Topic: Part D

An “October Surprise” in Medicare Advantage Star Ratings

John Gorman

Each year, one of the most anticipated announcements in the Medicare Advantage (MA) industry is the Star Ratings and program technical guidance for the coming year from the Centers for Medicare & Medicaid Services (CMS). This year’s includes an “October Surprise:” a little-known methodological change that could force dozens of 4- to 5-Star-rated plans to lose their hard-fought bonuses and rebates.

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Keep the End in Mind as 2017 Readiness Approaches

Wayne Miller

According to Author Stephen Covey, in his book The Seven Habits of Highly Effective People, you should “begin with the end in mind.” This means to start with a clear understanding of your destination so you know where you’re going and understanding where you are now so the steps you take are always in the right direction.

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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.

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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.

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CMS Announces Expansion of the Medicare Advantage Value-Based Insurance Design Model

Jean LeMasurier

The Centers for Medicare & Medicaid Services (CMS) announced plans to expand the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model to more states and more conditions in 2018 without the experience of the first year’s launch, which begins in January 2017. The schedule underlines the Administration’s goal of rapidly expanding the use of innovative payment and delivery models that emphasize quality and good outcomes rather than volume of services. VBID models have been used in the private sector to better manage the costs and care of persons with high healthcare needs and the Medicare population, which has the largest number of persons with chronic care conditions, and offers the potential to see even better results for more people.

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Lessons on the Audit Front

Caron Wingerchuk

The regulatory scrutiny continues. The Centers for Medicare & Medicaid Services (CMS) 2016 Compliance and Program Audits are in full swing, and it is readily apparent plan sponsors must be “audit ready.” CMS’ intent to hold plan sponsors accountable to comply with Medicare standards and ensuring beneficiary protection is evident. Plan sponsors must be ready to take the test.

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Meeting CMS Halfway: The 2016 Audit and Enforcement Conference

Regan Pennypacker

On June 16, the Centers for Medicare & Medicaid Services (CMS) held their third annual Medicare Advantage & Prescription Drug Audit and Enforcement Conference and Webcast. At the heart of this conference is the CMS Program Audit. Agency experts as well as Sponsor participants presented to an in-person and webcast audience on expectations, process enhancements, upcoming developments, and more.

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