government Programs are Booming, Bar is Rising

John Gorman

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

Leave a comment | Share | |

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.”

Read more

2 Comments | Share | |

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.

Read more

Leave a comment | Share | |

The 2015 Medicare Advantage Final Call Letter = Unicorn Rainbow Farts

John Gorman

The Center for Medicare and Medicaid Services’ (CMS) release of the final 2015 Call Letter for Medicare Advantage (MA) Monday after the close was a “unicorns farting rainbows” moment.  Unicorn rainbow farts bring happiness and joy to all those that observe them, and then dissipate quickly.  After a beating at the hands of the ever-more powerful insurance lobby for another draconian draft released in February, CMS reversed itself yet again and proclaimed a 0.4% increase in MA benchmarks.  Lobbyists and Wall Street analysts rejoiced…only to find after a closer look that there are some nasty hooks in the pie CMS put on the windowsill.

Read more

Leave a comment | Share | |