Topic: Clinical

Off-Cycle MOC Submissions – Is It Time?

Anita McCreavy

Remember, your plan must be operating from an approved Model of Care (MOC).

The off-cycle submission process allows for substantial changes such as fundamental organizational changes essential to the MOC process and functions; for example, changes to an organization’s MOC narrative that occur between approval periods (e.g., year 2 of a three-year approval) and have not expired.

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2018 Star Ratings Offer Valuable Insight into Competitive MA Industry

Melissa Smith

The Centers for Medicare & Medicaid Services (CMS) release yesterday of the 2018 Star Ratings offers valuable insights into the significantly competitive Medicare Advantage (MA) industry. Here are just a few early observations and some insight into why it’s important: Read more

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Influencing Your 2019 Star Ratings: Every Day Matters

Melissa Smith

With last week’s release by the Centers for Medicare & Medicaid Services (CMS) of draft 2018 Star Ratings to health plans, the now-annual “4th quarter Star Ratings fire drill” has officially begun.  Whether you dropped below the 4-star threshold required to earn quality bonus payments, or you hit 4 stars and are hoping to sustain it, the next six to eight weeks are critical to your success. But with only about 90 days remaining to connect members with the care they need for your success, every day and every decision matters.

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Care Management Interdependencies

Debra Devereaux

It’s impossible to achieve reasonable and prudent member care management in a vacuum. The three-legged stool supporting care management includes medical management, risk assessment, and medication therapy management. The care manager cannot make reasonable decisions about a member’s care unless he or she has knowledge of the member’s medical management history and current status, medication history and current status, and diagnostic history and current status based on risk assessment.

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Star Ratings – First Plan Preview is Underway!

Melissa Smith

The First Plan Preview period for the 2018 Star Ratings began last week with the Centers for Medicare & Medicaid Services’ (CMS’) release of measure rates and an initial draft of the technical notes. As is always the case, CMS is allowing only a very short review period with all feedback due by THIS FRIDAY, August 18 – so time is of the essence!

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Can Your Model of Care Walk an Audit Mile?

Mayling Naputi

In sports, a good coach will tell you, “Practice like you play, because you will play like you practice.” Well, the same can be said for case sampling. My colleague, Anita McCreavy and I advise plans, “You can use an audit practice run of your Model of Care’s Special Needs Plan Enrollees (MOC-SNPE) universe to tell you if your operations are ready for a Centers for Medicare & Medicaid Services (CMS) audit.” Additionally, there is opportunity to add to the universe fields to assist management in further prioritizing potential gaps.

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The True Path to Improving the Medicare Member Experience

John Gorman

I’ve been struck lately by two new research reports that demonstrate improving the member experience is the top challenge facing Medicare Advantage plans. First, JD Power is out with its 2017 Medicare Advantage Satisfaction Rankings. Among the results: Read more

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