The policy analysis and guidance you need by the experts you trust, daily.
- After Hours
- Agent Oversight
- Brain Food
- Health Insurance Exchanges
- Part D
- Performance Optimization
- Policy & Health Reform
- Prospective Evaluations
- Provider Relations
- Risk Adjustment
- Sales & Marketing
- Star Ratings
- Cathy Aquino on Benefits are Submitted. What’s Top of Mind for 2019 Marketing & Sales?
- CMS Doubles Down on Member Experience – FAQs | Gorman Health Group Blog on CMS Doubles Down on Member Experience
- Regan Pennypacker on Latest Audit Enforcement Actions Issued by CMS
- Kathleen Chapman on 2019 Medicare Advantage Rate Announcement & Call Letter
- Michelle Juhanson on Latest Audit Enforcement Actions Issued by CMS
Topic: Risk Adjustment
As for many who are in the depths of risk adjustment, you may be just coming up for air after a whirlwind of changes that were outlined in the Centers for Medicare & Medicaid Services (CMS) 2019 Final Call Letter, midyear adjustments, final reconciliations for 2016/2017, and the September sweep slated for September 14, 2018. Just when you thought the chaotic waters were calming down, we now get to leap head first into Open Enrollment, and some may ask, “Open Enrollment – Who Me? Captain Chaos of risk adjustment? How does Open Enrollment impact my already chaotic world?”
While the $10.4 billion halt still looms over issuers, it’s clear it won’t be a credit rating issue for them based on latest news. Health plans and providers have been lobbying and vocal about the impacts this hold has on their members/patients who are enrolled in an individual or small group risk-adjusted commercial plan. It has been status quo for operational processes in hopes the payments get released in October when they are planned to occur.
As if the complexities around healthcare affordability couldn’t get more convoluted, the latest news from the Trump administration to halt approximately $10.4 billion in risk adjustment payments has grave impacts to the healthcare industry.
The importance of Healthcare Information Exchange (HIE) is at an all-time high that is continually evolving to improve the quality and timeliness of care for patients. Access to medical records gives those providing care an understanding of the patient’s health history. Typical information that can be found in a primary care medical record includes but is not limited to: Read more
Risk adjustment audit season is upon us. Some health plans are already in the thick of retrieving charts and starting reviews. Whether it’s a Medicare Advantage (MA) Risk Adjustment Data Validation (RADV) audit or a Health and Human Services (HHS)-RADV, one thing is true: being prepared is a must!
Risk adjustment at its highest form is nothing more than a calculation. The unique processes surrounding the operations to ensure accuracy of the calculation can be complex. The processes developed and utilized throughout most organizations are relatively similar, however, they are often times misaligned in their approach to operationalize these processes, in turn adding little value or even increasing audit risk. Good strategy and planning with poor execution and oversight lead to an inaccurate risk score calculation overall.
The Gorman Health Group 2018 Client Forum concluded last week in Las Vegas with over 300 of our closest clients and partners. As we enter our 22nd (!) year, we returned to the Red Rock Resort where a great time and shared learnings were had by all.