Insights & Articles

Revenue & Quality

Information blocking enforcement: The impact on access to health information

Despite the challenges, if true interoperability can be achieved it would provide granular data that can be used to improve clinical outcomes, reduce utilization, and provide support for clinical research.

Medicare Market

Optimizing Appeals & Grievances Summit: A virtual event for compliance specialists

The 7th annual event, live streamed June 7-8, will feature strategies to improve ODAG & CDAG outcomes, a review of the latest changes to Centers of Medicare & Medicaid Services (CMS) regulations, and strategies to improve member satisfaction.

Revenue & Quality

OIG report on prior authorizations raises concerns about MA beneficiary access to medically necessary care

A new report released by the Office of Inspector General (OIG) determined Medicare Advantage Organizations (MAOs) sometimes delayed or denied MA beneficiaries’ access to services even when the requests met Medicare coverage rules.

Compliance

DOJ charges 21 with $150M in nationwide COVID-related fraud schemes

The Justice Department said on Wednesday that the cases allegedly resulted in approximately $150 million in COVID-19-related false billings to federal programs and theft from federally-funded pandemic assistance.

Compliance

Compliance 101: Everything you need to know about regulatory audits in 2022

Regulatory bodies are increasingly using data analytics to guide their audit processes to great effect. In this landscape, compliance can no longer be an afterthought. Health plans must take proactive steps to address issues before they arise so they may focus their valuable time and resources on what matters most—caring for patients.

Revenue & Quality

DOJ: Health care fraud the leading source of False Claim Act settlements in 2021

The Department of Justice (DOJ) collected more than $5.6 billion in settlements and judgments from civil cases involving fraud and false claims against the government in fiscal 2021 and most of that money came from health care fraud cases.

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

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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

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.

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.

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

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.

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

Have you checked out the RISE Talent Hub?

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

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.

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

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.

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.

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.

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.

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.

Compliance

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

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