Topic: Brain Food

Sales Oversight – Essential Guidelines

Carrie Barker-Settles

All agents are expected to comply with the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines, federal and state laws, and health plan rules, policies, and procedures.  But what does that mean, and how can health plans enable their employed sales staff and contracted agents to stay compliant while achieving target goals and growth?

Read more

Leave a comment | Share | |

Double Your Value: Three Critical Ways CMS Audit Readiness and the Member Experience Program Intersect

Julie Billman

What do the Centers for Medicare & Medicaid Services (CMS) program audits and member experience programs have in common? At their core, both activities are looking out for and protecting Medicare health plan members. CMS, in their oversight role, is responsible for ensuring Medicare Advantage (MA) and Prescription Drug Plan (PDP) members receive all the rights and benefits of original Medicare as well as the additional services agreed to in contracts with MA plans and PDPs. Operations has to own compliance with CMS as well as how operational functions touch and impact our members’ experiences. “The cornerstone of an effective member experience is cross-functional alignment, placing the member at the center of the health plan’s initiatives and core business functions” says Carrie Barker-Settles, Gorman Health Group’s (GHG’s) Director of Sales & Marketing Services. In days of shrinking payments, plans need to be even more efficient as they provide services to their Medicare members but without cutting corners that result in non-compliance or driving members away from our plans. We can each make a difference in the areas of compliance and member experience efficiently as the goals are so aligned.

Read more

Leave a comment | Share | |

MACRA Flexibility Proposal

Olga Walther

As we enter the last stretch of the year, many questions remain on what to expect from the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) come January 1, 2017. With the final rule due in November, much of the industry is quick to point out the difficulty in preparing for a brand new reporting program in just a month. Reporting in 2017 will affect payments in 2019.

Read more

Leave a comment | Share | |

Star Ratings Plan Preview #2: 2017 Trends to Improve 2018 Scores

Melissa Smith

With the Centers for Medicare & Medicaid Services (CMS) release of 2017 2nd Plan Preview Star Ratings and updated 2017 Technical Notes, the Star Ratings “busy season” is officially in high gear.

Read more

Leave a comment | Share | |

2018 Proposed Notice of Benefit and Payment Parameters (NBPP) Summary

Jessica Smith

This year, some of the biggest industry leaders such as Aetna and UnitedHealthcare have exited the Affordable Care Act (ACA) marketplace. The outlook for the longevity of Obamacare looked grim without some drastic changes coming down from the Department of Health and Human Services (HHS) to balance the deficits seen by health plans as they navigate this new world of healthcare.

Read more

Leave a comment | Share | |

Star Ratings: Medication Management Is Not Just for D Ratings Anymore!

Lisa Erwin

As a pharmacist and Star Ratings Senior Consultant for Gorman Health Group, whenever I am asked to provide insight on how to achieve or maintain Star Ratings success, the conversation has been limited to the “D” part of the metrics, and the folks involved with Medicare Advantage (MA) and Healthcare Effectiveness Data and Information Set (HEDIS®) kind of glaze over and mumble something like, “That’s for the Pharmacy folks to deal with.” That attitude has always been somewhat befuddling to me considering the historical and ever-increasing impact of appropriate clinical management of medications on many HEDIS® measures and the quality conversation in general. Equally confusing to me has been the willingness of many pharmacists to relinquish the ownership of the medication-related HEDIS® measures to Quality, Case Management, or other teams.

Read more

Leave a comment | Share | |

How to Efficiently Conduct an Audit

Regan Pennypacker

Audits from regulatory bodies swarm around an organization like bees.  And like a bee, upon first sight we do not think of the value they bring, but instead we first think of the sting that is to come.

Read more

1 Comment | Share | |