Topic: Risk Adjustment

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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DOJ Intervenes in Another MA Lawsuit, Putting Risk Adjustment Practices in the Hot Seat

Olga Walther

Risk adjustment has seen its share of action this year, with a sudden spotlight of alleged fraudulent risk scores by many insurers in Medicare Advantage (MA). Last Friday, we saw the latest escalation of these actions, with the Department of Justice (DOJ) filing yet another notice to intervene, this time in a California case brought about by whistleblower James Swoben in 2009.

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The New World of Data Submissions: Know Your Data

Jessica Smith

Even though the year has just begun, the healthcare industry is looking ahead to what the next four years has in store. The Centers for Medicare & Medicaid Services (CMS) released its 2018 Medicare Advantage and Part D Advance Notice and Draft Call Letter (“2018 Draft Call Letter”) on February 1, 2017. As a whole, the 2018 Draft Call Letter had minimal updates, however, there were important impacts to risk adjustment.

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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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