The Voice of Jessica Smith

Jessica Smith

About Jessica Smith

Jessica Smith is Vice President of Healthcare Analytics & Risk Adjustment Solutions at Gorman Health Group (GHG). In this role, she is responsible for the execution and oversight of risk adjustment consulting services for managed care, provider practice, and commercial market clients, and leading and integrating cross-functional teams to ensure superior performance outcomes related to risk adjustment operations. Read more

HICN to MBI: What your organization needs to know about the 2018 CMS change

Jessica Smith

The need to move away from utilizing a person’s social security number (SSN) as their Medicare Health Insurance Claim Number (HICN) has been talked about for years in the healthcare industry in an effort to support fraud prevention. As part of the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, the Centers for Medicare & Medicaid Services (CMS) is now required to discontinue use of the SSN-based HICN to identify Medicare members. Replacing the HICN will be a Medicare Beneficiary Identifier (MBI). The MBI will be a unique identifier, 11 characters long, comprised of numbers and uppercase letters, which is randomly assigned to a Medicare member. CMS will being utilizing the new MBI starting in April 2018. As they transition members from HICNs to MBIs, either identifier is able to be used during this time. The deadline for all members to be transitioned to MBIs is April 2019.

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Risk Adjustment Data Submission Fast Approaching for Medicare Advantage

Jessica Smith

It’s that time of year again when the risk adjustment data submission deadline is fast approaching for Medicare Advantage. Health plans are scrambling to ensure all critical data components are captured, supplemental diagnosis codes are linked, and deletion codes are aligned. The diligence and controls needed to obtain integrity in the information you are submitting can be quite cumbersome. Accuracy and completeness of data submissions are of upmost importance.

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The 2019 Proposed Notice of Benefit and Payment Parameters

Jessica Smith

The annual Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameter (NBPP) for 2019 proposed rule was released on October 27, 2017. It contains some eye-opening details about the future path of the Affordable Care Act (ACA). There have been many attempts this year to dismantle and drastically alter the course the ACA set out to achieve. The 2019 NBPP proposed regulations display the same message that has been heard all year – to make many changes to the foundational structure and administration process of the ACA.

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Risk Adjustment Importance During Open Enrollment

Jessica Smith

Now is the time of year when everyone is preparing for back-to-school events and the upcoming holidays, but in that mix is the ever-so-important…Medicare Open Enrollment. Medicare Open Enrollment is an important time to keep or lose valuable members who may have been long-time participants or new to the plan in the last year. There are many reasons member retention is important, but one that is not often talked about it risk adjustment. Risk adjustment has many different types of models utilized to calculate a member’s risk score. The more consistent information you have about a member, the more accurate risk score can be calculated and will allow for an easier understanding of member gaps in care.

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CMS Withholds Critical Medicare Advantage Analysis; Why?

Jessica Smith

Controversy is brewing in the healthcare insurance community since the much anticipated Medicare Advantage (MA) analysis due to be released at the AcademyHealth annual research meeting was cancelled. Today, MA plans enroll more Medicare-eligible beneficiaries than Fee-for-Service (FFS). The desire to understand the needs and services these beneficiaries have and are receiving is great.

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Guidance on the 2016 HHS-Operated Risk Adjustment Data Validation Program

Jessica Smith

Last week, the Centers for Medicare & Medicaid Services (CMS) announced the 2016 Health and Human Services Operated Risk Adjustment Data Validation (HHS-RADV) would be conducted as a pilot year in the same aspect as the 2015 HHS-RADV. This announcement came two days after the final risk adjustment data submissions were due to be submitted to the EDGE server for 2016 dates of service.

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The Transition from RAPS to EDPS

Jessica Smith

The comments have rolled in, and the concerns regarding the transition from Risk Adjustment Processing System (RAPS) to Encounter Data Processing System (EDPS) have been heard. The final Medicare Advantage Call Letter was released on April 3, 2017, and it contained a surprise on every page that was turned.

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