RISE News, Insights and Articles

Let RISE Be Your Preferred News Source

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.

RISE Nashville

2020 nominations now open for the Martin L. Block Award

RISE is now accepting nominations for the 2020 Dr. Martin L. Block Award for Excellence and Innovation. The prestigious award is given to an individual who has advanced the lives of America’s seniors through clinical leadership, policy vision, and by superior example.

RISE West

3 takeaways from RISE West 2019 on provider engagement, payer-provider collaboration, and the real reason seniors choose MA plans

SAN DIEGO—More than 450 attendees gathered at the Loews Coronado Bay Resort in San Diego for RISE West 2019 to learn about payer/provider collaboration, leadership, and the member experience. Below are takeaways from select sessions:

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.

RISE West

RISE West 2019: Keynote presenters inspire with leadership lessons, problem-solving strategies

SAN DIEGO —Among the highlights of RISE West 2019: An amazing story of survival and heroics during our nation’s darkest day; a new way of thinking about health care innovation; and tips to change behavior to enrich the member experience. Here’s a sampling of the keynote presentations.

Population Health & SDoH

RISE recommended reading: Deft Research’s blog post on social determinants of health and health outcomes

For the latest installment of our semi-regular series that recommends articles, white papers, or issue briefs of importance to RISE members, we turn to a recent blog post by Deft Research’s Richard Hamer, Steve Runfeldt, and Adam Johnson about some of the conclusions from the firm’s survey to measure social determinants of health (SDoH) and intervening factors. These factors, known as “frames of reference” are defined as “internalized concepts and experiences that predict health behavior” and may depend on the person’s upbringing, circle of friends, education, and experiences with health care.

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.

Population Health & SDoH

How to make social determinants of health actionable

With 70 percent of a person’s health attributed to environmental factors and lifestyle choices, it’s crucial to understand what social determinants are and how to apply them to support your population at an individual level.

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.

Compliance

CompliancePalooza 2019 speakers to reveal lessons learned from recent CMS audits

One of the most anticipated sessions at RISE’s upcoming CompliancePalooza is an in-depth look at recent CMS audits featuring a panel of four health plan compliance experts who will talk about their experiences. RISE interviewed two of the panelists ahead of the conference to find out what they would suggest that health plans do to improve audit preparation.

Compliance

CompliancePalooza 2019 keynote interview: Life and career lessons with retired FBI agent Rhonda Glover

Rhonda Glover spent 34 years working for the Federal Bureau of Investigation before retiring last year from a career she loved. She had no choice–the age cut off for agents in federal law enforcement is 57. But she had far too much energy and ambition to leave the working world behind. RISE talked to Glover ahead of CompliancePalooza about what she has learned about leadership and her own career reset as founder and CEO of a training, development, and career coaching firm.

Compliance

CompliancePalooza 2019 speaker spotlight: Gateway Health Plan’s Heather Metz on workplace audit engagement

There is no need to panic if your health plan receives a notification from the Centers for Medicare & Medicaid Services (CMS) that your organization has been selected for a workplace audit— that is, if you're prepared, according to Heather Metz, manager of government compliance for Gateway Health Plan, one of the country’s leading managed care organizations that currently serves Medicare and Medicaid enrollees across five states. RISE got a chance to interview Metz about her strategies for successful workplace audits, one of two topics that she will discuss at CompliancePalooza, Oct. 21-22, in Washington, D.C.

Compliance

CompliancePalooza 2019 promises new innovative ways to approach program audits, strategies to improve FDR oversight

This year’s conference will focus on the effective monitoring of departments and data, and the latest regulatory updates to mitigate compliance risks and ensure a successful Centers for Medicare & Medicaid Services (CMS) audit. Here’s a look at what compliance professionals can expect when RISE gathers on Oct. 21-22 at a brand-new venue—the elegant and historic Omni Shoreham Hotel in Washington D.C.

RISE West

7 reasons you don’t want to miss RISE West 2019

RISE is headed to San Diego Sept. 9-11 for our annual leadership conference. Here’s everything you need to know about the event, as well as fun things to do after hours at the Loews Coronado Bay Resort in San Diego.

Population Health & SDoH

RISE recommended reading: United Hospital Fund’s white paper on the social determinants of health

For the fifth installment of our semi-regular series that recommends articles, white papers, or issue briefs of importance to RISE members, we suggest United Hospital Fund of New York’s white paper Complex Construction: A Framework for Building Clinical-Community Partnerships to Address Social Determinants of Health. The paper provides an insightful look into the hurdles that organizations face when they try to leverage the resources of community-based organizations to meet the social determinants of health needs of their patients in a medical setting.

RISE West

Meet the RISE West 2019 speakers

RISE West 2019 will feature more than 50 speakers who will showcase their success stories and strategies to improve programs for leadership, risk adjustment, documentation, HCC coding, quality, social determinants of health, RADV audits, payer-provider collaboration, and member engagement. This article highlights five speakers who are scheduled to present during the first day of the main conference on Tuesday, Sept. 10.

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.

Population Health & SDoH

The National Population Health Summit: Jason Helgerson on trends in population health and the move to value-based payment

Jason Helgerson, chief solutions officer of Helgerson Solutions Group and former Medicaid director for the states of New York and Wisconsin, will be a featured speaker at the National Population Health Summit, Nov. 12-13, in Orlando. In this article, RISE talks to Helgerson and his co-presenter, Juliette Price, solutions architect for the social determinants of health, Helgerson Solutions Group, on trends in value-based payment (VBP), population health, and social determinants of health (SDoH).

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.

Medicare Market

7 lessons learned from the 2019 Medicare OEP

The return of the Medicare Open Enrollment Period (OEP) was fraught with uncertainty. No one knew how many Medicare Advantage (MA) members would use this year’s January 1-March 31 time period to switch plans or insurers, but now health plans can use the results of what happened to determine what to do during next year’s OEP as well as the traditional annual enrollment period (AEP). Here is what we’ve learned.

Population Health & SDoH

Community health takes center stage at RISE’s inaugural National Population Health Summit

The two-day, dual-tracked event on Nov. 12-13 in Orlando will address the most pressing issues associated with population health, addiction treatment, and disease management.

RISE West

RISE West 2019: Speaker Stephen Shapiro on what will drive practical innovation in health care

For years people have been told during brainstorming meetings to think “outside the box” and come up with innovative ideas to solve a problem. But that’s bad advice—it’s the walls within the box that hold the answer, according to innovation expert Stephen Shapiro, who will speak at RISE West’s plenary session this fall.

RISE West

Judge gives Trump administration the green light on sale of ‘skinny plans’, ACAP vows to appeal ruling

The Association for Community Affiliated Plans (ACAP) said Friday it would appeal a U.S. District Court’s ruling that the Trump administration can expand the sale and renewal of short-term limited-duration insurance (STLDI) as a substitute for comprehensive health insurance.

Medicare Market

New plan flexibility for Medicare Advantage brings opportunities for supplemental benefits and Part D drug coverage in 2020

The Centers of Medicare & Medicaid Services (CMS) recently issued its final Medicare Advantage (MA) and Part D plan payment policies and Final Call Letter for the 2020 plan year. This final notice continues the Trump administration’s efforts to introduce significant program changes with new plan option initiatives for the Medicare program.

RISE West

RISE West speaker Shannon Decker previews can’t-miss sessions on provider engagement, social determinants of health

Shannon I. Decker, Ph.D., one of 45 speakers at this year’s RISE West, talked to RISE about her work with social determinants of health (SDoH) and provider engagement ahead of the annual conference, which will take place Sept. 9-11 at the Loews Coronado Bay Resort in San Diego.

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.

Medicare Market

Award-winning author Meridith Elliott Powell named keynote speaker at RISE AEP Medicare Sales Readiness Summit

Powell, voted one of the Top 15 Business Growth Experts to watch by Currency Fair, will share strategies that attendees can use to turn uncertainty into a competitive advantage.

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.

Population Health & SDoH

Collaboration is key—the biggest takeaway from The National Summit on Social Determinants of Health

WASHINGTON, D.C.—Don’t wait for lawmakers on Capitol Hill to solve problems related to health care. They aren’t going to do it, according to Rich McKeown, the keynote speaker at RISE’s National Summit on Social Determinants of Health. Instead of lawmakers, solutions will come from the 250 attendees of the conference who represent community-based agencies, health plan providers, service providers, and consultants who will drive necessary changes.

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.

Medicare Market

Deft Research announces update of list scoring algorithms

Deft Research has announced the update of its 2019 Medicare Consumer List Scoring algorithms timed to coincide with marketing planning for Medicare’s fall Annual Election Period (AEP) and the rest of the year.

RISE West

RISE West to take a deep dive into UnitedHealthcare’s housing, wraparound care model that tackles social determinants of health

Speaker Kathleen Stillo, president and chief operating officer of the clinical redesign direct care delivery unit in UnitedHealthcare’s Community & State division, talks to RISE ahead of the September conference about the organization’s mission to provide its most medically and socially complex members with better care at lower cost.

Population Health & SDoH

RISE West to take a deep dive into UnitedHealthcare’s housing, wraparound care model that tackles social determinants of health

Speaker Kathleen Stillo, president and chief operating officer of the clinical redesign direct care delivery unit in UnitedHealthcare’s Community & State division, talks to RISE ahead of the September conference about the organization’s mission to provide its most medically and socially complex members with better care at lower cost.

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.

Medicare Market

Report: Medicare Advantage likely to reach 70 percent penetration within 20 years

Medicare Advantage (MA) enrollment has nearly doubled over the past decade, and it is showing no signs of slowing down. Indeed, a new report from L.E.K. Consulting finds that MA penetration will continue to rise as high as 70 percent between 2030 and 2040.

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.

Medicare Market

3 proven strategies to prevent disenrollment

The average Medicare Advantage (MA) plan turns over about 10 percent of its members in voluntary disenrollment every year. For a plan with 100K members, this equates to approximately $110M in lost premium reimbursements.

Medicare Market

Attracting age-ins: A persistent issue

Most health plans are not satisfied with the proportion of their former commercial members who convert into Medicare members. This under-performance is called the age-in conversion problem. And it challenges Medicare plans trying to enroll their own individual and employer-sponsored health plan customers.

RISE West

A sneak peek at RISE West 2019

RISE West 2019 is shaping up to be bigger than ever. Our annual event returns to San Diego on September 9-11 to bring together senior leaders from Medicare Advantage health plans, commercial marketplace sponsors, Part D health plans, providers groups, pharmacy benefit managers, and accountable care organizations to discuss strategies to improve payer-provider collaboration and the member experience and address social determinants of health. We talked to Kevin Mowll, executive director of the RISE Association, and Marina Adamsky, executive director of production for RISE, to learn what’s new and what attendees can expect at this year’s premier event.

Medicare Market

Preheat marketing: The easy way to generate measurable results during Medicare’s AEP

Sixty-eight days. As Medicare marketers, we all know the timeframe challenge that comes with every Annual Election Period (AEP). And we all play by the same rules imposed by the Centers for Medicare & Medicaid Services (CMS). So, how can you gain a competitive edge given all the marketing restrictions? Simple: preheat the market.

Medicare Market

3 takeaways from Deft Research’s 2019 Age-In Study

Deft Research’s latest national market research report examines the age-in conversions of current commercial members, the factors that drive enrollment with consumers after the age of 65, and the key times that seniors shop for Medicare coverage. Here are three findings from the executive summary of the 2019 Age-In Study, which surveyed 2,400 seniors who are eligible for Medicare.

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.

Population Health & SDoH

Social determinants of health: 68% of Americans surveyed have experienced at least one unmet social need in the past year

One-third of Americans say they have trouble meeting their basic human needs, such as stable housing, adequate food, and reliable transportation, and they want health care providers to help identify and address these non-medical social needs, according to the results of a new national survey from Kaiser Permanente. Those who experienced unmet social needs were twice as likely to rate their health as fair or poor compared to those who did not.

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

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.

Population Health & SDoH

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

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.

Medicare Market

HealthMine survey: Only 32% of Medicare Advantage members are familiar with star ratings

Only 32 percent of the 800 Medicare Advantage (MA) plan members with chronic conditions are familiar with the Centers for Medicare & Medicaid Services’ (CMS) star ratings systems, according to a HealthMine survey. Of those, nearly half said they used the grading system to help them choose a plan for 2019 enrollment.

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.

Medicare Market

Medicare Marketing & Sales Summit: 3 health plan leaders offer insight into the Medicare Advantage market

LAS VEGAS — One of most anticipated sessions at RISE’s 12th Annual Medicare Marketing & Sales Summit in February was a town hall discussion about the Medicare Advantage (MA) market. The panel was moderated by Hank Osowski, managing partner, Strategic Health Group, LLC, and included executives from Blue Cross Blue Shield of North Carolina (Blue Cross NC), Scan Health Plan in California, and MediGold in Ohio, who discussed the inclusion of supplemental benefits into health plan offerings in 2019, how those offerings might change in 2020, and how they are able to stand out in an increasingly competitive market. Here is what we learned.

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

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.

Population Health & SDoH

Data collection key to efforts that address social determinants of health

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.

Medicare Market

A look back at the 2019 Medicare OEP: What happened and why

RISE will examine what happened during the 2019 Medicare Open Enrollment Period (OEP) and what actions health plans should take to prepare for next year’s OEP during a webinar on June 11 at 1:30 p.m. EST. The webinar will feature speakers from Deft Research, a Blue Cross plan, a field marketing organization, and an agency. In this article we talk to one of the webinar speakers, Renée Mezzanotte, EVP/client engagement, DMW, about the OEP and the current state of Medicare.

Medicare Market

4 mistakes that can destroy your digital marketing campaigns and how to avoid them

LAS VEGAS—One session at RISE’s Medicare Marketing & Sales Summit made us rethink our digital marketing campaign strategies. Justin Stauffer, vice president of integrated marketing at DMW, an agency that specializes in marketing for the health insurance industry, spelled out the six most common mistakes that organizations make and how to fix them. In this article, we examine four of the biggest blunders, and what marketing, sales, and product development professionals can do to avoid them in the future.

Medicare Market

Half of middle-income seniors won’t be able to afford housing and health care by 2029, new study finds

A new study in Health Affairs paints a bleak picture for the future of middle-income seniors. Fifty-two percent of U.S. seniors who will be 75-years-old and older in the next 10 years will be unlikely to qualify for Medicaid long-term care but won’t have the financial means to cover the costs for assisting living rent and out-of-pocked medical costs. Researchers refer to this growing population as “the forgotten middle.”

Medicare Market

Health insurance agency fined $50K for misleading elderly about their Medicare coverage

A California-based health insurance agency was fined $50,000 and ordered to cease and desist from mailing misleading marketing materials to elderly residents in Minnesota.

Medicare Market

Highmark-UPMC legal dispute likely reason Medicare Advantage members switched insurers during extended open enrollment period

Nearly 2,000 Highmark Medicare Advantage (MA) members in western Pennsylvania switched insurers during this year’s extended open enrollment period. Most members signed up with big-name national carriers to ensure they would have in-network access to University of Pittsburgh Medical Center (UPMC) hospitals and physicians.

Medicare Market

Medicare Trustees Report: Part A funds will deplete in 7 years

The Medicare Board of Trustees has been sounding the alarm about the future of the Hospital Insurance Trust Fund for years. Its latest report warns that the trust fund, which supports Medicare Part A, won’t be able to pay full benefits after 2026. It also projected that overall Medicare costs will continue to grow at a faster pace than the economy and put a strain on the federal budget unless lawmakers act now. Officials from the Trump administration have jumped on the findings, using the latest figures to push back against some Democratic lawmakers’ calls for a Medicare-for-All program.

Medicare Market

3 stages to successfully launch a whole new Medicare brand—or a new plan from an established brand

The number of provider-sponsored health insurance plans entering the market is growing exponentially. Why? Because it can be profitable for both health systems and physician groups. But this endeavor is vastly more difficult than launching a new plan from an established brand. There are essential elements for planning, designing, launching, and sustaining a totally new Medicare plan and brand. Plans new to the market need even more of an edge to compete against the incumbents. Therefore, it is imperative to follow these three mission-critical stages of a plan launch.

Medicare Market

Rewards and incentives: Best practices to help improve star ratings

The introduction of a Five-Star Quality Rating System from the Centers for Medicare & Medicaid Services (CMS) for Medicare Advantage (MA) Plans has resulted in opportunities for high-performing organizations to reap significant financial compensation and the ability to offer supplemental benefits while underperforming organizations risk fines, notices to their current members, potential removal of contract, and other punitive actions.

Revenue & Quality

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

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.

Medicare Market

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

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.

Medicare Market

Medicare Advantage plans can offer additional telehealth benefits in 2020

Medicare Advantage (MA) plans have another new benefit to offer their members in 2020: telehealth services. The Centers for Medicare & Medicaid Services (CMS) recently announced it has finalized changes that would allow MA beneficiaries to access health care services from places like their homes, rather than require them to go to a health care facility for treatment.

Population Health & SDoH

Medicare Advantage plans can offer additional telehealth benefits in 2020

Medicare Advantage (MA) plans have another new benefit to offer their members in 2020: telehealth services. The Centers for Medicare & Medicaid Services (CMS) recently announced it has finalized changes that would allow MA beneficiaries to access health care services from places like their homes, rather than require them to go to a health care facility for treatment.

Revenue & Quality

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

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.

Population Health & SDoH

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

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

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:

Population Health & SDoH

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

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.

Medicaid

The latest on Medicaid Work requirements: Federal judge issues a major blow to Trump administration; KFF finds 18K lost coverage in Arkansas for failure to meet rules

Despite the Trump administration’s desire to force some Medicaid beneficiaries to work to maintain their benefits, a federal judge has thrown a monkey wrench into the plan by ruling against work requirements in Kentucky and Arkansas. The ruling comes in the wake of a Kaiser Family Foundation issue brief that found thousands of recipients in Arkansas have lost coverage because they failed to comply with the work requirements.

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.

RISE Nashville

RISE Nashville highlights: Inspiring keynotes, engaging sessions, and networking opportunities galore

NASHVILLE, Tenn.— More than 1,400 executives and senior leaders from hundreds of health plans, provider groups, integrated health systems and service providers across the country came together last week in Nashville to share strategies to address regulatory challenges, the latest trends and developments in the industry, member engagement strategies, and care outcomes.

Population Health & SDoH

RISE Nashville highlights: Inspiring keynotes, engaging sessions, and networking opportunities galore

NASHVILLE, Tenn.— More than 1,400 executives and senior leaders from hundreds of health plans, provider groups, integrated health systems and service providers across the country came together last week in Nashville to share strategies to address regulatory challenges, the latest trends and developments in the industry, member engagement strategies, and care outcomes.

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

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.

Medicare Market

A year of collaboration

Expect collaboration to reshape the Medicare Advantage landscape in 2019-20. Strategic alliances, partnerships, and affiliations are becoming a key component of successful MA programs as they coalesce around three key areas: Product, Care Delivery, & Distribution.

Medicare Market

Improve the member experience through value-based enrollment

When it comes to health insurance sales, the process doesn’t end once members sign their enrollment applications. Onboarding and care transition are key to member satisfaction and retention. When members have a positive experience with their new plan from the very beginning, it sets the stage for a successful, long-lasting relationship. In other words, the enrollment and onboarding process is an interaction, not just a transaction.

Medicare Market

National survey reveals greater risk of seniors switching Medicare Advantage plans in 2019

New research shows seniors want more health and well-being support from Medicare plans

RISE Nashville

RISE recognizes Dr. Mark Dambro with Martin L. Block Award

NASHVILLE, Tenn. (Mar. 18, 2019) – RISE announced today that Mark Dambro, M.D., senior vice president of health informatics for Signify Health, was awarded the Martin L. Block Award for Clinical Excellence and Innovation at the 13th Annual RISE Nashville Summit.

Medicare Market

Converting commercial members to Medicare members: Barriers and opportunities

Health insurers that have a low conversion of commercial to Medicare members may have an awareness issue. Challenges on increasing awareness include siloism among commercial and Medicare departments within health insurer corporations. Opportunities include creating strategies to encourage collaboration and incentives to provide the motivation for these groups to work together and provide the right Medicare plan to their commercial members.

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.

RISE Nashville

What to expect at RISE Nashville 2019: Can’t-miss sessions, exhibit hall activities, and networking opportunities

A St. Patrick’s Day party will kick off this year’s RISE Nashville Summit—the #1 ranked conference in the industry. The 13th annual event is designed for professionals of all levels in the Medicare Advantage and ACA market and will be our biggest one yet. We’ve compiled highlights, so attendees can make the most out of sessions and networking opportunities. For those who haven’t registered yet, don’t despair. There are a few delegate spots left. Take a look at what we’ve planned next week at the Gaylord Opryland.

Medicare Market

Agent fraud alert: Beware of potential genetic test scams

Warning: Many insurance carriers have recently issued alerts about a genetic testing program enticing agents with a generous commission for each client who provides a swab for the cancer screening. The agents are told that the program is legal because the test has been approved by the Centers for Medicare & Medicaid Services (CMS). Jameson Keller, vice president of strategic development for AgencyRM, says the program is a potential scam to get agents to “pay to play and to gain beneficiary Medicare information.”

RISE Nashville

RISE recommended reading: The promise and pitfalls of Medicare Advantage encounter data

For the fourth installment of our semi-regular series that recommends articles, white papers, or issue briefs of importance to RISE members, we suggest a recent Health Affairs blog post written by leaders at Avalere Health and Better Medicare Alliance. The post reviews the issues around Medicare Advantage (MA) encounter data, including its limitations to evaluate plan performance and its potential to offer new insights into MA.

Medicare Market

Medicare marketing & sales: 6 trends in 2019 Medicare shopping and switching

LAS VEGAS—Senior citizens typically don’t want to shop for insurance products. But this year 1 out of 3 seniors either switched health plans or felt compelled to at least look at other options, according to George Dippel, senior vice president of client services, Deft Research, LLC. And about half of those who switched plans did so even though they were happy with the coverage they had in 2018.

RISE Nashville

RISE-Cotiviti to reveal survey results on risk adjustment and quality integration at RISE Nashville

This year RISE partnered with health care analytics company Cotiviti to conduct research (both surveys and in-depth interviews) on risk adjustment and quality integration. More than 55 health plan systems contributed insights into the reasons for integration. Fifty-four percent of respondents were from smaller-sized health plans (less than 500,000 members) and 18 percent were from larger-sized health plans (more than 2 million members). In this article RISE previews highlights of the findings. The complete results will be unveiled during the 13th Annual RISE Nashville Summit, March 17-19 at the Gaylord Opryland Resort.

Medicare Market

Medicare Marketing & Sales Summit: 7 business gems from marketing guru John Moore

Las Vegas—John Moore, the keynote speaker at RISE’s 12th Annual Medicare Marketing & Sales Summit, offered attendees a jolt of “espresso shots of business wisdom” that he has gleaned over his long career as a marketing strategist, including his role that turned Starbucks into a global icon.

Leadership

Women in Health Care Leadership: Keynote Speaker Kay Hunter explains why women must be strategic about their personal and professional image

Kay Hunter, an image consultant, says a strategic personal brand can make a significant difference in whether a woman will attain personal and professional success. After working in “corporate America” for 18 years, she left her role as a senior vice president for human resources to establish Kay Hunter Image and help women develop a professional presence so they won’t be overlooked for bigger and better roles. Hunter, who will be the keynote speaker at The 3rd Annual RISE National Women in Health Care Leadership Summit, April 29-30, in San Diego, talked to RISE about how women can best develop their personal and professional image.

Leadership

Women in Health Care Leadership: Dr. Tiffany A. Love on how to overcome setbacks and help develop diverse health care executives

It’s common to hear positive stories about how leaders rose in the ranks to the executive suite. But not all leadership journeys are easy. Tiffany A. Love, Ph.D., regional chief nursing officer for Coastal Health Care Alliance, will discuss her own bumpy road to the C-suite at The 3rd Annual RISE National Women in Health Care Leadership Summit , April 29-30, in San Diego. RISE talked to Love ahead of the conference about her thoughts on leadership development, diversity, and the need for women to support one another.

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.

Medicare Market

Countdown to the Medicare Marketing & Sales Summit: Everything you need to know to make the most of your two days of learning and networking in Las Vegas

RISE’s 12th Annual Medicare Marketing & Sales Summit is less than two weeks away. If you’ve already registered for the #1 ranked conference in the industry, we’ve compiled the highlights, so you can make the most out of sessions and networking opportunities. And for those who haven’t yet registered for this premiere event for senior executives in Medicare Advantage, prescription drug plans, and health plan startups, it’s not too late—there are a few delegate spots left. Read on to learn what’s in store when we gather at the Paris Las Vegas Hotel & Casino on Feb. 25-26.

Medicaid

3 health plan executives to join CEO roundtable on Medicaid at the 4th Annual Medicaid Managed Care Leadership Summit in Chicago

Thomas Duncan of Trusted Health Plan, John Lovelace of UPMC Health Plan, and Jim Milanowski of Genesee Health Plan will discuss the evolving landscape of Medicaid and ROI of social determinants of health as part of a panel to kick off the Medicaid Managed Care Leadership Summit in Chicago.

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

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:

Population Health & SDoH

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

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.

Pharmaceutical & Biotech

TIPPA 2019: Alcon Laboratories’ Val Injev on evidence-based publication planning challenges for medical device and diagnostic firms

Val Injev, global medical publications lead for Alcon Laboratories, will lead a breakfast breakout session on evidence-based planning for medical device and diagnostic professionals at RISE’s 18th Annual International Publication Planning Meeting, February 20-21, in San Diego. RISE talked with Injev ahead of the conference about the importance of working with developers earlier in the process to ensure that high-quality studies about new products or diagnostics are published as soon as possible in peer-reviewed journals.

Revenue & Quality

5 health plan predictions for 2019

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.

Population Health & SDoH

5 health plan predictions for 2019

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.

Medicare Market

Boost AEP Campaigns with Targeted Lists

For many health insurance Marketers, a key problem is managing and improving the return on investment of their campaigns. A typical metric used is overall ROI: sales divided by marketing & sales dollars spent. Another metric capturing management’s attention is “cost-per-conversion” or marketing & sales dollars spent divided by number of sales.

Medicare Market

Health care consumer engagement: 7 insights from the 2018 RISE/Engagys Survey

One of the many highlights at this year’s RISE Star Ratings Master Class was the results of the 2018 RISE/Engagys Survey on Healthcare Consumer Engagement. The survey, now in its third year, included 140 participants who represent the top health plans, provider systems, and pharmacy benefit managers. More than 70 percent of the respondents work in risk adjustment and almost half of them said they also work on Stars and HEDIS. In addition, more participants were from regional health plans, an increase of 26 percent compared to last year. This greater representation of regional plans may indicate their increased interest in consumer engagement, according to Kathleen Ellmore, managing director of Engagys. Here are seven takeaways from the survey results.

Medicare Market

2019 Medicare OEP Update

Editor’s Note: The original version of this story, 2019 Medicare OEP: You Never Get a Second Chance to Make a First Impression, was published by RISE in July 2018, Open Enrollment Period (OEP) regulations have since changed and Wunderman has updated the article to reflect current requirements.

Pharmaceutical & Biotech

TIPPA 2019: Keynote speaker Dr. Patti Peeples on what the latest HEOR, RWE developments mean for communicators and the publication planning industry

Patti Peeples, R.Ph., Ph.D., founder and CEO of HealthEconomics.Com, will be a keynote speaker at RISE’s 18th Annual International Publication Planning Meeting, February 20-21, in San Diego. In this exclusive interview, Peeples talks about the changes in health economics and outcomes research (HEOR) and real-world evidence (RWE) in the last three years and what they mean for the publication planning industry.

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.

Medicare Market

CMS’ relaxed Medicare marketing guidelines give insurers more wiggle room but also serve as a reminder of past unethical practices

RISE previously reviewed the biggest changes contained in updated Medicare Communication and Marketing Guidelines, which include a new definition of marketing, the addition of the term communication, and guidance for the pre-enrollment checklist. The Centers for Medicare & Medicaid Services relaxed its previously stringent requirements and made what many consider to be long, overdue changes, just in time for the 2019 open enrollment period. RISE Executive Director Kevin Mowll looks back at the complex history of the guidelines, questionable health plan sales practices, and why now is the right time for CMS to have released the updated guidelines.

Revenue & Quality

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

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?

Population Health & SDoH

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

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.

RISE Nashville

RISE Nashville Speaker John Bandler on cybersecurity risks and the basic steps health plans can take to protect their members’ information

John Bandler, author of the book, “Cybersecurity for the Home and Office: The Lawyer's Guide to Taking Charge of Your Own Information Security,” will be a speaker at the 13th Annual RISE Nashville Summit in March 2019. In this article, RISE talks to Bandler about the four pillars of cybersecurity that health plans must follow to protect their organizations and members from fraud, identity theft, and cyber attacks.

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.

Leadership

Women in Health Care Leadership: Judy Hoberman on the glass floor, the #MeToo movement, and resilience

Judy Hoberman, a coach, trainer, and author of “Walking on the Glass Floor” and “Selling in a Skirt,” will be a featured speaker next April at the Women in Health Care Leadership Summit in San Diego. Her presentation will focus on how to ask for what you want and what you’re worth during negotiations. RISE caught up with this dynamic speaker to ask her about the different leadership styles of men and women, what she means by the glass floor, the unintended consequences of the #MeToo movement, and how to bounce back from failure.

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.

Medicare Market

The impact of Trump administration’s actions on the ACA: Silver plan premiums higher than they have to be

The good news: 2019 premiums in the Affordable Care Act (ACA) marketplace are flat or falling in many parts of the country. The bad news: A Kaiser Family Foundation (KFF) analysis finds that the premiums would be substantially lower still if the Trump administration didn’t make a series of changes to private insurance markets.

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.

RISE Nashville

RISE Nashville 2019: Q&A with Keynote Speaker John Medina

Brain Scientist Dr. John Medina, author of the New York Times bestseller, “Brain Rules: 12 Principles for Surviving at Work, Home and School,” will be the keynote speaker on the first day of RISE Nashville on Monday, March 18, 2019. In this exclusive Q&A, Medina answers questions about his research and common misconceptions about the brain.

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.

Medicare Market

6 things you need to know about the 2019 Medicare Open Enrollment Period

Medicare Open Enrollment is right around the corner. It’s formally known as the Annual Election Period, or AEP. However, in layman’s terms, the AEP is commonly known as the Open Enrollment Period. As noted below, the Centers for Medicare & Medicaid Services has expanded the OEP, which happens during the first quarter of 2019. In this article, RISE looks at what’s new for the upcoming year to make sure health plans are prepared to hold on to their existing members and attract new ones.

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.

Compliance

CompliancePalooza takes on the critical issues related to CMS audits, FDR monitoring, and compliance program effectiveness

Health plan leaders and compliance experts from across the country will address hot button issues from 2018 audits and potential changes for the 2019 audit season at CompliancePalooza on Oct. 29-30 in Baltimore.

RISE Nashville

RISE Nashville 2019: Speakers preview the must-attend conference of the year

The 13th Annual RISE Nashville Summit will take place March 17-19, 2019 at the Gaylord Opryland Resort. Here are six reasons why you don't want to miss the event of the year.

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"

RISE West

RISE West 2018: A look at how partnerships, tools can improve your risk adjustment program

The risk adjustment track at RISE West provided attendees with useful information and innovative strategies to strengthen their programs. This article looks at the success that Brown & Toland Physicians have had with three partnerships that provided HCC Analytics, Natural Language Processing, and the Annual Health Assessment Program.

RISE West

RISE WEST 2018: How to successfully manage and survive a CMS/HHS-RADV audit

It is possible to survive a Medicare Advantage Risk Adjustment Data Validation Audit, according to Deb Curry, RHIA, CCS-P, manager, risk adjustment, of Promedica, who spoke at RISE WEST 2018.

RISE West

RISE West 2018: OIG official provides insight on the potential of MA Encounter Data

RISE West 2018 featured a presentation by Joanna Bisgaier, Ph.D., deputy regional inspector general at the U.S. Department of Health & Human Services, on MA encounter data. Among the findings of the OIG report: The most common errors involved duplicated services, incorrect original control numbers, inappropriate codes, and missing values from other data.

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.

Medicare Market

The biggest changes in CMS’ updated Medicare Communications and Marketing Guidelines

The Centers for Medicare & Medicaid Services (CMS) discussed its updated communications and marketing guidelines during its annual Medicare Advantage and Prescription Drug Plan fall conference on Sept. 6. In this article, we look at the most notable changes.

Revenue & Quality

3 topics that generated the most buzz at RISE West 2018

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.

Population Health & SDoH

3 topics that generated the most buzz at RISE West 2018

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

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

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

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.

Medicare Market

2nd Annual RISE Survey Results

Engagys conducted our second annual examination of healthcare consumer engagement practices to further understand the rate at which the techniques pioneered by consumer marketing firms have been adopted by healthcare organizations.

Medicare Market

2019 Medicare OEP: You Never Get a Second Chance to Make a First Impression

Starting January 1st, 2019 there will be an Open Enrollment Period (OEP) that will allow Medicare beneficiaries to make “like plan” changes until March 31st, 2019. This is not just an extension of the Annual Enrollment Period (AEP) (which is between October 15th and December 7th each year); rather the OEP should be likened to a “grace period,” where Medicare beneficiaries are allowed the opportunity to disenroll from their current plan and select a new plan with their existing carrier or competitor.

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

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

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

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.

Medicare Market

Medicare Advantage Plans Cleared To Go Beyond Medical Coverage — Even Groceries

Air conditioners for people with asthma, healthy groceries, rides to medical appointments and home-delivered meals may be among the new benefits added to Medicare Advantage coverage when new federal rules take effect next year.

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?

Medicare Market

Boomerquake

Medicare products are expected to be the fastest growing insurance sector over the next 10-years. At the same time, Boomers are transforming care delivery, from aging-at-home services to convenience-driven alternate sites of care such as retail clinics, telemedicine and wearables to anti-aging nutraceuticals.

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.

Medicare Market

Prescription Drug Costs Play a Significant Role in Switching Medicare Health Plans

For the past 12 years, Deft Research has tracked Medicare consumer shopping and switching behavior during each fall’s annual enrollment period, or the fall AEP. The results of these national studies have many uses including predictive modeling, but most people first become familiar with them through the annual report Medicare Shopping and Switching.

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

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

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.

Medicare Market

Evaluating The Results Of The Enrollment Seasons

The annual review and selection of health insurance for one’s self and family has become an American tradition. During these annual enrollment periods (AEP’s, but referred to under various names), employees, Medicare recipients, and those in the individual and family markets conduct their own variations of the due diligence necessary to assure they will be in the right plan in the coming year.

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.

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.

Medicare Market

CMS Releases 2019 Advance Notice & Call Letter for MA Plans: What You Need to Know

On February 1, the Centers for Medicare & Medicaid Services (CMS) released Part II of the 2019 Advance Notice and Call Letter (ANCL). The ANCL is an annual regulatory policy document that describes the agency’s proposed payment and coverage policies for Medicare Advantage (MA) and Part D plans for the upcoming plan year. While normally a single document, this year’s ANCL was separated into 2 parts.