Topic: Compliance

Why Do We Make Simple Things So Difficult?

Aaron Eaton

Time and time again, we encounter “the coolest workarounds” ever invented within the government programs space. Said a different way, we encounter staff who are stuck inventing ways to accomplish the regulatory burden upon their shoulders when they don’t have the right processes and tools to efficiently do their job. The manual effort and workarounds almost get the job done but ultimately leave the plan short of their end goal. This phenomenon is not just seen in one operational area but is commonly experienced across multiple disciplines within the health plan.

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Tag, You’re It…RADV Selection Has Begun

Jessica Smith

The data submissions have been completed, and the Risk Adjustment Data Validation (RADV) selection process has begun. Are you prepared for what the RADV has in store for you? In April 2016, the U.S. Government Accountability Office (GAO) released a report titled, “Fundamental Improvements Needed in CMS’s Effort to Recover Substantial Amounts of Improper Payments.” This report is quite telling about the improvements needed to strengthen payment recoveries during a RADV audit. John Gorman highlighted in a previous blog, “[the Centers for Medicare & Medicaid Services] CMS is on pace for its most aggressive enforcement year ever.” So if you are one of the lucky plans that has an Affordable Care Act (ACA) plan and a Medicare Advantage (MA) plan selected for the RADV audit, my hat’s off to you because you are about to experience not one but two risk adjustment audits this year.

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An Important Component of MACRA: Quality Measures Development Plan

Olga Walther

The Centers for Medicare & Medicaid Services (CMS) recently released a proposed regulation that will implement the payment incentives through the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). An important component of these new incentives is the Quality Measure Development Plan (MDP), which CMS finalized and posted this week. The purpose of the MDP is to create a strategic framework for the future of quality measure development to support MIPS and advanced APMs.

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50/50 Just Won’t Cut It – You Have to Commit 100%. The Top 5 Components for Successful, Compliant, Committed Operations

Julie Billman

If you weren’t able to make it to the Gorman Health Group 2016 Forum this year, you missed a dynamic time. More than just relevant topics, it included engaged participants who added a wealth of depth to our discussions. The topic garnering a lot of audience participation was “Can Operational Efficiencies and Compliance Co-Exist?”  The struggle to align the two is real and takes constant, diligent effort, but the success it can create is priceless.

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3 Key Aspects from State of Compliance

Regan Pennypacker

They say people fear public speaking more than death. I can tell you from public speaking experience, it is far preferable than death (though if you could bring me back like the red witch did Jon Snow, that could be one heck of a ride). Having an audience of friendly faces is also a huge help when presenting. Today, I share highlights from a recent speaking engagement on the state of compliance. For the sake of time, I boiled it down to three key sections: audits, readiness initiatives, and compliance reviews. Read more

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Takeaways from the Gorman Health Group 2016 Client Forum

John Gorman

The Gorman Health Group 2016 Forum concluded last week with over 200 of our closest clients and partners. There was great news and rough news, so here are a few takeaways: Read more

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CMS Largely Holds Firm on Most Proposed MA Payment & Policy Changes for 2017

Olga Walther

On April 4th, the Centers for Medicare & Medicaid Services (CMS) issued the Final Notice of Methodological Changes for Calendar Year (CY) 2017 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies, and 2017 Call Letter. This is the final notice of changes in rates of payment and overall policy.

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