Insights & Articles

Revenue & Quality

5 ways to set up your team for success in risk adjustment

Here are best practices for medical groups—whether they are just starting out in their value-based care journey or already have a large portion of risk contracts.

Revenue & Quality

Is COVID ‘under control’ in the US? Experts say yes

PolitiFact has been tracking this campaign promise since 2020. Experts are now saying it’s fair to describe the COVID pandemic as “under control.”

Revenue & Quality

Moving to in-year HEDIS®: 5 best practices to boost scores and member engagement

To stay competitive today and drive the preventive care impact desired, plans must shift from focusing on retrospective HEDIS® collection toward building a select, structured, and intelligent foundation for in-year HEDIS.

Revenue & Quality

Navigating RA workflows for utilization reimbursement and performance outcomes

While the risk adjustment (RA) process is slowly catching up to become more efficient, there are several ways that payers can improve their workflows and provider relationships. These improvements not only result in better outcomes for payers, but they help improve patient care.

Revenue & Quality

KFF report: Few big differences between traditional Medicare and MA on various measures

A new Kaiser Family Foundation review of 62 studies published since 2016 compares Medicare Advantage (MA) and traditional Medicare on measures of beneficiary experience, affordability, utilization, and quality.

Revenue & Quality

Working together for greater interoperability in health care: Consent and data segmentation

Patients have long advocated for greater, easier access to their medical records while maintaining privacy. As the sharing of health data increases, all those who work across the health care industry have a responsibility to create a better and more interoperable health care system.

Revenue & Quality

8 questions every health plan should ask a health care analytics & technology partner

Here is a list of questions health plan representatives should ask any health care analytics and technology vendor you are currently working with or are considering hiring.

Revenue & Quality

Medicare Advantage prior authorization bill passes House, heads to Senate

The House of Representatives on Wednesday passed bipartisan legislation that would streamline prior authorization requirements under Medicare Advantage (MA) plans

Revenue & Quality

Medical coding creates barriers to care for transgender patients

The codes used by U.S. medical providers to bill insurers haven’t caught up to the needs of trans patients or even international standards. Consequently, doctors are forced to get creative with what codes they use, or patients spend hours fighting big out-of-pocket bills.

Revenue & Quality

Many preventive medical services cost patients nothing. Will a Texas court decision change that?

A federal judge in Texas issued a decision this week that affects the Affordable Care Act. It says one way that preventive services are selected for no-cost coverage is unconstitutional.

Revenue & Quality

Patient satisfaction surveys earn a zero on tracking whether hospitals deliver culturally competent care

In an industry obsessed with consumer satisfaction national patient surveys still don’t get at an important question: Are hospitals delivering culturally competent care?

Medicare Market

RISE-Engagys launch annual survey on consumer engagement: We need your feedback

RISE and Engagys, a health care consumer engagement consultancy, have once again joined forces to survey the health care industry to discover the current state of consumer engagement and learn what tactics and channels are effective, which programs are ineffective, and where there are pockets of excellence.

Revenue & Quality

CMS releases second plan preview of 2023 Medicare Advantage Star ratings

Medicare Advantage (MA) plans should closely review their posted data for each measure, as well as their preliminary Star Rating assignments and alert the Centers for Medicare & Medicaid Services (CMS) of any data issues or errors.

Revenue & Quality

Telehealth during the first year of COVID: OIG releases dual reports that examine dramatic increase in use, program integrity risks

The studies are part of a series that examines the use of telehealth in Medicare and the characteristics of beneficiaries who used telehealth during the pandemic.

Revenue & Quality

CMS proposes rule to make Medicaid, CHIP enrollment easier

The proposed rule would reduce red tape and simplify applications, verifications, and enrollment.

Revenue & Quality

RAND study: Higher premiums not always linked to better quality in Medicare Advantage plans

Enrolling in a higher-cost Medicare Advantage (MA) plan may not always provide seniors with better-quality health care, according to a new RAND Corporation study, which took a retrospective look at quality measures among plans in 2016 and 2017.

Revenue & Quality

ACOs saved Medicare $1.6B in Shared Savings Program in 2021

The Centers for Medicare & Medicaid Services (CMS) said this is the fifth consecutive year the program has generated overall savings and high-quality performance results.

Medicare Market

MA moves closer to becoming predominant way seniors get their health coverage and care

As Medicare Advantage (MA) continues to grow, a new Kaiser Family Foundation (KFF) analysis finds a gradual but significant reshaping of the Medicare program is taking place.

Revenue & Quality

Surprise medical bills: Feds issue final rules, guidance on arbitration process to protect consumers

The U.S. Departments of Labor, Health and Human Services (HHS), Treasury has issued final rules to clarify the federal process to protect consumers against surprise billing.

Revenue & Quality

CMS proposes mandatory quality measure reporting for Medicaid, CHIP

The proposed rule aims to standardize quality measures for Medicaid and the Children’s Health Insurance Program (CHIP) and promote health equity.

Medicare Market

Study: MA plans fall short in coverage of mental health, substance abuse services

A new study released by J.D. Power finds that overall member satisfaction with Medicare Advantage (MA) plans is on the rise, but the plans appear to miss the mark on mental health and substance abuse disorder services.

Population Health & SDoH

Community health centers’ big profits raise questions about federal oversight

Nonprofit federally funded health centers are a linchpin in the nation’s health care safety net because they treat the medically underserved. The average profit margins is 5 percent, but some have recorded margins of 20 percent or more in three of the past four years.

Revenue & Quality

Inflation Reduction Act contains important cost-saving changes for many patients

The legislation, which the House is expected to pass Friday, would allow the federal government, for the first time, to negotiate the price of some drugs that Medicare buys. It also would extend the enhanced subsidies for people who buy insurance on the Affordable Care Act marketplaces.

Revenue & Quality

No, the Senate-passed reconciliation bill won’t strip $300B from Medicare

A KHN and PolitiFact health check: Under the Medicare drug negotiations provisions in the reconciliation bill, the federal government would see its outlays reduced by about $300 billion. That reduction wouldn’t result from cuts in benefits. Instead, Medicare would be empowered to leverage its market power to pay lower prices for certain drugs.

Population Health & SDoH

CDC: Fewer than 1 in 3 insured hepatitis C patients receive timely treatment

Large gaps in treatment persist nearly a decade after a highly effective cure for hepatitis C was approved, the Centers for Disease Control and Prevention (CDC) reported this week.

Revenue & Quality

Lawsuit could end free preventive health checkups

More than 150 million Americans with private health coverage have access to the free preventive services due to the Affordable Care Act. Millions of others in Medicare and Medicaid also benefit from the provision.

Revenue & Quality

Star ratings and Tukey’s disappearing act

The Centers for Medicare & Medicaid Services (CMS) blames a codification error for the disappearance of the Tukey outlier deletion, a statistical method for removing outliers when calculating Star measure cut points, when the final rule for Medicare Advantage (MA) and Part D prescription drug programs was implemented on June 28. While we watch and wait for this to be fixed, here’s why “TukeyGate” matters and what to do next.

Population Health & SDoH

Patients and doctors trapped in a gray zone when abortion laws and emergency care mandate conflict

Since the U.S. Supreme Court overturned Roe v. Wade in June, ER doctors say they—and their patients—are trapped between state anti-abortion laws and the federal law requiring that care be delivered in emergency situations. Women’s lives hang in the balance

Revenue & Quality

Senate passes Inflation Reduction Act: What it means for health care

UPDATED August 12, 2022: The landmark legislation will lower health care costs for people across the country, according to Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure. Here’s a look of the health care aspects included in the bill and what was left out.

Revenue & Quality

HHS declares monkeypox a public health emergency

Health and Human Services (HHS) Secretary Xavier Becerra announced Thursday that the outbreak of monkeypox is a public health emergency, 78 days after the first case was confirmed in the United States.

Revenue & Quality

National uninsured rate reaches an all-time low

A new U.S. Department of Health and Human Services (HHS) report shows that the national uninsured rate reached an all-time low of 8 percent in early 2022.

Revenue & Quality

CMS final rule for inpatient, LTC hospitals: Updates payments, introduces new measures, and advances health equity

The Centers for Medicare & Medicaid Services (CMS) has released the fiscal year 2023 Inpatient Prospective Payment System (IPPS) and Long-Term Care Hospital (LTCH) Prospective Payment System (PPS) rule. Here is a summary of three major changes.

RISE West

RISE Radio Episode 12: RISE West 2022 panelists on the most pressing policy issues facing health plans this year

Five panelists who will speak about health policy at the upcoming RISE West 2022 conference 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.

Revenue & Quality

The rising importance of risk and quality in value-based contracts

Risk and quality metrics are increasingly being used to measure provider performance in value-based contracts, which has the potential to reduce health care costs over time and bring attention to those who are most in need of care

Revenue & Quality

Ad targeting Manchin and AARP mischaracterizes Medicare drug-price negotiations

A KHN and PolitiFact HealthCheck: The advocacy group American Commitment said empowering Medicare to negotiate drug prices would raid it of billions of dollars. Drug pricing experts say that that’s not the case and that such policies would instead reduce costs for the Medicare program and seniors.

Compliance

HHS proposes rule to reinstate, strengthen nondiscrimination protections removed by Trump administration

The proposed rule affirms protections on nondiscrimination based on sexual orientation and gender identity, and protection of access to reproductive health care.

RISE West

RISE West 2022 track preview: Quality and the intersection of risk adjustment, quality, and population health

In this article we look at the RISE West 2022 sessions planned as part of the Quality track and the Intersection of Risk Adjustment Quality, and Population Health track, two of the scheduled tracks to take place at the annual RISE West conference, September 1-2, in Los Angeles.

Medicaid

CMS launches home- and community-based services quality measures for Medicaid

The Centers for Medicare & Medicaid Services (CMS) has released for the first time a voluntary quality measure set to promote consistent quality measurement within and across state Medicaid home-and community-based services (HCBS) programs.

Revenue & Quality

Feds charge dozens with $1.2B in health care fraud, warn providers about telehealth scams

The Department of Justice (DOJ) has brought criminal charges against 36 defendants in 13 federal districts across the United States for more than $1.2 billion in alleged fraudulent telemedicine, cardiovascular, and cancer genetic testing, and durable medical equipment schemes. Meanwhile, the Office of Inspector General has issued a special fraud alert to warn providers about telemedicine scams.

Medicare Market

The state of Medicare Advantage in 2022: BMA compiles the latest findings on enrollment, access, value, and outcomes

The 2022 report from the Better Medicare Alliance (BMA), a research and advocacy organization that supports Medicare Advantage, gathers the latest data to provide a picture of the Medicare Advantage experience today–from beneficiary demographics and enrollment trends to supplemental benefit offerings and consumer savings, to health outcomes and bipartisan support in Washington.

Revenue & Quality

Conservative blocs unleash litigation to curb public health powers

Spurred on by opposition to pandemic-related health mandates, a coalition of religious liberty groups, conservative think tanks, and Republican state attorneys general has filed a cascade of litigation seeking to rein in the powers of public health authorities.

Revenue & Quality

2023 Physician Payment Rule: 5 things to know about the CMS proposal

The Centers for Medicare & Medicaid Services (CMS) on Thursday issued the Calendar Year 2023 Physician Fee Schedule proposed rule. If finalized, the rule would make significant changes to the Medicare Shared Savings Program and expand access to behavioral health services, cancer screening, and dental care, particularly in rural and underserved areas.

Revenue & Quality

Biden signs executive order to protect access to abortion, contraception

Two weeks after the Supreme Court’s bombshell ruling to overturn the constitutional right to abortion, President Biden has signed an executive order to protect a woman’s access to reproductive health care services.

Population Health & SDoH

Gun safety ‘wrapped in a mental health bill’: A look at health provisions in the new law

The bulk of the funds provided in the gun reform law known as the Bipartisan Safer Communities Act are for expanding mental health services. Will it help improve mental health outcomes and stem violence?

Revenue & Quality

Seeking to kick-start Biden’s agenda, Schumer unveils a bill for Medicare drug price negotiations

Democratic senators on Wednesday took a formal step toward reviving President Joe Biden’s economic agenda, starting with a measure to let Medicare negotiate prices with drugmakers and to curb rising drug costs more broadly.

Revenue & Quality

3 strategies to reduce risk score fluctuations when Medicare Advantage plan enrollment surges

Here are three ways to increase premium accuracy, close gaps in care, improve the member experience, and increase member retention.

Revenue & Quality

How much health insurers pay for almost everything is about to go public

New government rules force health insurers to publicly disclose what they pay for just about every service. That information could help consumers and employers know whether they’re getting a fair deal.

Population Health & SDoH

Deloitte: Health care inequities could cost the country $1T by 2040

A new model by Deloitte reveals a pending financial and health crisis if nothing is done to address the skyrocketing cost of health inequities.

Revenue & Quality

Government watchdogs attack Medicare Advantage for denying care and overcharging

The Government Accountability Office and the Health and Human Services inspector general’s office say seniors enrolled in the program are suffering and taxpayers are getting bilked for billions of dollars a year.

Revenue & Quality

HHS’ Becerra lays out 5-point action plan in response to Supreme Court ruling to overturn Roe v. Wade

Xavier Becerra, secretary of the Department of Health and Human Services (HHS), spoke to reporters Tuesday about the Supreme Court’s unprecedented decision on Friday to overturn a long-standing constitutional right and how the department intends to respond.

Revenue & Quality

5 things to know now that the Supreme Court has overturned Roe v. Wade

By undoing that landmark decision, the law of the land since 1973, the court has empowered states to set their own abortion restrictions—so where people live will determine their level of access.

Revenue & Quality

Supreme Court overturns Roe v. Wade

In a 6-3 vote, the Supreme Court’s conservative majority on Friday wiped out the constitutional right to an abortion and a half century of precedent. More than half of states are prepared to ban the procedure.

Revenue & Quality

Colorado to become first in the US to amend federal waiver, create public health option

The U.S. Department of Health and Human Services approved Colorado’s request to amend a federal waiver and create a state option that increases enrollment and lowers health care costs beginning in 2023.

Revenue & Quality

Commonwealth Fund Commission: 4 recommendations to build a national public health system

In the wake of the COVID-19 pandemic, the Commonwealth Fund Commission on a National Public System has issued a series of recommendations for Congress and the Department of Health and Human Services (HHS) to transform public health in the United States.

Revenue & Quality

Supreme Court rejects UnitedHealth’s challenge on MA overpayment rule

The High Court on Tuesday refused to hear UnitedHealth's challenge to the Center for Medicare & Medicaid Services’ (CMS) Medicare Advantage (MA) Overpayment Rule.

Revenue & Quality

Risk adjustment coding practices: Wolters Kluwer’s Amy Campbell on clinical documentation compliance and how to bridge the language gap between coders and physicians

RISE caught up with Amy Campbell, R.N., MSM, CCDS-O, clinical documentation integrity director, Wolters Kluwer, Health Language, one of the speakers at the recent Risk Adjustment Forum, to discuss coding challenges and strategies to improve compliance of clinical documentation.

Medicaid

Medicaid weighs attaching strings to nursing home payments to improve care

The Biden administration is considering a requirement that the nation’s 15,500 nursing homes spend most of their payments from Medicaid on direct care for residents and limit the amount that is used for operations, maintenance, and capital improvements or diverted to profits.

Revenue & Quality

Medicare Trustees Report: Medicare Part A now has enough funds to pay benefits until 2028

The financial outlook for the Hospital Insurance Trust Fund, or Medicare Part A, has improved slightly compared to last year. But uncertainty over COVID-19 and the economy could change projections again.

Revenue & Quality

Regulatory roundup: Medicare spending dropped 6% in 2020; Private insurers to pay $1B in consumer rebates

COVID-19 had an impact on both Medicare and the private insurer market, according to two recent reports from the Kaiser Family Foundation (KFF).

Revenue & Quality

Conference preview: 10 hot-topic sessions at the virtual 2022 Medicare Advantage Member Accounting and Reconciliation Summit

Get the latest regulatory updates and learn about the future of member accounting and reconciliation at the virtual conference June 29-30.

Revenue & Quality

HHS ends Trump’s controversial SUNSET rule

The Department of Health & Human Services (HHS) has formally withdrawn a policy implemented under the Trump administration that would have required a review of all regulations issued by HHS and its sub-agencies.

Revenue & Quality

Surgeon General Advisory lists 6 proposals to address health worker burnout and resignation

United States Surgeon General Dr. Vivek Murthy has issued an advisory that highlights the urgent need to address the health worker burnout crisis across the country.

Revenue & Quality

The risky business of risk adjustment coding and auditing

The world of risk adjustment is tricky–but critical to ensuring payers are fairly compensated for covering patients who are more likely to incur high health care costs. With risk adjustment, government programs such as Medicare and Medicaid will adjust the revenue provided to a health plan/payer based on the health of those covered.

Revenue & Quality

Beyond the data weeds: Analytics for stronger performance across the risk adjustment lifecycle

Do you have a clear picture of your data, and tools that allow you to easily identify the most impactful interventions to improve patient care?

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.

Revenue & Quality

The RISE Value-Based Contracting Summit: Payer-provider conference offers roadmap to value-based health care delivery

RISE brings payers and providers together June 28-29 at Caesars Palace in Las Vegas to uncover new strategies to align financial incentives, improve patient outcomes, and better navigate the value-based care space.

Revenue & Quality

Why so slow? Legislators take on insurers’ delays in approving prescribed treatments

Insurers say prior authorization requirements are intended to reduce wasteful and inappropriate health care spending. But they can baffle patients waiting for approval. And doctors say that insurers have yet to follow through on commitments to improve the process.

Revenue & Quality

Home visits play a critical role in diabetes prevention and management for seniors

Home visits help identify health risks before they become severe, preventing expensive adverse events and facilitating holistic condition management across care settings for better cost and quality outcomes.

Revenue & Quality

OIG report: 1 in 4 Medicare patients harmed during hospital stays

These events cost Medicare and patients hundreds of millions of dollars for October 2018.

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

Qualipalooza 2022: RISE heads to Las Vegas for the latest on quality-of-care measures, Star ratings, member experience, and the pursuit of health equity

The leading “teamcentric” conference on quality of care and improving member experience will take place June 28-29 at Caesars Palace in Las Vegas. Check out the featured speakers and planned sessions.

Revenue & Quality

What’s next if ‘Roe v. Wade’ falls? More than half of states expected to ban or restrict abortion

If the Supreme Court’s conservative majority affirms the leaked decision overturning abortion rights in the U.S., the effects would be sweeping for 40 million women in more than two dozen states where Republican-led legislatures have been eagerly awaiting the repudiation of the right to terminate a pregnancy.

Revenue & Quality

Medicare surprise: Drug plan prices touted during open enrollment can rise within a month

Even the savviest Medicare drug plan shoppers can get a shock when they fill prescriptions: That great deal on medications is no bargain after prices go up.

Revenue & Quality

CMS issues the 2023 Medicare Advantage and Part D Final Rule: 10 things to know

The Centers for Medicare & Medicaid Services (CMS) late Friday released its final rule for the Medicare Advantage (MA) and Part D prescription drug programs. The final rule revises MA and Part D regulations related to marketing and communications and makes changes to quality ratings, medical loss ratio reporting, special requirements during disasters or public emergencies, and reduces out-of-pocket costs for prescription drugs under Part D.

Revenue & Quality

Regulatory update: Calls to ban ‘junk’ health plans; Record enrollment in ACA coverage; and more

RISE summarizes recent regulatory headlines.

Revenue & Quality

Final 2023 Payment Notice for the ACA marketplace: Standardizes plan options, makes changes to risk adjustment models

The 2023 Notice of Benefits and Payment Parameters Final Rule (final 2023 Payment Notice) finalizes many of the changes announced in the proposed rule.

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.

Revenue & Quality

Sen. Orrin Hatch’s legacy tracks the GOP’s evolution on health

When it comes to health policy, former Utah Republican Sen. Orrin Hatch, who died April 23 at age 88, leaves a complex legacy of major legislative achievements, changing positions, compromises, and fierce opposition. In many ways, though, Hatch’s evolution and leadership on health policy during his four decades in the U.S. Senate mirror that of the Republican Party.

Revenue & Quality

A health care crisis looms: Inovalon’s Dr. Paige Kilian on the need to integrate quality and risk programs, improve provider engagement, and reduce administrative burden

The health care industry is facing a crisis, warns the chief medical officer for Inovalon. Risk and quality measurement are major contributors to the administrative burden faced by physicians, which is causing them to leave the practice of medicine. And that means reduced access to care.

Medicare Market

CMS proposes rule to create special Medicare enrollment periods

The proposed rule aims to expand Medicare coverage and establishes five special enrollment periods.

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.

Revenue & Quality

Judge’s ruling on the CDC mask mandate highlights the limits of the agency’s power

A recent court decision that overturns one of the Centers for Disease Control and Prevention’s few pandemic rules—masks required on public transportation—spotlights how little power remains in federal hands to enforce public health protections.

Population Health & SDoH

Event preview: Join us at the top conference for Special Needs Plan leaders

As the only non-association conference focused on special needs plans (SNP), the annual event provides key insights for operational, clinical, compliance, and marketing specialists. This year’s conference will be held live and in-person, June 22-24, at the Westin Times Square in New York City.

Revenue & Quality

Regulatory update: CMS outlines action plan to advance health equity; CDC launches National Weather Service-like forecasting center for infectious diseases; and more

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

Revenue & Quality

Keynote announcement: CMS panel to present at upcoming Risk Adjustment Forum

RISE is excited to announce that a panel of three representatives from the Centers for Medicare & Medicaid Services’ Consumer Information and Insurance Oversight Financial Management Group will kick off the second day of the Risk Adjustment Forum, May 11, in Chicago, with an update to the HHS-operated risk adjustment program.

Medicare Market

MA saves seniors $2K a year compared to FFS Medicare, study finds

A new analysis conducted by ATI Advisory for Better Medicare Alliance finds that Medicare Advantage (MA) beneficiaries report a 35 percent lower rate of cost burden compared to fee-for-service (FFS) Medicare.

Revenue & Quality

As COVID cases rise again, US renews public health emergency

Xavier Becerra, secretary of the Department of Health and Human Services (HHS), extended the COVID-19 public health emergency (PHE) another 90 days. The extension will allow most of the emergency waivers to remain in place through July.

Revenue & Quality

Regulatory roundup: CMS finalizes decision on Aduhelm coverage during clinical trials; HHS to take part in easing medical debt; and more

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

Revenue & Quality

Conference preview: Hot topics, planned sessions at the upcoming Risk Adjustment Forum

This year’s in-person event will include a focus on the impact of RADV audit strategies, compliance updates, and an entire track on ACA risk adjustment.

Revenue & Quality

CMS final rate notice: Medicare Advantage plans to see an 8.5% pay increase in 2023

The Centers for Medicare & Medicaid Services (CMS) announced Medicare Advantage (MA) plans will see an even bigger pay bump than what the agency originally proposed in February. CMS also finalized policies for risk adjustment and Star ratings for 2023.

Revenue & Quality

Insulin copay cap passes House hurdle, but Senate looks for a broader bill

Sens. Susan Collins (R-Maine) and Jeanne Shaheen (D-N.H.) are seeking to craft a compromise that members from both parties could accept. Their plan, still being ironed out, would not guarantee a specific limit on out-of-pocket costs but seeks to roll back insulin prices by barring rebate payments to pharmacy benefit managers.

Medicare Market

MA members have new way to get free over-the-counter COVID-19 tests

The Centers for Medicare & Medicaid Services (CMS) has expanded access to free over-the-counter COVID-19 testing for people with Medicare Part B, including those enrolled in a Medicare Advantage (MA) plan.

Revenue & Quality

US health care spending: 4 findings on projected spending growth for Medicare, Medicaid, and private health insurance

A new report prepared by the Centers for Medicare & Medicaid Services’ (CMS) Office of the Actuary finds that despite increased demand for patient care in 2021, the growth in national health spending slowed as supplemental funding for public health activity and other federal programs associated with the pandemic declined significantly.

Revenue & Quality

HHS Becerra on COVID, upcoding in Medicare Advantage, and telehealth

During an hour-long press conference late last week, Department of Health and Human Services (HHS) Secretary Xavier Becerra discussed a wide range of topics, including risk adjustment in Medicare Advantage, COVID, and telehealth.

Revenue & Quality

Americans are drowning in medical debt

A Kaiser Family Foundation (KFF) analysis finds that Black adults, those in poor health, and people living with disabilities are most likely to carry significant medical debt.

RISE National

Conference chair reflections: 5 takeaways from RISE National 2022

RaeAnn Grossman, EVP, Cotiviti, who co-chaired RISE National 2022 with Kevin Healy, CEO, Allymar Health Solutions, reflects on her experience at this year’s conference, which returned to Nashville as a live, in-person event for the first time since March 2019.

Revenue & Quality

OIG: Telehealth critical to Medicare enrollees during first year of COVID-19 pandemic

The data brief provides insight into the use of telehealth in both Medicare fee-for-service and Medicare Advantage (MA) during the first year of the COVID-19 pandemic from March 2020 through February 2021.

Revenue & Quality

Medicare Part B drugs: 3 cost implications for members in MA, original Medicare

A new brief published by the Kaiser Family Foundation analyzes cost-sharing liability for Part B drugs in traditional Medicare and cost-sharing requirements in Medicare Advantage (MA) plans. Here are the key findings.

Revenue & Quality

MedPAC releases annual report to Congress, BMA disputes agency’s stance on quality, Star ratings

Better Medicare Alliance (BMA), a research and advocacy organization that supports Medicare Advantage, says MedPAC’s recommendations don’t consider data that shows lower per-beneficiary government spending in Medicare Advantage, even as Medicare Advantage maintains lower consumer costs and better health.

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

Medicare Advantage plans send pals to seniors’ homes for companionship—and profits

Many Medicare Advantage plans send caregivers to the homes of seniors periodically to help with housework and provide companionship. But the workers may also prod seniors into activities that boost the plans’ Medicare ratings and federal reimbursements.

Revenue & Quality

Regulatory roundup: Spending bill extends telehealth flexibility; 16M could lose Medicaid when PHE ends; and more

RISE summarizes the latest regulatory headlines.

Revenue & Quality

HHS delays start date of SUNSET rule to September 22

The Department of Health & Human Services (HHS) will once again delay the implementation of the Trump administration’s controversial SUNSET rule, according to a notice in the Federal Register.

Revenue & Quality

Biden rolls out new pandemic strategy: Protect against and treat COVID-19, prepare for variants, avoid shutdowns

The White House has unveiled a national preparedness plan, which provides a roadmap to fight COVID-19 and return to a new normal. But execution of the plan requires congressional support and funding.

Revenue & Quality

Biden’s promise of better nursing home care will require many more workers

The president wants to set minimum staffing levels for the beleaguered nursing home industry. But, given a lack of transparency surrounding the industry’s finances, it’s a mystery how facilities will shoulder the added costs.

Revenue & Quality

Fact check: Biden sets high bar in 1st State of the Union speech

Here are the health care highlights from Biden's address.

Revenue & Quality

Silo busting: 5 ways to improve your organization’s customer focus for Star ratings achievement

Experts tell us that we must break down silos to streamline our activities and make sure our work and investments pay off. But how do we go about actually doing it? Here are practical steps you can take.

Population Health & SDoH

Health care firms were pushed to confront racism, now some are investing in Black startups

In health care, there are long-standing and well-documented disparities in care for Black and white patients. Those disparities have carried over into who gets funding for research and health startups.

Population Health & SDoH

Addressing social determinants begins with data

New CMS rule supports standardization of data to better understand drivers of health.

Revenue & Quality

7 lessons from a Contract-Level RADV audit

Contract-level RADV audits can seem daunting, but with these tips they do not need to be overwhelming.

Revenue & Quality

Moving beyond ADT data to proactively affect member outcomes

HL7 Version 3 Standard: Patient administration is better known as ADT-Admission, Discharge, and Transfer. ADT feeds allow managed care organizations to see and share a patient’s medical history with other providers in the care continuum. ADT systems also securely store large amounts of patient data. But are ADT feeds the best resource for improving member outcomes?

Revenue & Quality

The key to effective utilization management: Better patient care, reduced cost

Utilization management (UM) is commonly assumed to be a strategy payers implement to reduce health care cost. Although successful programs do result in reduced cost of claims, the focus of an effective UM program is improved quality of care.

Revenue & Quality

RISE weighs in on the proposed 2023 Medicare Advantage and Part D Advance Notice

Members of the RISE Risk Adjustment Policy Committee share their thoughts on the Centers for Medicare & Medicaid Services’ (CMS) recently released proposed 2023 Medicare Advantage (MA) and Part D Advance Notice and its impact on MA plans.

Revenue & Quality

Health care paradox: Medicare penalizes dozens of hospitals it also gives five stars

Among the 764 hospitals hit with a 1 percent reduction in Medicare payments this year for having high numbers of patient infections and avoidable complications are more than three dozen that Medicare also ranks as among the best in the country.

Medicare Market

Medicare will cover free over-the-counter COVID-19 tests this spring

After it became increasingly clear that the White House’s efforts to expand access to free testing didn’t make it easy for older Americans who need the tests the most, the administration has decided to rectify it.

Medicare Market

2022 Medicare Shopping and Switching: MA market faces increased competition, fewer switchers

Deft Research’s annual national market research report examined the shopping and switching habits of more than 3,300 Medicare beneficiaries during the most recent Annual Election Period (AEP). The insights on what triggers led seniors to shop for other plans and ultimately choose a new carrier can help Medicare Advantage (MA) plans better prepare for the 2023 AEP.

Revenue & Quality

At nursing homes, long waits for results render COVID tests ‘useless’

As omicron surges, more nursing homes are facing a double whammy: Lab tests are taking too long, and fast antigen tests are in short supply.

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

The 2023 Medicare Advantage and Part D Advance Notice is out: What you need to know about the proposed changes

The Centers for Medicare & Medicaid Services (CMS) on Wednesday released proposed payment policy changes for Medicare Advantage (MA) and Part D drug programs in 2023. Here’s a summary of the proposed changes to risk adjustment, Star Ratings, and the agency’s plans to advance health equity.

Revenue & Quality

Medicare patients win the right to appeal gap in nursing home coverage

If federal officials accept a court’s decision, some patients will get a chance to seek refunds for their nursing home and other expenses.

Revenue & Quality

Federal watchdog report: HHS has failed to prepare and respond to public health emergencies in 5 key areas

The Government Accountability Office (GAO) on Thursday said that for more than a decade it has found issues with how the Department of Health and Human Services’ (HHS) prepares for and responds to emergencies, including COVID-19, the H1N1 influenza pandemic, Zika, Ebola, and extreme weather events, such as hurricanes.

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.

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.

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.

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

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.

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).

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

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.

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.

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

Revenue & Quality

Researcher: Medicare Advantage plans costing billions more than they should

Researcher: Medicare Advantage plans costing billions more than they should

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.

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

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.

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

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.

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).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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).

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

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.

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.

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.”

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Revenue & Quality

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

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

Medicare Market

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

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

Revenue & Quality

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

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

Revenue & Quality

Have you checked out the RISE Talent Hub?

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

Revenue & Quality

Seeing through the Interim Final Rule fog to lift 2022 Stars

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

Revenue & Quality

The sunsetting of RAPS for Medicare Advantage

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

CMS: Medicare Advantage premiums plunge as enrollment soars

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

Revenue & Quality

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

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

Population Health & SDoH

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

RISE West

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

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

RISE West

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

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

Population Health & SDoH

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

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

RISE West

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

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

Medicare Market

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

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

Revenue & Quality

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

RISE reviews the latest headlines that impact Medicare Advantage plans.

RISE West

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

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

Revenue & Quality

Supreme Court will hear ACA legal challenge after the November elections

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

RISE West

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

RISE West

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

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

Revenue & Quality

Measuring the ROI of social determinants of health interventions

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

CCIIO clarifies what telehealth claims are valid for risk adjustment

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

RISE West

NCQA Q&A session added to RISE West 2020

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

Revenue & Quality

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

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

Revenue & Quality

COVID-19 emergency declarations, flexibilities, and waivers

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

Population Health & SDoH

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

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

Revenue & Quality

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

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

RISE West

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

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

Revenue & Quality

CMS releases report on 2019 ACA risk adjustment transfers

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

Revenue & Quality

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

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

Population Health & SDoH

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

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

Revenue & Quality

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

RISE rounds up the latest news on COVID-19.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Population Health & SDoH

Telehealth study: Technology disparities correlate with health disparities

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

RISE looks at the latest headlines on the pandemic.

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

NAACOS urges CMS for more ACO participation options

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

Revenue & Quality

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

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

Revenue & Quality

New complimentary dashboard helps monitor COVID-19 pandemic response efforts

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Level up: Advancing health care analytics through data lakes

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

Revenue & Quality

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

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

Revenue & Quality

Closure in a time of closures: EDPS and RAPS submissions

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Why risk adjustment technology is more essential than ever

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Coronavirus fuels explosive growth in telehealth―and concern about fraud

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

Revenue & Quality

The 3 fundamentals of risk adjustment success

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

CMS releases 2021 Medicare Advantage and Part D rates

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

Revenue & Quality

Researcher seeks health care leaders for Medicare Advantage performance study

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

CMS halts RADV audits due to COVID-19 concerns

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

Revenue & Quality

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

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

Revenue & Quality

COVID-19 response: 5 recommendations for payers

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

A checklist to ensure HEDIS® 2020 success

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

Revenue & Quality

Checklist: 8 steps to improve risk adjustment coding accuracy

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Federal court reinstates HHS risk adjustment methodology

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Federal appeals court strikes down portion of Obamacare

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Supreme Court seems sympathetic to insurers In Obamacare case

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Feds release long-awaited Risk Adjustment Data Validation White Paper

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Feds propose price transparency rule for health insurers

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

Revenue & Quality

The definitive guide to encounter platform selection success: Part 3

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

The definitive guide to encounter platform selection success: Part 2

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

Revenue & Quality

The definitive guide to encounter platform selection success: Part 1

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Kaiser Family Foundation report: Individual insurance market remains profitable

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

Revenue & Quality

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

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

Revenue & Quality

Lab data: The missing piece of your member profiles

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

Revenue & Quality

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

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

Revenue & Quality

The science behind value-based care modernization

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

Revenue & Quality

Addressing peripheral artery disease through enhanced clinical services

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

Revenue & Quality

How artificial intelligence is transforming risk adjustment

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Artificial intelligence and the power of deep learning in health care

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

CMS releases RADV auditor guidance

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

5 health plan predictions for 2019 (1)

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

OIG officials to discuss Medicare Advantage work at RISE Nashville

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

The 2019 Star Ratings program: making the cut

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

The Three Fundamentals of Risk Adjustment Success

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Fate of ACA is now in hands of federal judge

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

Revenue & Quality

Lawsuit seeks to invalidate the Affordable Care Act

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

Revenue & Quality

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

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

Revenue & Quality

2019 Star Ratings set to go live on Oct 10

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

The CMS 2019 Final Notice: Star Ratings Changes

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

Revenue & Quality

Analyzing Provider Behavior Patterns to Improve Medical Record Retrieval Success

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

Revenue & Quality

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

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

Revenue & Quality

An expert viewpoint: Five questions to evaluate your HEDIS performance

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

Revenue & Quality

An expert viewpoint: Discover HEDIS improvements beyond standard workstreams

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

Revenue & Quality

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

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

Revenue & Quality

Current State of the Individual and Family Plan Market

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

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

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

Revenue & Quality

Part 3: The Physician-Hospital Alignment Decision

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

Revenue & Quality

RAPS to EDPS Dual-Submission: No End in Sight

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

Revenue & Quality

Whitepaper: The Changing Quality Improvement Landscape

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

Revenue & Quality

RISE Nashville Recap: A Record-Setting Event

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

Revenue & Quality

RISE Presents 2018 Martin L. Block Award

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

Revenue & Quality

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

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

Revenue & Quality

Top 5 Actionable Uses For Marketing Analytics

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

Revenue & Quality

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

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