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Tag Archives: risk adjustment
My last article explained the choice of Medicare Advantage (MA) health plans to evolve or disappear. Evolution is certainly the preferable choice, so let’s examine the steps needed to do so.
As with all program and technology initiatives, the short- and long-term successes realized as a result of the investments made rely on the critical stages of vendor transitions, data and system readiness, and project management – A well-oiled Vendor and Program Implementation Initiative. Quite often, our health plan and provider clients have multiple projects running in parallel, making for an environment of competing priorities and scarce resources.
In 2016, the Centers for Medicare & Medicaid Services (CMS) will start to transition from utilizing Risk Adjustment Processing System (RAPS) files, to support the Medicare risk adjustment payment, to encounter files. The transition process is gradual, with a weighted percentage being taken for 2016: 10 percent based on the encounter files and 90 percent based on the RAPS files. With this transition, it is critical that health plans ensure that their RAPS files and Encounter files are in sync. Oh- and the vendors are on the hook for this too.
The Affordable Care Act (ACA) made a tremendous impact on the healthcare industry. What was once a free-flowing commercial market with very low requirements and data interaction has now transformed—it has morphed into a highly-regulated market heavily dependent on data to deliver quality outcomes for members and to remain financially sound. The processes set forth in the ACA mirror existing Medicare processes with adjustments in order to make the processes work for the Commercial population.
Now that you have digested the Centers for Medicare & Medicaid Services’ (CMS) announcement on the proposed demonstration for high-value benefit designs, the clock is ticking on determining an optimal set of benefits prior to the CMS deadline of November 15, 2015.
The fall season is a good reality check – back to school, cooler weather, end of summer, and …. Budgeting/financial forecasting. Forecasting is like predicting the future – you have to know how to read the tea leaves and see the efficiencies and interdependencies of your current performance to have a better idea of future performance and challenges.
The signing of the Affordable Care Act (ACA) into law threw health insurers into a whirlwind of changes. The guaranteed issue law made it so no enrollee in the individual or small group commercial market would be denied coverage due to their health status. In addition, the rate for all members now had to stay the same for all enrollees, with fluctuations only allowed for a few factors such as tobacco status. That key process, known as underwriting, could no longer serve as the method to evaluate risk and either deny coverage or set the enrollee’s premium accordingly. With that shift came the introduction of risk adjustment, reinsurance, and risk corridor (“3 Rs”) into the commercial market.