Insights & Articles

Revenue & Quality

RISE Risk Adjustment Policy Committee: Position Paper on Telehealth

The Risk Adjustment Policy Committee offers policy guidelines for risk adjustment involving telehealth services.

Revenue & Quality

2021 nominations now open for RISE quality award

RISE is now accepting nominations for its annual Martin L. Block Award that recognizes excellence and clinical leaders’ passion to improve patient care. For 2021, RISE has broadened the criteria beyond risk adjustment and Stars to ensure the spirit of excellence and innovation lives on.

Revenue & Quality

Regulatory roundup: CMS OKs Nebraska Medicaid expansion program; MA plans offer more supplemental benefits in 2021

RISE reviews the latest headlines that impact Medicare, Medicare Advantage, Medicaid, and the Affordable Care Act marketplace.

Medicare Market

Video interview: Kevin Mowll reflects on his tenure at RISE and the future of the association

In this video interview recorded prior to his retirement as executive director of the RISE Association, Kevin Mowll, discusses his work with RISE over the past seven years and what the future holds for the association and its related communities.

Revenue & Quality

Regulatory roundup: CMS expands list of telehealth services for Medicare FFS; Health care policy implications under a newly configured Supreme Court;

RISE looks at recent headlines in the news that impact the health care industry.

Revenue & Quality

Have you checked out the RISE Talent Hub?

Learn more about one of the exciting benefits of joining the RISE Association.

Revenue & Quality

Seeing through the Interim Final Rule fog to lift 2022 Stars

Multiple versions of Interim Final Rules and Final Rules have been released in 2020, all related at least somewhat to COVID-19’s impact on Star Ratings. Health plans often interpret the rules differently. In this piece, Rex Wallace of Rex Wallace Consulting and Mick Twomey of Hyperlift, help clarify the rules.

Revenue & Quality

The sunsetting of RAPS for Medicare Advantage

The RISE Risk Adjustment Policy Committee looks at the implications of the Centers for Medicare & Medicaid Services’ (CMS) plans to fully phase in the CMS-HCC model in 2022.

Revenue & Quality

CMS releases 2021 Star ratings for MA, Part D Prescription Drug Plans

The Centers for Medicare & Medicaid Services (CMS) released the quality ratings so that beneficiaries can compare plans before Medicare Open Enrollment begins on Oct. 15.

Revenue & Quality

COVID-19 update: Fauci warns 400K Americans may die; Azar reauthorizes public health emergency; NEJM editorial slams Trump’s handling of coronavirus

COVID-19 continues to dominate headlines in the wake of President Trump’s diagnosis and hospitalization. Here’s a roundup of the latest news.

Revenue & Quality

RISE’s Special Needs Plan Leadership Summit to explore integration requirements for D-SNPs

William Dede, MPP, health policy associate, Special Needs Plan Alliance, will lead a session on CY21 integration requirements for FIDE-, HIDE-, and D-SNPs during RISE’s upcoming live-streamed virtual event on Oct. 27-28.

Population Health & SDoH

Trump tests positive for COVID-19 as cases surge in the United States

After downplaying the seriousness of the virus for months, President Donald Trump and the First Lady Melania Trump tested positive for the coronavirus. He is now under quarantine.

Revenue & Quality

What to expect at this year’s Payer/Provider Engagement & Contracting Summit

RISE’s two-day virtual event is the only conference in the market to bring together payers and providers to collaborate about the shift to value-based health care delivery.

Revenue & Quality

Trump’s executive order on preexisting conditions lacks teeth, experts say

President Donald Trump’s executive order says that people with preexisting conditions can get affordable insurance. But it doesn’t explain how.

Revenue & Quality

CMS: Medicare Advantage premiums plunge as enrollment soars

The average 2021 premium for Medicare Advantage (MA) plans will be the lowest in 14 years, according to the Centers for Medicare & Medicaid Services (CMS).

Revenue & Quality

Regulatory roundup: Trump signs exec order on preexisting conditions; OIG officials weighs in on MA investigations; and more

RISE summarizes the latest headlines that impact Medicare, Medicare Advantage, and Medicaid.

Population Health & SDoH

Geriatric house calls can increase access to care in a COVID world

The innovative model of care saves money, improves patient satisfaction, and may boost Medicare Advantage plan enrollment.

Revenue & Quality

Without Ginsburg, judicial threats to the ACA, reproductive rights heighten

With the death of Justice Ruth Bader Ginsburg, a lawsuit brought by Republican state officials has become the latest existential threat against the federal health law, scheduled for oral arguments at the Supreme Court a week after the general election in November.

Revenue & Quality

Regulatory roundup: MA health risk assessments under fire; ACOs saved Medicare $1.2B in 2019; CMS withdraws MFAR rule

RISE looks at the latest headlines that impact Medicare, Medicare Advantage, and Medicaid.

Revenue & Quality

2022 Medicare Advantage Advance Notice: CMS reveals plans to fully use encounter data for risk adjustment

The Centers for Medicare & Medicaid Services (CMS) on Monday released Part 1 of its 2022 Advance Notice, which outlines changes to Part C CMS-Hierarchical Condition Categories (HCC) risk adjustment model and the use of encounter data for 2022. CMS intends to finalize the payment policies by April 5, 2021.

Revenue & Quality

NCQA’s Paul Cotton named keynote speaker of the RISE virtual HEDIS® & Quality Improvement Summit

Paul Cotton, director of federal affairs for NCQA, will deliver a keynote presentation on the importance of quality measurement and HEDIS® measures in times of crisis.

RISE West

RISE Association Executive Director Kevin Mowll to retire in mid-October

RISE Managing Director Ellen Wofford made the following announcement during RISE West on Friday:

RISE West

Countdown to RISE West 2020: What you need to know to make the most out of your virtual experience

Learn more about the interactive virtual sessions and activities we’ve planned for RISE West 2020, which will take place Sept. 9-11.

Population Health & SDoH

New survey reveals health care affordability crisis amid COVID-19 pandemic

The Commonwealth Fund recently explored the quality of health coverage for U.S. working-age adults in the first half of 2020. Among the findings: Two in five adults do not have stable health coverage.

RISE West

Video interview: Jefferson Health’s Dr. Stephen Klasko on the pandemic of the future and what the health care delivery landscape will look like

In this 10-minute video with RISE, Stephen Klasko, M.D., MBA, president and chief executive officer, Thomas Jefferson University and Jefferson Health, provides a glimpse into what a global pandemic would look like in 2030 based on what we’ve learned during the COVID-19 public health emergency of 2020.

Medicare Market

5 takeaways about member communications from the second RISE/Engagys COVID-19 response survey

RISE has once again teamed up with Engagys to find out how communications tactics have changed throughout the COVID-19 pandemic. Here are five findings from our most recent survey. Learn more when we discuss the complete results during a one-hour webinar at 1:30 p.m. EST, Wednesday, Sept. 16. The webinar is free to RISE Association members.

Revenue & Quality

Regulatory roundup: OIG reports MA data missing info needed for oversight; CMS makes changes to disaster policy for MA star ratings due to COVID-19

RISE reviews the latest headlines that impact Medicare Advantage plans.

RISE West

RISE West 2020 to shine a spotlight on member engagement during new preconference workshop

COVID-19 has made member engagement more important than ever before. In this article, RISE talks to three of the facilitators of RISE West’s upcoming preconference workshop that tackles the need for Medicare Advantage (MA) plans to double down on member engagement in the second half of 2020.

Revenue & Quality

Supreme Court will hear ACA legal challenge after the November elections

The High Court will hear oral arguments over the constitutionality of the Affordable Care Act (ACA) on November 10, a week after the presidential election.

RISE West

The long-term effects of COVID-19 on health care: Part 2 of a video interview with John McDonough of the Harvard T.H. Chan School of Public Health

Part 2 of our interview with John E. McDonough, DrPH, MPA, professor of public health practice, Harvard T.H. Chan School of Public Health, who will be a featured speaker at RISE’s upcoming virtual event, RISE West 2020, Sept. 9-11.

Revenue & Quality

Fed appeals court rules that insurers should get unpaid cost-sharing subsidies, but limits amount they can recover

A federal appeals court has ruled that the government does owe insurers unpaid cost-sharing reduction payments mandated by the Affordable Care Act (ACA) but in a separate ruling said they cannot receive the entire unpaid amount.

Revenue & Quality

Judge blocks Trump’s anti-transgender health care rule one day before it was to take effect

A New York federal judge on Monday stopped the Trump administration from enforcing a new rule that rolls back nondiscrimination protections for transgender patients.

Revenue & Quality

Rolling back the surge: New Cotiviti map helps forecast COVID-19 health risk severity

As COVID-19 cases and deaths surge in several hot spots across the United States, many individuals and organizations continue to ask, “What else can we do to help protect ourselves, our families, our communities, and our nation?”

RISE West

The 2020 election’s impact on health care: Part 1 of a video interview with John McDonough of the Harvard T.H. Chan School of Public Health

John E. McDonough, DrPH, MPA, professor of public health practice, Harvard T.H. Chan School of Public Health, will be a featured speaker at RISE’s upcoming virtual event, RISE West 2020, Sept. 9-11.

Revenue & Quality

Measuring the ROI of social determinants of health interventions

Consider the following framework to effectively assess the ROI of SDoH interventions.

Revenue & Quality

Mitigating the impact of COVID-19 on risk adjustment and quality scores

Health plans can use proactive telehealth and remote care strategies to help to mitigate the potential negative impact of the pandemic on risk adjustment and quality measurement programs.

Revenue & Quality

What health plans need to know to comply with the FHIR®-Based Patient Access API mandate

Health plans have 12 months before they must have a FHIR®-Based Patient Access API built, running and easily accessible to consumers.

Revenue & Quality

Regulatory roundup: Cigna accused of MA fraud; Trump emergency order expands access to telehealth;

RISE reviews the latest headlines involving Medicare, Medicaid, and the ACA marketplace.

Revenue & Quality

Researchers warn COVID-19 deaths could spike to 300K in the US

The death toll in the United States may reach nearly 300,000 by December 1, according to new data released Thursday from the Institute for Health Metrics and Evaluation (IHME) at the University of Washington’s School of Medicine.

Revenue & Quality

CCIIO clarifies what telehealth claims are valid for risk adjustment

The Center for Consumer Information & Insurance Oversight (CCIIO) at the Centers for Medicare & Medicaid Services this week issued guidance for the ACA marketplace about risk adjustment and telehealth and telephone services during COVID-19.

RISE West

NCQA Q&A session added to RISE West 2020

RISE is pleased to announce that Frank Micciche, vice president of public policy and external relations for the National Committee for Quality Assurance (NCQA), will be a featured speaker at the RISE West 2020 virtual event Sept. 9-11.

Revenue & Quality

RISE’s take: The trouble with telehealth for coordinated care plans

Telehealth visits have been a lifeline to patients and a financial one for health care providers during COVID-19 and may become a standard practice of care in the post-pandemic world. But health plans and providers with a financial stake in risk adjustment must press for research and medical-driven policy decisions regarding effective and appropriate use of telehealth and not allow financial motives to drive policy direction.

Revenue & Quality

COVID-19 emergency declarations, flexibilities, and waivers

Staying on top of emergency declarations and health care-related flexibilities and waivers due to the COVID-19 public health emergency is more than a full-time job.

Population Health & SDoH

What seniors can expect as their new normal in a post-vaccine world

Experts say adults 60 and up must continue to limit exposure in the years to come—even after there is a vaccine for COVID-19.

Revenue & Quality

What to look for in your next risk adjustment coding technology vendor

Considering a technology vendor to support your next risk adjustment coding season? Here’s what to evaluate.

RISE West

RISE West 2020 goes virtual: Sneak a peek at this year’s agenda and speakers

The live-streamed virtual event will take place Sept. 9-11 and features presentations from leading experts in risk adjustment, quality performance, documentation, HCC coding practices, member engagement, payer-provider collaboration, and social determinants of health. Take a look at the sessions we’ve planned.

Revenue & Quality

CMS releases report on 2019 ACA risk adjustment transfers

CMS has released a summary report on issuer payments and changes under the Affordable Care Act’s risk adjustment program for insurers that sold individual and small group market plans in 2019.

Revenue & Quality

Health Care Impact Investing Summit: A first look at the topics and speakers featured at the inaugural live streaming event

FRA and RISE will join forces for the first time in a premier virtual event August 19-20 to bring together investors, health plans, and community-based organizations (CBOs) to discuss how to couple improved health outcomes with positive financial return.

Population Health & SDoH

New CMS data shows the impact of COVID-19 on Medicare beneficiaries

The Centers for Medicare & Medicaid Services (CMS) on Tuesday released its first monthly update of data that reveals the impact of the coronavirus on the Medicare population, including American Indian/Alaskan Native Medicare beneficiaries.

Revenue & Quality

COVID-19 update: HHS extends public health emergency, takes over hospital data reporting as cases surge

RISE rounds up the latest news on COVID-19.

Revenue & Quality

A win for Trump administration: Appeals court upholds expansion of short-term health plans

The Court of Appeals for the District of Columbia has upheld a 2018 Trump administration rule that significantly expands the sale and renewal of short-term, limited duration insurance (STLDI), as a substitute for comprehensive health insurance.

Revenue & Quality

Another problem on the health horizon: Medicare is running out of money

With millions out of work because of the coronavirus pandemic, fewer payroll taxes are coming in to help keep Medicare’s trust fund intact.

Revenue & Quality

Regulatory Roundup: CDC no longer to collect COVID-19 data; CMS releases stats on telehealth use during outbreak

RISE reviews the latest headlines that have an impact on Medicare and Medicaid.

Revenue & Quality

5 findings on the state of Medicare Advantage in 2020: Trends in enrollment growth, health care quality, and consumer attitudes

The report, released by the Better Medicare Alliance (BMA), a research and advocacy organization that supports Medicare Advantage (MA), looks at beneficiary demographics, consumer satisfaction, health outcomes, and projections for the future.

Population Health & SDoH

Telehealth study: Technology disparities correlate with health disparities

A new study by EmblemHealth, one of the largest nonprofit health insurers in the United States, reveals ownership of electronic devices, access to internet services, and overall lack of technology impinge on access to telehealth.

Revenue & Quality

Medicare Minutes: CMS’ Position on Medicare Advantage MSOs and IPAs Access to MSP Private Cause of Action

RISE is pleased to bring you the latest installment of Medicare Minutes, a three-part blog series by industry expert Rafael Gonzalez that features news of interest to the Medicare Secondary Payer industry. This first installment focuses on the private right of action. Learn more at RISE’s upcoming virtual event, The 4th Annual Medicare Secondary Payer Conditional Payment Forum, July 27-28.

Revenue & Quality

Medicare Minutes: NJ federal district court finds mutual mistake on Medicare conditional payment lien nullifies settlement

RISE is pleased to bring you the latest Medicare Minutes blog post by industry expert Rafael Gonzalez. Medicare Minutes features news of interest to the Medicare Secondary Payer industry. Learn more at RISE’s upcoming virtual event, The 4th Annual Medicare Secondary Payer Conditional Payment Forum, July 27-28.

Revenue & Quality

Medicare Minutes: RI federal court finds state made good faith effort to comply with MSP; excused from Medicare civil money penalties

RISE is pleased to bring you the latest Medicare Minutes blog post by industry expert Rafael Gonzalez that features news of interest to the Medicare Secondary Payer industry. Learn more at RISE’s upcoming virtual event, The 4th Annual Medicare Secondary Payer Conditional Payment Forum, July 27-28.

Revenue & Quality

Regulatory roundup: More calls for permanent telehealth reform; Oklahoma first state to expand Medicaid during COVID-19

RISE reviews recent headlines that have an impact on Medicare and Medicaid.

Revenue & Quality

COVID-19: Cases surge in the U.S.; HHS likely to renew public health emergency; WHO says worst yet to come

RISE looks at the latest headlines on the pandemic.

Revenue & Quality

COVID-19 update: U.S. cases may be 10 times higher than reported; Trump administration aims to scrap ACA despite pandemic

RISE examines the latest news on COVID-19. Among the many headlines: For every COVID-19 case reported, there actually are 10 other infections, according to health experts from the Centers for Disease Control and Prevention (CDC).

Revenue & Quality

NQF’s new goal: Improve health and patient outcomes by 2030

The National Quality Forum (NQF) this week released national recommendations to drive better health outcomes for people and communities by the end of the decade.

Revenue & Quality

Regulatory update: LGBTQ clinics sue over HHS transgender discrimination rule; CMS calls for faster move to value-based care due to COVID-19;

RISE looks at the latest headlines involving HHS’ anti-transgender health care rule, price transparency, the impact of COVID-19 on Medicare beneficiaries, prior authorization reform, and the Affordable Care Act.

Revenue & Quality

Regulatory roundup: MedPac urges faster transition to value-based care; Senators push to expand telehealth permanently;

RISE looks at the latest regulatory news that impacts Medicare and Medicaid.

Revenue & Quality

Supreme Court landmark ruling protects LGBTQ work rights, days after HHS rolls back transgender health care protections

The Supreme Court on Monday ruled 6-3 that employers cannot fire a person for being gay or transgender. The decision is a big win for the LGBTQ community. Just three days earlier the Trump administration removed discrimination protections for transgender individuals under the Affordable Care Act.

Revenue & Quality

Rapid changes to health system spurred by COVID might be here to stay

The coronavirus pandemic has forced the nation’s doctors and hospitals to reevaluate how they work. At least three major changes may have a lasting impact.

Revenue & Quality

CMS issues HHS-RADV proposed rule: 4 things you need to know

The Centers for Medicare & Medicaid Services (CMS) on Friday proposed a rule to amend the methodology for the U.S. Departments of Health and Human Services’ risk adjustment data validation (HHS-RADV) program. The technical changes, CMS said, will provide states and payers in the Affordable Care Act market with a more stable and predictable regulatory framework, promote integrity, and increase competition. In this article, RISE looks at the proposed changes and asks J. Gabriel McGlamery, J.D., senior HCR policy consultant for Florida Blue Center for Health Policy, and a member of RISE’s Risk Adjustment Policy Committee, to weigh in.

Revenue & Quality

Regulatory roundup: Part D Senior Savings Model will lower out-of-pocket insulin costs; CMS delays enforcement of API provisions due to COVID-19; and more

RISE gathers up the latest news that impacts Medicare and Medicare Advantage (MA).

Revenue & Quality

CMS finalizes changes to telehealth, ESRD, supplemental benefits, and Star ratings for Medicare Advantage

The Centers for Medicare & Medicaid Services (CMS) has finalized requirements to increase access to telehealth for seniors in Medicare Advantage (MA) plans, expand the types of supplemental benefits for MA members with chronic diseases, increase access to MA for patients with End Stage Renal Disease (ESRD), and modify calculations for Star ratings.

Revenue & Quality

NAACOS urges CMS for more ACO participation options

The National Association of ACOs (NAACOS) and eight other leading health care organizations seek longer termination deadline and other changes as providers continue to combat the COVID-19 pandemic.

Revenue & Quality

Study reveals 5 trends in Medicare Advantage member clinical characteristics, health care use, and spending

Medicare Advantage (MA) is enrolling more low-income and medically complex beneficiaries, according to a new analysis from the Commonwealth Fund.

Revenue & Quality

New complimentary dashboard helps monitor COVID-19 pandemic response efforts

Learn more about the interactive dashboard that provides data-driven insights to inform COVID-19 response plans.

Revenue & Quality

Unburden your providers and lead them to success with the Strategy of One

Employing powerful data and technologies can greatly simplify the workflow and number of chart retrievals.

Revenue & Quality

Second level review gives you the peace of mind that you are ready for RADVs

GeBBS Healthcare Solutions applies insights to encounter details that lead to appropriate risk scores and ensures compliance.

Revenue & Quality

What you need to know about risk adjustment changes outlined in the 2021 Payment Notice for ACA marketplace

The Centers for Medicare & Medicaid Services (CMS) last week issued its final Affordable Care Act marketplace 2021 Notice of Benefit and Payment Parameters Rule, commonly known as the 2021 Payment Notice. The rule primarily includes technical changes to the risk adjustment program and risk adjustment data validation (RADV). Here are four things you need to know.

Revenue & Quality

Legal analysis finds CMS has authority to modify risk adjustment calculation for MA plans before June bid submission

A new legal analysis prepared for the Better Medicare Alliance by the law firm Foley Hoag LLP finds that the Centers for Medicare & Medicaid Services (CMS) has the statutory authority to modify its risk adjustment calculation permitting the use of 2019 and 2020 data and/or to lower the fee-for-service normalization factor ahead of the June 1, 2020 deadline for bid submissions.

Revenue & Quality

Unlocking the power of health care data through patient-centered collaboration and innovation amid COVID-19

Lack of information is one of the greatest obstacles to efficient and effective health care. The data needed to save lives is available, but we must break down barriers to accessibility. A patient-centered approach can align the health care ecosystem to remove barriers.

Revenue & Quality

Level up: Advancing health care analytics through data lakes

Across the health care ecosystem, payers, providers, pharmacy, and life sciences organizations are leveraging data lakes, seeking to unite disparate structured and unstructured data from multiple sources such as claims data, clinical data, social determinants of health, and quality insights to name a few. But what exactly are we talking about when we talk about a data lake?

Revenue & Quality

CMS clarifies actual dates of special enrollment period due to COVID-19

Last week’s memo that addressed the exceptional conditions that qualify for a special enrollment period (SEP) for individuals affected by a FEMA-declared major disaster caused a bit of confusion in the industry. The conflict: What are the actual start and end dates of the SEP?

Revenue & Quality

Closure in a time of closures: EDPS and RAPS submissions

Dawn R. Carter of Centauri Health Solutions, Inc. examines risk adjustment gap closure through effective Encounter Data Processing System and Risk Adjustment Payment System comparative analytics and implementation of best practices.

Revenue & Quality

ONC & CMS final rulings grant patients unprecedented control of health data

Two recent final rules on the way electronic health information is exchanged represent a huge step forward for interoperability and increased patient access, giving members unprecedented control over their health data.

Revenue & Quality

Regulatory update: COVID-19 crisis leads to more CMS waiver and policy changes

RISE rounds up the latest news from the Centers for Medicare & Medicaid Services (CMS).

Revenue & Quality

2021 bid process: MA advocacy group urges CMS to issue guidance to help stabilize market in the wake of COVID-19

The Better Medicare Alliance is concerned that Medicare Advantage (MA) beneficiaries will face increased premiums and/or reduced plan benefits in 2021 during the upcoming open enrollment period unless the Centers for Medicare & Medicaid Services (CMS) takes action now to minimize uncertainty and instability in the 2021 bid process.

Revenue & Quality

CMS: Special enrollment period available to those affected by COVID-19 pandemic in a FEMA declared disaster area

The Centers for Medicare & Medicaid Services on Tuesday issued a memorandum that clarifies the exceptional conditions that qualify for a special enrollment period (SEP) for individuals affected by a FEMA declared weather related emergency or major disaster.

Revenue & Quality

RISE virtual seminar series explores best practices for navigating telehealth amid COVID-19

Join RISE and top industry speakers for a two-day virtual event May 12-13 that examines the regulatory landscape and how to prepare for the changing delivery of health care.

Revenue & Quality

Why risk adjustment technology is more essential than ever

While risk adjustment programs have faced growing challenges with accuracy, scale, and ROI over the past few years, COVID-19 has exacerbated these challenges overnight.

Revenue & Quality

Health insurers prosper as COVID-19 deflates demand for elective treatments

With most nonemergency procedures shelved for now, many health insurers are expected to see profits in the near term, but the longer view of how the coronavirus will affect them is far more complicated and could well impact what people pay for coverage next year.

Revenue & Quality

Supreme Court ruling: Feds owe ACA insurers billions for risk corridor payments

In an 8-1 decision, the high court ruled the federal government must pay insurers $12 billion in promised funds under the Affordable Care Act (ACA).

Revenue & Quality

Medicare Trust Fund is set to run out in 2026, but that doesn’t account for COVID-19

Medicare Trustees released their annual report on Wednesday and once again predicted that the Medicare Part A trust fund will be insolvent in 2026. But the COVID-19 outbreak could cause the funds to run dry before then.

Revenue & Quality

Coronavirus fuels explosive growth in telehealth―and concern about fraud

“Unscrupulous providers” could take advantage of the boom in treatment delivered via voice or video calls.

Revenue & Quality

The 3 fundamentals of risk adjustment success

Risk adjustment is complex, but breaking it down into three critical fundamentals helps health plans focus their efforts.

Revenue & Quality

How payers can address unplanned costs and implications resulting from the pandemic

As the world struggles to come to grips with the global pandemic of the novel coronavirus (COVID-19) and what it means to our everyday lives, unavoidable questions arise. In the forefront, are questions related to managing unforeseen costs. Specifically, how do insurance carriers and health systems deal with the vast cost overruns associated with treating those stricken with the virus?

Revenue & Quality

Visualize Health CEO Kenneth Persaud: Shift to value-based care may stall unless CMS provides relief to Medicare ACOs

Kenneth Persaud, M.D., CEO of Visualize Health, a Sharecare Company, and a member of the RISE Association Advisory Executive Committee, talks to RISE about the impact COVID-19 may have on value-based care, accountable care organizations, and telehealth.

Revenue & Quality

COVID-19 may force more than half of ACOs to drop out of Medicare Shared Savings Program

A new survey by The National Association of Accountable Care Organizations (NAACOS) finds that 56 percent of health care organizations in the risk-based Medicare ACO program may drop out of the program because of fear they will have to pay massive losses as the result of the COVID-19 pandemic.

Revenue & Quality

CMS issues official guidance on diagnoses from telehealth services for risk adjustment: What you need to know

The Centers for Medicare & Medicaid Services (CMS) said the COVID-19 pandemic has created an urgency to expand the use of virtual care to reduce the risk of spreading the disease. In a memo sent on Friday to Medicare Advantage (MA) organizations, the agency explains how to submit diagnoses from telehealth visits. Here are the details.

Revenue & Quality

CMS releases 2021 Medicare Advantage and Part D rates

Medicare Advantage plans will see a 1.66 percent pay increase in 2021, according to the Centers for Medicare & Medicaid Services’ (CMS) rate announcement on Monday.

Revenue & Quality

Researcher seeks health care leaders for Medicare Advantage performance study

The study will focus on those who have experience in the Medicare Advantage (MA) market and influencing physician performance.

Revenue & Quality

COVID-19 updates: CDC launches weekly surveillance report; CMS answers FAQs on expanded telehealth benefit; and more

Here are the latest regulatory actions as of Monday, April 6.

Revenue & Quality

COVID-19 update: NCQA announces new HEDIS and CAHPS reporting policies

The National Committee for Quality Assurance (NCQA) on Thursday announced new policies concerning the collection of quality reporting for HEDIS® and CAHPS® for Health Plan Accreditation for Measurement Year (MY) 2019 to allow organizations to focus on the COVID-19 crisis.

Revenue & Quality

COVID-19’s impact on the 2021 and 2022 Star ratings

Rex Wallace, principal of Rex Wallace Consulting, takes a closer look at the Centers for Medicare & Medicaid Services’ announcement about data collection for Star ratings in the wake of COVID-19.

Revenue & Quality

Medicare telehealth: CMS further expands services in the wake of COVID-19

The agency said it will temporarily allow more than 80 additional services to be provided via telehealth.

Revenue & Quality

CMS announces changes to 2021- and 2022-Star ratings data calculations in response to COVID-19

To provide health care organizations with the full ability to respond to the COVID-19 pandemic, the Centers for Medicare & Medicaid Services has issued temporary regulatory waivers and new rules to lift administrative burdens. Those changes involve data collection for HEDIS®, CAHPS, and the Star ratings program.

Revenue & Quality

CMS halts RADV audits due to COVID-19 concerns

The agency sent out a memo Monday stating that it is suspending non-emergency federal and State Survey Agency surveys so organizations can focus on protecting individuals from the spread of COVID-19.

Revenue & Quality

3 tips for MA plans to address Star ratings during the COVID-19 pandemic

Until the Centers for Medicare & Medicaid Services (CMS) says otherwise, Medicare Advantage (MA) plans still must stay on top of Star rating measures during the COVID-19 outbreak. Here are three suggestions.

Revenue & Quality

COVID-19 response: 5 recommendations for payers

Here are five pieces of advice from Health Data Decisions to help health plans respond to COVID-19.

Revenue & Quality

COVID-19 crisis: RISE webinar explores a free, turnkey text-messaging program to help providers and payers quickly provide COVID-19 education to patients

The RISE Association and CareSignal, a remote patient monitoring company, have partnered to offer a public service webinar on Friday, March 27 about COVID Companion, a free COVID-19 texting program for providers and plans to offer to their patients.

Revenue & Quality

Learn more about Carrot Health’s COVID-19 Critical Infection Risk Dashboard in this complimentary webinar

Carrot Health is offering a complimentary webinar on the use of its COVID-19 Critical Infection Risk dashboard.

Revenue & Quality

RISE Association launches new communities, member portals for health care professionals in quality and revenue roles, and those tasked with addressing social determinants of health

The new Quality & Revenue Community focuses on the industry’s transformation to value-based care; The Social Determinants of Health community will allow cross-sectional thought leaders to share strategies to achieve better outcomes for the most vulnerable populations.

Revenue & Quality

Regulatory roundup: COVID-19 leads to expanded telehealth benefits, new CPT code; CMS unveils model to lower insulin out-of-pocket expenses; and more

RISE reviews the latest regulatory news, including the interoperability final rules and actions taken due to the coronavirus outbreak.

Revenue & Quality

6 things Medicare Advantage health plans must do in response to the coronavirus (1)

The coronavirus is spreading so quickly throughout the United States and the rest of the world that the response to the outbreak seems to change by the hour. Make sure your organization is in the best position to keep operations running smoothly and ensure that your members—who are among those at higher risk of becoming seriously ill from the virus—know they can rely on you for helpful, accurate, and the most up-to-date information.

Revenue & Quality

What you need to know about proposed 2021 changes to ESRD patients in the Medicare Advantage program

A February 2020 proposed rule from the Centers for Medicare & Medicaid Services (CMS) regarding the 2021 Medicare Advantage (MA) program included an important change that could have a significant impact on plans as it could increase membership of beneficiaries who are diagnosed with end-stage renal disease (ESRD).

Revenue & Quality

Coronavirus update: WHO declares COVID-19 a pandemic; CMS issues guidance for Medicare Advantage plans to waive cost-sharing for tests, treatments

COVID-19, the Novel Coronavirus, has now spread to 114 countries, according to the World Health Organization (WHO). As of Wednesday, March 11, the agency reports 118,000 cases and 4,291 deaths. Thousands more are hospitalized.

Revenue & Quality

Medicare Secondary Payer alert: CMS issues proposed rule on civil money penalties

The Centers for Medicare & Medicaid Services published a long-awaited proposed rule in the Federal Register on Tuesday that outlines when it may impose civil money penalties when a group health plan or non-group health plan entity fails to comply with Medicare Secondary Payer (MSP) reporting requirements.

Revenue & Quality

CMS releases Part 2 of the 2021 Medicare Advantage Advance Notice: 3 things you need to know

The Centers for Medicare & Medicaid Services (CMS) proposes updates and changes to the methodologies used to pay Medicare Advantage (MA) plans. The agency said the proposed updates will maximize competition among MA and Part D plans.

Revenue & Quality

A checklist to ensure HEDIS® 2020 success

The HEDIS 2020 season is upon us and the countdown to submission has started. Every moment during this stretch is valuable and can ultimately impact your measure scores.

Revenue & Quality

Checklist: 8 steps to improve risk adjustment coding accuracy

You can’t achieve 95 percent risk adjustment coding accuracy without getting it right from the beginning. Are you following best practices to ensure accurate code capture, or is there room for improvement? This checklist will help you find out.

Revenue & Quality

What you need to know about the 21st Century Cures Act & 2020 APCC Model

Since the 21st Century Cures Act (CCA) was passed in 2016, there have been several changes to the existing risk adjustment model. Over the next few years, and until the Alternative Payment Condition Count (APCC) is fully implemented in Payment Year (PY) 2023, we expect to see even more.

Revenue & Quality

Fed court won’t reconsider decision to vacate overpayment final rule

A United States District Court won’t reconsider its decision to invalidate the Medicare Advantage (MA) 2014 Overpayment Rule. RISE Association Executive Director Kevin Mowll weighs in on what this may mean for CMS’ plans for the FFS adjuster in the RADV process, extrapolation of data, and annual audits.

Revenue & Quality

Medicare Advantage proposed rule: CMS pitches changes to Star ratings, prescription drug pricing, telehealth, and more

The Centers for Medicare & Medicaid Services (CMS) published a proposed rule on Feb. 5 that updates the Medicare Advantage (MA) and the Medicare prescription drug benefit program. Here’s what you need to know.

Revenue & Quality

The Supreme Court won’t fast-track ACA legal challenge before November elections

The Supreme Court has no plans to take up a pivotal case involving the Affordable Care Act (ACA) before the presidential election in November but also didn’t rule out a full review in the future.

Revenue & Quality

ACA legal watch: DOJ in no hurry for Supreme Court to hear case over validity of health care reform law

Despite the Trump Administration’s attempts to kill the Affordable Care Act (ACA), the Department of Justice (DOJ) and a coalition of Republican governors and state attorneys general told the Supreme Court last week that there is no need to fast track a case that challenges the constitutionality of the health care reform act.

Revenue & Quality

2021 Medicare Advantage Advance Notice: CMS announces plans to increase encounter data for risk adjustment

The Centers for Medicare & Medicaid Services (CMS) has released Part 1 of the 2021 Advance Notice of Methodological Changes for Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies. Here’s what you need to know about proposed updates to the Hierarchical Condition Categories (HCC) risk adjustment model and the use of encounter data.

Revenue & Quality

RISE news roundup: Computer error leaves 60K Humana MA seniors without coverage; Dems push for Supreme Court to hear ACA case

RISE looks at the latest headlines that impact the health care industry.

Revenue & Quality

Federal court reinstates HHS risk adjustment methodology

The United States Court of Appeals for the Tenth Circuit has reversed a district court decision that found flaws in the Department of Health & Human Services’ (HHS) risk adjustment formula. The decision is a blow to small insurers, particularly the New Mexico co-op that argued in a lawsuit that the way the federal government implemented the Affordable Care Act risk adjustment program “brutally penalizes new innovative, low-cost insurance companies and flouts Congress’ intent in enacting the ACA.”

Revenue & Quality

One-on-one with Trump’s Medicare and Medicaid chief: Seema Verma

Seema Verma, the administrator for the Centers for Medicare & Medicaid Services, sat down for a rare interview with KHN senior correspondent Sarah Varney. They discuss her views on President Donald Trump’s plan for sustaining public health insurance programs, how the administration would respond if Obamacare is struck down by the courts in the future,and her thoughts on how the latest "Medicare for All" proposals would affect innovation and access to care.

Revenue & Quality

HHS Risk Adjustment Data Validation: Feds eye potential changes to 4 components of the program

Earlier this month the Centers for Medicare & Medicaid Services (CMS) released a white paper that outlined concerns with the Risk Adjustment Data Validation (RADV) program. The agency addressed the current process for sampling, outlier detection, error rate calculation, and risk adjustment transfer features and wants feedback to help form future RADV policy. Comments are due on Jan. 6, 2020.

Revenue & Quality

3 top health care stories in 2019 that will reverberate in 2020

RISE looks at three health care headlines in 2019 that will have implications for health plans in 2020.

Revenue & Quality

Medicare Minutes: CMS announces Work Comp MSA Electronic Attestation Enhancements for Self and Professionally Administered Accounts

In his final post of this blog series, Rafael Gonzalez, Esq., president, Optum Settlement Solutions, looks at changes made to the Workers’ Compensation Medicare Set-Aside (WCMSA) Electronic Attestation Enhancements and what it means to Medicare Secondary Payer compliance.

Revenue & Quality

Medicare Minutes: U.S. Department of Justice again goes after plaintiff attorney seeking reimbursement of Medicare Conditional Payments

Part six in a series of seven blog posts related to Medicare Secondary Payer issues. In this piece, industry expert Rafael Gonzalez reviews three recent cases involving attorneys representing Medicare beneficiaries in auto, liability, no-fault, and workers’ compensation claims.

Revenue & Quality

Federal appeals court strikes down portion of Obamacare

A federal appeals court panel on Wednesday struck down a key provision of the Affordable Care Act but will send the case back to the lower court to decide the fate of the rest of the law.

Revenue & Quality

Medicare Advantage news roundup: Insurers could reap big benefits from tax repeal; rebates to reach record highs in 2020; calls to delay start of hospice carve-in demo; and more

Medicare Advantage continues to make headlines. RISE examines the most recent news, including MedPAC’s annual status update of the MA program and what a repeal of the health insurance tax may mean for enrollment and earnings.

Revenue & Quality

Medicare Minutes: Publishing of Future Medicare Interests Notice of Proposed Rulemaking extended to February 2020

In his latest blog post, Rafael Gonzalez, Esq., president, Optum Settlement Solutions, looks at the possible creation of federal regulations that provide options on how to take Medicare’s future interests into account.

Revenue & Quality

Medicare Minutes: Mandatory Reporting Civil Money Penalties Notice of Proposed Rulemaking extended to December

In the latest installment of a blog series on issues related to the Medicare Secondary Payer industry, Rafael Gonzalez, Esq., president, Optum Settlement Solutions, reviews the recent announcement that a Notice of Proposed Rulemaking related to civil money penalties will be published this month.

Revenue & Quality

Gallup: 1 in 4 Americans delayed care for a serious medical condition this year due to cost

The results of a new Gallup poll are sobering: A record 25 percent of Americans surveyed couldn’t afford care this year and put off seeking treatment for a serious medical condition.

Revenue & Quality

OIG questions $6.7B in risk adjustment payments to Medicare Advantage plans, but RISE argues methodology is flawed

A new report from the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) raises concerns that Medicare Advantage (MA) plans may use chart reviews to inflate risk adjustment payments from the Centers for Medicare & Medicaid Services (CMS). But the OIG’s methodology and findings don’t add up, according to Sean Creighton, managing director, Avalere, and chair of the RISE Risk Adjustment Policy Advisory Committee.

Revenue & Quality

Medicare Minutes: Lots of changes in CMS’ latest WCMSA Reference Guide

In the third installment of his seven-part blog series on issues related to the Medicare Secondary Payer industry, Rafael Gonzalez, Esq., president, Optum Settlement Solutions, provides a detailed review of the changes in the Centers for Medicare & Medicaid Services’ Workers’ Compensation Medicare Set-Aside Arrangement Reference Guide.

Revenue & Quality

Supreme Court seems sympathetic to insurers In Obamacare case

Justices from the right and left ask whether Congress needs to keep its promises regarding risk-corridor payments.

Revenue & Quality

Medicare Minutes: CMS indicates stance on settlements of less than $750

In this second installment of a semiregular blog on Medicare Secondary Payer matters, industry expert Rafael Gonzalez looks at the Centers for Medicare & Medicaid Services (CMS) calculation of annual recovery thresholds for certain liability insurance, no-fault insurance, and workers’ compensation settlements, judgments, awards, or other payments.

Revenue & Quality

The FFS Adjuster matters for accurate Medicare Advantage payment: An examination of the methodology and evidence behind a regulatory proposal to eliminate the adjuster

Eliminating the Fee-for-Service Adjuster from the Risk Adjustment Data Validation methodology would likely have significant implications for plan payment and could change plan incentives and behavior, including plans’ willingness to assume the risk of participating in the program, writes Sean Creighton, managing director of Avalere, who also serves as a RISE board member and the chair of the RISE Risk Adjustment Policy Advisory Committee.

Revenue & Quality

Medicare Minutes: CMS announces changes to MSP Recovery Portal to Access Open Debt Report

RISE is pleased to introduce Medicare Minutes, a seven-part blog series by industry expert Rafael Gonzalez that features news of interest to the Medicare Secondary Payer industry. This first installment focuses on the accessibility of open debts reports.

Revenue & Quality

Obamacare back at the high court—with billions for insurers on the line

The case revolves around risk corridor payments, a provision under the Affordable Care Act that was designed to help insurers recover some losses because they had an unusually high number of sick and expensive customers.

Revenue & Quality

Feds release long-awaited Risk Adjustment Data Validation White Paper

The Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) on Friday released a white paper to outline and seek feedback on issues that the agencies will use to inform future policy on HHS-Risk Adjustment Data Validation.

Revenue & Quality

CMS Bid Bootcamp preview: Sessions cover the entire bid process, including the value of adding supplemental benefits that address social determinants of health

RISE looks at the planned sessions for this year’s CMS Bid Bootcamp and shines a spotlight on a presentation that will help attendees evaluate the financial impact of incorporating social determinants of health (SDOH) benefits into the bid process.

Revenue & Quality

Medicare Advantage updates: Satisfaction reaches record high; KFF report on plan switchers; gaps that hinder personalized experience; and more

RISE looks at the latest headlines involving Medicare Advantage (MA), including a new poll rating beneficiaries’ satisfaction and a Kaiser Family Foundation analysis on the number of people who switch plans during Medicare’s open enrollment period.

Revenue & Quality

One on one with Rafael Gonzalez: The driving force behind RISE’s Medicare Secondary Payer Master Class

Learn why the Medicare Secondary Payer Master Class has become the must-attend conference for those responsible for Medicare Secondary Payer compliance. Industry expert Rafael Gonzalez, Esq., the person who inspired the annual event, explains.

Revenue & Quality

Feds propose price transparency rule for health insurers

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on Friday that would require health insurers to make pricing and cost-sharing information available to the public.

Revenue & Quality

The definitive guide to encounter platform selection success: Part 3

This is the final article of a three-part blog series that highlights the crucial capabilities required for encounter submission and reconciliation success. This post focuses on how to ensure continuous compliance.

Revenue & Quality

Obamacare’s star ratings offer a glimmer of insight―but not for all

Federal officials unveil new ratings for the Affordable Care Act’s marketplace plans. Missouri is one of eight states that has no plans earning at least three stars on a five-star scale.

Revenue & Quality

Regulatory roundup: Premiums for ACA health plans will drop in 2020; Feds ordered to pay insurers $1.6B in unpaid subsidies

RISE looks at the latest regulatory news related to health plans on HealthCare.gov, Medicare Advantage, fraud and abuse, and cost-sharing reduction subsidies.

Revenue & Quality

The definitive guide to encounter platform selection success: Part 2

This is the second of a three-part blog series that highlights the crucial capabilities required for encounter submission and reconciliation success. This post will focus on how to reduce encounter submission cost and complexity.

Revenue & Quality

The definitive guide to encounter platform selection success: Part 1

This is the first of a three-part blog series that highlights the crucial capabilities required for encounter submission and reconciliation success. Upcoming posts will focus on reducing encounter submission cost and complexity; and ensuring continuous compliance.

Revenue & Quality

CMS star ratings update: Members will have greater access to higher-rated MA-PD plans when open enrollment begins Tuesday

Fifty-two percent of Medicare Advantage plans with prescription drug coverage (MA-PD) offered in 2020 will boast 4 stars or higher, according to new data released by the Centers for Medicare & Medicaid Services.

Revenue & Quality

HEDIS® & Quality Improvement Summit preview: BCBSNJ’s secret shopper program improves patient care, member engagement

Steven R. Peskin, M.D., executive medical director of population health, Horizon Blue Cross Blue Shield of New Jersey, talks to RISE about the key takeaways from the health plan’s secret shopper pilot and the lessons learned on member engagement. Peskin will present a case study on the program at RISE’s 9th annual HEDIS® & Quality Improvement Summit, Oct. 23-25, in Miami.

Revenue & Quality

New federal initiatives expand benefits for effective risk adjustment—but success will require solutions that thoughtfully integrate into clinical and revenue cycle workflows

It’s a time of rapid transformation for risk adjustment. Newly announced payment models are expanding opportunities in providers’ value-based care strategies all the time. These models could make it easier than ever for hospitals and practices to recognize the benefits of risk-sharing arrangements. However, providers must incorporate new tools and practices that work within, rather than against, existing care and revenue cycle workflows.

Revenue & Quality

CFOs no longer rely on PBMs to provide the objective pharmacy reporting, analytics, and benchmarks needed to control costs

Pulse8's Scott Fries looks at why CFOs have started to take the lead within their organizations to control pharmacy spend and why this is the right approach to achieve a more efficient and effective pharmacy benefit program.

Revenue & Quality

What health care executives must know about the interoperability and patient access rules

The federal government's proposed interoperability rule with major new requirements for payers and could create true data interoperability, opening the way to more efficient processes, enhanced quality of care—and new business models and competition.

Revenue & Quality

Data-driven consumer experience: Leveraging artificial intelligence to improve patient outcomes

The past decade has been one of significant evolution for the health care industry, shifting from a disparate and transactional environment to a more value-based model where patients are at the center. With untold amounts of health and medical information at their fingertips, patients now are in the driver’s seat as a consumer–playing a more active role in selecting their provider, demanding better quality of care, and requiring greater transparency for health care costs.

Revenue & Quality

HEDIS® 2020: How health plans can impact the opioid epidemic through preventive measures

SS&C's Theresa Lane looks at the HEDIS® 2020 guidelines and the preventive measures plans can take under the pharmacy benefit to manage opioid overuse.

Revenue & Quality

RISE: Small MAOs face unfair financial risks under CMS proposed changes to MA RADV audits

RISE’s Risk Adjustment Policy Committee weighs in on the Centers for Medicare & Medicaid Services’ proposed changes to Medicare Advantage risk adjustment data validation provisions.

Revenue & Quality

RISE applauds CMS’ move to expand star ratings to plans on the ACA exchanges

The Centers for Medicare & Medicaid Services (CMS) recently announced it will require carriers that offer health plans on the federal and state health insurance exchanges to display star ratings beginning with the 2020 open enrollment period. The move is leading the industry into an exciting and long-awaited phase of public transparency in health care financing and delivery, says Kevin Mowll, executive director of the RISE Association.

Revenue & Quality

Customer experience expert Jeff Tobe offers insight on member engagement ahead of the RISE HEDIS® & Quality Improvement Summit

Jeff Tobe, dubbed “The Guru of Creativity” by Insider Magazine, will be the keynote speaker at the 9th Annual HEDIS® & Quality Improvement Summit, Oct. 23-25, in Miami. His topic: How to create a new customer experience in health care.

Revenue & Quality

Insurers running Medicare Advantage plans overbill taxpayers by billions as feds struggle to stop it

An enhanced government effort to catch insurers that overcharge Medicare faces resistance from the insurance industry.

Revenue & Quality

Federal appeals court takes up case that could upend U.S. health system

The fate of the Affordable Care Act is again on the line Tuesday, as a federal appeals court in New Orleans takes up a case in which a lower court judge has already ruled the massive health law unconstitutional.

Revenue & Quality

Kaiser Family Foundation report: Individual insurance market remains profitable

Despite concerns that recent White House administration’s actions would undermine the Affordable Care Act (ACA) market, the individual insurance market is still going strong, according to a new report by the Kaiser Family Foundation ((KFF). New data from the first three months of 2019 indicates that insurers in the individual insurance market are profitable, even with average premiums falling for the first time since the health care reform law was implemented.

Revenue & Quality

Regulatory roundup: Recap on the latest on risk adjustment, price transparency, health care costs

RISE looks at recent regulatory news related to the Affordable Care Act (ACA) risk adjustment program as well as efforts to lower healthcare costs and make those costs more transparent.

Revenue & Quality

Lab data: The missing piece of your member profiles

Payers offering Medicare Advantage, managed Medicaid, and ACA products have developed proven processes and analytics for demographic, claims, and encounter data to manage member risk. However, one piece of data missing from many member profiles is laboratory data. Using historical and current lab data to calculate risk scores ensures that all clinical conditions and comorbidities are factored into risk adjustment calculations, leading to a more complete and accurate reimbursement.

Revenue & Quality

The crusade for value-based care: Rising risk and return models

The Centers for Medicare & Medicaid Services (CMS) continues to lead the charge in the paradigm shift from traditional fee-for-service (FFS) to value-based healthcare. These models also shift financial risk to the providers. These changes are often met with pessimism and apprehension. However, CMS continues to introduce new and updated models to help with the transition for healthcare providers by giving them more options.

Revenue & Quality

The science behind value-based care modernization

The health care industry has been talking and hearing about value-based care (VBC) for several years, but the time for talk is quickly shifting to a call for action.

Revenue & Quality

Addressing peripheral artery disease through enhanced clinical services

Medicare Advantage plans need a comprehensive picture of their members’ overall health status, including conditions such as peripheral artery disease (PAD).

Revenue & Quality

How artificial intelligence is transforming risk adjustment

The health care market is one of the fastest growing markets in the digital universe. But this growth presents the problem of how to effectively and efficiently analyze and understand this data.

Revenue & Quality

America is losing ground on dire diabetes complications: Let’s turn it around

We must do more to prevent diabetes and reach diabetic individuals who are on a collision course with serious maladies. Much has been done toward reversing this untoward trend–but there is more work to do.

Revenue & Quality

Survey: SDoH tops list of most difficult information to share through HIEs (1)

The health care industry is focusing more attention to the impact that living conditions, lifestyle, and employment have on people’s quality of life and health outcomes. Information collected about these social, economic, and physical conditions, known as the social determinants of health (SDoH), are among the most difficult to share through health information exchanges (HIEs), according to a recent report from eHealth Initiative and Foundation and Orion Health.

Revenue & Quality

Artificial intelligence and the power of deep learning in health care

In the past decade, no technology has generated more buzz than artificial intelligence. Speculation surrounding its ability to add value to the health care space has dominated conversations at every level, sparking debate over how—and at times even if—artificial intelligence should be incorporated into the business strategy of health care organizations.

Revenue & Quality

Avalere report: Medicare Advantage outperforms fee-for-service Medicare plans on cost of care and quality

New research from Avalere finds that Medicare Advantage (MA) plans outperformed fee-for-service (FFS) Medicare on overall cost of care, quality measure outcomes, and utilization of high cost health services for the care of dual eligible beneficiaries with chronic conditions.

Revenue & Quality

New study cast doubts on how much MA plans lower Medicare spending, but is the methodology flawed?

Research published by the Kaiser Family Foundation (KFF) made headlines this month for calling into question whether Medicare is overpaying Medicare Advantage (MA) plans by billions of dollars each year. The study found that even after risk adjustment, beneficiaries who switch to MA plans spent less on care and used fewer services in the year prior to signing up for their MA plans than members who stay in traditional Medicare plans. The research raises questions about how much MA plans lower spending. But Kevin Mowll, executive director of The RISE Association, believes the data researchers used to make the comparisons is flawed.

Revenue & Quality

Data collection key to efforts that address social determinants of health (1)

Many health care organizations are establishing programs to address the social needs of their patients and members in response to the growing recognition that personal, social, economic and environmental factors have a greater influence on health status than medical care. RISE looks at some of these efforts, including the Centers for Medicare & Medicaid Services’ data-collection initiatives, and Kaiser Permanente’s rollout of a social health network to address needs on a broad scale.

Revenue & Quality

4 insights into individual and family plan shopping and switching during the 2019 OEP (1)

A new study that looks at how 4,700 consumers under the age of 65 bought insurance in 2019 provides insights into what prompted them to shop plans. The research, conducted and published by Deft Research, may help marketing, sales, and product development professionals better compete for members in 2020. Here are four findings from the market research firm’s Individual and Family Plan Shopping and Switching Study.

Revenue & Quality

Considering 'single payer' proposals in the U.S.: Lessons from abroad

The Commonwealth Fund recently published an abstract that examines universal health care systems in other countries. RISE is publishing an excerpt of the abstract, which compares universal coverage systems across three areas: distribution of responsibilities and resources between levels of government; breadth of benefits covered and extent of cost-sharing in public insurance.

Revenue & Quality

UnitedHealthcare, American Medical Association push for 23 new ICD-10 codes to address social determinants of health (1)

As the health care industry turns its attention to models that address social barriers that prevent people’s access to better health, two big-name organizations have joined forces to push providers to use data for social determinants of health to improve and simplify how referrals are made to social services.

Revenue & Quality

MedPAC takes on MA encounter data quality and health plans could pay the price

It’s no secret that implementing the encounter data reporting and validation continues to be a challenge for regulators and health plans. However, a Medicare advisory panel wants to ratchet up the pressure on plans to submit accurate data by withholding a portion of their payments if the information that they submit is inaccurate or incomplete. In this article, RISE looks at the Medicare Payment Advisory Commission’s (MedPAC) proposal for encounter data and what it could mean for MA plans if the Centers for Medicare & Medicaid Services (CMS) adopts the recommendation.

Revenue & Quality

The 2020 Final Call Letter and Rate Announcement is out: 5 things you need to know (1)

The Centers for Medicare & Medicaid Services (CMS) on Monday released its final policy and payment updates to Medicare Advantage (MA) and Part D programs for 2020. In addition to updated payment rates, the agency outlined policy changes to address the opioid crisis, star ratings enhancements, and social determinants of health. Here ‘s what you need to know about the Call Letter and payment updates:

Revenue & Quality

Affordable Care Act news roundup—DOJ now supports full repeal; House Democrats make moves to strengthen law

The Affordable Care Act is back in the headlines. House Democrats last week made moves to shore up the ACA in the wake of the Department of Justice’s sudden reversal in policy, now saying it agrees with a district court decision to overturn the entire health care reform law. RISE looks at the latest developments and what they mean for the future of health care reform.

Revenue & Quality

CMS releases RADV auditor guidance

The Center for Medicare & Medicaid Services (CMS) has released an updated version of its contract-level risk adjustment data validation (RADV) medical record reviewer guidance that went into effect as of March 20.

Revenue & Quality

Medicare Advantage achieves cost-effective care and better outcomes for beneficiaries with chronic conditions relative to fee-for-service Medicare

The Medicare Advantage (MA) program is one of the largest healthcare payers in the United States, comprising 34 percent of all people with Medicare in 2018 and witnessing rapid growth relative to traditional fee-for-service (FFS) Medicare. As policymakers look to encourage value-driven, high-quality, and cost-effective care delivery models, there is growing interest in directly comparing traditional FFS Medicare and MA. However, despite the increasing role of MA, there have until now been few full-scale studies that offer insights into the composition, utilization, quality, and cost of care of the MA population relative to FFS Medicare.

Revenue & Quality

Analytics toolkit + techno-functional SMEs = HEDIS® & Star success

We have seen many health plans spend millions of dollars in HEDIS® analytics solutions and big data software, but left wondering what to do next! You can’t afford to ignore HEDIS® and Star ratings. Every incremental opportunity―whether small or large―needs to be squeezed to get to that all-important 4+ Star rating.

Revenue & Quality

Value-based payment: A 5-step makeover for health plans

Value-based payment (VBP) is a buzz term that has been discussed for several years now as an imperative for our country. Why? Our projected national health care spending is set to grow at an average rate of 5.5 percent per year and it is expected to reach nearly 20 percent of gross domestic product (GDP) by 2026, which is unsustainable.

Revenue & Quality

CMS HCC 2019 Risk Adjustment Model: 4 things to know about the latest changes and how they impact risk scores

Every year the Centers for Medicare & Medicaid Services (CMS) makes updates to the Medicare program, including changes on how it calculates risk scores for Medicare Advantage (MA) plans. This year’s changes include the addition of several new risk-generating hierarchical condition categories (HCCs) and updates to risk score coefficients. To assess the potential impact of these changes, Cotiviti data scientists recently compared the 2019 HCC risk model to the 2017 payment year model for three Medicare Advantage plans of different sizes. Lesley Brown, vice president of risk adjustment for Cotiviti, recently presented the findings of the analysis during a RISE webinar. Here are four takeaways from the analysis and what the findings mean for MA health plans.

Revenue & Quality

Regulatory wrap-up: Recap of the latest on Medicare, Medicaid, and the Affordable Care Act

Although last month’s partial government shutdown briefly put a hold on the legal drama surrounding the Affordable Care Act (ACA), it didn’t have an impact at the Centers for Medicare & Medicaid Services (CMS), which rolled out proposed changes to the Medicare Advantage program during the 35 days that other federal offices and departments were closed. In this article, RISE looks at recent regulatory actions that impact Medicare Advantage plans, the legal challenges to the ACA, and the latest news involving Medicaid.

Revenue & Quality

Social determinants of health: 5 takeaways from the 2nd annual RISE Symposium (1)

The health care industry’s shift in focus to truly address the social determinants of health is a make it or break it opportunity, according to Jamo Rubin, M.D., founder and CEO of TAVHealth, who served as the chair of last month’s RISE Symposium on Partnering to Address the Social Determinants of Health in Fort Lauderdale. Social determinants left unaddressed or unresolved flow into the health care system as unintended consequences and become health care claims, he said. The two-day symposium highlighted the challenges and successes of organizations that have made progress tackling social determinants, including behavioral health, opioid addiction, housing, and transportation. Here are five takeaways from the conference:

Revenue & Quality

Unlock the Secret to Close Gaps, Improve Star Ratings: proven, personalized approach increases cancer screenings, med adherence and other key quality measures

Consumer awareness of quality measures like Star Ratings is on the rise, and a growing number of Medicare eligible consumers are choosing plans based on these measures. With the release of the 2019 Medicare Advantage Star Ratings, plans across the nation are strategizing to target or maintain specific areas to keep a competitive edge. Approaches include identifying risk for, and closing, gaps in care like cancer screenings or medication refills, and boosting Star Ratings by getting seniors continuously engaged in their health.

Revenue & Quality

5 health plan predictions for 2019 (1)

Health plan leaders began the year 2019 just as they did in 2018 with uncertainty over the future of the Affordable Care Act (ACA). RISE turned to industry experts for their thoughts on the ACA and what other challenges the industry may face this year. Here are five predictions from Sean Creighton, managing director of the healthcare consulting firm Avalere; John Criswell, CEO of health care data analytics and technology company Pulse8; and John Broderick, M.D., FACEP, CPE, chief clinical officer-East for the risk-based provider group Landmark Health.

Revenue & Quality

RISE recommended reading: Avalere report on CMS changes to the MA Hierarchical Condition Category Risk Adjustment Model

For the third installment of our semi-regular series that recommends articles, white papers, or issue briefs of importance to RISE members, we turn to a recent report written by Avalere about the impact of Medicare Advantage (MA) risk adjustment model changes for payment year 2020. The report is essential reading in the wake of the Centers for Medicare & Medicaid Services’ Dec. 19, 2018 release of Part 1 of the 2020 Advance Notice of Methodological Changes for MA Capitation Rates and Part D Payment Policies. Comments about the CMS proposals must be submitted by Feb. 19. The agency intends to publish the final 2020 rate announcement by April 1.

Revenue & Quality

Healthcare Industry Outlook: New Laws, Data Streams and Technology to Chart 2019 Course

From the launch of new initiatives aimed at increasing patient access to health data to the rising potential of artificial intelligence (AI) to meaningfully impact the outlook of healthcare delivery, 2018 was a year flush with change and new opportunities, with data and its role in transforming the industry at the forefront. In 2019, the healthcare industry can expect continued emphasis on delivering care that focuses on patients more holistically, as the evolving data exchange landscape and innovative technologies continue to alter the face of clinical decision making.

Revenue & Quality

OIG officials to discuss Medicare Advantage work at RISE Nashville

Joanna Bisgaier and Rosemary Rawlins will join a roster of 50 speakers at the 13th Annual RISE Nashville Summit, March 17-19, 2019.

Revenue & Quality

How many HCCs does it take? Running the numbers with the PCC/APC model proposal

The time has come for the PCC/APC models to start being implemented, changing the way populations and their scores shape up. With the PCC model now including the additive risk scores for the condition count, CMS has decreased many of the individual HCC risk scores used in the current model—for instance diabetes will see a 14% decrease, with reductions counterbalanced by an increase in other risk scores. The change led us to do a statistical analysis that assessed the impact of these substantial changes.

Revenue & Quality

The top news stories that rocked the health insurance industry in 2018

2018 has been a rollercoaster of a year for health plans, beginning with uncertainty over the future of the Affordable Care Act (ACA) and ending in mid-December with a bombshell ruling by a federal judge declaring the entire health care reform law as invalid. The continued assault on the ACA was just one of many stories to hit the industry this year. RISE looks at 10 of the biggest headlines that had implications for health plans in 2018.

Revenue & Quality

Federal judge rules the ACA is unconstitutional and creates chaos, uncertainty for millions of Americans

A federal district judge in Texas on Friday singlehandedly tried to put an end to the Affordable Care Act, ruling that the entire law is unconstitutional because the Congressional tax bill passed last December eliminated the penalty for not having health insurance. Although the case will be appealed and will likely appear before the Supreme Court, the judge’s decision has led to uncertainty for almost every American as the ACA touches nearly all aspects of health care. Kevin Mowll, executive director of RISE, offers his thoughts on the latest legal twists and turns and what’s next for the ACA.

Revenue & Quality

Despite pending litigation, CMS issues final rule on the CMS risk adjustment program for 2018 benefit year

The Centers for Medicare & Medicaid Services (CMS) finalized a rule Friday that reissues the risk adjustment methodology previously established for the 2018 benefit year. Despite the fact litigation is pending on the issue, the final rule will allow government to continue normal operations of the risk adjustment program for 2018 and give insurers confidence to continue participating in the markets, said CMS Administrator Seema Verma.

Revenue & Quality

A potential game changer: CMS takes aim at the social determinants of health, may pay for housing, other social services (1)

Alex Azar, secretary of the Department of Health & Human Services, made a surprising announcement earlier this month during a speech at the Hatch Foundation for Civility and Solutions when he said the agency wants to pay for services that address social determinants of health, the root cause of a large portion of U.S. health spending. Azar says social determinants are tied to the agency’s move toward a value-based healthcare system that delivers better outcomes at a lower cost. But will health plans be a part of the equation?

Revenue & Quality

RISE exclusive: Two competing health plans join forces to train providers, staff on documentation, coding, and billing requirements

PORTLAND, Ore.— It’s not common for health plans competing in the same market space to work together, but this fall that’s precisely what Regence BlueCross BlueShield of Oregon and Moda Health did when they had RISE present an in-depth workshop in downtown Portland for coders and providers on best practices (that were not payer-specific) for chart documentation, coding, and billing. This unique learning opportunity led to a collaborative work group that addressed populations at risk, regardless of the insurer. And both health plans and attendees told RISE they’d recommend other payers give this unique learning opportunity a try.

Revenue & Quality

Star ratings: Use consumer data, journey mapping to improve the member experience and boost quality scores

The 9th Annual RISE Star Ratings Master Class next month in San Diego will provide health plans with cutting-edge strategies they need to boost their Stars scores. RISE talked to two of the presenters, Angela Perri of UPMC Health Plan, and Dr. Tracey Veal of Aetna, to learn more about their sessions and what steps they suggest health plans take to help improve the quality of care and the consumer’s overall experience.

Revenue & Quality

CMS proposed rule could change the way qualified health plans bill for abortion coverage; Final rule expands contraception exemptions

The Centers for Medicare & Medicaid Services (CMS) recently issued a proposed rule, “Patient Protection and Affordable Care Act: Exchange Program Integrity,” to ensure that people are accurately determined eligible for premium subsidies they receive through the Exchange. But the proposal also calls for insurers to send a separate bill and collect separate payments for the tiny portion of the consumer’s premium that covers certain abortion services prohibited from using public funding. CMS has also issued two final rules that expands religious and moral exemptions for providing contraceptives. RISE looks at the key takeaways for health plans.

Revenue & Quality

News recap: Federal court refuses to hear appeal over risk corridor payments but case isn’t over; early reports on association health plans are positive

In this column, RISE looks at the latest news to impact health care insurers. Among the biggest headlines: Federal judges denied a request to reopen a case involving $12 billion in risk corridor payments to payers, and early reports reveal that the first association health plans are offering comprehensive benefits.

Revenue & Quality

5 reasons you don’t want to miss the 9th Annual RISE Star Ratings Master Class in San Diego next month

Only a few spots are left for this year’s RISE Star Ratings Master Class, which will take place Dec. 11-12 at the Fairmont Grand Del Mar Hotel in San Diego. This 9th annual event will feature a special session with Ashby Wolfe, M.D., chief medical officer for Regionals VIII, IX, X at the Centers for Medicare & Medicaid Services, who will provide an update on CMS policy for the Medicare Stars program. Read on to learn what else is in store at this year’s Star Ratings Master Class and why you don’t want to miss it.

Revenue & Quality

Medicare’s financial picture may be better than previously thought, study finds

Earlier this year a federal report indicated that the financial status of Medicare was dire. Indeed, the report from program trustees revealed that Medicare funds would run out in 2026 and the trust fund wouldn’t be able to fully cover projected medical bills for inpatient care. But a new study conducted by the Center for Retirement Research at Boston College finds the Medicare program is in better financial shape than it was 10 years ago.

Revenue & Quality

Renewable short-term health plans and the future of the ACA marketplace

Short-term health plans were originally meant to last 90 days to serve as gap coverage for consumers who were between jobs or transitioning from one health plan to another. But a new federal final rule allows states to sell short-term plans that can last up to 364 days and may be renewed for up to 36 months. These health plans are often inexpensive but also don’t cover as many medical services and can deny coverage to consumers with pre-existing conditions. Yet, these yearly, renewable plans now compete with plans that comply with the Affordable Care Act (ACA). Can the ACA marketplace survive if healthy people turn to these short-term plans for coverage?

Revenue & Quality

CMS proposed rule: Big changes to RADV audits could lead to hefty penalties for Medicare Advantage plans

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule last week that will change the way it audits Medicare Advantage plans–and the new policy may result in significant financial penalties for insurers. The agency wants to extrapolate data generated from Risk Adjustment Data Validation (RADV) audits dating back to 2011 without the use of a fee-for-service (FFS) adjuster to offset the error rate. RISE looks at the changes in the proposed rule.

Revenue & Quality

Avalere report: The repeal of ACA’s pre-existing conditions will impact 102M people

A recent analysis from Avalere finds that 102 million people not enrolled in Medicaid or Medicare have a pre-existing medical condition and could face higher premiums or significant out-of-pocket costs if lawmakers repeal the Affordable Care Act’s (ACA) pre-existing condition protections. Kevin Mowll, executive director of RISE, weighs in on the findings.

Revenue & Quality

New federal policy gives states more flexibility in the marketplace, but may send ACA plans in a ‘death spiral’

The Centers for Medicare & Medicaid Services (CMS) and the U. S. Department of the Treasury issued new guidance last week that provides more flexibility for states to get waivers to design health plans that don’t meet the coverage requirements of the Affordable Care Act (ACA). RISE Executive Director Kevin Mowll examines what this new flexibility may mean for the future of the health insurance market.

Revenue & Quality

Legal update: Judge won’t reconsider risk adjustment methodology ruling

A U.S. District Court judge has denied the federal government’s request to reconsider a prior ruling that found flaws in the Department of Health and Human Services’ risk adjustment formula. But this doesn’t mean the court case is over.

Revenue & Quality

RISE recommended reading: Commonwealth Fund’s David Blumenthal op-ed on pre-existing conditions

For the second installment of our semi-regular series that recommends articles, white papers, or issue briefs of importance to RISE members, we turn to a recent opinion piece written by Commonwealth Fund President David Blumenthal and published by STAT. His column looks at the status of the Affordable Care Act and its growing popularity regarding the protection of covering people with pre-existing conditions.

Revenue & Quality

RISE recommended reading: Kaiser Family Foundation’s Medicare-for-All issue brief

This month RISE is introducing a new feature that will run periodically. The column will recommend articles, white papers, or issue briefs that we believe contains important information for RISE Association members. For our first column, we suggest you take the time to read the Kaiser Family Foundation’s recent issue brief on Medicare-for-All and Public Plan Buy-in Proposals.

Revenue & Quality

OIG report: Medicare Advantage plans may deny claims to boost profits

Medicare Advantage plans continue to thrive and now cover more than one third of all Medicare beneficiaries. But a new report by the Office of Inspector General (OIG) at the Department of Health and Human Services finds they may have an incentive to deny claims to increase their profits. The OIG found that when beneficiaries and providers appealed preauthorization and payment denials, Medicare Advantage Organizations overturned 75 percent of their own denials during 2014-2016, overturning an estimated 216,000 each year. “Because Medicare Advantage covers so many beneficiaries (more than 20 million in 2018), even low rates of inappropriately denied services or payment can create significant problems for many Medicare beneficiaries and their providers,” the OIG said.

Revenue & Quality

Nominations now open for the Dr. Martin L. Block Award for Excellence and Innovation

Nominations will be accepted through Dec. 31, 2018 and the award will be presented at The 13th Annual RISE Nashville Summit at the Gaylord Opryland Resort, on Monday, March 18, 2019.

Revenue & Quality

The 2019 Star Ratings program: making the cut

The Centers for Medicare & Medicaid Services (CMS) recently published its 2019 Part C and Part D Medicare Star Ratings data and, along with it, the Technical Notes describing the methodology for the Star Ratings. Here, Ashley McNairy, product director for Cotiviti’s Government Quality solutions, breaks down the changes to the cut points, which can have a significant impact on a health plan’s score.

Revenue & Quality

New report shows finances are stronger than expected for insurers in the individual insurance market, but future profitability remains unclear

A new brief issued by the Kaiser Family Foundation analyzes financial data for the first six months of 2018 to determine how the individual insurance market has responded to changes made under the Trump administration that tended to destabilize the Affordable Care Act (ACA). The good news is that insurers in the individual market are showing a profit, even returning to levels not seen since before 2014 when new ACA insurance market rules took effect. The bad news: The future is murky due to the repeal of the individual mandate penalty that is part of tax reform legislation and the Trump administration’s decision to expand the sale and renewal of short-term, also known as “skinny,” insurance plans.

Revenue & Quality

The industry-wide implications of the DaVita Medical $270M settlement for alleged improper Medicare Advantage risk adjustment payments

The Department of Justice last week announced that DaVita Medical Group agreed to pay $270 million to the Centers for Medicare & Medicaid Services to settle False Claim Act allegations over questionable billing practices that led Medicare Advantage plans to receive inflated Medicare Part C risk adjustment payments. The improper billing activity pertained to HealthCare Partners Holdings LLC, a large independent physician association that DaVita acquired in 2012. RISE Executive Director Kevin Mowll and Jason Christ, a member of Epstein Becker Green in the health care and life sciences practice, and one of the scheduled speakers at the 13th Annual RISE Nashville Summit in March 2019, talk about the broader implications of the case.

Revenue & Quality

The RISE Institute: Make the most of these flexible learning opportunities to advance your career

Earlier this year the Resource Initiative and Society for Education (RISE) launched the RISE Institute, an educational entity that offers several learning opportunities for health care professionals. In this article, we talk to Executive Director Kevin Mowll about the RISE Institute and how members can take advantage of the training options.

Revenue & Quality

'E-Patient Dave' to Speak at the 9th Annual RISE Star Ratings Master Class in San Diego

RISE announces Dave deBronkart, leading patient engagement advocate, to present, "One Patient's Compelling Story of Beating Cancer: How Your Plan Can Better Serve Its Members"

Revenue & Quality

3 Strategies to Engage and Activate Hard-to-Reach Members

Engaging your members in their health is easier said than done. Members move, prioritize other “to-dos” over wellbeing activities, and frequently ignore communications. Traditional communication channels, like direct mail, tend to treat all members the same while using significant staff and financial resources, and delivering limited results. But there’s good news! You can increase member engagement rates and optimize your communications by combining advanced analytics and multi-channel communications.

Revenue & Quality

MEDICARE ADVANTAGE AND MACRA: ARE YOU READY FOR THE ALL-PAYER COMBINATION OPTION?

A fundamental change is well underway in healthcare payment models, with a shift toward value over volume. While this transition is occurring industrywide, CMS is accelerating the pace of reform, largely through the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This bipartisan legislation changes the way providers are reimbursed for traditional Medicare services through the Quality Payment Program (QPP), which over time ties an ever increasing portion of payment to quality.

Revenue & Quality

3 topics that generated the most buzz at RISE West 2018 (1)

Social determinants of health was the hottest topic at RISE West 2018, an indication that in the upcoming year health plans will likely pursue models of care that aim to improve the health and quality of life of their members. Speaker Aaron Horsfield, administrative fellow, UPMC Health Plan, predicted that the industry will see rapid change in this area as more plans collaborate with community partners to address the housing and food needs of their patient populations.

Revenue & Quality

The Three Fundamentals of Risk Adjustment Success

The term “risk adjustment” means different things to different people depending on their role. The Centers for Medicare & Medicaid Services’ (CMS) textbook definition is that risk adjustment is “a statistical process that takes into account the underlying health status and health spending of the enrollees in an insurance plan when looking at their health care outcomes or health care costs.” In contrast, a certified medical coder would tell you that risk adjustment is about making sure the medical record accurately reflects the diagnoses and procedures captured on a claim. And a health plan chief financial officer would say that risk adjustment ensures that the plan is properly compensated for its clinical burden.

Revenue & Quality

Rosy forecast: Average health care marketplace premiums for 2019 will stabilize

Two new reports show modest increases for average premiums on the health insurance exchanges next year. Another piece of good news: Insurers are expanding in new markets.

Revenue & Quality

Court sides with Montana CO-OP in cost-sharing reduction payment case

A small insurer in Montana is the first to win a court case against the federal government over unpaid cost-sharing reduction payments for the last quarter of 2017. The legal victory is good news for other insurers that have also filed lawsuits to recover the unpaid payments, which total approximately $7 billion.

Revenue & Quality

Fate of ACA is now in hands of federal judge

U.S. District Judge Reed O’Connor didn't issue an immediate ruling Wednesday after listening to arguments for nearly four hours about whether to find the Affordable Care Act unconstitutional.

Revenue & Quality

Lawsuit seeks to invalidate the Affordable Care Act

The Affordable Care Act is in the hot seat today. A federal court judge is set to hear oral arguments in a case that pits Republican attorneys general against a Democratic coalition over the validity of the health care reform law. Plaintiffs say the law is unconstitutional because Congress implemented a tax overhaul that eliminated the tax penalty that was part of the law's individual mandate. Democratic attorneys general disagree and argue the mandate remains constitutional. U.S. District Judge Reed O’Connor is being asked to issue a preliminary injunction that would temporarily end the law until the case is decided.

Revenue & Quality

What the latest ACA developments mean for the future of health care reform

Since Senate Republicans failed to pass a bill to repeal the Affordable Care Act last year, the Trump administration has taken several actions to undermine the ACA’s insurance markets. But recent developments may indicate that the administration is losing the battle on chipping away at a cornerstone of the ACA philosophy. Kevin Mowll, executive director of the RISE Association, reviews the latest actions as part of the bigger picture of what it may mean to the future of health care reform in the United States.

Revenue & Quality

2019 Star Ratings set to go live on Oct 10

The Centers for Medicare & Medicaid Services continues to tweak the Stars program. The agency intends for the changes to improve the program, but Kevin Mowll, executive director of the Rise Association, says the shifting areas of emphasis often generate uncertainty. Read on to learn more about the changes planned for the 2019 Star Ratings.

Revenue & Quality

Oscar Health to offer MA plans in 2020 thanks to $375M investment from Alphabet

Oscar Health, the technology-driven, consumer-focused health insurer, is already in the individual and small employer markets. But big money from the parent company of Google will allow the six-year-old company to add Medicare Advantage plans to the mix. Kevin Mowll, executive director of the RISE Association, weighs in on why so many companies want a piece of this market.

Revenue & Quality

Pre-Emptive and Analytics-Based Early Action Can Delay Kidney Dialysis, Reduce Plan Costs and Improve Quality of Life

Early intervention is the key to slowing or stopping chronic kidney disease (CKD), improving the quality of lives for those at risk and containing health plan costs. Avoiding dialysis for just one member represents a health plan savings of $350,000 to $700,00 per year, which more than pays for the CKD program by itself. A well-reasoned, proactive kidney disease management program is a necessity, not a luxury.

Revenue & Quality

New Mexico insurer tries to block CMS rule that reinstated risk adjustment payments

The legal squabble between the Centers for Medicare & Medicaid Services and the New Mexico Health Connections over risk adjustment payments continues. The insurer on Monday filed a second lawsuit to block the federal agency from implementing its formula for calculating risk adjustment payments.

Revenue & Quality

Study: Medicare Advantage quality rankings penalize plans that serve disadvantaged populations

Medicare Advantage plan rankings may not accurately reflect the quality of care given to plan enrollees, according to a recent study by Brown University researchers. The study, published in Health Affairs,  found that Medicare Advantage plans suffer in federal quality rankings when they serve a higher number of non-white, poor and rural Americans.

Revenue & Quality

New Wunderman Health Inertia Report: How We Triggered the Motivation to Change

“Health Inertia” is a phenomenon challenging marketers across categories. People know they should practice healthy behaviors like working out and eating well, taking prescribed medications, getting recommended screenings and more. But, they don’t.

Revenue & Quality

The CMS 2019 Final Notice: Star Ratings Changes

Verscend’s Ashley McNairy, product director for Verscend’s Government Quality Solutions, breaks down the key changes to the Star Ratings program on the docket for 2019 and the potential impact on health plan processes and bottom lines.

Revenue & Quality

Analyzing Provider Behavior Patterns to Improve Medical Record Retrieval Success

Medical record retrieval is a crucial component of any risk adjustment or HEDIS® project, yet it is perhaps one of the most difficult. Retrieval is labor intensive, consumes time and resources, and requires great patience and persistence.

Revenue & Quality

Natural Language Processing in Today’s Risk Adjustment Coding Landscape: Delivering Accuracy, Efficiency and Control

As the shift to both value-based care and risk-based contracting continues, health plans’ reimbursements – and overall financial performance – are increasingly tied to risk adjustment, forcing them to find ways to improve the efficiency and ROI of their risk adjustment programs.

Revenue & Quality

An expert viewpoint: Five questions to evaluate your HEDIS performance

If you are feeling relieved (and perhaps somewhat exhausted) now that your HEDIS submissions are in for the year, you are not alone. But if you want to be even more successful with your HEDIS effort next year, take action now to evaluate what went well, what didn’t, and how you can improve moving forward.

Revenue & Quality

An expert viewpoint: Discover HEDIS improvements beyond standard workstreams

There are excellent strategies to improve your HEDIS performance by reflecting on the past year and making course corrections. But there are even more transformational considerations that can yield exponentially higher benefits.

Revenue & Quality

Will CMS Policy Changes Have an Impact on the Healthy Age-in Market?

For many years Deft Research studies have shown that persons who are aging into Medicare coverage are equally likely to gravitate toward Supplemental Medicare (aka, Medsupp) products and Medicare Advantage (MA) products. The primary reasons for Medsupp remaining attractive despite its price disadvantage are its unrestricted access to doctors and hospitals, and the simplicity of coverage terms leading consumers to feel more certain about what they are buying. Suspicion and lack of trust in Medicare Advantage’s detailed list of provisions and restrictions drives many away.

Revenue & Quality

Current State of the Individual and Family Plan Market

In March, Deft Research published its annual Individual and Family Plan Shopping and Switching Study. The study surveyed over 3,600 people who obtain their health insurance directly from health insurers and without the sponsorship or assistance of an employer (no employer group coverage). If we include the uninsured as part of this market (it is here that they might receive premium assistance and are able to find plan options) the population represents over 50 million people, or one in seven Americans.

Revenue & Quality

CMS Largely Finalizes Part D Provisions, Announces Significant Updates to MA Payment Rates, Risk Adjustment and Quality Provisions

On April 2, the Centers for Medicare & Medicaid Services (CMS) released the 2019 Rate Announcement and Final Call Letter (RACL). The RACL is an annual regulatory policy document that establishes payment and coverage policies for Medicare Advantage (MA) and Part D plans for the upcoming plan year. The RACL incorporates proposed changes from both Part I and Part II of the 2019 Advance Notice and Call Letter (ANCL). CMS announced an upward revision to the growth rate which will positively impact health plan revenue. In the RACL, CMS largely finalized many of the changes proposed in Part II of the ANCL. CMS announced it will not implement the Payment Condition Count changes to the MA Risk Adjustment Model for PY 2019. It will instead look to implement the counts, required by the Comprehensive Addiction and Recovery Act of 2016 (CARA), starting in PY 2020.

Revenue & Quality

The Rise of Illumin8 Active Intelligence: Natural Language Processing and Generation (NLP, NLG), Personalized KPIs, Alerts, and Chatbots

Today’s systems mostly help Jerry Maguire: “Show me the money!” Packaged as snazzy dashboards with various charts, tables, and filters, such systems remain passive. You must click, filter, and sort to find what you need. You must find context to interpret what you see. You must decide who needs to know about or to act on this – and, ultimately, you must select, package, and alert them. The insights themselves may be great, but the effort needed to find them can be demanding, much less the effort required to turn the data into action. Out of the office or away from your laptop?

Revenue & Quality

Find More, Spend Less, Take Control: Leveraging Technology to Improve the ROI on Risk Adjustment

Due to changing market dynamics, there is increasing pressure for risk-bearing organizations to improve the effectiveness of their risk adjustment programs. Several trends present pervasive challenges—for example, increasing number of risk-adjusted lives, rising coding intensity factor, and heightened focus on compliance. Risk adjustment departments are constantly being asked to do more with less.

Revenue & Quality

Part 3: The Physician-Hospital Alignment Decision

Part 3 of the Successful Health and Wellness MACRA article series explores the impact of the legislation on the physician-hospital alignment strategy.

Revenue & Quality

RAPS to EDPS Dual-Submission: No End in Sight

As the industry focuses on the progress of MAOs as they transition to Encounter Data Process System (EDPS)-based risk scores and the effect on revenue, the industry must also consider the impact of the dual submission model.

Revenue & Quality

Whitepaper: The Changing Quality Improvement Landscape

The quality improvement landscape has grown much more complex and touches a wider number of health plan functions than ever before. Quality measurement and reporting have evolved from an annual routine into a year-round strategic initiative as payers used quality data to drive performance improvement initiatives across their organizations.

Revenue & Quality

RISE Nashville Recap: A Record-Setting Event

In mid-march, the 12th Annual RISE Nashville Summit saw record attendance of over 1,300 attendees and sponsors. Held at the Omni Hotel in downtown Nashville, the three-day conference is the premier event for professionals leading the US government healthcare reform movement. It offers ample networking opportunities and invaluable content in the areas of risk adjustment, quality management, financial compliance and performance analytics.

Revenue & Quality

RISE Presents 2018 Martin L. Block Award

The Resource Initiative and Society for Education (RISE) announced that Manjusri Vennamaneni, MD, was awarded the Martin L. Block Award for Clinical Excellence and Innovation at the 12th Annual RISE Nashville Summit earlier this week.

Revenue & Quality

Newly Launched RISE Institute Expands Education for Healthcare Professionals (change name test)

CHARLOTTE, N.C., March 15, 2018 - The Resource Initiative and Society for Education (RISE) today announced the launch of the RISE Institute, the new educational entity established to meet the needs of its members, providing a variety of educational programs and certifications related to government healthcare (Medicare Advantage, ACA and healthcare reform).

Revenue & Quality

Top 5 Actionable Uses For Marketing Analytics

As the health insurance industry continues to become more competitive and the consumer becomes more discerning, strong business analytics can be the key to both differentiating your plan, and making a positive impact to your bottom line. Today’s Medicare audience is evolving just like any other segment of the population and demanding a better consumer journey. This journey needs to be personalized both from a messaging and media standpoint.

Revenue & Quality

Final Report Impact Evaluation: Medicare Advantage Transition From RAPS To EDS

As CMS transitions the calculation of Medicare Advantage (MA) plan risk scores from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS), questions remain regarding how the shift may impact future MA plan payment rates.