Topic: Prospective Evaluations

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

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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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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.

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Lighting the Path in the Golden Age of Government-Sponsored Health Programs: Join Us for the GHG Client Forum

John Gorman

More than 300 guests will convene on May 1-2 at the Red Rock Casino in Las Vegas for the 2014 Gorman Health Group Forum, our annual strategic retreat for leaders in government-sponsored health programs. This year’s gathering promises to be the most actionable, content-packed conference you could attend on how to succeed in this new Golden Age of government business. And when the learning and planning is done for the day, we will celebrate this unique moment in health care history as only GHG can in Vegas.  Here’s what’s happening this year and why you’ve got to join us: Read more

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The New Post-Reform Core Capability for Health Plans: Risk Adjustment

John Gorman

Medicare Advantage and Part D have for years been the world’s largest experiments in paying insurers more for the care of sick members while paying less for healthier members, or risk adjustment.  Some two dozen states now risk-adjust Medicaid payments to health plans, and the hundreds of Accountable Care Organizations (ACOs) launching this year and next are risk-adjusted as well.  Now that the election has been decided, we know that health plans operating in the insurance exchanges launching in 2014 will also be risk-adjusted based on a similar methodology to that used in MA and Part D.  It’s the new core capability for health insurers in the post-reform world, and it’s examined closely by my two top experts, Bill MacBain and Dr. Jack McCallum, in this month’s Managed Healthcare Executive magazine here.

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Insourcing: So you are thinking about internalizing risk adjustment . . .

RaeAnn Grossman.

We talk to health plans everyday that want to internalize risk adjustment.  Bottom line: It is a good idea.

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