January 15, 2020
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.
January 09, 2020
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.
January 09, 2020
RISE looks at the latest headlines that impact the health care industry.
January 03, 2020
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.”
January 03, 2020
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.
December 30, 2019
RISE looks at three health care headlines in 2019 that will have implications for health plans in 2020.
December 30, 2019
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.
December 27, 2019
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.
December 26, 2019
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.
December 19, 2019
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.
December 19, 2019
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.
December 19, 2019
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.
December 18, 2019
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.
December 17, 2019
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.
December 16, 2019
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.
December 12, 2019
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.
December 11, 2019
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.
December 11, 2019
Justices from the right and left ask whether Congress needs to keep its promises regarding risk-corridor payments.
December 11, 2019
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.
December 10, 2019
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.
December 09, 2019
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.
December 06, 2019
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.
December 05, 2019
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.
December 05, 2019
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.
November 26, 2019
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.
November 15, 2019
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.
November 07, 2019
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.
November 01, 2019
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.
October 30, 2019
RISE looks at the latest regulatory news related to health plans on HealthCare.gov, Medicare Advantage, fraud and abuse, and cost-sharing reduction subsidies.
October 28, 2019
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.
October 22, 2019
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.
October 14, 2019
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.
October 08, 2019
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.
October 04, 2019
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.
October 03, 2019
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.
October 02, 2019
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.
October 01, 2019
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.
September 30, 2019
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.
August 21, 2019
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.
August 20, 2019
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.
August 09, 2019
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.
July 17, 2019
An enhanced government effort to catch insurers that overcharge Medicare faces resistance from the insurance industry.
July 09, 2019
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.
July 08, 2019
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.
July 03, 2019
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.
June 20, 2019
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.
June 20, 2019
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.
June 20, 2019
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.
June 10, 2019
Medicare Advantage plans need a comprehensive picture of their members’ overall health status, including conditions such as peripheral artery disease (PAD).
June 10, 2019
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.
June 06, 2019
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.
June 03, 2019
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.
June 02, 2019
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.
May 30, 2019
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.
May 17, 2019
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.
May 15, 2019
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.
April 22, 2019
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.
April 22, 2019
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.
April 11, 2019
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.
April 10, 2019
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.
April 03, 2019
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:
April 01, 2019
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.
March 27, 2019
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.
March 25, 2019
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.
March 25, 2019
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.
March 13, 2019
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.
February 21, 2019
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.
February 11, 2019
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.
February 05, 2019
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:
January 22, 2019
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.
January 16, 2019
Health plan leaders began the year 2019 just as they did in 2018 with uncertainty over the future of the Affordable Care Act (ACA). RISE turned to industry experts for their thoughts on the ACA and what other challenges the industry may face this year. Here are five predictions from Sean Creighton, managing director of the healthcare consulting firm Avalere; John Criswell, CEO of health care data analytics and technology company Pulse8; and John Broderick, M.D., FACEP, CPE, chief clinical officer-East for the risk-based provider group Landmark Health.
January 16, 2019
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.
January 04, 2019
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.
January 04, 2019
Joanna Bisgaier and Rosemary Rawlins will join a roster of 50 speakers at the 13th Annual RISE Nashville Summit, March 17-19, 2019.
January 02, 2019
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.
December 20, 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.
December 17, 2018
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.
December 10, 2018
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.
December 03, 2018
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?
November 30, 2018
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.
November 28, 2018
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.
November 21, 2018
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.
November 21, 2018
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.
November 20, 2018
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.
November 19, 2018
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.
November 08, 2018
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?
November 06, 2018
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.
November 05, 2018
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.
October 30, 2018
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.
October 26, 2018
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.
October 22, 2018
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.
October 18, 2018
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.
October 17, 2018
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.
October 16, 2018
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.
October 15, 2018
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.
October 10, 2018
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.
October 09, 2018
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.
September 27, 2018
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.
September 26, 2018
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"
September 25, 2018
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.
September 25, 2018
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.
September 17, 2018
Social determinants of health was the hottest topic at RISE West 2018, an indication that in the upcoming year health plans will likely pursue models of care that aim to improve the health and quality of life of their members. Speaker Aaron Horsfield, administrative fellow, UPMC Health Plan, predicted that the industry will see rapid change in this area as more plans collaborate with community partners to address the housing and food needs of their patient populations.
September 12, 2018
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.
September 07, 2018
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.
September 06, 2018
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.
September 06, 2018
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.
September 05, 2018
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.
August 31, 2018
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.
August 23, 2018
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.
August 21, 2018
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.
August 16, 2018
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.
August 16, 2018
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.
August 15, 2018
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.
July 10, 2018
“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.
July 09, 2018
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.
July 09, 2018
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.
July 08, 2018
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.
July 07, 2018
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.
July 06, 2018
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.
July 06, 2018
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.
April 26, 2018
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.
April 25, 2018
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.
April 12, 2018
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?
April 11, 2018
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.
April 11, 2018
Part 3 of the Successful Health and Wellness MACRA article series explores the impact of the legislation on the physician-hospital alignment strategy.
April 11, 2018
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.
April 11, 2018
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.
March 20, 2018
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.
March 15, 2018
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).
March 15, 2018
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.
March 05, 2018
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.
March 05, 2018
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.