Topic: Star Ratings

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.

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19 Lessons from 19 Years

John Gorman

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

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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.

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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:

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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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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.

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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.

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