A Christmas Wish List for Claims

Here’s what I am wishing for all our health plan clients….an uneventful start to the 2015 Plan Year. By that I mean that all the prescription claims that should adjudicate without rejecting actually do, and the claims that should not pay, reject as expected. Either the beneficiary leaves the pharmacy with their medication or the pharmacist is alerted that there is a potential problem with the dose of the medication. Here are some of the issues that we have found from our reviews:

Federal Study Raises Questions about Access to Care for People Gaining Medicaid Coverage under the Affordable Care Act

Federal investigators said in a new report that large numbers of doctors who are listed as serving Medicaid patients are in reality, not available to treat them.

Patients select their physicians from a list of providers associated with each Medicaid health plan. The investigators, led by the inspector general, Daniel R. Levinson, called the doctors’ offices and found that in many cases the doctors were unavailable or unable to make appointments.

Medicare Secondary Payer – A Simple Process with a Big Impact

We’ve heard many organizations say, “We do MSP” or “MSP, it’s easy, we’ve got it covered”. MSP processing may not be rocket science but it’s a regulated process with steps that need to be executed correctly. The MSP transactions that your organization submits directly affect the monthly payment to your Plan and impact your financial reports.

Medicare and Exchange Risk Adjustment: Data Quality Matters

Plans/Issuers participating in the Exchange may think they have dodged a bullet because HHS has stated payments will not be adjusted during the first two years of the program as a result of RADV audits. However, other remedies such as prosecution under the False Claims Act may still be applied to non-compliant issuers (health plans).

Medicare Advantage Rates for 2016: Chanel No. 5 or Another Unicorn Fart?

This week CMS issued a surprise announcement on payment rates for Medicare Advantage in 2016.  The 2.02% increase is in line with projections we have been using for 2016, and is also consistent with other projections for Medicare FFS per capita cost growth.  But there should be no confusion: this is NOT the final rate, and this will either end up smelling like Chanel No.5 or another

Best Practices in Medicaid Claims Administration and Oversight

Every Medicaid operation needs high-performing claims administration. With strict medical loss ratios as required by healthcare reform, ongoing regulatory changes, timeliness, and payment accuracy relevant to provider pricing and benefit administration, covering operating costs poses significant challenges. Claims adjudication must be efficient and cost effective.