Topic: Star Ratings

Claims Leakage and the Path to Avoidance

Mae Regalado

All managed care organizations must operate a high-performing Claims Management. With strict medical loss ratios (MLR) as required by healthcare reform, timeliness provisions, payment accuracy, and constant regulatory requirement changes, covering operating costs pose significant challenges. Cost containment whereby eliminating excess, leakage and waste must be top priority.

Read more

Leave a comment | Share | |

How Do You Cross a Threshold to Success When There Isn’t One?

Jane Scott

Many plans are reacting to the changes affecting the Star Ratings as described by the most recent release of the 2016 Advanced Notice.  One of the most impactful changes is that of the removal of the thresholds for plan year 2016 measures.  CMS gave early warning of the removal of the thresholds for many of the measures and restates their position as per page 86 of the Call Letter:

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 | |

The Model of Care: More than Just a Technical Requirement

Melissa Smith

The Model of Care (MOC) represents the backbone of a health plan’s operational infrastructure and offers powerful potential through which to drive quality improvement, service excellence and improved health outcomes.

Read more

Leave a comment | Share | |

Key Changes to Star Ratings from 2016 Draft Call Letter

Melissa Smith

Now that the news from last month’s 2016 Advance Notice (also known as “the Call Letter”) from the Centers for Medicare & Medicaid Services (CMS) has had time to sink in, it’s time for the real work to begin.

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 | |

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

Leave a comment | Share | |