Topic: Clinical

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 TrumpCare Sausage Factory Grinds Away in the Senate

John Gorman

While headlines rage in DC about Trump’s leaks to Russian spies visiting the White House last week, the Senate’s sausage factory grinds away on TrumpCare. You’ll recall following House passage of the American Health Care Act (AHCA), the Senate essentially declared it DOA in the upper chamber and started over. Health plans are in the middle of bid development for the ObamaCare Marketplace and for Medicare Advantage and Part D, so timing and details matter.

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A New Source of Capital for Star Ratings and Clinical Innovations

John Gorman

For years, every conversation we’ve had with clients about improving Star Ratings and launching clinical innovation projects involved a common barrier to progress: money. So for months, we have been working to bring a new source of capital to the health plan and provider industries to help drive this evolution, called social impact investing. We are getting some early successes and can ask, “If money was no object, what initiatives would you chase?”

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The Twin Icebergs Dead Ahead for TrumpCare

John Gorman

I sure hope Republicans enjoyed their victory lap for getting the American Health Care Act (AHCA) through the House by the thinnest margin, because there are two huge icebergs dead ahead: the backlash, and the Senate.

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Takeaways from the Gorman Health Group 2017 Client Forum

John Gorman

The Gorman Health Group 2017 Forum concluded last week in New Orleans with over 200 of our closest clients and partners. As we enter our 21st year, we returned to where it all began for us, with a little startup called Peoples Health, our first and closest client who now dominates southern Louisiana. The Forum ended the day JazzFest 2017 began, so many of us stayed to enjoy the festival and the best of New Orleans heritage and culture.

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The Importance of Accurate Provider Data and Network Adequacy

Elena Martin

For almost two years, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data integrity is at the forefront of the initiatives enforced by government mandates, and provider data has topped the list of areas that not only need the most improvement, but the most oversight, correction, and, potentially, sanction. As we saw with the CMS network requirement changes, many plans were unprepared to submit their entire network footprint in their service area expansion applications. By moving the online directory guidance in the Medicare Managed Care Manual from Chapter 3 (Marketing) to Chapter 4 (Beneficiary Protections), CMS has solidified the fact it is no longer acceptable to have inaccuracies in an area key for members to evaluate their health plan choices and find access to care. CMS released its first “Online Provider Directory Review Report” in January 2017 and followed up on January 17, 2017, with a CMS Memo on Provider Directory Policy Updates.

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Will Trump and Price Pull Out the Scalpels for Star Ratings?

John Gorman

Star Ratings have driven the market in Medicare Advantage (MA) and Part D since the Affordable Care Act turned the consumer information tool into the biggest experiment in value-based payment on the planet. There’s little argument Star Ratings is working, and MA quality has improved. The program is being adopted in the ObamaCare Health Insurance Marketplace, and the Medicare Access and CHIP Reauthorization Act (MACRA) included the Quality Reporting System, or Stars for Medicaid, starting in 2019. Then Trump got elected President and appointed Tom Price the Department of Health and Human Services (HHS) Secretary. Could they pull out the scalpels for Star Ratings?

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