Topic: Star Ratings

Engaging Providers in Quality

Melissa Smith

According to a recent study by researchers from Weill Cornell Medical College, and as recently reported in Health Affairs, medical practices in four common specialties (cardiology, orthopedics, primary care, and multi specialty practices) spend an average of 785 hours per physician and $15.4 billion annually reporting quality measures to Medicare, Medicaid, and private payers.

Read more

Leave a comment | Share | |

MA Plans’ Must-Fix: the Member Experience

John Gorman

Now more than ever, it’s clear to us health plans and their stakeholders will thrive or die based on the member experience they provide. The member experience, especially with drug benefits, now represents more than half of a health plan’s Star Rating in Medicare Advantage (MA), with millions in bonuses and bid rebates hanging in the balance.  It also drives member retention and thereby acquisition expense (now averaging $1,200 per/member, or more than an average month’s premium), so how members are treated now determines both health plan revenues and costs. Read more

Leave a comment | Share | |

CMS’ Recent Enforcement Actions Show Agency Means Business in 2017

Olga Walther

As we predicted, the Centers for Medicare & Medicaid Services (CMS) is off to an aggressive start on the compliance front in the last year of this administration and shows no signs of slowing down with $832,250 worth of fines levied in the month of February alone. The list of enforcement actions released comes with even graver announcements of two immediate suspensions of enrollment and marketing for the year. These fines augment two huge penalties with which CMS closed out last year − $3.1 million and $1.3 million.

Read more

Leave a comment | Share | |

CMS gears up for major quality performance program overhaul for ACA program

Melissa Smith

The Centers for Medicare & Medicaid Services’ (CMS’) recent issuance of the 2017 Letter to Issuers in the Federally-facilitated Marketplaces and Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule affirms the agency’s plans to elevate the importance and transparency of quality performance by Qualified Health Plans (QHPs). Despite the continued absence of financial incentives for high-quality QHP performance, CMS’ approach to quality oversight for QHPs is looking much like the early years of the Star Ratings program within Medicare Advantage (MA).

Read more

Leave a comment | Share | |

Star Ratings: Moving the Needle

Melissa Smith

Now more than ever before, plans must streamline their Star Ratings programs to meet member expectations while encompassing all aspects of care delivery and breaking down internal silos.  This requires innovation amidst a backdrop of the ever-changing Centers for Medicare & Medicaid Services (CMS) landscape. CMS continues to treat Star Ratings as an ever-evolving, dynamic measurement program that is consistently expanding to include challenging new clinical areas, the impact of socio-economic status on Star Ratings, and operational evolution within the risk assessment processes.

Read more

Leave a comment | Share | |

CMS Releases New Medicaid Rule, OMB in Final Review

Sunmi Janicek

Last week, the Centers for Medicare & Medicaid Services (CMS) finalized the new Medicaid rule ‒ a 653-page proposal requiring Medicaid managed care organizations (MCOs) to enhance their network adequacy, establish quality ratings, set a medical loss ratio (MLR) threshold of 85%, and develop a robust managed long-term care program. The new Medicaid rule has now been sent to the Office of Management and Budget (OMB) for final review. This means the new Medicaid rule could be published by mid- to late May. There are 39 states and the District of Columbia that currently outsource their Medicaid programs and about 46 million lives that will be affected by this new change.

Read more

Leave a comment | Share | |

Noteworthy Evolution for Star Ratings in 2017 MA Draft Call Letter

Melissa Smith

Last week’s release by the Centers for Medicare & Medicaid Services (CMS) of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter ended the mystery surrounding potential policy and payment changes on the horizon.  As our Founder and Executive Chairman, John Gorman, recently noted: “There’s a lot to like ‒ and much to fear.” Although CMS is proposing higher-than-expected rates for 2017 and has introduced both payment and Star Ratings relief for plans serving dual-eligible beneficiaries, this positive news was counterbalanced somewhat by a number of factors, including proposals to increase compliance scrutiny in challenging areas such as network adequacy, provider directory accuracy, and medication therapy management programs.

Read more

Leave a comment | Share | |