Tag Archives: risk adjustment

Spotlight on Risk Adjustment in 2019 Final Call Letter for Medicare Advantage & Part D

Jessica Smith

The Centers for Medicare & Medicaid Services (CMS) released the Final Call Letter on April 2, 2018. The Call Letter solidifies some of the proposed changes that were within the Part 1 Advance Notice released on December 27, 2017, and Part 2 released on February 1, 2018. The final 2019 risk adjustment changes were adjusted slightly in comparison to the proposed but are overall a step in the right direction for the healthcare industry.

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Advance Notice Update – Risk Adjustment

Jessica Smith

Now that Part II of the Advanced Notice and Call Letter has been released, we are able to get a full view of the proposed policy changes to pave the way for the future. For risk adjustment, the release of Part II did not contain any surprise policy changes. The crux of risk adjustment changes were included in the Part I release. Preliminary industry impacts of the Part I release are outlined in one of my prior blogs at the following link: https://www.gormanhealthgroup.com/blog/the-ever-growing-complexity-of-risk-score-calculation-proposed-changes-for-2019-payment-year/.

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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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Preserving Your Investment Through the Member Experience

Nilsa Lennig

I was on a client call last week with a few of our Gorman Health Group Sales, Marketing & Strategy subject matter experts presenting a sales and marketing budget the team created to help illustrate pre-operational investments in sales distribution and marketing strategies to a potential “new market” entrant. These budgets are two pieces of a much larger “Go, No Go” analysis we performed for this client, however, the discussion around these budgets led to a question from our client’s CEO that could, in essence, define the future success of this health plan in Medicare Advantage: “Does this budget account for initiatives that will enhance the members’ experience?”

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Evolution Through Strategy: Pinpointing Growth Opportunities

Nancy Djordjevic

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.

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Technology and Vendor Implementations

Daniel Weinrieb

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.

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The Transition From RAPS to EDS: New Offering Helps Your Plan Calculate & Define Risk Level

Daniel Weinrieb

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.

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