Topic: Clinical

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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Why Your Organization Should Consider Accreditation or Certification Status

Anita McCreavy

Many organizations find accreditation and certifications to be a requirement in a standard book of business. They provide a roadmap for your organization to be clinically sound, quality driven, and integrated. These accreditations assist organizations in demonstrating to their customer’s compliance with regulatory standards and a fundamentally sound structure.

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Evolve from Restrictive to Supportive Medical Management, or Die

John Gorman

I am continually amazed by how many health plans in Medicare Advantage (MA) and Medicaid still cling to restrictive, “Dr. No”’90’s-style managed care practices like pre-authorizations, referrals, and concurrent review. With massive policy changes looming in Medicaid, and the influence of Star Ratings in MA greater than ever, health plans may soon have a gun to their heads: evolve medical management from restrictive to supportive, or die.

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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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