Topic: Risk Adjustment

Risk Adjustment Importance During Open Enrollment

Jessica Smith

Now is the time of year when everyone is preparing for back-to-school events and the upcoming holidays, but in that mix is the ever-so-important…Medicare Open Enrollment. Medicare Open Enrollment is an important time to keep or lose valuable members who may have been long-time participants or new to the plan in the last year. There are many reasons member retention is important, but one that is not often talked about it risk adjustment. Risk adjustment has many different types of models utilized to calculate a member’s risk score. The more consistent information you have about a member, the more accurate risk score can be calculated and will allow for an easier understanding of member gaps in care.

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CMS Withholds Critical Medicare Advantage Analysis; Why?

Jessica Smith

Controversy is brewing in the healthcare insurance community since the much anticipated Medicare Advantage (MA) analysis due to be released at the AcademyHealth annual research meeting was cancelled. Today, MA plans enroll more Medicare-eligible beneficiaries than Fee-for-Service (FFS). The desire to understand the needs and services these beneficiaries have and are receiving is great.

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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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Guidance on the 2016 HHS-Operated Risk Adjustment Data Validation Program

Jessica Smith

Last week, the Centers for Medicare & Medicaid Services (CMS) announced the 2016 Health and Human Services Operated Risk Adjustment Data Validation (HHS-RADV) would be conducted as a pilot year in the same aspect as the 2015 HHS-RADV. This announcement came two days after the final risk adjustment data submissions were due to be submitted to the EDGE server for 2016 dates of service.

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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 Transition from RAPS to EDPS

Jessica Smith

The comments have rolled in, and the concerns regarding the transition from Risk Adjustment Processing System (RAPS) to Encounter Data Processing System (EDPS) have been heard. The final Medicare Advantage Call Letter was released on April 3, 2017, and it contained a surprise on every page that was turned.

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The Sun Shines on Medicare Advantage Payments and Policy in 2018

John Gorman

Yesterday the Trump Administration released the final notice of payment policy for Medicare Advantage for 2018, and it was better than expected. It’s a rare ray of sunshine for health plans and their members since Trump took office with a vow to repeal ObamaCare, and confirms that Medicare Advantage (MA) is the only safe game in all of health insurance these days.

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