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RISE National

Future forecaster/gaming expert to join RISE National 2022 as third keynote speaker

Jane McGonigal, Ph.D., a world-renowned designer of alternate reality games—games that are designed to improve real lives and solve real problems—will speak on the second day of the main conference about how we can apply gaming to the health care industry.

Revenue & Quality

Beyond the Z codes: Promoting health equity and population health through advancing the use of SDoH data

Health plans operating in the Medicare Advantage space will need to optimize their risk adjustment and quality prospective and retrospective strategies to optimally align and make provider engagement and data governance the foundation to an effective social determination of health and population health strategy.

Population Health & SDoH

The Commonwealth Fund outlines framework to assess racial equity in health policy

The Racial Equity and Policy (REAP) framework serves as a tool for researchers, policymakers, and others to identify and examine racial equity implications of health policies.

Revenue & Quality

3 tech-led retrospective strategies to maximize program performance without provider abrasion

These tech-led retrospective approaches can help health plans ensure the data they submit is complete and accurate—without leading to further provider abrasion.

RISE National

CMS, OIG officials to speak at RISE National 2022

RISE is pleased to confirm that representatives from the Centers for Medicare & Medicaid Services (CMS) and Office of Inspector General (OIG) will join our roster of more than 150 speakers at RISE National 2022, which will take place live, in-person in Nashville, Tenn. on March 7-9.

Medicare Market

Why Medicare doesn’t pay for rapid at-home COVID tests

The laws governing Medicare don’t provide coverage for self-administered diagnostic tests, which is precisely what the rapid antigen tests are and why they are an important tool for containing the pandemic.

Population Health & SDoH

Biden administration’s rapid-test rollout doesn’t easily reach those who need it most

Two rapid-testing initiatives the Biden administration released in the past week are inaccessible to some residents of multifamily housing, people who don’t speak English well, or those without internet access.

Population Health & SDoH

HHS announces funding initiatives to promote mental health among health care workers, improve behavioral health in rural communities

The funding announcements include $103 million in American Rescue Plan funds to reduce burnout and improve retention in the health care workforce as well as $13 million in funding to increase behavioral health in rural communities.

Population Health & SDoH

Diverse patient engagement approaches reduce barriers to patient retention

A new study found Black patients in a remote monitoring program had higher retention rates when providers reached out to them over the telephone rather than a smartphone app.

Revenue & Quality

HHS proposal for marketplace plans carries a hefty dose of consumer caution

The Department of Health and Human Services issued preliminary rules regarding health insurance marketplaces that aim to deter fraudulent sign-ups for coverage. Experts say the agency’s action indicates a problem exists.

Medicare Market

MA supplemental benefits: Common plan offerings, consumer preferences, and how to stand out from the competition

Two new studies on Medicare Advantage (MA) supplemental benefits indicate that more and more plans are taking advantage of the ability to use non-medical incentives to differentiate themselves among the increasing competition. While one report looks at the number of plans across the country offering these new non-medical benefits, the other study uncovers member preferences when it comes to common supplemental benefits.

Medicare Market

The ROI of automating Medicare plan materials management

The annual AEP preparation is a complex, human intensive and costly process for MAOs. To handle these challenges, MAOs employ a wide variety of approaches and solutions for managing their plan materials.

Medicare Market

Industry trends survey: Why health plans report increased member engagement importance, SMS text use, and ROI measurements

The findings of the latest Engagys-RISE survey on consumer engagement practices highlight the focus health plans place on consumer health engagement, effective communication channels, and the ways they measure engagement effectiveness. The following column analyzes the key results and maps them to industry trends to illustrate the reasons behind the newer results.

Medicare Market

Medicare member experience and prescription discount cards

Insurers that offer Medicare Part D prescription drug program plans (PDP), beware. Member use of a prescription drug discount card is associated with lower intent to stay with their plan,

Revenue & Quality

Justices block broad worker vaccine requirement, allow health worker mandate to proceed

The Supreme Court on Thursday blocked a key Biden administration COVID-19 initiative—putting a stop, for now, to a rule requiring businesses with more than 100 workers to either mandate that employees be vaccinated against COVID or wear masks and undergo weekly testing.

Revenue & Quality

Regulatory roundup: CMS to reassess Part B premium after Alzheimer’s drug price cut; White House orders private insurers to cover at-home COVID tests; and more

RISE summarizes this week’s regulatory news from the Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS), and Office of Inspector General (OIG).

Population Health & SDoH

The RISE Summit on Social Determinants of Health: A day-by-day preview for our return to Nashville

The annual event will be held live at The Omni in Nashville, Tenn., March 20-22. Here’s a look at what we have planned so far for preconference workshops, networking opportunities, keynote presentations, general sessions, track sessions, and our health and safety protocols.

Revenue & Quality

CMS releases 2023 Medicare Advantage Proposed Rule: Aims to tighten marketing of MA plans

The proposed rule would revise Medicare Advantage (MA) and Medicare Part D regulations related to marketing and communications, Star ratings, the criteria used to review applications for new or expanded plans, provider network adequacy requirements, medical loss ratio reporting, special requirements during disasters or public emergencies, and the use of pharmacy price concessions to reduce the out-of-pocket costs for prescription drugs under Part D.

Population Health & SDoH

Supreme Court weighs Biden’s workplace vaccine requirements

The Supreme Court on Friday took up one of the most contentious issues of the COVID-19 pandemic, hearing a series of cases challenging the Biden administration’s authority to require workers to get a COVID vaccine or be tested for the virus regularly.

RISE National

Future forecaster/gaming expert to join RISE National 2022 as third keynote speaker

Jane McGonigal, Ph.D., a world-renowned designer of alternate reality games—games that are designed to improve real lives and solve real problems—will speak on the second day of the main conference about how we can apply gaming to the health care industry.

Revenue & Quality

4 health care trends to watch in 2022

Here are our predictions for the health care industry in 2022 based on interviews with industry experts in 2021, presentations at RISE conferences, and observations from our editorial team.

Revenue & Quality

20 health care podcasts you should listen to in 2022

Whether you want to learn more about health policy, COVID, health care costs, or the latest news, we’ve gathered our picks for health care podcasts to add to your listening library in 2022. And a shameless plug – of course RISE Radio is on the list!

Revenue & Quality

2023 Proposed Payment Notice for the ACA marketplace: What you need to know

The Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) today issued the Notice of Benefit and Payment Parameters 2023 Proposed Rule, also known as the proposed 2023 payment notice. In addition to lowering health care costs and making coverage options more equitable, the proposal also makes changes to risk adjustment models and HHS-Risk Adjustment Data Validation.

Revenue & Quality

The latest on COVID-19: As cases surge, CDC changes isolation guidance; Study finds unvaccinated patients cost health care system billions of dollars; and more

The COVID-19 pandemic continues as we close out 2021. Here is the latest news.

Population Health & SDoH

Feds issue new guidance to boost accessibility, equity in COVID-19 vaccine programs

The Office for Civil Rights (OCR) at the U.S. Department of Health and Human Services (HHS) issued guidance this week tied to legal standards and best practices for improving access to COVID-19 vaccine programs and ensuring nondiscrimination based on race, color, and national origin.

Revenue & Quality

Is 95% coding accuracy good enough?

It’s become industry standard to code medical records to 95 percent. But would you be satisfied with receiving 95 percent of your paycheck each month? Or 95 percent of your retirement savings? Probably not. Yet many health plans currently accept a 95 percent coding accuracy rate.

Revenue & Quality

Record number of Americans sign up for ACA health insurance

Nearly 14 million Americans have enrolled in Affordable Care Act (ACA) marketplace health plans for next year—a record since the health law’s coverage expansion took effect in 2014. A boost in subsidies marketing and assistance in navigating the process increased the rolls of the insured.

Revenue & Quality

Editor picks: Our favorite interviews from 2021

Our editorial team has had the pleasure of conducting dozens of interviews during 2021. We enjoyed them all and learned so much. Here’s a look back at a few of our favorite conversations.

Revenue & Quality

Our 10 most-read articles for 2021

As we head into 2022, here’s a look back at our most viewed articles of 2021. Trending topics included fraud lawsuits, Star ratings, and federal investigations into overpayments.

RISE National

RISE National 2022: Q&A about COVID with keynote speaker and public health expert Dr. Nancy Messonnier

Dr. Nancy Messonnier, former director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, answers questions about the pandemic. The Q&A was originally published by Participant.

Medicare Market

RISE-Engagys annual survey: 5 findings on member engagement in 2021

Member engagement was a priority for health plans this year, but consumers proved hard to reach, according to the Sixth Annual Survey of Healthcare Consumer Engagement Practices, which is conducted each year as a joint effort between RISE and Engagys. The annual survey tracks the consumer engagement tactics, budgets, challenges, and priorities of the nation’s leading health plans.

Population Health & SDoH

SDoH in the news: CMS takes steps to improve maternal care outcomes; Mental health continues to take a toll amid pandemic; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

Regulatory roundup: National health spending rose nearly 10% in 2020 due to COVID; Medicare members aren’t receiving meds to treat opioid use disorder; and more

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

Population Health & SDoH

Medicaid Managed Care programs enable states to address SDoH, report finds

A new report from Together for Better Medicaid reveals states’ commitments to address social determinants of health (SDoH) and health equity through their partnerships with Managed Care Organizations (MCOs).

Revenue & Quality

HHS distributing $9B in relief funds to providers impacted by COVID-19 pandemic

The U.S. Department of Health and Human Services (HHS) this week will release Provider Relief Fund (PRF) Phase 4 payments to health care providers who have experienced revenue losses and expenses related to the pandemic.

Medicaid

Mattresses and mold removal: Medi-Cal to offer unconventional treatments to asthma patients

Starting in January, California will embark on an ambitious experiment to control asthma in its most vulnerable patients.

RISE National

RISE Radio Episode 11: RISE National 2022 Keynote Ryan Avery on how to take your leadership to the next level

Ryan Avery, a world record holder, two-time best-selling author, Emmy award winning journalist, and world champion, joins us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

Revenue & Quality

Suit by doctors, hospitals seeks change in how arbitrators settle surprise billing cases

The American Medical Association and American Hospital Association are not arguing to halt the law that protects patients from unexpected bills from providers they didn’t know were outside their insurance network. Instead, they want to change the rules for the mediators who will settle the dispute between insurers and providers.

Medicare Market

West Virginia Sen. Manchin takes the teeth out of Democrats’ plan for seniors’ dental care

In West Virginia, older residents often go without dental care, and a quarter of people 65 and older have no natural teeth, the highest rate of any state in the country. But a powerful senator from West Virginia, Joe Manchin, has rebuffed efforts to add a dental benefit to Medicare.

Medicare Market

Advocacy group urges CMS to allow MA plans to add benefits that address social determinants of health

In a letter to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, the Better Medicare Alliance proposed strategies to better serve Medicare Advantage (MA) members. The letter was sent as CMS prepares its Calendar Year 2023 MA rate and policy-setting process.

Population Health & SDoH

Health experts worry CDC’s COVID vaccination rates appear inflated

Accuracy issues raise red flags because the data is used to plan and direct resources in the nation’s continuing response to the COVID-19 pandemic.

Revenue & Quality

HHS reports increased marketplace enrollment trends

Nearly 4.6 million Americans signed up for health plan coverage through HealthCare.gov and State-based Marketplaces since the start of the 2022 Open Enrollment Period on November 1, according to the U.S. Department of Health & Human Services (HHS).

Revenue & Quality

Post-pandemic, what’s a phone call from your physician worth?

Medicare billing codes for audio-only follow-up check-ins lead to new reimbursement battles.

Revenue & Quality

2022 Star ratings: 3 trends to follow

Was your 2022 Star rating score too close for comfort? Pay attention to these three trends as you look to the (near) future.

Medicare Market

HHS report: Medicare telehealth use spiked 63-fold during pandemic

A new report from the U.S. Department of Health and Human Services (HHS) found that massive increases in the use of telehealth helped maintain some health care access during the COVID-19 pandemic, with specialists like behavioral health providers seeing the highest telehealth utilization compared to other providers.

Revenue & Quality

Regulatory roundup: CMS halts COVID-19 vaccination mandate for health care workers pending legal challenge; Urges Medicare members to get COVID booster shot; and more

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

Compliance

Report: Nearly $4B could be recouped due to HHS-OIG work in FY 2021

America’s taxpayers could see recoupment of billions of dollars in misspent Medicare, Medicaid, and other health and human services funds due to the work of the Department of Health and Human Services (HHS), Office of Inspector General (OIG), according to a new report.

Revenue & Quality

U.S. judge blocks nationwide COVID-19 vaccination mandate for health care workers

A day after a federal judge blocked a vaccine mandate of staff at Medicare and Medicaid-certified facilities in 10 states, a second U.S. judge applied the ruling nationwide where the mandate was still in effect.

Leadership

Conference preview: Strategies to cultivate female leadership in health care

RISE’s Women in Health Care Leadership Summit will return for its sixth consecutive event Dec. 14-15 in San Diego to connect entry-level and top executives in health care, career coaches, and leadership gurus to share tools for women empowerment and leadership in the industry. Speaking with RISE ahead of the summit, keynote speaker Dr. Amy Nguyen, senior national physician executive, Optum, shared strategies she leveraged to position herself as a leader.

Leadership

Women in Health Care Leadership Summit: Speaker Dale Klein on helping other people sound their best

Dale Klein has a built a business helping people present themselves, become better networkers and level up their careers. She'll be speaking about active listening at the upcoming RISE Women in Health Care Leadership Summit.

Population Health & SDoH

Fed judge blocks vaccine mandate for staff at Medicare, Medicaid-certified facilities in 10 states

A federal judge on Monday ruled that the Centers for Medicare & Medicaid Services (CMS) doesn’t have the authority to enforce a vaccine mandate of staff at Medicare and Medicaid-certified facilities in 10 states.

Leadership

Women in Health Care Leadership: Keynote speaker Lisa Orrell on managing a leadership mindset to revive and thrive

After launching her career as a global keynote speaker and certified leadership and success coach, Lisa Orrell realized just how many people were unhappy at work. An expert on leadership development and personal branding, she focused her efforts on helping teams and organizations around the globe enhance their workplaces to improve culture and retain employees. Orrell will kick-off the annual RISE Women in Health Care Leadership Summit, held Dec. 14-15 in San Diego, with a fun and insightful keynote presentation on how to use your personal leadership brand to manage a leadership mindset even in the most difficult times.

Population Health & SDoH

California joins states trying to shorten wait times for mental health care

In California, health insurers blame long waits for therapy appointments on workforce shortages, but state lawmakers say that’s an excuse. A new law requires insurers to reduce wait times for mental health appointments to no more than 10 business days.

Revenue & Quality

Becerra says surprise billing rules force doctors who overcharge to accept fair prices

The Health and Human Services secretary says the administration has heard complaints from doctors and hospitals about the rules it unveiled for implementing the law to end surprise medical bills. But he says providers who have exploited a complicated system to charge exorbitant rates will have to bear their share of the cost—or close.

Medicare Market

Conference preview: CMS Bid Bootcamp pulls out all the stops to cover the entire bid process from start to finish

The 6th Annual CMS Bid Bootcamp will return as a live, in-person event, January 13-14, 2022 at the Luminary Hotel & Co. in Fort Myers, Fla. From a pre-conference workshop on bid essentials to strategies that support and improve Star ratings, here’s everything we’ve planned to help you create, update, and execute your own CMS bid roadmap to set your organization up for plan growth year after year.

Population Health & SDoH

The Commonwealth Fund releases new health equity scorecard, reveals profound racial, ethnic health disparities across all states

The analysis measured health equity for people of different races and ethnicities within and between each state and their health system’s performance for racial and ethnic groups.

Revenue & Quality

Post-COVID-19 health impacts: Executive insights on the increased risk to insurers

Change Healthcare has been using claims reports from its commercial health plan clients to project the increased risk to insurers of post-COVID health impacts in 2021 through 2023. The research is ongoing, but RISE interviewed Peter Colbert, director, customer success decision analytics, to find out what the health care technology company has learned so far.

Population Health & SDoH

Strategies for health plans to achieve health equity

Achieving health equity requires the participation of individuals, communities, businesses, government, social service agencies, and more.

Revenue & Quality

The complex effects of COVID-19 on risk adjustment strategy

The COVID-19 pandemic has suddenly presented payers with new and unexpected challenges.

Revenue & Quality

What health plans need from their post-acute network

Insights learned from a recent focus group Real Time Medical Systems conducted with 10 experienced health plan executives about their organization’s relationship with skilled nursing facilities (SNF) and what information they use to help drive both quality and value with their SNF partners.

Medicare Market

BMA study: Newly expanded supplemental benefits in Medicare Advantage grew 43% for 2022

A new brief commissioned by Better Medicare Alliance (BMA), and prepared by the actuarial consulting firm Milliman, finds 2022 offers more availability of home-based palliative care, in-home support services, caregiver support, and therapeutic massage.

Medicaid

CMS administrator outlines strategic vision for Medicaid and CHIP

In a Health Affairs blog post, Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure and Center for Medicaid & CHIP Services (CMCS) Director Dan Tsai described their policy agenda for Medicaid and Children’s Health Insurance Program (CHIP).

Revenue & Quality

House narrowly passes $1.75T social policy bill; now heads to Senate

The House of Representatives on Friday voted 220-213 in favor of President Joe Biden’s Build Back Better Bill. Although it’s significantly scaled back from the originally proposed $3.5T package, it’s unclear whether it will pass the Senate, where it needs 51 votes.

Revenue & Quality

Interim final rule requires health plans to report prescription drug, health coverage costs

The rule requires health plans, and other group health plans to submit key data to the federal government that will be used for a report on prescription drug pricing trends and rebates, as well as their impact on premiums and drug spending for patients, compared to their employers and/or group health plans/health insurance issuers.

Leadership

Women in Health Care Leadership: Erin Hatzikostas on authenticity as a secret weapon for success

After more than 20 years in the corporate world, Erin Hatzikostas left her role as CEO at a health care financial institution and reimagined her career as a best-selling author, TEDx speaker, executive coach, and founder of b Authentic. Hatzikostas, who will be a speaker at the RISE Women in Health Care Leadership Summit on Dec. 14-15 in San Diego and RISE National 2022 on Mar. 7-9 in Nashville, talked to RISE about strategic authenticity and how women can change the job rather than change themselves for the job.

Revenue & Quality

Congressional doctors lead bipartisan revolt over policy on surprise medical bills

Congress last year shielded consumers from unexpected out-of-network charges, but hospitals and doctors have decried the arbitration plan put forward by the Biden administration for negotiating these bills as favoring insurers. More than 150 members of the House agree.

Population Health & SDoH

Nominations open for the inaugural RISE Health Care Hero Award

Do you know someone who has made a significant impact in the lives of underserved populations through health care and/or social services interventions? If so, nominate them for the first-ever RISE Health Care Hero Award!

Revenue & Quality

Medicare FFS improper payments down $20 billion since 2014

The Centers for Medicare & Medicaid Services (CMS) said its aggressive corrective actions led to an estimated $20.72 billion reduction of Medicare Fee-for-Service (FFS) improper payments over seven years.

Population Health & SDoH

How rural communities are losing their pharmacies

As independently owned pharmacies struggle to stay open amid competition with large retail drugstores, individuals in rural communities are left without easy access to a pharmacy.

Revenue & Quality

Medicare premiums will skyrocket in 2022—here’s why

Seniors may have sticker shock when they open their Medicare monthly premium bills in January. The Centers for Medicare & Medicaid Services (CMS) has released the 2022 Medicare Part B premiums and it’s one of the largest increases ever.

Revenue & Quality

6 important questions you should ask your quality analytics and technology vendor

Here's a list of questions you should ask any quality analytics and technology vendor, whether you are evaluating your current partner or shopping for a new one. Their answers will help you assess whether their goals, priorities, and expertise meet your individual needs.

Revenue & Quality

Regulatory update: CMS repeals MCIT/R&N Rule; Feds sue Uber for overcharging physically disabled people; Average family premiums spiked in 2021

RISE summarizes the latest regulatory headlines that impact the health care industry.

Revenue & Quality

RISE Star Ratings Master Class preview: All-star speakers, key sessions you don’t want to miss

Our 12th annual conference will take place Dec. 14-15 at the Manchester Grand Hyatt San Diego. Check out the sessions and speakers we’ve planned to help you boost your Star ratings in 2022.

RISE National

World-class public health leader and Emmy-award winning journalist to headline RISE National 2022

RISE National 2022—the #1 trusted source for all things Medicare Advantage—returns to Nashville, Tenn. on March 7-9 as a live, in-person event and will feature two blockbuster keynotes.

Revenue & Quality

Researcher: Medicare Advantage plans costing billions more than they should

Researcher: Medicare Advantage plans costing billions more than they should

Medicare Market

Medicare’s open enrollment is open season for scammers

Medicare officials say complaints are rising from seniors lured into private plans with misleading information or enrolled without their consent.

Revenue & Quality

OIG estimates UPMC received $6.4M in overpayments for high-risk diagnoses

The Office of Inspector General (OIG) audited UPMC Health Plan, Inc. to determine whether the Medicare Advantage organization appropriately submitted selected diagnoses codes to the Centers for Medicare & Medicaid Services’ (CMS) risk adjustment program.

Revenue & Quality

Medicare enrollment blitz doesn’t include options to move into Medigap

TV ads and mailings targeting seniors tout Medicare Advantage plans this time of year, but millions choosing traditional Medicare make a costly and difficult decision about Medigap coverage, which gets much less attention.

Revenue & Quality

14 things to know about Medicare Advantage, Medicare Part D plans in 2022

Two new studies by the Kaiser Family Foundation (KFF) offer a comprehensive look at Medicare Advantage (MA) plans and Medicare Part D stand-alone prescription plans. Here’s what they uncovered.

Revenue & Quality

Commonwealth Fund: Older adults on Medicare and those near Medicare age face costs barriers to care

Although Medicare provides older adults with significant financial protection from health care costs, many still struggle to afford needed care, according to a blog post on the Commonwealth Fund.

Medicare Market

New BMA report finds MA helped sustain providers, enabled faster telehealth adoption during the pandemic

The research shows how capitation and faster claim payment in Medicare Advantage (MA) helped maintain cash-strapped physician practices, while risk stratification methods allowed health plans to quickly reach seniors most in need.

Population Health & SDoH

SDoH in the news: CMS reviewing first measures to assess SDoH; Majority of Americans say SDoH affect health of their community; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

Deft Research survey uncovers the key to member loyalty in the individual under 65 market

Deft Research’s 2021 Individual and Family Plan Member Experience and Engagement Study reveals the commercial health plan benefits that create and destroy member loyalty. Spoiler alert: It’s not cost.

Revenue & Quality

CMS policy updates: The latest on final RADV audit rules, ESRD payment rule, risk adjustment model changes for ACA market, and so much more

The Centers for Medicare & Medicaid Services (CMS) has been busy. Here is a roundup of the agency’s recent news and actions.

Revenue & Quality

New health plans offer twists on existing options, with a dose of ‘buyer beware’

Fueled by consumer frustration with high premiums and deductibles, two new offerings promise a means for consumers to take control of their health care costs. But experts say they pose risks.

Revenue & Quality

CMS OPPS/ASC final rule aims to increase patient safety and access to quality care

The Centers for Medicare & Medicaid Services (CMS) on Tuesday released the 2022 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center Final Rule.

Revenue & Quality

Dems reach deal on drug pricing reform, allow Medicare D to negotiate prices directly with manufacturers

President Joe Biden and Congressional Democrats announced they reached a compromise plan for drug pricing that will reduce the costs of prescription drugs and insulin and finally allow Medicare to negotiate prices for high-cost prescription drugs.

Population Health & SDoH

KFF survey: State Medicaid program efforts to reshape policies in response to pandemic help further address SDoH, health equity

The survey of Medicaid directors in states and the District of Columbia explored current policies or planned changes for the current fiscal year.

Population Health & SDoH

Seema Verma to present keynote at RISE’s 2022 Summit on Social Determinants of Health

Former CMS Administrator Seema Verma will share insights on high value, low-cost health care at The RISE Summit on Social Determinants of Health on Monday, March 21 at The Omni Nashville.

Revenue & Quality

Regulatory update: Feds drop plans to add dental, vision benefits to original Medicare; HHS plans to reverse Trump administration’s Sunset rule

RISE rounds up the latest regulatory headlines that impact Medicare, Medicare Advantage, and Medicaid.

Revenue & Quality

RISE Radio Episode 10: Liz Haynes & Melissa Smith on 2022 Medicare Star ratings and what plans must do to maintain those scores

Join us for the latest episode of RISE Radio, our podcast series that focuses on issues of interest to our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

Revenue & Quality

Democrats’ plans to expand Medicare benefits may pinch Advantage plans’ funding

As lawmakers weigh new spending provisions to cover dental, hearing and vision services for Medicare beneficiaries, a group supporting Medicare Advantage plans is airing commercials that raise concerns about the funding for those private plans.

Population Health & SDoH

SDoH in the news: Wearable health devices “game-changer” for clinicians; Efforts to address SDoH increase cancer survival rates, close gaps in racial inequities; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

UnitedHealthcare sues TeamHealth, alleging $100M fraud

UnitedHealthcare, one of the largest health insurers in the country, filed suit this week against TeamHealth, claiming the staffing company deliberately upcoded commercial insurance claims for emergency room services, which led to overpayments of more than $100 million

Revenue & Quality

Medicare plans’ ‘free’ dental, vision, hearing benefits come at a cost

Medicare plans’ ‘free’ dental, vision, hearing benefits come at a cost

Revenue & Quality

AI: Next-gen risk adjustment for VBC success

Any effort to apply AI to risk adjustment in a VBC context must start with the right strategy and technology for data capture across formats, systems, and providers.

Medicare Market

Connected TV: Why it’s the media platform to watch

Medicare marketers are making connected TV (CTV) an integral part of their media mix during AEP (it is easy to include as a mid-AEP boost). In addition, it’s also a great low-cost channel to leverage throughout the year. So, what is CTV? And why is it important?

Medicare Market

Medicare beneficiaries want communications from their health plan: Make sure yours are effective

A recent panel of Medicare beneficiaries revealed that every beneficiary wanted and welcomed communications from their health plan. Here's how to make communications the most effective in driving action.

Population Health & SDoH

RWJF Commission releases recommendations to transform public health data systems, announces $50M in grant funding toward initiative

The Commission’s recommendations aim to modernize current data systems to address structural racism and advance health equity.

Leadership

The RISE Women in Health Care Leadership Summit to return as in-person event with powerful keynote address, robust networking, and collaborative discussion

The sixth consecutive event will return to San Diego December 14-15 to connect pioneering senior-level women inspired to advance diversity and inclusion and cultivate female leadership in health care.

Medicare Market

Commonwealth Fund blog post highlights the role of Medicare agents and their impact on beneficiary choice

Licensed Medicare agents, or brokers, can help beneficiaries choose the right coverage, but financial incentives also can influence which plans they highlight, according to a Commonwealth Fund blog post.

Medicare Market

Insurance brokerage study: 3 out of 4 seniors say Medicare is ‘confusing and difficult to understand’

A new survey released by Medicare Advantage.com prior to the Annual Election Period finds a widespread lack of knowledge among beneficiaries about Medicare enrollment and basic health insurance terms.

Revenue & Quality

New cloud-based Medicare Advantage-in-a-box aims to simplify operations for health plans

Digital health startup nirvanaHealth this week launched Aria Medicare, a Medicare Advantage-in-a-box solution that runs on Amazon Web Services.

Revenue & Quality

Using technology to reduce the risk of RADV audit

The use of analytics for the proactive review of and oversight into coding and submission processes has become more critical than ever. But instead of only looking for undercoding or gaps, health care organizations need to look for overcoding as well. In this landscape, even plans that did not think they were on the radar for RADV may now be at risk—and all plans should prepare for some kind of audit each year.

Medicare Market

CMS third-party marketing memo calls out advertising tactics that mislead, confuse MA beneficiaries

The Centers for Medicare & Medicaid Services (CMS) issued a long-awaited memo outlining best practices for Medicare marketing campaigns conducted by third parties. But does it go far enough? RISE weighs in.

Population Health & SDoH

How Nashville General Hospital is addressing SDoH, promoting health equity

The hospital has implemented several programs targeting food insecurity, education attainment, health literacy, and health care access.

Revenue & Quality

Schedule online visits first? It’s the next big thing in health insurance

New, often lower-cost plans capitalize on the convenience of telemedicine—and patients’ growing familiarity with it. But consumers should weigh costs and care options before enrolling in a “virtual-first” plan.

Medicare Market

KFF report: 7 in 10 Medicare beneficiaries didn’t shop around for new plans during 2018 open enrollment

The new Kaiser Family Foundation (KFF) analysis examines how many seniors compared different health plans during the 2018 Medicare open enrollment period for coverage in 2019 (the most recent year available).

Medicare Market

Medicare Marketing & Sales Summit to return to Vegas in 2022: Everything we’ve planned so far

RISE will return to Caesars Palace, Las Vegas, Feb. 16 to 18, 2022 for the 15th annual Medicare Marketing & Sales Summit. Here’s what you need to know about planned preconference workshops, networking opportunities, keynote presentations, general sessions, track sessions, roundtables, and our health and safety protocols.

Revenue & Quality

Surprise-billing rule ‘puts a thumb on the scale’ to keep arbitrated costs in check

Patients soon will not have to worry about the prospect of these often-costly unexpected bills, a federal law promises. Some experts say the new policy could also slow the growth of health insurance premiums.

Revenue & Quality

The public backs Medicare Rx price negotiation even after hearing both sides’ views

But Americans generally have little confidence that the White House or Congress will recommend the right thing, a new poll shows.

Revenue & Quality

RISE Risk Adjustment Forum to feature an exclusive CMS update with Ashby Wolfe, M.D.

Ashby Wolfe, M.D, regional chief medical officer, Centers for Medicare & Medicaid Services (CMS), will kick off the second day of the 18th Risk Adjustment Forum, Nov. 15-17, with a keynote address that includes an industry update on risk adjustment and a review of CMS policy changes in 2021.

Revenue & Quality

Breaking: CMS releases 2022 MA and Part D Star ratings

The Centers for Medicare & Medicaid Services (CMS) on Friday released Star ratings ahead of Medicare open enrollment. Seventy-four Medicare Advantage plans received the highest rating of 5 stars.

Revenue & Quality

Risk Adjustment Forum preview: Keynote Laura Cooley on simple recommendations that health care leaders can take to improve communication, outcomes

Laura Cooley, Ph.D., senior director of education and outreach, Academy of Communication in Healthcare, will kick off RISE’s 18th Risk Adjustment Forum on November 16. In this article Cooley shares time-effective steps health care leaders can take to manage complex change.

Revenue & Quality

COVID-19: Two new reports show vaccinations prevented thousands of deaths among seniors, lower hospitalizations among MA members compared to FFS Medicare

The Department of Health and Human Services and Better Medicare Alliance released separate reports this week that show promising findings about COVID-19 vaccinations and seniors, and hospitalization and mortality rates for Medicare Advantage members.

Revenue & Quality

RISE’s new safety protocols require proof of COVID-19 vaccination to attend in-person events

RISE is excited to return to in-person conferences. To ensure the health and safety of attendees, speakers, exhibitors, and staff, RISE will require proof of full COVID-19 vaccination status to attend the events. Here’s everything you need to know before you make your travel arrangements.

Population Health & SDoH

Blue Cross Blue Shield of Massachusetts to offer financial incentives to physicians who improve care for people of color

Blue Cross Blue Shield of Massachusetts plans to incorporate equity measures into its payment models to address racial disparities identified through its recent health equity analysis.

Revenue & Quality

Major insurers running billions of dollars behind on payments to hospitals and doctors

Patients are caught in the middle as insurers clamp down on paying for treatments or force prior authorizations for care.

Population Health & SDoH

Racism a strong factor in Black women’s high rate of premature births, study finds

A recent review of persistent gaps in preterm birth rates between Black and white women underscores racism as a key factor.

Population Health & SDoH

A pulse check on SDoH: Barriers, funding, and congressional activity in 2021 and beyond

RISE looks at current trends and challenges related to social determinants of health (SDoH) with Melissa Quick, co-chair, Aligning for Health, a coalition advocating to Congress for solutions to address SDoH across the country.

Medicaid

Centene to pay $71M in Illinois, Arkansas Medicaid overpayment dispute

The attorneys general in Illinois and Arkansas on Thursday separately announced settlements with Centene Corporation, the largest Medicaid managed care organization in the United States, over inaccurate billing practices.

Revenue & Quality

Feds issue dispute resolution details for surprise billing rule

A new interim rule outlines a process that will take patients out of the middle of payment disputes, explains how payers and providers can settle out-of-network payment disagreements, and details a process for self-paying and uninsured individuals to resolve issues over bills.

Medicaid

As Democrats bicker over massive spending plan, here’s what’s at stake for Medicaid

More than 2 million low-income adults are uninsured because their states have not accepted Medicaid expansion under the Affordable Care Act. Congressional Democrats want to offer them coverage in the massive spending bill being debated, but competition to get into that package is fierce.

Revenue & Quality

Medicare Advantage premiums will drop to historic lows in 2022

The Centers for Medicare & Medicaid Services (CMS) announced Wednesday that the average premium for Medicare Advantage (MA) plans will be $19 per month in 2022. The agency also projects enrollment in MA plans to spike to 29.5 million people in the upcoming year.

Population Health & SDoH

SDoH in the news: HHS awards nearly $1B in American Rescue Plan funding to support vulnerable communities; SAMHSA distributes $825Min grants to CMHCs; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

An ad’s charge that price haggling would ‘swipe $500 billion from Medicare’ is incorrect

The ad, advanced by a right-leaning seniors advocacy organization, mischaracterizes proposals to bargain on drug prices, regarding both the effects on the Medicare program and on beneficiaries.

Medicare Market

Real-life inspiration behind the hit movie “Rudy” to present keynote at RISE’s Medicare Marketing & Sales Summit

Daniel “Rudy” Ruettiger will share his message on how to “dream big” and the importance of building relationships at the RISE Medicare Marketing & Sales Summit, February 16-18, 2022, at Caesars Palace.

Revenue & Quality

RISE accepting nominations for 2022 quality award

Nominations are now open for RISE’s annual Martin L. Block Award for Innovation & Excellence. RISE’s highest honor recognizes excellence and clinical leaders’ passion to improve patient care.

Population Health & SDoH

5 reasons to register for the virtual RISE Population Health Summit, a can’t-miss event uniting forward-focused innovators

For the third year in a row, health plans striving to improve population health efforts will convene to hear more than 20 industry experts’ and thought leaders’ expertise on the actionable strategies that take initiatives to the next level. The live-streaming virtual event, November 16-17, will spotlight critical issues in the population health space; from the dramatic increase in hospital readmissions post-pandemic to maternal health care among vulnerable populations to the mental health crisis, we’re covering it all.

Revenue & Quality

Regulatory roundup: CMS suspends enrollment in UnitedHealth, Anthem MA plans; OIG urges stronger oversight of telehealth for behavioral health in Medicaid; and more

RISE summarizes the latest regulatory headlines that impact Medicare, Medicare Advantage (MA), and Medicaid.

Revenue & Quality

DOJ health care fraud crackdown: 138 people charged in $1.4B schemes involving telemedicine, COVID-19, and illegal opioid distribution

The Department of Justice (DOJ) said 42 doctors, nurses, and other licensed medical professionals are among the 138 defendants facing criminal charges for their alleged involvement in health care fraud schemes that resulted in nearly $1.4 billion in alleged losses.

Revenue & Quality

OIG: 20 MA plans used questionable billing practices to maximize risk adjustment payments

A new Office of Inspector General (OIG) report found that 20 of 162 Medicare Advantage (MA) companies studied drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and health risk assessments (HRA) and on no other service records.

Revenue & Quality

The high cost of dental and hearing care: Seniors face big bills whether they are in traditional Medicare or Medicare Advantage

A new Kaiser Family Foundation (KFF) analysis provides context about existing coverage and costs as Congress debates adding dental, hearing, and vision benefits to Medicare.

Population Health & SDoH

CDC: Number of states with high obesity prevalence nearly doubled since 2018

Sixteen states have an adult obesity prevalence at or above 35 percent, an increase from nine states in 2018, according to new data from the Centers for Disease Control and Prevention (CDC), which notes social determinants of health (SDoH) play an influential role.

Revenue & Quality

Dentists chip away at uninsured problem by offering patients membership plans

The plans are designed for people who don’t get dental coverage through their jobs and can’t afford an individual plan. For about $300 to $400 a year, patients receive certain preventive services at no charge and other procedures at a discount.

Revenue & Quality

Regulatory roundup: Feds propose more 'no surprise billing' rules; Unvaccinated COVID patients cost the US health system billions of dollars; and more

RISE summarizes recent headlines that impact the U.S. health system, Medicare, Medicare Advantage, and Medicaid.

Population Health & SDoH

SDoH in the news: San Francisco launches abstinence-based program for adults in justice system; Stress due to SDoH found to increase risk of heart disease; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

Census: Insured population holds steady, with a slight shift from private to public coverage

The Census Bureau on Tuesday released its 2020 findings regarding Americans’ income, poverty, and health insurance coverage.

Population Health & SDoH

Gates Foundation 2021 Goalkeepers report: Pandemic drove millions into extreme poverty

According to the report, COVID-19 and the subsequent economic downturn has reversed progress on eliminating poverty by four years, with 31 million more people around the world living in extreme poverty.

Revenue & Quality

Justice department targets data mining in Medicare Advantage fraud case

The feds’ civil suit links exaggerated patient bills to “tens of millions” in overcharges.

Leadership

Cybersecurity best practice: Integra Managed Care’s unique CCO-CISO partnership offers a model for all health care organizations

It’s not easy to get the necessary resources to ensure your organization is able to prevent and properly respond to ransomware attacks. But as the number of attacks increase in the health care industry, it’s vital that organizations put the right people and resources in place. Here’s how Integra Managed Care has responded to the growing threats and why your organization may want to follow the managed long-term care plan’s lead.

Leadership

RISE honors our 9/11 heroes and never forgets

Two years ago, RISE West had the honor of having Richard Picciotto, retired NYC fire department chief, present an amazing story of his survival and heroics during 9/11. As the nation commemorates the 20th anniversary of our darkest day, we look back on his inspiring keynote.

Revenue & Quality

CMS Administrator Brooks-LaSure lays out her strategic vision for the agency

In a new blog post, Chiquita Brooks-LaSure, administrator, Centers for Medicare & Medicaid Services (CMS), reflects on her first 100 days in office and her vision for the future.

Revenue & Quality

CMS mandates COVID-19 vaccinations for staff at all Medicare, Medicaid-certified facilities

The Centers for Medicare & Medicaid Services (CMS) said the new action will protect patients, providers, and health care workers in Medicare and Medicaid settings.

Revenue & Quality

Regulatory roundup: House Ways and Means to hold markup on adding new benefits to Medicare; HHS releases plan to negotiate costs of drug prices; and more

RISE summarizes recent headlines that impact Medicare and Medicare Advantage.

Population Health & SDoH

SDoH in the news: Staggering increase of youth-onset diabetes found among Black and Hispanic children; Aetna, ACES partner to improve quality autism care; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Medicaid

Colorado Clinic’s prescription for healthier patients? Lawyers

Although Medicaid traditionally doesn’t fund clinics to supply legal assistance, Colorado is one of several states that have been given permission to use some of their Medicaid money to help pay for such programs.

RISE West

RISE West 2021: Highlights from day two of the conference

The learning continued at our hybrid-event with two keynotes, a Medicare Advantage member focus group, legal insights, and a panel discussion on member engagement and experience. Here are a few highlights from our favorite sessions.

RISE West

5 takeaways from the first day of RISE West 2021

Our 2021 hybrid event kicked off on Wednesday with 400 attendees gathering in-person at The Broadmoor in Colorado Springs, while 200 others participated in the event via their home offices.

Revenue & Quality

OIG report reveals the range of complex conditions experienced by Medicare beneficiaries hospitalized with COVID-19

The Office of Inspector General (OIG) said the findings may help hospitals and health officials better prepare for and address the wide-ranging and extensive needs of COVID-19 patients, particularly when local communities experience a surge in cases.

Revenue & Quality

How to leverage your recently released CAHPS® survey results for maximum impact

2023 Stars is around the corner. Here's an action plan to design your CAHPS® improvement strategy.

Revenue & Quality

Regulatory roundup: Sutter Health to pay $90M to settle MA fraud charges; COVID-19 a leading cause of death in US; and more

RISE summarizes the latest regulatory headlines that impact Medicare, Medicare Advantage (MA), and Medicaid.

Population Health & SDoH

Disadvantaged neighborhoods a key SDoH in older adults’ disability status

Older adults who live in disadvantaged neighborhoods become disabled two years earlier than those living in more affluent areas, according to researchers from Yale School of Medicine.

Revenue & Quality

Regulatory roundup: ACOs generated billions in savings for Medicare; CMS urge MAOs to ease up on prior authorization requirements due to COVID-19; and more

RISE summarizes recent headlines that have an impact on Medicare, Medicare Advantage, and Medicaid.

Medicare Market

3 findings on how Medicare members use digital health tools

A new study by Deft Research uncovers how Medicare members use digital health tools provided by their insurers, their providers, and other third parties to manage their health and navigate their coverage.

Revenue & Quality

AHIP warns of potential costs to seniors if Congress adds dental, hearing, and vision benefits to traditional Medicare without adjusting MA benchmark

A new analysis from Wakely Consulting Group, funded by AHIP, finds that adding dental, hearing, and vision benefits to traditional Medicare without adjusting the benchmark for Medicare Advantage (MA) could result in fewer benefit dollars for MA plans to pay for supplemental benefits, including those that address social determinants of health.

Revenue & Quality

Executive insights on the evolution and future of digital transformation: What payers need to know

In this white paper, we explore the opportunities, as well as the technical and strategic challenges that payers face on the path to achieve complete digital transformation in health data access, interoperability, and data-driven health care.

Revenue & Quality

7 considerations when choosing the best health care BPO partner

Outsourcing clinical workflows to offshore partners is becoming increasingly popular and is highly cost effective. But there are challenges that come with outsourcing,

Compliance

Health care cybersecurity attacks on the rise, exposing millions of patient records and costing organizations billions of dollars

Scripps Health recently revealed it was the victim of a significant cyberattack, which forced the organization to shut down its systems and initiate emergency manual down-time procedures until it could restore all its systems 25 days later. The massive attack cost the San Diego-based health system nearly $113 million. The organization is far from alone. Ransomware attacks on the health care industry are increasing in number and severity.

Population Health & SDoH

Pandemic unveils growing suicide crisis for communities of color

Though overall suicide rates have decreased in the U.S. in recent years, rates continue to rise in communities of color.

Revenue & Quality

How AI, NLP technologies automate risk adjustment processes

For a health care payer to ensure its population’s risk burden is accurately represented, optimal technology tools must be used to monitor encounter data, isolate aberrancies, and quickly and efficiently address any errors.

Revenue & Quality

Regulatory roundup: UnitedHealth loses appeal over MA overpayments; Business group sues HHS to stop insurer price transparency rule; and more

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

Population Health & SDoH

SDoH in the news: Disproportionate health care spending on white individuals; Depression and anxiety rates doubled in children amid pandemic; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Population Health & SDoH

3 conclusions from the latest review of SDoH and health outcomes among adults during COVID-19

The pandemic has had a disproportionate impact on racial/ethnic groups, low-income earners, and women, according to a new review from Public Health Nursing (PHN).

RISE West

8 ways to maximize your in-person and virtual RISE West 2021 experience

Our guide to hot-topic sessions, keynotes, and networking opportunities at RISE West, a hybrid event that will take place August 30-Sept. 2.

Revenue & Quality

Vaccine schedule adherence promotes better health outcomes

Vaccines are one of the best tools to promote better health outcomes.

Revenue & Quality

Regulatory roundup: OIG audit targets Aetna MA program; Medicare continues to make overpayments for chronic care management services; and more

RISE reviews the latest headlines, including the Office of Inspector General (OIG) reports, trending telehealth diagnoses, and the introduction of a new bill to improve the oversight of nursing homes.

Revenue & Quality

Why doesn’t Medicare cover services so many seniors need?

When the program began half a century ago, backers believed the benefits would expand over time, but politics and concerns about money have stymied most efforts. Now congressional Democrats are looking to add vision, dental, and hearing care.

Revenue & Quality

CMS Star Ratings alert: Two highly-weighted HOS measures removed from 2022 and 2023 calculations due to COVID-19

In an August 5 memo to all Medicare Advantage (MA) plans, the agency announced that the COVID-19 public health emergency significantly impacted the validity of measures related to physical and mental health currently used in the Star Ratings.

RISE West

RISE West 2021 spotlight: Precon workshops to address HCC coding and documentation, risk adjustment, member engagement and provider education

Learning will take place at RISE West even before the main conference begins.

Revenue & Quality

Reimagining member engagement

How behavioral science, segmentation, and hyper-personalization helps health plans activate their members.

Population Health & SDoH

Kaiser Family Foundation report: Medicaid authorities and options for states to address social determinants of health

While federal Medicaid rules prohibit costs related to non-medical services, such as social determinants of health (SDoH), there are opportunities for state Medicaid programs to address enrollees’ social needs both within and outside of managed care, according to a new report by the Kaiser Family Foundation (KFF). In the brief, KFF discusses the options and federal Medicaid authorities that states can leverage to address enrollees’ SDoH, as well as examples of initiatives launched in response to the COVID-19 pandemic.

Revenue & Quality

Report: MA plans need stronger CMS standards, modifications to Star ratings and risk adjustment to truly address social determinants of health

A new report conducted by NORC at the University of Chicago on behalf of Better Medicare Alliance’s Center for Innovation in Medicare Advantage (MA) highlights innovative approaches that MA plans are doing to address social determinants of health (SDoH) for beneficiaries. However, researchers acknowledge that barriers remain.

Revenue & Quality

Regulatory update: CMS inpatient rule repeals MA rate disclosure requirement; Premium for Medicare Part D projected to increase 5% in 2022; and more

RISE summarizes the latest health care news from the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), and the Commonwealth Fund.

Population Health & SDoH

Low vaccination rates among racial/ethnic minorities stress need for COVID-19 vaccine equity

A recent study from the American Journal of Preventive Medicine (AJPM) found socioeconomic and racial/ethnic disparities in vaccine uptake have persisted over the last decade in adults. As COVID-19 vaccine roll-out continues throughout the United States, efforts to promote health equity among racial/ethnic minority and low-income populations are critical to improve population health.

Revenue & Quality

GAO report: Large number of dying MA beneficiaries switch to traditional Medicare in last year of life

Medicare Advantage (MA) beneficiaries in the last year of life dropped their coverage to join traditional Medicare at more than twice the rate of all other MA beneficiaries, according to a new Government Accountability Office (GAO) report.

Revenue & Quality

Justice Department joins MA fraud lawsuit against Kaiser Permanente

The government has intervened in False Claims Act lawsuits against Kaiser Permanente affiliates for submitting inaccurate diagnosis codes for risk-adjusted payments to the Medicare Advantage (MA) program. Mary A. Inman, a partner in the whistleblower practice group at Constantine Cannon, which is representing one of the whistleblowers, will take a deeper look at the case as part of a RISE West session on lessons learned from whistleblower-litigated False Claims Act cases.

Compliance

Pfizer court fight could legalize Medicare copays and unleash ‘gold rush’ in sales

Pharmaceutical companies routinely cover the cost of patient copays for expensive drugs under private insurance. A federal judge could make the practice legal for millions on Medicare as well.

Medicare Market

Report: Most on Medicare forgo dental care due to lack of dental coverage

Many people enrolled in Medicare go without dental care, especially beneficiaries of color, according to a new Kaiser Family Foundation analysis of dental coverage and costs for people with Medicare.

Population Health & SDoH

SDoH in the news: Medicare eligibility associated with reduction in racial disparities; Mental health response teams achieve greater outcomes than police; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Population Health & SDoH

The 2021 Health Care Investing Summit: A tailored experience to unite investors and emerging solution providers

For the second year, FRA and RISE will join forces to produce a live-streaming virtual event August 24-25 to connect health care service providers, the investment community, and leaders in the health care industry to cultivate the business partnerships needed to foster change and achieve positive financial returns. Ahead of this year’s event, Alison Rein, vice president, health and human services, Quantified Ventures, who is a presenter at this year’s summit, shared with RISE an inside look at how the outcomes-based capital firm connects organizations with innovative program models in need of capital with the right investors.

Revenue & Quality

Issue brief: Millions of Medicare Part D enrollees have had out-of-pocket drug costs high enough to exceed the catastrophic threshold over time

The Kaiser Family Foundation (KFF) findings come as lawmakers in Congress consider establishing a hard cap on such spending.

Revenue & Quality

The pandemic made telemedicine an instant hit. Patients and providers feel the growing pains.

Patients seem to like remote visits, and health care providers now depend on them. But outages, freezing, and other glitches cost time and money, and compromise quality of care.

Population Health & SDoH

Decline in health coverage under ACA for 3 consecutive years amplifies health disparities among racial/ethnic populations

A recent brief from Kaiser Family Foundation (KFF) found that after years of progression in coverage across all racial/ethnic groups, uninsured rates have increased through 2019.

Revenue & Quality

Regulatory roundup: Most ACA insurers don’t expect COVID-19 to impact 2022 costs; CMS issues OPPS proposed rule; and more

RISE summarizes recent regulatory news, including announcements and proposals from the U.S. Department of Health and Human Services and the Centers for Medicare & Medicaid Services.

Revenue & Quality

Sen. Wyden: $3.5T budget may have to trim but it can set a path to ‘ambitious goals’

Sen. Ron Wyden (D-Ore.), who is helping to negotiate the health care spending framework for the Democrats' budget plan, said lawmakers may have to settle for very basic versions of programs deployed in the package. But the key, he added, is to get the "architecture of these changes, bold changes," started and show people what is possible.

RISE West

Sneak peek at RISE West 2021: 5 hot topics on the agenda at this year’s hybrid event

RISE West 2021 will 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 the hot topics facing the industry. We talked to four of the 50 speakers about their sessions to learn what attendees can expect at this year’s hybrid event, which will take place live in Colorado Springs and virtually via livestream August 30-September 2.

RISE West

RISE West 2021 Session Spotlight: Current and future telehealth efforts

COVID-19 accelerated the adoption of telehealth services. But what does the future hold? RISE West will explore innovative approaches to telehealth efforts during a panel discussion on Wednesday, Sept. 1, the first day of the main conference. We talked to Andy Ellner, M.D., one of the panelists ahead of the hybrid event, about Firefly Health, a virtual primary care practice established in 2016.

RISE West

RISE West 2021 Session Spotlight: Payer experiences in provider engagement

Provider engagement is a key theme at this year’s RISE West, a hybrid event that will take place live in Colorado Springs and via livestream August 30-Sept. 2. In this article we talk to Jeslie Jacob of Blue Cross and Blue Shield of Illinois, one of the panelists at the session on payer experiences in provider engagement.

Medicare Market

How to tackle the complexity of preparing for the Annual Enrollment Period

Recommendations to help Medicare Advantage Organizations to effectively address challenges of timelines, quality, and user fatigue associated with Annual Enrollment Period update cycles.

Pharmaceutical & Biotech

RISE Radio Episode 9: Dr. Angela Huskey on emerging drug threats, the rise in substance use among the elderly

Angela G. Huskey, PharmD, CPE, senior vice president and chief clinical officer at Millennium Health, joins us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

Revenue & Quality

CMS’ Physician Fee Schedule proposed rule aims to expand telehealth reimbursement for mental health, improve health equity, patient access

The Centers for Medicare & Medicaid Services (CMS) released the proposed 2022 Physician Fee Schedule on Tuesday. In addition to proposed payment rates for Medicare next year, the agency included policy proposals to address health equity and expand patient access to comprehensive care.

Population Health & SDoH

Health disparities report identifies persistent, widening gaps in maternal mortality, mental and behavioral health, and food insecurity

The new report sheds light on the health disparities that continue to exist by gender, geography, socioeconomic status, race and ethnicity, and educational attainment.

Revenue & Quality

Regulatory roundup: 3.5T budget package would expand Medicare; COVID cases on the rise again; and more

RISE rounds up the latest health care headlines that impact Medicare, Medicaid, and the Affordable Care Act.

Population Health & SDoH

SDoH in the news: Climate change as a social determinant; HHS releases new interoperability standards for electronic exchange; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

As Congress wrestles with plans to expand Medicare, Becerra says any one will do

HHS Secretary Xavier Becerra says the administration is eager for Congress to make changes to Medicare that will provide more benefits and make more older adults eligible for the program.

Population Health & SDoH

BCBS, Humana, Centene, and more sign letter of support for Social Determinants of Health Accelerator Act

A coalition of more than 100 organizations have expressed their support for the reintroduction of the bipartisan bill.

Population Health & SDoH

5 ways SNPs can support special needs populations with SDoH programs to drive health equity

Learn about the innovative strategies special needs plans (SNPs) can leverage to support individuals with significant, complex social needs while advancing health equity.

Medicare Market

New RISE Association workgroups tackle Medicare marketing compliance issues, KPIs for marketing and sales

The new workgroups will address issues of most concern to members of RISE’s Medicare Member Acquisition & Experience (MAE) community. Up first, the fallout from Joe Namath’s Medicare television commercials and key performance indicators (KPIs) around marketing and sales.

Revenue & Quality

HHS unveils interim rule aimed at putting an end to surprise medical bills for all consumers

The new regulation is the first in a series of rules that will help shield consumers from surprise medical bills. Balance billing is already banned in Medicare and Medicaid–the rule offers similar protections to those insured through employer-sponsored and commercial health plans.

Medicare Market

Medicare Age-Ins: 4 findings from Deft Research’s 2021 study

For the second year in a row, Deft Research has found a higher proportion of age-ins lean toward selecting a Medicare Advantage (MA) plan when they enter Medicare. Although the balance of interest between MA and MedSupp may have changed during the COVID-19 pandemic, it doesn’t appear to be reversing, according to an executive summary of the 2021 Age-In Study.

Revenue & Quality

CMS proposes rule to reduce health care disparities for patients with chronic kidney disease, ESRD

The Centers for Medicare & Medicaid Services (CMS) said the proposed changes mark the Innovation Center’s first direct effort to close health equity gaps.

Revenue & Quality

Regulatory update: OIG says CMS unable to ensure hospitals are ready for future pandemics; 3 big name California health insurers sued over ‘ghost networks’; and more

RISE rounds up the latest regulatory headlines involving emerging infectious disease emergencies; mental health, deceitful health plan marketing practices, health care cost-related problems and racial disparities, health literacy, and the American Hospital Association’s lawsuit on site-neutral payments.

Revenue & Quality

2022 Payment Notice: CMS proposes rule to increase access to health care coverage

The proposed provisions are part of the third installment of the payment notice for 2022.

Population Health & SDoH

SDoH linked to increased Medicare spending

A new study indicates social determinants of health (SDoH) are associated with an increase in Medicare per beneficiary spending in certain geographic variations.

Population Health & SDoH

4 strategies programs can take to increase food access in vulnerable communities

A look at community-based health care organizations’ proven-successful approaches to address food insecurity.

Population Health & SDoH

Black and Hispanic Americans suffer most in biggest US decline in life expectancy since WWII

The pandemic will undermine Americans' health for years. Even those not infected by the coronavirus could suffer health problems related to poverty, job loss, eviction — or all of the above

Medicaid

Biden quietly transforms Medicaid safety net

In a sharp shift from Trump-era policies, President Joe Biden looks at expanding Medicaid eligibility to new mothers, inmates, and undocumented immigrants and adding services such as food and housing.

Revenue & Quality

COVID-19: OIG on impact of pandemic in nursing homes; spike in Medicaid enrollment during PHE; threat of variant grows

RISE rounds up the latest news concerning COVID-19.

Population Health & SDoH

Study: Increased COVID-19 mortality rate among Black patients due to disproportionate hospital quality

The findings indicate that fewer Black patients would have died from COVID-19 if they were admitted to different hospitals.

RISE West

RISE West 2021: 4 sessions, speakers you don’t want to miss at our upcoming hybrid event

Check out the keynotes and officials who have joined our blockbuster roster of more than 50 speakers and 30 sessions for RISE West 2021. The hybrid event will take place August 30-September 2 both live in Colorado Springs and virtually via livestream. This article spotlights four of the can’t-miss sessions.

Revenue & Quality

Former HHS chief of staff to take over as president and CEO of the Better Medicare Alliance

Mary Beth Donahue has been tapped to lead the Better Medicare Alliance’s (BMA) community of 160 ally organizations and more than 500,000 grassroots advocates supporting Medicare Advantage.

Medicare Market

Study: Despite overall customer satisfaction, MA plans continue to struggle with member communication, engagement

The annual study, conducted by J.D. Power, measures member satisfaction with Medicare Advantage (MA) plans based on six factors: coverage and benefits; provider choice; cost; customer service; information and communication; and billing and payment.

Revenue & Quality

The latest trends in Medicare Advantage: What enrollment, Star ratings, and plan benefits look like in 2021

Three Kaiser Family Foundation (KFF) analyses examine the latest data trends in Medicare Advantage (MA). Among the findings: Enrollment is way up, premiums have dropped, and more members are in plans with Star ratings of 4 or higher.

Population Health & SDoH

COVID-19 interrupts global poverty decline

New research shows global poverty trends are on the rise amid the pandemic for the first time in decades.

Revenue & Quality

Regulatory roundup: Health insurer faces backlash for ‘dangerous’ ER policy; MedPAC suggests Congress recalculate MA payments; and more

RISE summarizes recent headlines that impact the health care industry.

Revenue & Quality

RISE Radio Episode 8: Dr. Abdullah Albeyatti on the acceleration of telemedicine during COVID

The latest episode of our podcast series, RISE Radio, focuses on the explosion of telemedicine during COVID-19 and what the future holds.

Revenue & Quality

Supreme Court dismisses GOP-led challenge to Affordable Care Act, leaves law intact

The Supreme Court on Thursday dismissed a challenge to kill the Affordable Care Act (ACA) and saved health care coverage for millions.

Population Health & SDoH

The RISE Summit on SDoH 2021 Day Two Recap: Innovative financing models, sustainability, and what the future holds

What an amazing RISE Summit on Social Determinants of Health it’s been! Day two delivered another impressive lineup of compelling speakers, timely discussions, and cross-sectional connection.

Population Health & SDoH

The RISE Summit on SDoH 2021 Day One Recap: Powerful keynote address, timely panel discussions, and an update on what's happening on the Hill

It’s been a busy first day at The RISE Summit on Social Determinants of Health! After a long 16 months, many of us have experienced a thrilling return to in-person attendance in Nashville, and others joined from the comfort of their home offices thanks to our reimagined hybrid conference experience. It is great to be back and reconnect, both in-person and virtually!

Revenue & Quality

Doctor on call? Lawmakers debate how much to pay for phone appointments

Phone visits became an option for many Medicare and Medicaid patients during the pandemic. Now policymakers are deciding whether they’re worth the money.

Population Health & SDoH

Study: 5-Star ratings don’t necessarily mean all MA members receive top-level care

A new analysis by researchers at Brown University reveals that the current Star rating system for Medicare Advantage (MA) plans doesn’t always mean gold-level care for racial/ethnic minorities and socioeconomically disadvantaged enrollees in the plans.

Revenue & Quality

Labor department issues emergency rules to protect health care workers from COVID

Citing the deaths of thousands of health care workers, the new rules will force employers to report fatalities or hospitalizations to the Occupational Safety and Health Administration, and provide higher-quality protective gear, among other actions.

Revenue & Quality

Health care industry groups to CMS: Include audio-only telehealth visits in MA risk adjustment

Health care organizations and industry trade groups continue to put pressure on the Centers for Medicare & Medicaid Services (CMS) to allow audio-only encounters to be included in Medicare Advantage (MA) risk adjustment.

Revenue & Quality

New HHS report shows record number of Americans have health coverage through the ACA

The latest data reveals 31 million Americans are enrolled in health coverage through the Health Insurance Marketplaces and Medicaid expansion under the Affordable Care Act (ACA).

Revenue & Quality

COVID was a tipping point for telehealth. If some have their way, virtual visits are here to stay.

Pressure is mounting on Congress and the Biden administration to make permanent pandemic-inspired rules that fueled telehealth growth. Some fear fraud and ballooning costs.

Population Health & SDoH

HHS announces water assistance program for low-income households

The new relief program aims to expand access to affordable water and assist low-income households impacted by the COVID-19 pandemic pay their water and wastewater bills, prevent shutoffs, and support water system reconnections related to non-payment.

Population Health & SDoH

The RISE Summit on SDoH: Sessions to spotlight innovative food access programs, partnership across sectors, and more

RISE’s annual summit will be held as a hybrid event on June 14-15, with preconference workshops on Friday, June 11. Whether attending virtually via livestream or in-person in Nashville, participants will hear from cross-sectional thought leaders driving change in the transition to value-based care. Here’s an inside look at some of this year’s anticipated sessions.

Population Health & SDoH

In Missouri and other states, flawed data makes it hard to track vaccine equity

Throughout the covid-19 vaccination effort, public health officials and politicians have insisted that providing shots equitably across racial and ethnic groups is a top priority.

Revenue & Quality

Expanding insurance coverage is top priority for new Medicare-Medicaid chief

The new head of the Centers for Medicare & Medicaid Services said the administration will focus on getting more people insured and is interested in finding a way to alleviate the gap keeping low-income families in states that haven’t expanded Medicaid from enrolling in Affordable Care Act health plans.

Revenue & Quality

RISE Radio Episode 7: Colleen Gianatasio & Dean Ratzlaff on managing a remote workforce

The latest episode of our new podcast series explores the positive aspects of working from home as well as the challenges of managing a remote workforce.

Revenue & Quality

AHIP rebrands, updates mission to advocate for all Americans

The industry trade association says its new mission and brand reflects its commitment to innovation, solutions, equity, and delivering results for every patient in every community.

Revenue & Quality

MA plans lose bid to require CMS to collect patient care, satisfaction data during pandemic

A U.S. District Court judge has found the U.S. Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) did not exceed their statutory authority when they suspended the collection of data on patient care and satisfaction during COVID-19.

Revenue & Quality

RISE Radio: Kristy Smith and Joshua Edwards on how to maintain a 5-Star plan rating

Join us for the sixth episode of RISE Radio, our new podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

Population Health & SDoH

SDoH in the news: CHWs reduce hospital readmissions; U.S. hospitals ranked on racial inclusivity; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

RISE quality conferences go hybrid: What you need to know about the reimagined conference experience

Three of our biggest quality-related conferences will become hybrid events this summer. What exactly does that mean? Here’s what you can expect at Qualipalooza 2021, the 17th Risk Adjustment Forum, and RISE West–as well as future RISE hybrid events.

Medicare Market

Senate confirms Chiquita Brooks-LaSure as CMS administrator

The Senate voted 55-44 on Tuesday to confirm President Joe Biden’s nominee to oversee the Centers for Medicare & Medicaid Services (CMS).

Revenue & Quality

Regulatory roundup: Lowering age of Medicare eligibility to 60 may create winners and losers; HHS gives states billions to address behavioral health; and more

RISE looks at the latest news from the Department of Health and Human Services as well as studies that impact Medicare.

Population Health & SDoH

The RISE Summit on Social Determinants of Health: Claim your seat at the table for cross-sector collaboration

RISE is thrilled to host this year’s Summit on Social Determinants of Health as a hybrid event to provide all attendees, whether joining in-person in Nashville or virtually via livestream, ample time to network and collaborate with professionals across the ecosystem. Ahead of this year’s event, RISE talked to conference Steering Committee member Kristen Daugherty, chief executive officer, Emergence Health Network, about what she’s gained as a past attendee of the summit and what she’s looking forward to at this year’s event.

Revenue & Quality

The 2021 ‘State of Medicare Advantage’: 7 findings from BMA’s annual report

The annual report compiles the latest data to provide a full picture of the Medicare Advantage (MA) landscape from beneficiary demographics and enrollment trends to consumer savings and improved outcomes, as well as MA’s response to COVID-19 and the continued drive to health equity.

Population Health & SDoH

As pandemic eases, many seniors have lost strength, may need rehabilitative services

A little-discussed, long-term toll of the pandemic is that large numbers of older adults have become physically and cognitively debilitated and less able to care for themselves after sheltering in place.

Revenue & Quality

RISE’s Special Needs Plan Leadership Summit: A live-streaming virtual event to improve member outcomes for hard to reach, at-risk populations

The event, held on June 22-23, is the only non-association yearly gathering for Special Needs Plan (SNP) professionals who are mid- to senior-level management to stay current in a highly regulated and evolving environment.

Revenue & Quality

Biden announces $7.4 billion in funding to recruit and train public health workers

The investment will create tens of thousands of jobs and prepare the United States for future outbreaks.

Revenue & Quality

Leveraging NLP and machine Learning to improve performance in risk adjustment and value-based care

Automation and artificial intelligence are proving to be key to the future of risk adjustment and value-based care. By combining the expertise of human coders, with the speed and efficiency of machine learning we will be able to maximize the outcomes from risk adjustment programs.

Revenue & Quality

Purposeful member engagement and outreach can be a vehicle for reducing health disparities and advancing health equity

Health plans can help advance the goal of achieving health equity.

Population Health & SDoH

Latinos are the most eager to get vaccinated, survey shows — but face obstacles

Hispanics who have yet to receive a covid shot are about twice as likely as non-Hispanic whites or Blacks to say they’d like to get vaccinated as soon as possible, according to a survey released Thursday. The findings hint at fixable, though difficult, vaccine access problems for the population.

Revenue & Quality

Regulatory update: HHS restores transgender health protections; 1M enroll in ACA coverage during SEP; AMA vows to advance health equity; and more

RISE summarizes the latest headlines that impact the health care industry.

RISE West

World-renowned performance psychologist Dr. Jim Loehr to share the most important factor in achievement, life satisfaction at RISE West 2021

Join RISE for a special presentation with Jim Loehr, Ed.D., co-founder of Johnson & Johnson Human Performance Institute, who will offer insights into his 30-plus years of propriety research and training of elite performers, including Olympic gold medalists, military Special Forces, hostage rescue teams, surgeons, and Fortune 500 CEOs to achieve sustained high performance.

Revenue & Quality

CMS panel, international strategic forecaster to headline the 17th annual Risk Adjustment Forum

The event will take place live in Orlando and via livestream June 30 and July 1, with pre-conference virtual workshops on June 25.

Population Health & SDoH

Horizon Blue Cross Blue Shield of New Jersey finds success in SDoH pilot program, expands community partnerships

The program addresses social determinants of health (SDoH) needs among members by making the most of its partnerships with health care provider organizations, community health workers, and a community referral platform.

Revenue & Quality

Data, data and more data–why more data can improve your bottom line

For risk adjustment and HEDIS® programs, most payers will agree that more data, and not less, is critical to ensuring fair and accurate reimbursement.

Revenue & Quality

Research roundup: AEP switchers take advantage of OEP; MA beats Medicare in quality, outcomes, and costs; and more

RISE examines the latest research news on Medicare, Medicare Advantage, and Medicaid.

Revenue & Quality

2022 Payment Notice: CMS issues second notice that includes risk adjustment changes for ACA marketplace

The Centers for Medicare & Medicaid Services (CMS) on Friday released the second final payment notice, finalizing risk adjustment changes and cost-sharing limits for the Affordable Care Act (ACA) marketplace in 2022.

Revenue & Quality

CMS chief medical officer, customer experience expert to present keynotes at Qualipalooza 2021–a RISE hybrid event

RISE is pleased to announce two keynote speakers for Qualipalooza 2021, which will take place June 28-29, 2021 in-person in Orlando and virtually via livestream for those unable to travel.

Population Health & SDoH

Mental health services wane as insurers appear to skirt parity rules during pandemic

A report from the Government Accountability Office paints a picture of an already strained behavioral health system struggling after the pandemic struck to meet the treatment needs of millions of Americans with conditions like alcohol use disorder and post-traumatic stress disorder.

Medicare Market

Medicare marketing alert: Google will now require certification for health insurance advertisers

Without certification, health insurers will no longer be able to run advertisements on Google’s platform after June 2.

Revenue & Quality

Regulatory roundup: New survey looks at insurers’ role in improving COVID-19 vaccine uptake; CMS wants to repeal requirement that hospitals post private MA rates

RISE summarizes recent headlines that impact Medicare, Medicare Advantage, and Medicaid.

Population Health & SDoH

SDoH in the news: HHS announces actions to improve maternal health; Blue Cross Blue Shield sets goal to reduce racial disparities

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

RISE’s Payer/Provider Engagement & Contracting Summit: A virtual event to bridge the gap between payers and providers

For the third year in a row, RISE will bring together payers and providers for open dialogue and idea exchange to deliver quality value-based care, align financial incentives, and improve patient outcomes. The live-streaming virtual event, held on May 20-21, will feature critical topics and insights relating to the current health care landscape.

Population Health & SDoH

Blue Cross NC launches prevention programs to address food insecurity, nutrition

The health plan’s programs aim to equip individuals and communities struggling with food insecurity with equitable access to healthy foods.

Leadership

RISE Women in Health Care Leadership Summit: 11 sessions designed to inspire, promote leadership skills

This year’s Women in Health Care Leadership Summit will be a live-streaming virtual event on June 14-15.

Medicare Market

Study: Agents play a big role in Medicare plan selection but the current model may limit MA plan choice

New research from the Commonwealth Fund explores the role agents play in influencing Medicare beneficiary plan choices. But without financial incentives, agents don’t’ necessarily offer information on Medicare Advantage plans not in their contracts.

Revenue & Quality

Feds give huge funding boost to Navigator program for ACA enrollment

The $80 million is the largest allocation the government has made to the Navigator program and is an eight-fold increase in funding from the previous year.

Revenue & Quality

Everything you need to know about RISE’s upcoming Medicare Advantage Member Accounting and Reconciliation Summit

Master the essentials of membership and revenue reconciliation at the live-streaming virtual conference June 16-17.

Revenue & Quality

From rotten teeth to advanced cancer, patients feel the effects of treatment delays

Health providers are seeing the consequences of pandemic-delayed preventive and emergency care, from longer hospital stays to more root canals.

Population Health & SDoH

How to achieve true member centricity with a grassroots approach

Here’s how three organizations targeted social determinants of health (SDoH) and accomplished improved health outcomes beyond the clinical walls.

Revenue & Quality

Humana health plan overcharged Medicare by nearly $200M, federal audit finds

Medicare Advantage company may face record penalty over alleged billing errors.

Revenue & Quality

Regulatory roundup: HHS to spend $150M to support underserved communities with COVID-19 response; Medical associations protest CMS prior authorization requirements; and more

RISE summarizes the latest headlines that impact the Department of Health & Human Services, Medicare, and Medicare Advantage.

Medicare Market

AEP Medicare Readiness Summit: 10 sessions to supercharge your sales, marketing communications, and retention strategies

Get your sales, marketing, member communications and enrollment teams ready for a successful AEP! This year’s annual conference will run June 21-22 as a live-streaming virtual event and will feature sessions that address strategies for member acquisition and retention and best practices for onboarding.

Revenue & Quality

Regulatory roundup: Nearly 1 in 3 American seniors lack knowledge about their Medicare options; Study examines changes in Medicare spending during COVID-19; and more

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

Revenue & Quality

RISE Radio Episode 5: Dr. Heather O’Toole on population health, quality measures, COVID, telehealth, and opioid safety in the ambulatory setting

Join us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

Population Health & SDoH

SDoH in the news: The impacts of COVID-19 one year later; NIH to address COVID testing disparities in vulnerable communities; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Population Health & SDoH

Pandemic brings digital inclusion to light as critical SDoH

It’s been a digital year like no other due to COVID-19, causing Americans to rely on telehealth, virtual learning, and video chats as their new normal for health care, education, and social interaction. But the heightened reliance on digital tools has increased disparities and inequities among individuals without digital skills and access to internet, computers, or mobile devices.

Revenue & Quality

Regulatory roundup: Legislation introduced to overturn controversial Sunset Rule; OIG report indicates MA could improve the use of NPIs; and more

RISE reviews recent headlines in the news that impact Medicare and Medicare Advantage.

Population Health & SDoH

Survey reveals frontline health care workers face serious mental health challenges due to pandemic

A national survey conducted by the Kaiser Family Foundation and The Washington Post reveals worry and stress related to COVID-19 has negatively affected the mental health of most frontline health care workers.

Medicare Market

The intersection of depression and health plan satisfaction: How MA plans can improve satisfaction in an unsatisfied population

Members diagnosed with depression tend to have comorbidities and often report more access issues and show less satisfaction with their health plan than other members.

RISE National

RISE Radio Episode 4: Ana Handshuh on COVID, behavioral health, and takeaways from RISE National 2021

Join us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

Population Health & SDoH

How one health plan improved member engagement, Stars, and quality performance by addressing SDoH

Here’s how UnitedHealthcare, a health insurance plan with benefit programs for individuals and families, employers, and Medicare and Medicaid beneficiaries, leveraged social determinants of health (SDoH) programs to better meet member needs, improve Star ratings, and close quality and HEDIS® gaps.

Population Health & SDoH

How to accelerate SDOH interventions: Insights from RISE’s webinar on social risk analytics

Social risk analytics hold immense potential in achieving business goals, reducing costs and improving the lives of consumers, patients and members. As organizations recognize socioeconomic data’s value, they can capitalize on its full potential with the right mechanism and collaboration.

Medicare Market

Medicare Advantage is the fastest growing business segment in the health care insurance industry in the United States

This growing market segment represents a big opportunity for Medicare Advantage Organizations.

Revenue & Quality

BMA study: Medicare Advantage saves members $1,640 a year

A new analysis released by the Better Medicare Alliance finds that Medicare Advantage (MA) beneficiaries report more savings each year than those in original Medicare.

RISE National

RISE exclusive: Innovation Care Partners’ Dr. Heather O’Toole named this year’s Martin L. Block Award winner

Heather O’Toole, M.D., chief medical officer at Innovation Care Partners, a clinically integrated network and an accountable care organization in Arizona, received RISE’s highest quality award at this year’s RISE National.

RISE National

RISE National 2021 Tuesday Recap: Keynotes wow with presentations on COVID-19, digital innovation, and health care mega-trends

It’s been an amazing three days of RISE National 2021!

RISE National

RISE National 2021 Day One Recap: Regulatory updates, policy implications, and strategies for risk adjustment, member engagement, and social determinants of health

RISE National was in full swing today, filled with timely updates for 2021 and 2022, an insightful keynote address, collaborative panel discussions, and so much more.

Revenue & Quality

‘Incredibly concerning’ lawsuit threatens no-charge preventive care for millions

A Texas federal judge, who previously ruled the Affordable Care Act unconstitutional, has signaled his openness to ending the law’s popular coverage requirement for preventive services.

Revenue & Quality

House bill would expand telehealth coverage to include audio-only for MA members

Bipartisan legislation introduced this week would expand telehealth services for seniors during the COVID-19 pandemic.

RISE National

RISE National 2021 Preconference Day Recap

RISE National is finally here! Our 2021 virtual summit kicked off Friday with pre-conference workshops, an inspiring family-friendly keynote, and virtual networking. If you missed it, we’ve got you covered. We’ve summarized the day below—and there’s still time to register for the main conference, which begins on Monday.

Revenue & Quality

News notes: CMS extends special enrollment period, releases snapshot on COVID-19; Murthy to serve as US surgeon general for a second time

RISE rounds up the latest headlines from the White House and the Centers for Medicare & Medicaid Services (CMS).

Population Health & SDoH

SDoH in the news: US aims for an equitable vaccine rollout; Medicare beneficiaries struggle to manage chronic conditions due to COVID-19; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Population Health & SDoH

Top 5 features of The RISE Summit on Social Determinants of Health

This year’s hybrid event on June 14-15 will bring together cross-sectional thought leaders who aim to drive change in the transition to value-based care. Whether attending in-person in Nashville or virtually via livestream, community-based organizations (CBOs), payers, hospitals/health systems, funders, and manufacturers or government entities will have two jam-packed days to discuss actionable and scalable solutions to address social determinants of health (SDoH) and achieve better outcomes for the most vulnerable populations.

Revenue & Quality

Democrats eye Medicare negotiations to lower drug prices

Progressive and conservative Democratic lawmakers, as well as President Joe Biden, are in favor of authorizing federal officials to negotiate with drugmakers over what Medicare pays for at least some of the most expensive brand-name drugs and to base those prices on the drugs’ clinical benefits. Such a measure could put Republicans in the uncomfortable position of opposing an idea that most voters from both parties generally support.

Revenue & Quality

Regulatory roundup: HHS responds to lawsuit, postpones effective date of Sunset Rule; CDC director warns of avoidable surge in COVID cases due to relaxing protocols; and more

RISE summarizes the latest regulatory news that impacts Medicare and Medicare Advantage.

Population Health & SDoH

A reimagined conference experience: The RISE Summit on Social Determinants of Health goes hybrid

What exactly does a hybrid event entail? Here’s your one-stop guide for what to expect at the June 2021 event.

Population Health & SDoH

BCBSA, Feeding America partner to drive education of COVID-19 vaccination

Blue Cross Blue Shield Association (BCBSA) announced this week it has partnered with Feeding America® and its network of 200 food banks to educate Americans about the safety and the effectiveness of the COVID-19 vaccine.

Revenue & Quality

Health care leaders welcome Becerra’s confirmation as HHS secretary

Xavier Becerra was narrowly confirmed as secretary of the Department of Health and Human Services (HHS) on Thursday but health care organizations across the country applauded the move.

Revenue & Quality

Regulatory roundup: MedPAC issues telehealth recommendation in Congressional report; Senate set to confirm Becerra as HHS secretary; and more

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

RISE National

Countdown to RISE National 2021: 8 things you need to know to make the most of your virtual experience

RISE National is right around the corner. Check out the interactive virtual sessions and activities planned for our live-streamed event, which will take place March 26, 29, and 30.

Revenue & Quality

The boom in out-of-state telehealth threatens in-state providers

Health provider conflicts, fraud, and access disparity temper the COVID telehealth revolution.

Revenue & Quality

Regulatory roundup: MedPAC disputes AHIP’s blog post on Medicare Advantage spending; Health care groups sue HHS over Sunset Rule; and more

RISE reviews the latest headlines that impact Medicare and Medicare Advantage.

Revenue & Quality

Pandemic aid package includes relief from high premiums

Experts say the two-year expansion of subsidies for most people who buy insurance through the government exchanges would be among the most significant changes to the affordability of private insurance since the passage of the Affordable Care Act.

Revenue & Quality

Designing Medicare Advantage health plan benefits for our changing times

This benefit season, more than any other, it’s critical to address medical services that target complex medical needs and non-medical services that target social factors, to stay competitive.

RISE National

RISE National preview: Infectious disease expert Dr. Luciana Borio on COVID—the past, the present, and the future

Luciana Borio, M.D., who warned the public in an opinion piece published in the Wall Street Journal in late January 2020 about the pending COVID-19 pandemic, will be a keynote speaker at RISE National, a virtual live-streaming event, later this month. In this interview, Dr. Borio talks to RISE about COVID, what’s on the horizon, and what health plans can do to support their members.

Revenue & Quality

RISE Radio Episode 3: How RISE evolved during COVID and what the future holds

Join us for the third episode of RISE Radio, our new podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

Revenue & Quality

Regulatory roundup: Calls to make Medicare reimbursement for telehealth services permanent; COVID relief package could bring major changes to the ACA; and more

RISE summarizes the latest news involving Medicare, Medicare Advantage, and the Affordable Care Act.

Population Health & SDoH

SDoH in the news: Children’s mental health claims doubled amid pandemic; Health equity medical school curriculum found to improve understanding of SDoH; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

RISE National

CMS officials to present policy update at RISE National 2021

Four representatives from the Centers for Medicare & Medicaid Services (CMS) will kick off the RISE National main conference with a policy update on Monday, March 29. The virtual live-streamed event will include preconference workshops on Friday, March 26 and the main conference March 29-30.

RISE National

RISE National 2021 preview: Dr. Ezekiel Emanuel on the Biden administration’s health care priorities and the need for the industry to invest in primary care, digital innovation

Health care policy expert Ezekiel J. Emanuel, M.D., will present a keynote on the future direction of the American health care system on Monday, March 29, the first day of RISE National. Dr. Emanuel, former advisor to President Joe Biden’s transition team on COVID-19, talked to RISE ahead of the virtual conference about the current health care landscape and potential changes that could improve it.

Revenue & Quality

The impact of comprehensive health assessments during a pandemic

A new whitepaper explores how the COVID-19 pandemic has impacted beneficiaries and how a comprehensive health assessment can bridge care gaps for high-risk members.

Revenue & Quality

Regulatory roundup: OIG reports hospitals may upcode severity levels for Medicare patients; AHIP disputes MedPAC report on MA spending; and more

RISE looks at recent headlines that impact Medicare and Medicare Advantage.

Medicare Market

Highlights from the 2021 Medicare Marketing & Sales Summit: Lessons learned from AEP, strategies to compete with national plans, customer tips from Disney, and so much more

If you missed this year’s virtual summit, we’ve got you covered. Here’s a recap of what we learned during each day of the jam-packed conference.

Population Health & SDoH

Latest data reinforces racial/ethnic disparities persist in COVID-19 vaccination rates

A recent analysis from Kaiser Family Foundation (KFF) found continued disparities based on state-reported data of COVID-19 vaccinations by race and ethnicity.

Medicare Market

Study: Email, SMS text soar as effective health care consumer engagement channels in 2020, reflecting urgency of COVID-19 communications

Engagys and RISE presented results, insights from fifth annual survey of health care consumer engagement practices during this week’s virtual RISE Medicare Marketing & Sales Summit.

Medicare Market

Top 3 tips for Medicare marketing and sales in a post-pandemic world

Stakeholders across the spectrum convened for a state of the industry address during RISE’s virtual Medicare Marketing & Sales Summit this week to discuss their strategies to stand-out from the crowd, increase members’ accessibility to products and services, and ensure a friendly user experience. Here are the key takeaways from their conversation.

RISE National

RISE National 2021 preview: Keynote Dr. Wendy Sue Swanson on digital innovation during COVID and the next steps for industry transformation

Wendy Sue Swanson, M.D., a pediatrician, author of Mama Doc Medicine, and a pioneer in the use of the digital space to provide humanistic doctor-patient information, will be one of five keynote speakers at RISE National, a virtual live-streamed event March 26, 29, and 30. In this interview, Dr. Swanson previews her talk and offers insight into the current landscape as well as the potential for even more innovation to transform the health care system into one that is both patient-centered and provider-centered.

Revenue & Quality

The CMS extension and the 2021 outlook for record retrieval

Now that 2021 has arrived, a national election recently completed, and significant changes to the health care landscape in America continuing to unfold amidst a pandemic, the time for health data preparation is here.

Revenue & Quality

Medicare cuts payment to 774 hospitals over patient complications

Renowned medical centers are among the quarter of general hospitals that will lose 1 percent of Medicare payments for one year because their patients have high rates of bedsores, sepsis, and other preventable complications.

Revenue & Quality

Regulatory update: Biden to nominate Brooks-LaSure to head CMS; Calls for HHS to revamp value-based payment and rein in Medicare spending; and more

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

RISE National

RISE National 2021 speaker update: OIG officials to discuss current priorities—including impact of COVID-19 and telehealth—at March virtual conference

Representatives from the U.S. Department of Health & Human Services’ Office of Inspector General (OIG) will join our roster of more than 50 speakers at RISE National, which will be live-streamed March 26, 29, and 30.

Revenue & Quality

RISE Radio Episode 2: Regulatory issues that commercial ACA plans need to watch in 2021

Join us for the second episode of RISE Radio, our new podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.

Population Health & SDoH

Key takeaways from the first meeting of the SDOH Community’s Across the Ecosystem User Group

RISE’s Social Determinants of Health (SDoH) Community held its first Across the Ecosystem User Group meeting last week, led by Jessica Kahn, senior expert, McKinsey & Company, and Denise Harlow, CEO, National Community Action Partnership. The user group connects cross-sectional stakeholders (payers, providers, community-based organizations, government, and funders) to discuss actionable and scalable solutions to SDoH challenges and drive social good. Here are key takeaways from the initial discussion on executive orders from the new administration and the interactive McKinsey & Company dashboard.

Population Health & SDoH

6 reasons to register for RISE’s virtual Medicaid Managed Care Leadership Summit

The live-streaming virtual event will be a one-stop shop for state and federal legislators, health plans, providers, and community-based organizations (CBOs) to gain tactics to navigate a changing environment, move forward amid the pandemic, and further the drive for value-based care.

Revenue & Quality

COVID-19 update: Lockdown led to huge drop in Medicare FFS claims; the link between pandemic and increase in mental health troubles and substance use;

RISE summarizes recent research on the impact COVID-19 has had on outpatient Medicare fee-for-service claims, mental health, and patients with dementia.

Revenue & Quality

The new age of risk adjustment

Success in the COVID-19 world requires critical considerations and new approaches.

Revenue & Quality

The new era of interoperability: Achieving compliance with the CMS Interoperability Final Rule and beyond

With the introduction of HIPAA in 1996, interoperability has often taken center stage in the health care arena. Amid new federal regulatory requirements and an unprecedented global pandemic, the importance of the industry’s journey to achieve a truly interoperable and connected health care delivery system that supports improved patient care and quality outcomes has never been clearer.

Medicare Market

Avalere: Enrollment in MA plans with supplemental benefits for chronic illnesses tripled in 2021

The new report notes a dramatic increase in the number of Medicare Advantage (MA) beneficiaries who have access to additional supplemental benefits to individuals with chronic illnesses in 2021. Last year a little more than one million MA members were enrolled in plans offering the chronic care benefits. That number grew to more than three million in 2021.

Population Health & SDoH

OIG: Thousands of Medicare beneficiaries died of opioid overdoses during onset of the COVID-19 pandemic

A recent Department of Health and Human Services’ Office of Inspector General (OIG) report examines opioid use in Medicare Part D during the first eight months of 2020, the beginning of the COVID-19 outbreak. Here are the key takeaways from the report.

RISE National

Olympic Gold Medalist Tara Lipinski to give special presentation keynote at RISE National welcome reception

Tara Lipinski, internationally acclaimed figure skater and Olympic gold medalist, will share her inspirational life lessons about how she overcame adversity to achieve her storied career in figure skating, at 4 p.m. EST Friday, March 26 during a presentation to kick off RISE National, a live-streaming virtual event.

Revenue & Quality

Riding off into the RAPS sunset

Most of us can appreciate the beauty and splendor of a beautiful sunset and all that it represents, such as the completion of a day's work and the passage of time. There is a sunset of a different type about to occur in the Medicare Advantage space, and although it may not be as spectacular as an actual sunset, there are things to consider to ensure that there are no dark clouds on the horizon that diminish the ability to see it clearly and have a positive experience.

Revenue & Quality

Introducing RISE Radio: First podcast episode features risk adjustment experts on legislative and regulatory issues MA plans need to watch in 2021

RISE is pleased to introduce the launch of RISE Radio, a series of podcast episodes that will focus on issues that impact our three RISE communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health. Joining us for our inaugural episode of RISE Radio are the members of the RISE Risk Adjustment Policy Committee.

Revenue & Quality

Research roundup: 3 ways to improve MA Star measures; insight into telehealth use during COVID-19; and more

RISE summarizes recent research of interest to our RISE Quality & Revenue community.

Population Health & SDoH

What Americans really think about social determinants of health

In a recent survey conducted by The Root Cause Coalition (TRCC), researchers found the general population considers economic stability and access to health care the most impactful social determinants of health (SDoH).

Medicare Market

2021 Medicare shopping and switching: Frustration with dental benefits, customer service issues, and new supplement benefits may predict enrollment changes

Deft Research surveyed more than 3,000 seniors to better understand their shopping and switching behavior during the most recent Annual Enrollment Period (AEP). RISE looks at three of the findings that indicate reasons members may shop around and switch carriers.

Population Health & SDoH

An innovative home-based outpatient therapy model for geriatrics saves money, boosts patient satisfaction

In a recent webinar for the RISE Association, FOX Rehabilitation offered an inside look at its geriatric house calls model to provide outpatient therapy to vulnerable seniors in the comfort of their homes. As an alternative option to the traditional models of post-acute rehabilitation, the program improves patient satisfaction while reducing total cost of care.

Population Health & SDoH

As Vaccine Rollout Expands, Black Americans Still Left Behind

Black Americans are still receiving covid vaccinations at dramatically lower rates than white Americans even as the chaotic rollout reaches more people, according to a new KHN analysis.

Revenue & Quality

Regulatory roundup: New bill would allow audio-only telehealth services to count toward MA risk adjustment; MA satisfaction hits new high;

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

Revenue & Quality

5 policy recommendations to improve patient experience measures in the MA-PD CAHPS survey

The Better Medicare Alliance’s Center for Innovation in Medicare Advantage today released new research that examines the current limitations of measuring patient experience in the Medicare Advantage and Prescription Drug (MA-PD) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Based on those findings, the advocacy group proposes changes to modernize the measurement tool.

Population Health & SDoH

How an emergency department social medicine team can improve care for complex needs

A San Francisco-based hospital’s emergency department social medicine (EDSM) team has improved care delivery to patients with psychosocial needs. Here’s what the team has accomplished so far since it formed in October 2017.

Medicare Market

Medicare Marketing & Sales Summit 2021 preview: One-on-one with keynote presenter and customer experience expert Dean Lindsay

Customer experience expert Dean Lindsay will present the opening keynote at the virtual Medicare Marketing & Sales Summit 2021 on Monday, Feb. 22, the first day of the main conference. In this exclusive Q & A, Lindsay answers questions about the common mistakes marketing professionals make when it comes to member engagement and what they can do to inspire loyalty.

Revenue & Quality

Regulatory roundup: Biden appoints acting heads for CMS, HHS; Medicare ACO participation dropped in 2021

RISE summarizes the latest headlines that impact Medicare and Medicaid.

Revenue & Quality

Biden takes the reins, calls for a united front against COVID and other threats

On health care, President Joe Biden made it clear that combating the COVID-19 pandemic will be his top priority. “We must set aside politics and finally face this pandemic as one nation,” he said. “We will get through this together.”

Medicare Market

RISE’s virtual Medicare Marketing & Sales Summit to offer pre-conference workshops on product design, member engagement

For the first time, RISE will offer pre-conference workshops at the Medicare Marketing & Sales Summit. Two three-hour virtual workshops will be offered the afternoon of Friday, Feb. 19, followed by a welcome reception and a keynote address by former Disney executive Louie Gravance.

Population Health & SDoH

On Trump’s last full day, nation records 400,000 COVID deaths

On the day before the inauguration of a new president, the country marks a once unthinkable milestone of 400,000 deaths. The winter surge of the pandemic claimed 100,000 Americans in just five weeks.

Population Health & SDoH

Surgeon General releases first report on importance of community health

The report sheds light on the U.S. health disadvantage and the role business leaders can play in improving community health through engagement and investment.

Revenue & Quality

CMS releases 2022 Medicare Advantage and Part D Rate Announcement

The Centers for Medicare & Medicaid Services late Friday announced it released Medicare Advantage (MA) and Part D payment information due to COVID-19. The Rate Announcement includes final policies on risk adjustment for 2022.

Revenue & Quality

2020 Payment Notice: CMS finalizes portion that address consumer costs in the ACA marketplace

The Centers for Medicare & Medicaid Services (CMS) Thursday issued a rule that finalizes several of the proposed provisions for the annual Notice of Benefit and Payment Parameters for 2022 (the 2022 payment notice). The rule makes changes to reduce consumer costs in the Affordable Care Act (ACA) marketplace, empowers states to develop their own health care program, accelerates innovation, and clarifies program requirements.

Medicare Market

3 findings from the RISE-Engagys 2020 survey on the state of consumer health care engagement

Engagys and RISE have collaborated once again to release our 5th annual State of Healthcare Engagement Survey. Here’s a sneak peek on what the 2020 findings revealed. Engagys Managing Director Kathleen Ellmore will review the full survey findings during the RISE 2021 Medicare Marketing & Sales Summit, a live-streaming virtual event, Feb. 22-23.

Medicaid

CMS finalizes interoperability and prior authorization rule

The Centers for Medicare & Medicaid Services (CMS) on Friday finalized the “CMS Interoperability and Prior Authorization” to improve the electronic exchange of health care data and streamline processes related to prior authorization.

Revenue & Quality

CMS: 2022 Medicare Advantage and Part D Final Rule will save $75.4M over 10 years

The Centers for Medicare & Medicaid Services (CMS) Friday issued a final rule that aims to advance the agency’s efforts to strengthen and modernize the Medicare Advantage and Part D prescription drug programs. Most of the changes are effective for the 2022 plan year and could lower enrollee cost sharing on some of the most expensive prescription drugs.

Medicare Market

Pandemic to opportunity—How Medicare marketers are surviving and thriving: 2020 and into 2021

2020 was truly a year for the ages. The COVID-19 pandemic caused tragic illness, lockdowns, and untold economic consequences. Simultaneously, it also spurred technology adoption like telemedicine, and life-changing realizations, such as work-from-home works. And Medicare plans were affected too—with marketing experiencing a shift to digital strategies, data insights, and more that are likely to continue into 2021, and beyond.

Population Health & SDoH

AHIMA releases 2020 SDoH survey results

The American Health Information Management Association (AHIMA) has released the results from its 2020 social determinants of health (SDoH) survey.

Medicare Market

RISE announces keynotes for February’s virtual Medicare Marketing & Sales Summit

A former Disney executive, an award-winning business author, and a Hall of Fame motivational speaker will present keynote addresses at the 2021 Medicare Marketing & Sales Summit, a live-streamed virtual event, which includes pre-conference workshops and a member reception on Feb. 19 and the main event. Feb. 22-23.

Population Health & SDoH

CMS final rule offers fast-track path for seniors to get access to latest medical technology

The Centers for Medicare & Medicaid Services (CMS) issued a final rule Tuesday that will speed Medicare beneficiaries’ access to the latest advanced devices.

Population Health & SDoH

SDoH in the news: Behavioral health most common treatment in telehealth; Pharmacy deserts linked to vulnerable communities; and more

RISE looks at recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

Regulatory update: CMS approves first Medicaid block grant; HHS extends COVID-19 public health emergency

RISE reviews the latest from the Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS).

RISE National

Dr. Ezekiel Emanuel to lead blockbuster lineup of keynote speakers at RISE National 2021

Dr. Emanuel,  a member of President-elect Joe Biden’s transition COVID-19 advisory board, will kick off the first day of RISE National on Monday, March 29,  with a keynote address on the future direction of the American health care system.  Also slated to speak at the virtual conference: Tara Lipinski, internationally acclaimed figure skater and Olympic gold medalist; infection disease expert Dr. Luciana Borio, who warned the public in January 2020 about the pending COVID-19 pandemic; Dr. Wendy Sue Swanson, M.D., a leading innovator in digital health, innovation and prevention; and health care futurist Ian Morrison.

Revenue & Quality

4 health care trends to watch in 2021

What’s in store for the RISE Association communities in 2021? We asked experts in Medicare Advantage, quality and revenue, consumer engagement, and social determinants of health for their predictions on trends that will impact the industry in the upcoming year. Spoiler alert: COVID-19 will continue to play a big role.

Population Health & SDoH

CMS issues new SDoH guidance for states to improve beneficiary health outcomes and lower costs

The Centers for Medicare & Medicaid Services (CMS) on Thursday issued new guidance for states to address social determinants of health (SDoH) in Medicaid and the Children’s Health Insurance Program (CHIP).

Revenue & Quality

When Biden takes office, undoing Trump's health policies won't be easy

President Donald Trump made substantial changes to the nation’s health care system using executive branch authority. But reversing policies that Democrats oppose would take time and personnel resources, competing with other priorities of the new administration.

Pharmaceutical & Biotech

TIPPA 2021: A live-streaming virtual event to further medical communication strategy

The International Publication Planning Meeting (TIPPA) will be held as a virtual event on February 23-24. The conference will feature more than 25 industry experts who will explore the future of scientific and medical publications, the impact and engagement of digital innovations, and data integrity.

Population Health & SDoH

Social determinants of health funding included in COVID-19 omnibus bill

The new bill includes $3 million in funding to establish a social determinants of health (SDoH) pilot program.

Revenue & Quality

Inside the first chaotic days of the effort to vaccinate America

Within just a few days, the logistical barriers of the vaccine made by Pfizer and BioNTech were laid bare. Many officials now hang their hopes on Moderna, whose vaccine comes in containers of 100 doses, doesn’t require deep freezing and is good for 30 days from the time it’s shipped.

Medicare Market

An inside look at RISE’s virtual Medicare Secondary Payer Master Class

The live-streaming event will be held on February 9-10, 2021 and will feature 16 sessions and more than 20 industry leaders who will discuss critical topics and developments related to mandatory reporting, legislative updates, conditional payments, and Medicare set-asides.

Medicare Market

Check out the preliminary agenda for RISE’s virtual 2021 Medicare Marketing & Sales Summit

AEP 2020 shopping trends and lessons learned, regulatory changes that impact sales and marketing, and strategies that small and regional plans can use to compete with national plans are just a few of the sessions planned for the live-streamed virtual event in February.

Revenue & Quality

Regulatory roundup: Medicare spending grew 6.3% in 2019; CMS offers new Medicaid MCO model for dual eligibles

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

Revenue & Quality

Report gives insight into the impact of COVID-19 deferred care on MA risk scores

RISE summarizes the findings of a recent Wakely report commissioned by the America’s Health Insurance Plans (AHIP) that analyzes the information contained in the 2022 Medicare Advantage Advance Notice, including changes to the risk adjustment models, and the impact of COVID-19 on the Centers for Medicare & Medicaid Services (CMS) projections.

Medicare Market

5 strategies for a Medicare Part D 5-star rating amid COVID-19

Industry leaders shared exclusive insights and best practices during RISE’s 11th Annual Star Ratings Master Class held virtually mid-December. Here are five actionable tips to ensure a positive member experience while improving quality scores.

Revenue & Quality

Medicare Advantage vs. traditional Medicare: 10 findings on utilization, outcomes, and costs

New research offers insight into how high-need, high-cost beneficiaries in Medicare and Medicare Advantage fare on a broad range of quality measures, including pneumonia and flu vaccines to diabetic eye exams, post-acute care, and avoidable hospitalizations.

Population Health & SDoH

Trusted messengers may help disenfranchised communities overcome vaccine hesitancy

Persuading vulnerable low-income and ethnic communities hit hard by the coronavirus to take a new vaccine may be challenging. But established local health leaders, like a group in Rochester, Minnesota, home of the Mayo Clinic, may be one answer.

Compliance

Medicare Secondary Payer Compliance for Beneficiaries: Everything you need to know about RISE’s new virtual seminar

RISE’s new seminar on March 23-24 is designed for Medicare beneficiary representatives, plaintiff attorneys, paralegals, legal assistants, payee representatives, and other advocates of Medicare beneficiaries associated with workers compensation, liability, and no-fault insurance claims. The ultimate purpose of the seminar is to provide attendees with an understanding of how to protect Medicare beneficiaries compliantly. We talked to industry expert Rafael Gonzalez, Esq., about the planned sessions and why you don’t want to miss this groundbreaking seminar.

Revenue & Quality

Supply is limited and distribution uncertain as COVID vaccine rolls out

High stakes and big challenges await as the U.S. prepares to roll out vaccines against COVID-19, with front-line health care workers and vulnerable nursing home residents recommended as the top priority.

Population Health & SDoH

How to finance SDoH initiatives for children, a critical step to their wellbeing and health

Manatt Health, in collaboration with the Robert Wood Johnson Foundation and the Nemours Children’s Health System, released a report outlining how organizations can drive social determinants of health (SDoH) investments for children through a Children’s Health and Wellness Fund.

Revenue & Quality

In Becerra, an HHS nominee with political skill but no front-line health experience

Xavier Becerra, President-elect Joe Biden’s choice to head the Department of Health and Human Services, is set to be a pandemic-era secretary with no public health experience. Whether that matters depends on whom you ask.

Medicare Market

RISE 2021 Medicare Marketing & Sales Summit now a virtual event

We were looking forward to our return to Vegas, but due to uncertainty around the COVID-19 pandemic, the RISE 2021 Medicare Marketing & Sales Summit will now become a live-streaming virtual experience.

Revenue & Quality

Biden names picks to lead HHS, CDC

President-elect Joe Biden today announced his nominations and appointments of his health team and the names will be familiar to those in the health care industry.

Population Health & SDoH

Financial and Overall Health are Deeply Connected: How Accurate Data Can Improve Outcomes

Identifying risk attributes — social determinants of health (SDOH) — for populations can enhance an organization’s ability to develop sound, data-driven interventions that can influence change, enrich wellness, and improve profitability.

Revenue & Quality

Regulatory roundup: CMS permanently expands Medicare telehealth services; announces new payment model to advance regional value-based care

RISE reviews the latest headlines from the Centers for Medicare & Medicaid Services (CMS).

Revenue & Quality

The RISE Annual CMS Bid Boot Camp: Implications of the drug rebate rule; strategies to optimize your CMS bid; and more

The live-streaming virtual event offers actuaries, product managers, and CMS bid stakeholders interactive discussions, comprehensive updates, and key strategies for the CMS bid process from start to finish.

Population Health & SDoH

SDoH programs aim to address Medicaid members’ social needs

RISE looks at the latest news regarding social determinants of health (SDoH), including recent approaches from Medicaid programs.

Revenue & Quality

Proposed 2022 Payment Notice: What it means for risk adjustment in the ACA marketplace

The Centers for Medicare & Medicaid Services (CMS) on Wednesday released its proposed annual Notice of Benefit and Payment Parameters for the 2022 benefit year. The proposal, more commonly known as the proposed 2022 Payment Notice, provides a blueprint for the changes CMS plans to make to the risk adjustment program and risk adjustment data validation (RADV) in the Affordable Care Act marketplace.

Revenue & Quality

CMS finalizes changes to the HHS-Risk Adjustment Data Validation Program

The Centers for Medicare & Medicaid Services (CMS) on Tuesday issued a final rule to amend the methodology for the U.S. Department of Health and Human Services’ risk adjustment data validation (HHS-RADV) program. The new regulation aims to provide states and payers with more stability and predictability, promote program integrity, and foster competition.

Population Health & SDoH

Social determinants in the news: AMA adopts new policies to address SDoH; Cardiovascular death linked to food insecurity; and more

RISE rounds up recent headlines concerning social determinants of health (SDoH).

Revenue & Quality

Feds finalize drug rebate rule, but mandate likely faces legal challenges

The Trump administration on Friday finalized the rebate rule, which excludes rebates on prescription drugs paid by manufacturers to pharmacy benefit managers and Part D plans from safe harbor protection under the Anti-Kickback Statute. The regulation is set to take effect Jan. 1, 2022 but is expected to face opposition.

Revenue & Quality

CMS overhauls Stark Law: What you need to know

The Centers for Medicare & Medicaid Services (CMS) on Friday finalized changes to the Physician Self-Referral Law, more commonly referred to as the Stark Law, which prohibits physicians from making referrals to providers or entities if they have a financial relationship with them. Here is a summary of the changes.

Population Health & SDoH

COVID-19 escalates opioid epidemic and other addictions, intensifies mental health issues

Research indicates a concerning increase in relapse, fatal and non-fatal overdose, anxiety and depression, and other mental health conditions due to the pandemic.

RISE National

Health Care Futurist Ian Morrison named keynote for RISE National 2021

Morrison will address the future of the health care marketplace, trends, and implications during RISE National 2021, which will take place March 28-30, 2021.

Medicare Market

MA supplemental benefits grew 64% in 2021

A new data brief finds that in 2021 more and more Medicare Advantage (MA) plans will offer supplemental benefits like adult day care services, home-based palliative care, in-home support services, and career support.

Revenue & Quality

Take it from an expert: Fauci’s hierarchy of safety during COVID

In a new interview with Kaiser Health News, the nation's top infectious disease expert breaks down how to survive the coming months and describes how hard it is when people still insist the coronavirus outbreak is “fake news.”

Revenue & Quality

Make these opening plays to set up your organization to outperform on the member experience measures

If you’ve been tasked with championing member experience measures at your organization, consider organizing and launching an improvement team along with a well-defined game plan for how that group will work together to manage the endeavor.

Revenue & Quality

Regulatory update: Medicare saves $15B in improper payments; Kaiser agrees to pay $6.4M to settle MA false claims allegations

RISE summarizes the latest headlines that have an impact on Medicare and Medicare Advantage.

Revenue & Quality

RISE’s Star Ratings Master Class to feature presentations on the impact of COVID-19, regulatory updates from CMS and NCQA, and other hot button topics

The 11th annual RISE Star Ratings Master Class will return as a live-streamed virtual event on December 14-15. Here’s a look at the topics industry specialists will discuss to arm you with the strategies to boost your Star ratings in 2021 and beyond.

Revenue & Quality

Red states’ case against ACA hinges on whether they were actually harmed by the law

The Republican-led states are trying to prove they were harmed by the 2010 health law—and thus have “legal standing”—because their Medicaid costs increased, even though Congress eliminated the penalty for not having health coverage in 2019. At least one justice was skeptical.

Population Health & SDoH

Social Determinants of … HELP!

While there is not a one-size-fits-all answer to social determinants or social needs, there is some basic information that can help you address the unmet needs of your member population.

Medicaid

CMS offers new flexibilities in final Medicaid, CHIP final rule

The rule puts an end to overly prescriptive regulations that stakeholders have complained about since 2016, according to CMS Administrator Seema Verma.

Revenue & Quality

Is technology the remedy for HEDIS headaches?

While HEDIS® is an effective tool for measuring quality–tracking performance against these measures can be seriously challenging and time-consuming for payers.

Revenue & Quality

Understanding the 2021 CMS Star ratings for Medicare Advantage plans

Lessons learned from the 2021 CMS Star ratings can prepare Medicare Advantage plans for the lasting effects of COVID-19 on quality improvement initiatives.

Population Health & SDoH

2020 Survey of America’s Physicians: COVID-19 Impact Edition results underscore focus on SDoH

The survey explored physicians’ perspectives on the COVID-19 pandemic and the future of the health care system. A key factor: social determinants of health (SDoH).

Revenue & Quality

Justices bound to see ACA as ‘indispensable,’ says Californian leading defense

The U.S. Supreme Court will hear arguments today in a case that could overturn the Affordable Care Act. California Attorney General Xavier Becerra, who is defending the law with the backing of more than 20 other states, told California Healthline that he predicts the justices will uphold it.

Revenue & Quality

Avalere report: MA plans may see reduced risk scores, payments in 2021 due to COVID-19

A new analysis by the health care consulting firm uses Medicare Advantage (MA) claims data through June 2020 to estimate the impact of the reduction in claims on risk scores and payments for 2021.

Population Health & SDoH

COVID-19 update: Experts warn Trump to take action to stop spike in cases; Biden names members to coronavirus task force; Pfizer offers encouraging news on vaccine

The United States on Monday became the first country to surpass 10 million cases and public health experts warn numbers may continue to climb unless the Trump administration takes steps now to stop the spread of the deadly virus.

Revenue & Quality

What to know as ACA heads to Supreme Court—again

The Supreme Court on Tuesday will hear oral arguments in a case that, for the third time in eight years, could result in the justices striking down the Affordable Care Act (ACA).

Revenue & Quality

Biden wins, but his health agenda dims with GOP likely to hold Senate

Democrats had hoped not only to defeat President Donald Trump but also to capture the Senate so they could make major policy changes, such as bolstering the Affordable Care Act (ACA) and reducing the number of uninsured.

Revenue & Quality

Additional reconciliation run for CMS PY2020 Risk Adjustment data submission allows more time to close gaps and increase submission accuracy

While the 2020 Interim Final Run deadline remains Feb. 01, 2021, a recent Centers for Medicare & Medicaid Services memo officially sets the 2020 Final Run deadline to Aug 02, 2021, allowing Medicare Advantage Organizations six additional months to ensure a complete and accurate data submission.

Population Health & SDoH

RISE prepares to welcome attendees back to in-person conferences

The RISE team is looking forward to seeing conference attendees live and in person when the time is right. Here are the measures RISE has taken to create a healthier and safer conference experience− let us know when you’re ready.

Population Health & SDoH

SDoH and diabetes: American Diabetes Association unveils scientific review on risks and outcomes

The American Diabetes Association (ADA) conducted a scientific review of previous research and literature on the association of social determinants of health (SDoH) and diabetes risk and outcomes as well as the impact of targeted interventions.

Revenue & Quality

No winner for president yet and health care hangs in the balance

As the votes continue to be counted in the tight battle between President Donald Trump and former Vice President Joe Biden, the federal role in health care is at stake.

Revenue & Quality

Feds approve fractious Georgia plan to change ACA marketplace

Under the plan pushed by Gov. Brian Kemp, the HealthCare.gov website will no longer provide options for Georgia starting next fall, and consumers will need to rely on private brokers, insurance companies, agents, and commercial websites.

Leadership

Women in Health Care Leadership: Everything you need to know about harassment in the C-suite

Sexual harassment, age bias, and discrimination of race, sexual orientation, and gender all remain pervasive issues in the workplace, and the C-suite is not immune. During RISE’s virtual Women in Health Care Leadership Summit, Heather S. Sanderson of Franco Signor LLC, offered seven tactics employers can take to address and eliminate sexual harassment at the workplace, instill accountability, and improve workplace culture.

Revenue & Quality

2022 Medicare Advantage Advance Notice Part 2: CMS aims to boost MA plan revenue by 2.8%

The Centers for Medicare & Medicaid Services (CMS) released the second part of its 2022 Medicare Advantage advance notice three months earlier than usual to help Medicare Advantage (MA) plans prepare their bids for 2022.

Population Health & SDoH

7 strategies to improve care delivery by addressing social determinants of health

Addressing social determinants of health (SDoH) has enabled one special needs plan to improve health outcomes for members and has led to a decrease in emergency room visits, inpatient admissions, and inpatient lengths of stay.

Revenue & Quality

COVID-19 update: Fauci issues new warning as US cases surge to a record high; CMS sets coverage rules for vaccine

COVID-19 cases are spreading across the United States with a new case added every second, according to the latest Johns Hopkins University data.

Revenue & Quality

16th Risk Adjustment Forum to tackle the impact of the COVID-19 pandemic on risk adjustment

This year’s annual conference will take place as a live-streamed virtual event November 9-11, 2020. Take a look at just a few of the industry experts and sessions we’ve lined up.

Medicare Market

Regulatory update: MA penetration rate reaches all-time high; CMS’ Verma weighs in on the future of value-based care

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

Revenue & Quality

RISE Risk Adjustment Policy Committee: Position Paper on Telehealth

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

Revenue & Quality

2021 nominations now open for RISE quality award

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

Population Health & SDoH

New report proposes to include individuals with social vulnerabilities in first round of COVID-19 vaccine

For the first time, the National Academy of Medicine recommended vaccine prioritization be given to individuals who struggle with social determinants of health (SDoH).

Revenue & Quality

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

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

Medicare Market

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

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

Medicare Market

Back to Vegas baby! RISE’s Medicare Marketing & Sales Summit set to return to the ‘entertainment capital of the world’ in 2021

RISE will once again take over Las Vegas in February 2021 for the can’t-miss Medicare Marketing & Sales event of the year.

Medicare Market

Coming soon: RISE and Engagys to launch annual survey on state of consumer health engagement

Each year, Engagys and RISE partner to conduct the annual State of Consumer Health Engagement Survey. The survey is an examination of health care consumer engagement practices to further understand the rate at which health plans across the country are achieving engagement success and where they are investing in the future for better engagement and experience. Started in 2016, this survey now has four complete years of trend data.

Revenue & Quality

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

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

Population Health & SDoH

RISE Population Health Summit to feature an interview with four-time U.S. Paralympian Lex Gillette

During the second day of RISE’s live-streamed virtual conference, Gillette will share his firsthand experiences and perspective on health care accessibility.

Population Health & SDoH

Equality Health integrates SDoH efforts in primary care practices to improve care delivery

The health system’s model will enable primary care practices to effectively screen for social determinants of health (SDoH) to improve health equity in vulnerable communities.

Revenue & Quality

Have you checked out the RISE Talent Hub?

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

Revenue & Quality

Seeing through the Interim Final Rule fog to lift 2022 Stars

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

Revenue & Quality

The sunsetting of RAPS for Medicare Advantage

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

Population Health & SDoH

The COVID “pivot”: How programs to address social drivers of health are responding to and learning from the COVID crisis

The COVID pandemic changed the landscape of the social needs that drive health overnight. Millions of people lost their jobs; millions of people were ordered to stay home. People lost access to food for themselves and their families because they couldn’t afford it, or they couldn’t get to a grocery store. Miles of cars waiting at drive-through food pantries dominated the headlines. People became more isolated and depressed. People’s ability to pay for their housing was jeopardized.

Population Health & SDoH

SDoH partnership: Independence Blue Cross and Signify Health to launch community health network

The new network seeks to break down barriers between clinical and social care to better address member’s socioeconomic needs in the Philadelphia area.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

The unintended consequence of social distancing on older adults

Under normal circumstances, an older adult is treated every 11 seconds in an emergency department (ED) because of a fall.

Leadership

Women in Health Care Leadership Summit: Guided meditative sessions to empower the leader within

RISE’s two-day virtual event features a jam-packed agenda with keynote addresses, panel discussions, and industry leader presentations. But we’ve also planned beginner-friendly, guided meditations throughout the conference to help attendees balance their minds, bodies, emotions, and spirits.

Population Health & SDoH

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

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

Revenue & Quality

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

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

Population Health & SDoH

Meet Ellen Fink-Samnick, RISE’s new lead for the SDoH Community

The principal of EFS Supervision Strategies, LLC, will work with the RISE Association to help guide our Social Determinants of Health (SDoH) Community.

RISE National

RISE National 2021 to feature new tracks on digital health care delivery, member experience, and compliance/regulatory updates

Mark your calendars! We are excited to return to Nashville, Tenn. in March for RISE National 2021. Get a first look at the new tracks we’ve already planned for you.

Population Health & SDoH

SDoH in the news amid COVID-19: Loneliness rates double in adults; communities of color suffer disproportionate financial strain; and more

RISE looks at recent headlines concerning social determinants of health (SDoH), including the impact of COVID-19 on Latino, Black, and Native American communities.

Revenue & Quality

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

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

Revenue & Quality

CMS: Medicare Advantage premiums plunge as enrollment soars

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

Revenue & Quality

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

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

RISE West

RISE West 2020: Keynotes share timely messages to overcome times of crisis

The two-day virtual event featured inspiring keynote presentations on how to successfully lead through crisis and how to prioritize your mental health through stress management and better sleep.

Population Health & SDoH

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

Spotlight on RISE’s upcoming Special Needs Plan Leadership Summit

Learn best practices to improve outcomes for hard to reach and at-risk populations during a live-streamed virtual event on Oct. 27-28.

Population Health & SDoH

Top 5 features of RISE’s Population Health Summit

The live-streaming virtual event will feature two days filled with timely discussion on how to best pivot to the new landscape of population health in a post-pandemic world. The 2nd annual summit will take place November 17-18. Here’s an inside look at some of the speakers and hot topics included in this year’s event.

Revenue & Quality

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

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

Medicare Market

RISE virtual seminar series to focus on member experience

The virtual seminar, Driving Change in Member Experience to Impact Your Bottom Line, will take place Sept. 29-30. The two-day interactive event is part of RISE’s ongoing response to COVID-19.

RISE West

Live from RISE West 2020: Day Two Recap

It’s been a busy couple of days and the virtual RISE West 2020 has officially come to a close!

RISE West

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

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

RISE West

Live from RISE West 2020: Day One Recap

The first full day of RISE West 2020 is on the books and what a day we had!

Population Health & SDoH

Study: MA serves beneficiaries with higher social risk factors

A new study released by Better Medicare Alliance (BMA), a leading research and advocacy organization supporting Medicare Advantage, finds that MA beneficiaries have lower incomes, speak English as a second language, are more likely to rent their home, and are reliant on public transit. The findings, BMA said, show MA’s value to underserved populations.

Population Health & SDoH

SDoH case study: 3 takeaways from RISE’s webinar on medical respite innovations

The RISE Association’s webinar series recently featured a case study on a community-based, multi-hospital system medical respite program in Pittsburgh, Pa. that aims to provide care to people experiencing homelessness.

RISE West

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

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

Population Health & SDoH

Why Black aging matters, too

Older Blacks are perishing quietly, out of sight, victims of the pandemic and a lifetime of racism and its attendant adverse health effects.

Population Health & SDoH

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

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

RISE West

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

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

Medicare Market

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

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

Revenue & Quality

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

RISE reviews the latest headlines that impact Medicare Advantage plans.

RISE West

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

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

Population Health & SDoH

HHS releases Healthy People 2030 initiative to address public health priorities and challenges

The agency’s most recent 10-year plan aims to prioritize critical public health issues including the COVID-19 pandemic and social determinants of health (SDoH).

Leadership

Women in Health Care Leadership: A first look at can’t-miss features of the virtual event

For the fourth consecutive year, the industry’s brightest minds, renowned leadership coaches and trainers, and motivational speakers will come together for The RISE Women in Health Care Leadership Summit, held virtually on October 29-30, to promote and advance women in the health care industry. All genders are welcome in this drive for diversity and inclusion.

Compliance

CompliancePalooza 2020: The impact of COVID-19 on compliance, implications of the 2020 CMS protocols, the future of telehealth, and key strategies to move forward

For the first time, RISE’s 4th annual CompliancePalooza will be a virtual event! The October event will feature two days of high-quality content, timely updates, lively discussion, and networking.

Population Health & SDoH

Survey indicates Americans face greater mental health and economic challenges from COVID-19

A recent international survey found people in the United States are struggling more than people in other wealthy nations amid the global pandemic.

Revenue & Quality

Supreme Court will hear ACA legal challenge after the November elections

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

RISE West

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

RISE West

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

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

Revenue & Quality

Measuring the ROI of social determinants of health interventions

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

Medicare Market

Medicare Product Design Master Class: Virtual summit will address new CMS guidelines, COVID-19, supplemental benefits, and the inclusion of ESRD members

The live-streamed virtual event, designed for those involved in Medicare Advantage product design, sales and marketing, and finance and revenue management, will take place Sept. 21-22.

RISE West

RISE West Keynote Dr. Marc Milstein on the importance of a good night’s sleep to manage stress and protect your mental health

Marc Milstein, Ph.D., a scientist and researcher on health and happiness, will be a keynote speaker at RISE West 2020 in September. In this article, RISE talks to Milstein about his upcoming presentation and how American adults can get a better night’s sleep amid worries of COVID-19.

Population Health & SDoH

Study: Social determinants of health increase likelihood of stroke among adults below age 75

The findings indicate that adults who experience one or more social determinant of health (SDoH) have an increased risk of stroke.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

America’s Obesity Epidemic Threatens Effectiveness of Any COVID Vaccine

Researchers caution that a COVID-19 vaccine is likely to be less effective in obese adults.

Revenue & Quality

CCIIO clarifies what telehealth claims are valid for risk adjustment

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

RISE West

NCQA Q&A session added to RISE West 2020

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

Revenue & Quality

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

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

RISE West

RISE West 2020 to shine a spotlight on SDoH cross-sector community paramedic program

Chief Derek Bergsten of the Rockford, Ill. Fire Department talks to RISE ahead of the RISE West virtual summit, where he will share the success of a collaborative social determinants of health (SDoH) program that has reduced emergency department visits, ambulance runs, and hospital admissions.

Revenue & Quality

COVID-19 emergency declarations, flexibilities, and waivers

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

Population Health & SDoH

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

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

Population Health & SDoH

COVID-19 disparities derive from racial and ethnic differences in health risk, job characteristics, and household composition

A recent study found racial and ethnic disparities beyond underlying health conditions play a significant role in the disproportionate impact of COVID-19 on communities of color.

Revenue & Quality

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

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

RISE West

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

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

Revenue & Quality

CMS releases report on 2019 ACA risk adjustment transfers

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

Revenue & Quality

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

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

Population Health & SDoH

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

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

Medicaid

The COVID-19 downturn triggers jump in Medicaid enrollment

For the first time since 2017, Medicaid enrollment has begun to increase, but not by as much as many analysts expected.

Population Health & SDoH

3 strategies to address unmet social needs in larger patient population

Recent research indicates a hotspotting approach to meet physical, behavioral, and social needs of high-cost patients is too narrow to have a lasting impact.

Revenue & Quality

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

RISE rounds up the latest news on COVID-19.

Revenue & Quality

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

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

Revenue & Quality

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

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

Medicare Market

Medicare member acquisition: Tips to develop a dual enrollment approach amid the pandemic

The global pandemic has drastically limited in-person interactions and triggered the need for Medicare Advantage health plans to embrace a virtual world to connect with existing and prospective members. Here’s how one Florida health plan has maintained member connection, acquisition, and retention during this unsettling time.

Population Health & SDoH

NIH project homes in on COVID racial disparities

The pandemic has given the National Institutes of Health an opportunity to show the value of its $1.5 billion “All of Us” research program. A major effort to make the platform’s database representative of America resulted in minorities making up more than half of its more than 270,000 volunteers.

Medicare Market

4 strategies for Medicare member acquisition leading up to the AEP

Although the COVID-19 pandemic, combined with the upcoming presidential election, may limit health plans’ reach, there are still opportunities to connect with prospective members and engage with your current members.

Population Health & SDoH

Communities of color impacted disproportionately by COVID-19 due to social risk factors

Here are five actionable steps that organizations can take to support communities of color hit especially hard by the global pandemic.

Medicare Market

The impact of COVID-19 on Age-In campaigns

Deft Research’s new Age-in Study takes a deep dive into how the global pandemic recession has affected consumers as they move from commercial group or Affordable Care Act coverage into Medicare.

Medicare Market

Embracing the new member experience

Many variables can impact the member/patient experience—but some are more controllable than others.

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

Study finds Black Americans more likely to be hospitalized or die from COVID-19 due to racial disparities

A study from Sutter Health underscores the role race and ethnicity play in how individuals access care and the health outcomes caused by existing inequities.

Medicare Market

5 ways to take advantage of your RISE Association membership

The Medicare Member Acquisition & Experience Community (MMA&E) offers a multitude of member benefits including conference discounts, live webinars, user group meetings, and more. Here are some recommended tips to make the most of your online community.

Medicare Market

Empower your agents and brokers with virtual tools

Whether agents and brokers need to present Medicare Advantage (MA) insurance options to beneficiaries over the phone or online, health plans must now accommodate telephonic or telehealth videoconference presentations.

Population Health & SDoH

Telehealth study: Technology disparities correlate with health disparities

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

RISE National

Highlights from 10 RISE National sessions: Regulatory updates, strategies to improve Star ratings, risk adjustment, payer/provider collaboration

Did you miss last month’s RISE National 2020 virtual conference? Here’s a summary of a few of the sessions.

RISE National

RISE National 2020: Keynotes inspire with life stories that show the power of resilience, courage, and kindness under the worst of circumstances

Phenomenal keynote speakers took the virtual stage over two days at the annual event, RISE National 2020, and offered stories of hope and perseverance during the darkest of times.

Medicare Market

Study: MA plans miss the mark when it comes to member communication

The analysis measures member satisfaction with Medicare Advantage (MA) plans based on coverage and benefits, provider choice, cost, customer service, information and communication, and billing and payment. The result: Information and communication is a weakness for member satisfaction, which drives a general lack of engagement among consumers and increases the likelihood of health plan members switching plans.

RISE National

Provider/payer collaboration imperative for improved patient care

Leading experts in the Medicare Advantage and Affordable Care Act market continue to call for collaboration between providers and payers. Take an inside-look at their tips to bridge the gap.

Revenue & Quality

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

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

Revenue & Quality

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

RISE looks at the latest headlines on the pandemic.

Population Health & SDoH

5 step approach for payers to improve behavioral health access and quality amid COVID-19

Learn about the actions BlueCross BlueShield of North Carolina (Blue Cross NC) took as part of a payer-based strategy to improve behavioral health access, quality, and efficiency.

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

HHS announces $40M initiative to combat COVID-19 in racial, ethnic minority, and vulnerable communities

The U.S. Department of Health & Human Services (HHS) Office of Minority Health (OMH) will partner with Morehouse School of Medicine to help the communities hit hardest by the global pandemic.

Population Health & SDoH

HHS launches MENTAL Health Innovation Challenge to tackle social isolation amid pandemic

The Administration for Community Living (ACL) and the Office of the Assistant Secretary for Health created the challenge to find an online tool to help isolated Americans connect with others and engage in the community.

Revenue & Quality

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

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

Medicare Market

AEP planning: 4 tactics to align compliance, sales, and marketing

Learn about the strategies BlueCross BlueShield NC uses to build positive relationships, goal alignment, and a problem-solving approach among the three departments.

RISE National

10 ways to make the most of your virtual experience at RISE National 2020

Check out the interactive learning sessions and fun activities we’ve got planned for our 14th annual event, which takes place June 26-30.

Population Health & SDoH

Social determinants of health: 3 takeaways from RISE’s virtual summit

Client perspectives call for more action from plans and providers, community-based organizations (CBOs) thrive in cross-sector collaboration, and loneliness and mental wellness remain areas of concern.

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

From poverty to Emmy Award winning journalist: How John Quiñones managed to defy the odds

The ABC news veteran shared his inspiring story during a keynote fireside chat at last week’s virtual RISE National Summit on Social Determinants of Health.

Population Health & SDoH

Exclusive insight into the results of RISE’s benchmarking survey on SDoH

The benchmarking survey focused on how health plans and community-based organizations define success for programs that address social determinants of health (SDoH) and measure their outcomes and impact.

Population Health & SDoH

Staggering rate of loneliness identified in Cigna study

The survey examined the occurrence of loneliness among Americans and the link between factors such as age, social media use, income, and occupation.

Medicaid

Update: Medicaid providers to finally receive $15B from COVID-19 relief fund

U.S. Department of Health and Human Services (HHS) announced Tuesday it would distribute relief funds to Medicaid providers following complaints from Congressional leaders about the payment delay.

Medicare Market

How one health plan developed a rapid response for member communications during COVID-19

Here’s how Indiana University (IU) Health Plans elevated customer service and member communications when COVID-19 hit.

Revenue & Quality

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

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

Medicare Market

3 strategies for AEP planning in a COVID world

Industry-leading experts in the AEP and Medicare Advantage space joined RISE for this week’s virtual AEP Medicare Readiness Summit 2020 to share best practices, strategies, and tips to navigate member needs amid a global pandemic. Here’s an inside-look at one Medicare sales manager’s recommended steps for annual election period (AEP) planning in such an uncertain time.

Population Health & SDoH

Social determinants in the news: Patients postpone care amid pandemic; School closures leave children neglected and hungry; and more

RISE looks at recent news regarding social determinants of health (SDoH), including the different impacts the global pandemic presents to children and adults.

Revenue & Quality

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

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

Medicare Market

Poll: Seniors give two thumbs up to telehealth, Medicare Advantage amid COVID-19 pandemic

The poll, conducted by Morning Consult and sponsored by the Better Medicare Alliance, surveyed 1,020 seniors in mid-May on Medicare Advantage. Here are the key findings.

Population Health & SDoH

For seniors, COVID-19 sets off a pandemic of despair

The guidance to stay sheltered as society slowly reopens wears on older Americans, who have a growing sense of isolation and depression.

Population Health & SDoH

Drastic health disparities intensify in communities of color amid COVID-19

The global pandemic has exacerbated existing inequities for the black and Latino populations, putting them at heightened risk for physical and mental health issues.

Revenue & Quality

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

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

RISE National

RISE’s 2020 Block Award to honor health care providers who have died from COVID-19

Each year RISE presents an award to an individual who exemplifies the life work of Dr. Martin L. Block, an expert in the risk adjustment industry who had a passion to improve patient care. This year RISE National will forgo the traditional criteria of the award and present it in honor of health care professionals within our affiliated provider networks who contracted and died from COVID-19.

Revenue & Quality

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

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

Medicare Market

Age-in outreach strategies: A video interview with Inter Valley Health Plan’s Larry Baca

Larry Baca, vice president, sales & marketing, for Inter Valley Health Plan will be a featured speaker at RISE’s upcoming virtual event, AEP Medicare Readiness Summit 2020, June 2-3.

Revenue & Quality

NAACOS urges CMS for more ACO participation options

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

RISE National

RISE National: New name, new virtual format—same amazing content

The annual event, formerly known as RISE Nashville, will now stream live on June 29-30 with pre-conference workshops on Friday, June 26.

Population Health & SDoH

RISE virtual seminar series returns: Managing Behavioral & Mental Health During & Post Pandemic

The virtual event on June 4 and June 5. will bring together industry experts to examine the impacts of COVID-19 on vulnerable population and strategies for adaptation in this uncertain time.

Revenue & Quality

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

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

Population Health & SDoH

5 reasons to register for RISE’s Virtual National Summit on Social Determinants of Health

Leading experts from cross-sector health care organizations will share insights to address challenges related to social determinants of health (SDoH). If you’re a professional involved with community-based organizations (CBOs), payers, hospitals/health systems, funders, manufacturers or government entities, you’ll want to be a part of this drive for social good.

Revenue & Quality

New complimentary dashboard helps monitor COVID-19 pandemic response efforts

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

Revenue & Quality

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

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

Population Health & SDoH

7 tips to tackle stress and create resiliency amid COVID-19

While people across the country continue to experience different impacts from the global pandemic, they all have one thing in common: Stress. Here are some tips to build resiliency in these uncertain times.

Medicaid

Medicaid providers at the end of the line for federal COVID funding

Casa de Salud, a nonprofit clinic in Albuquerque, New Mexico, provides primary medical care, opioid addiction services and non-Western therapies, including acupuncture and reiki, to a largely low-income population. And, like so many other health care providers that serve as a safety net, its revenue—and its future—are threatened by the COVID-19 epidemic.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Medicare Market

OIG report: CMS must take more action to address opioid misuse among Medicare Part D beneficiaries

Thousands of Medicare beneficiaries are at extreme risk for opioid use disorder. A federal report urges the Centers for Medicare & Medicaid Services (CMS) to do more to ensure they receive treatment.

Revenue & Quality

Level up: Advancing health care analytics through data lakes

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

Revenue & Quality

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

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

Revenue & Quality

Closure in a time of closures: EDPS and RAPS submissions

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

New CDC data emphasizes role homelessness plays in COVID-19 spread

A recent report from the Centers for Disease Control and Prevention (CDC) confirms homelessness is a significant contributor to virus spread.

Revenue & Quality

Why risk adjustment technology is more essential than ever

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

Medicaid

Medicaid Managed Care Leadership Summit: Case studies show real power behind community partnerships

Community collaboration was a common theme throughout RISE’s two-day virtual event. Here are highlights from two case study sessions that offered an inside look at pilot programs that have proven partnership is key to addressing social determinants of health and improving population health outcomes.

Medicare Market

RISE/Engagys webinar to examine member communication strategies during COVID-19

Join Kevin Mowll, executive director, RISE Association, and Kathleen Ellmore, managing director, Engagys, for a deep dive into the results of a RISE-Engagys survey that uncovers how health plans are communicating with members during the COVID-19 pandemic. The webinar, COVID-19 Communications Response Survey: Addressing Near and Long-Term Member Communication Strategies, will take place at 1:30 p.m. EST, Tuesday, May 5.

Revenue & Quality

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

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

Revenue & Quality

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

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

Medicare Market

3 takeaways from the first meeting of the MA&E Sales User Group

User group members discussed the impact of COVID-19 on Medicare sales strategies, the annual election period (AEP), and broker loyalty.

Medicare Market

Medicare Advantage in 2020: KFF looks at the latest trends in enrollment, premiums, and out-of-pocket limits

Here are five findings from the latest Kaiser Family Foundation (KFF) report.

Revenue & Quality

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

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

Revenue & Quality

Coronavirus fuels explosive growth in telehealth―and concern about fraud

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

Population Health & SDoH

A simple phone call goes a long way when it comes to loneliness amid coronavirus

Social isolation due to COVID-19 has friends and families left to their own devices…literally. So much so, that grandparents are trying to learn new communication technologies to stay in touch.

Revenue & Quality

The 3 fundamentals of risk adjustment success

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

Medicare Market

MA&E Marketing User Group brainstorms on COVID-19, age-ins, and marketing strategies for the AEP during a national election

RISE’s Medicare Member Acquisition Experience Community held its first user group meeting in March. Kathleen Ellmore, managing director of Engagys, and Renee Mezzanotte, EVP of client engagement at DMW, served as co-chairs. Here are highlights from the discussion.

Revenue & Quality

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

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

Medicare Market

DMW execs offer key takeaways from RISE’s 2020 Medicare Marketing & Sales Summit

DMW staff offer their impressions from RISE’s 13th annual Medicare Marketing & Sales Summit in February.

Medicare Market

Expansion of telehealth services in response to coronavirus

The ability to offer telehealth services not only addresses a critical need at this time, it also signals to your members that you are their partner in health care and will provide support through a strenuous time.

Revenue & Quality

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

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

Population Health & SDoH

CDC study examines demographics behind coronavirus hospitalizations

The findings indicate that older adults, males, black Americans, and those with underlying health conditions are at a higher risk for hospitalization due to the virus.

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

New population health website enables researchers to examine SDoH in California as it relates to COVID-19

The launch of the interactive mapping website, which curates publicly available data at the census tract level, provides an added resource to California-based researchers amidst the COVID pandemic.

Medicaid

RISE’s Medicaid Managed Care Leadership Summit goes virtual

The annual, two-day event will still feature the high-quality content that attendees are accustomed to but will now take place from the comfort of your home offices.

Medicare Market

COVID-19: New-to-Medicare outreach to newly unemployed or uninsured

As the COVID-19 crisis unfolds, Medicare marketers across the country find themselves in a unique position to aid a group of individuals who they serve and who need their immediate help.

Revenue & Quality

CMS releases 2021 Medicare Advantage and Part D rates

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

Revenue & Quality

Researcher seeks health care leaders for Medicare Advantage performance study

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

Revenue & Quality

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

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

Medicaid

Medicaid nearing ‘eye of the storm’ as newly unemployed look for coverage

The coronavirus outbreak has forced millions out of work and the federal-state health program for low-income people could face unprecedented strains as many states don’t necessarily have the resources or systems in place to meet the demand.

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

Medicare eligibility expansions could improve existing racial and ethnic health disparities

Several proposals to expand the Medicare program are under consideration. Here’s a breakdown of each approach and what they could mean for those at risk of racial and ethnic health disparities.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

CMS halts RADV audits due to COVID-19 concerns

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

Medicare Market

RISE survey: How are you handling member communications during COVID-19?

Please take this short survey developed by RISE and Engagys that looks at member communication strategies in response to COVID-19.

Population Health & SDoH

Social distancing may exacerbate loneliness in older adults, putting their health at serious risk

While it’s vital that Americans hunker down at home to avoid spreading COVID-19, doing so may amplify another public health threat: loneliness. Research has shown that loneliness is as damaging to a person’s health as smoking 15 cigarettes per day.

Population Health & SDoH

Select progress on social determinants of health harms other essential safety-net programs

The Department of Health and Human Services (HHS) has implemented efforts to better address social determinants of health (SDoH) for certain programs and groups of people, but others face worsened conditions, according to a Health Affairs blog post.

Revenue & Quality

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

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

Medicaid

Medicaid news roundup: 11 more states receive Section 1134 waivers for COVID-19; CMS releases checklists to help states respond to outbreak

RISE looks at the latest actions from the Centers for Medicare & Medicaid Services to help state Medicaid agencies respond to the coronavirus outbreak.

Population Health & SDoH

Social determinants of health intensify alongside coronavirus

Gaps in the social safety net have become apparent as public health leaders try to halt the spread of the virus.

Medicare Market

Hoping that insurance expansion will help tamp outbreak, 9 states reopen marketplaces

The states are allowing new enrollments this month to help ease consumers’ concerns about the cost of health care so that the sick will not be deterred from seeking medical attention and inadvertently spread the virus.

Revenue & Quality

COVID-19 response: 5 recommendations for payers

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

Compliance

OIG issues COVID-19 fraud alert over health scare scams

Christi A. Grimm, the principal deputy inspector general, warns about “bad actors” preying on people’s fears over COVID-19 and perpetuating fraud schemes.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

Study confirms strong link between socioeconomic status and health for older adults

Mortality rates for low-income older adults who are dually enrolled in Medicare and Medicaid are twice as high compared to those more affluent and solely enrolled in Medicare.

Revenue & Quality

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

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

Population Health & SDoH

Social determinants in the news: Social distancing may put those most vulnerable at risk; rural communities more likely to skip preventive care; and more

RISE looks at recent headlines concerning social determinants of health (SDoH), including the impact social distancing has on those already most vulnerable.

Medicare Market

Social determinants in the news: Social distancing may put those most vulnerable at risk; rural communities more likely to skip preventive care; and more (1)

RISE looks at recent headlines concerning social determinants of health (SDoH), including the impact social distancing has on those already most vulnerable.

Medicare Market

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

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

Revenue & Quality

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

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

Population Health & SDoH

Deft Research report: Social determinants drive ‘convenience use’ of emergency rooms – but not for the reasons you may think

A new blog post from Deft Research looks at the link between non-medical circumstances and the use of the emergency room for non-emergency and routine medical care.

Medicare Market

Deft Research report: Social determinants drive ‘convenience use’ of emergency rooms – but not for the reasons you may think (1)

A new blog post from Deft Research looks at the link between non-medical circumstances and the use of the emergency room for non-emergency and routine medical care.

Medicaid

Coronavirus copay conundrum: State Medicaid programs can waive copayments but CMS doesn’t make it easy

New Medicaid guidance reveals what states must do in response to the coronavirus outbreak.

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

RISE Nashville, National Summit on Social Determinants of Health postponed to late June 2020

RISE reschedules national conferences due to concerns over COVID-19.

RISE National

RISE Nashville, National Summit on Social Determinants of Health postponed to late June 2020 (1)

RISE reschedules national conferences due to concerns over COVID-19.

Leadership

Communication Coach Angela Chee named keynote for The RISE National Women in Health Care Leadership Summit

The award-winning former TV news anchor and reporter broke through Hollywood, paid her dues in television, and created her own business and signature coaching program YOU, Amplified!®. Angela Chee will share life lessons and tips for leaders to own their voice and power at The RISE National Women in Health Care Leadership Summit, October 29-30, a virtual event.

Population Health & SDoH

CMS official to speak at The RISE National Summit on Social Determinants of Health

Speaker update: Calder Lynch from the Center for Medicare & Medicaid Services has been added to a roster of more than 50 speakers at the annual event, March 15-17, 2020 at the Omni Nashville Hotel.

Medicare Market

RISE Association launches new community, member portal for Medicare Advantage health plan professionals

The new Medicare Member Acquisition & Experience Community will help local and regional Medicare Advantage health plans grow and retain their membership base.

Medicaid

A first look at topics and speakers to take the stage at the 5th Annual Medicaid Managed Care Leadership Summit

The two-day conference will be a one-stop shop for Medicaid stakeholders to hear from leading experts as they share clinical best practices, first-hand experiences and insights, and how to prepare for the push toward value-based care.

RISE National

CMS, OIG officials to speak at RISE Nashville 2020

Speaker update: Erin Sutton, Kelly Drury from the Center for Medicare & Medicaid Services (CMS) have been added to a roster of more than 100 speakers at RISE National, a virtual event, June 29-30.

Revenue & Quality

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

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

Medicare Market

5 lessons learned from the 2020 AEP

Unable to attend RISE’s January webinar that examined the 2020 Annual Enrollment Period (AEP) and emerging trends in the Medicare Advantage (MA) marketplace? We have you covered. Here’s a summary of what we learned.

Population Health & SDoH

The National Summit on Social Determinants of Health: CBOs are ready and willing to partner with health systems

Leading experts in the community-based organization (CBO) space will join together for an open panel discussion about firsthand experiences, strength and constraint areas, and bridging the gap between health care partners-a necessity for continued improvement in social determinants of health (SDoH), according to Denise Harlow, chief executive officer, National Community Action Partnership. Harlow will moderate the panel on June 10, the first full day of this year’s virtual summit.

Medicare Market

2020 Medicare shopping and switching: Deft Research brief examines the growth of $0 PPOs

Deft Research recently surveyed more than 3,200 seniors to better understand their shopping and switching behavior during the annual election period (AEP). An executive research brief about the survey focuses on one of the findings: how the growth of $0 Preferred Provider Organizations (PPO) have permanently changed the Medicare landscape.

Revenue & Quality

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

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

Revenue & Quality

A checklist to ensure HEDIS® 2020 success

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

Revenue & Quality

Checklist: 8 steps to improve risk adjustment coding accuracy

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

Revenue & Quality

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

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

Population Health & SDoH

CMS report reveals the most commonly used codes for social determinants of health

The Centers for Medicare & Medicaid Services (CMS) recently released its first report on the use of diagnostic codes for social determinants of health (SDoH) in Medicare claims since the Z codes were implemented in 2016. The main finding: It’s difficult for the government to capture consistent data because providers aren’t assigning Z codes even when patients reveal their SDoH concerns.

Revenue & Quality

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

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

Revenue & Quality

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

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

Leadership

Women in Health Care Leadership: Dr. Ginny Baro shares what it takes to rise to your full potential

Ginny Baro, Ph.D., had more than 20 years of corporate leadership experience before becoming a certified professional coach through the International Coach Federation. Now a motivational speaker, executive coach, career strategist, and #1 bestselling author, she’s teaching professionals how to become exceptional leaders. Baro will share her strategies for success in a special presentation at The RISE National Women in Health Care Leadership Summit, which will be held as a virtual event.

RISE National

Emmy-Award winner John Quiñones named keynote speaker at RISE Nashville 2020

The broadcast journalist and host of the popular television show, What Would You Do?, will speak at RISE National Summit, a virtual event, on Monday, June 29.

RISE National

RISE Nashville 2020: Keynote Allison Massari to offer an inside look into the patient experience

An executive coach and celebrated artist, Allison Massari survived a devastating car accident that left her severely burned. She’ll share her health care experience, the importance of compassionate care, and how to transform lives through the art of person-centered care at RISE National.

RISE National

Risk adjustment: 6 legal and compliance issues to watch in 2020

Expect the Centers for Medicare & Medicaid Services (CMS) to take a closer look at retrospective chart reviews this year, says Jason Christ, a member of the health care and life sciences practice of Epstein Becker & Green.

Population Health & SDoH

Despite new doubts, ‘hotspotting’ help for heavy health care users marches on

Gov. Gavin Newsom has earmarked nearly $600 million in his 2020-21 state budget plan to provide intensive care management to high-needs, high-risk patients around the state. The programs are similar to an initiative in Camden, New Jersey, that was called into question by a recent study finding hospital readmissions dropped, but at only about the same rate as patients who didn’t receive the same kind of intensive services.

Revenue & Quality

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

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

Population Health & SDoH

RISE Association announces the launch of research project on social determinants of health

RISE Association partners with Mossavar-Rahmani Center for Business and Government at Harvard Kennedy School senior fellow to identify the drivers of successful social determinants of health programs.

Revenue & Quality

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

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

Pharmaceutical & Biotech

TIPPA 2020: New conference features, hot topics on the agenda, and key sessions back by popular demand

Global stakeholders in biopharma, medical device/diagnostics, agencies, and publishers will convene at RISE’s 19th Annual International Publication Planning Meeting on Feb. 25-26 in San Diego.

Population Health & SDoH

The National Summit on Social Determinants of Health: Jacob Reider, M.D., on the progress made so far with social determinants and what to expect in 2020

Jacob Reider, M.D., chief executive officer, Alliance for Better Health, former deputy national coordinator for health information technology at the U.S. Department of Health and Human Services (HHS), will moderate a fireside chat on the federal government’s plans to address social determinants of health at The RISE National Summit on Social Determinants of Health, which will be held virtually on June 9-11. In this article, Reider shares his thoughts on the value of cross-sector collaboration.

Medicare Market

6 trends that will impact the Medicare market in 2020

What does the future hold for the Medicare market in the upcoming year? We asked Tim Brousseau, vice president client services, Deft Research, a member of the RISE Medicare Market Advisory Board, and Rachel Silva, vice president, strategy and Innovation for DMW, for their thoughts on emerging trends that will impact health plans in 2020.

Revenue & Quality

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

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

Revenue & Quality

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

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

Medicare Market

How your Medicare marketing can win in the 2020 elections

Here is a six-point checklist for 2020 election planning throughout the year.

Revenue & Quality

Federal court reinstates HHS risk adjustment methodology

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

Revenue & Quality

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

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

Medicare Market

RISE webinar to explore factors that influenced the AEP for 2020

Members of RISE’s Medicare Member Acquisition & Experience Advisory Board will join Kevin Mowll, executive director of the RISE Association, during a January 30th webinar to discuss trends in the Medicare Advantage (MA) marketplace that emerged from the 2020 Annual Enrollment Period. In this article, RISE talks to Mowll about some of the factors that have changed the MA landscape in recent years.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Federal appeals court strikes down portion of Obamacare

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Medicare Market

4 challenges that MA plans face when implementing new supplemental benefits

A new study from the Duke Margolis Center for Health Policy looks at early trends on Medicare Advantage (MA) offerings of supplemental benefits for patient populations with serious illnesses. Among the findings: Only a small number of plans have added new benefits in the first two years that the Centers for Medicare & Medicaid Services (CMS) has provided MA plans the flexibility to offer members new benefits outside of traditional medical services. The report looks at the barriers to implementation and strategies to promote greater adoption.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

RISE National

Brain Scientist Dr. John Medina returns to lead pre-conference workshop at RISE Nashville 2020

Back by popular demand! Brain Scientist Dr. John Medina, last year’s top keynote speaker at RISE Nashville, will return for our 2020 conference to lead a half-day virtual workshop on the brain science behind delivering powerful and engaging presentations.

Medicare Market

A first look at the speakers and hot topics lined up for the 13th annual Medicare Marketing & Sales Summit

Find out what’s in store when marketing, sales, and product development professionals from local and regional Medicare Advantage health plans gather at The Venetian in Las Vegas for the annual Medicare Marketing & Sales Summit on Feb. 25-26, 2020.

Revenue & Quality

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

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

Revenue & Quality

Supreme Court seems sympathetic to insurers In Obamacare case

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

5 reasons you need to register for The RISE National Summit on Social Determinants of Health

Cross-sector health care organizations will come together in Nashville March 15-17 to address challenges related to social determinants of health (SDoH). If you’re a professional involved with community-based organizations (CBOs), payers, hospitals/health systems, funders, manufacturers or government entities, you’ll want to be a part of this drive for social good.

Revenue & Quality

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

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

Revenue & Quality

Feds release long-awaited Risk Adjustment Data Validation White Paper

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

Medicare Market

Website errors raise calls for Medicare to be flexible with seniors’ enrollment

Members of Congress and others complain Medicare’s revamped Plan Finder had problems. Federal officials say they can help consumers who got bad information change their plans next year. But details about how switching will work are yet to come.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

RISE recommended reading: Dr. Jacob Reider’s op-ed on payer philanthropy and social determinants of health

Well-intentioned, payer philanthropy is the wrong approach to solving the social determinants of health (SDoH) needs in American communities, writes Jacob Reider, M.D., CEO of Alliance for Better Health, and the former deputy director of the Office of the National Coordinator Health Information Technology, in a piece published by Health Payer Intelligence.

RISE National

Award-winning Celebrity Chef Jeff Henderson to share his inspirational life story, lessons for success at RISE Nashville 2020

You may know him as the star of the nationally syndicated series, Flip My Food with Chef Jeff, where he prepares healthier versions of favorite family and restaurant recipes. But before he discovered his passion for culinary arts, Jeff Henderson was a drug dealer and spent nearly a decade incarcerated in federal prison. He’ll tell his emotional story of how he overcame all odds during a virtual keynote presentation at RISE National (formerly known as RISE Nashville) on June 30th.

Population Health & SDoH

RISE announces agenda for National Summit on Social Determinants of Health and virtual attendance option

The annual event will take place March 15-17, 2020 at the Omni Nashville Hotel and will feature cross-sectional collaboration as thought leaders discuss actionable, tactical, and scalable solutions to social determinants of health (SDoH). Virtual attendance option is also available for those unable to travel.

Revenue & Quality

Feds propose price transparency rule for health insurers

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

Medicare Market

Star Ratings Master Class: Don’t forget about the impact of sales and marketing on member retention and star ratings

One of the mistakes that Medicare Advantage plans make when prioritizing efforts to improve their star ratings is focusing only on quality measures, says Malik Abdur-Razzaq, MPH, the chair of this year’s RISE’s Star Ratings Master Class in December.

Medicare Market

Study: More Medicare Advantage plans will offer adult day care services, in-home support as supplemental benefits for 2020

A new independent study finds that Medicare Advantage plans are incorporating new benefits in 2020 to care for the whole person and address social determinants of health.

Revenue & Quality

The definitive guide to encounter platform selection success: Part 3

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

Medicare Market

Coming soon to your inbox: The 2019 RISE/Engagys survey on health care consumer engagement

RISE and Engagys, a health care consumer engagement consultancy, are set to launch their fourth annual survey on the state of health care consumer engagement and need your input. Results will be revealed at 10th annual Star Ratings Master Class, December 12-13 in Carlsbad, Calif.

Revenue & Quality

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

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

Revenue & Quality

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

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

RISE National

Learning at its finest: 5 reasons to attend RISE Nashville 2020

Early bird registration is now open for RISE Nashville 2020, the mega-conference for professionals of all levels in the Medicare Advantage and Affordable Care Act market. Read on to find out why people return year after year and why you don’t want to miss the 2020 event at Music City Center, March 15-17.

Revenue & Quality

The definitive guide to encounter platform selection success: Part 2

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

Revenue & Quality

The definitive guide to encounter platform selection success: Part 1

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

RISE National

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:

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.

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.

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.

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.

RISE West

RISE West to take a deep dive into UnitedHealthcare’s housing, wraparound care model that tackles social determinants of health (1)

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.

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

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

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

Revenue & Quality

Artificial intelligence and the power of deep learning in health care

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

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.

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.

Revenue & Quality

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

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

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.

Pharmaceutical & Biotech

Managed Care Pharmacy Innovation Summit to examine the role of the pharmacy and its impact on star ratings

Although the pharmacy profession has evolved over the last several decades, pharmacists remain an untapped resource within the health care industry. Indeed, health plans could see their star ratings improve if they work with pharmacists on innovative programs, says Victoria Losinski, PharmD, Ph.D., MBA, director of portfolio strategy and implementation, Blue Cross and Blue Shield of Minnesota, and a featured speaker at RISE’s upcoming Managed Care Pharmacy Innovation Summit. In this article, Losinski discusses strategies health plans can adopt to work with pharmacists to boost star ratings and health outcomes.

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.

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

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

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

Revenue & Quality

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

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

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.

Medicare Market

Medicare Advantage plans can offer additional telehealth benefits in 2020 (1)

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

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

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

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

Revenue & Quality

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

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

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

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

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

Revenue & Quality

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

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

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.

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.

RISE National

RISE Nashville highlights: Inspiring keynotes, engaging sessions, and networking opportunities galore (1)

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

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

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

Revenue & Quality

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

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

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 National

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 National

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 National

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 National

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.

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

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

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

Revenue & Quality

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

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

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.

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

5 health plan predictions for 2019 (1)

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

Revenue & Quality

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

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

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.