CMS to Monitor Access to Care, Defines Provider Network Adequacy Pilot Program

During the Centers for Medicare & Medicaid Services (CMS) Audit & Enforcement Conference & Webinar held on June 16, 2015, CMS provided a glimpse as to how the Provider Network Adequacy (PNA) Pilot Program would begin to monitor beneficiary access to care.

Game Changer: Key Reforms Proposed in CMS Medicaid Rule

You’ve got your nose to the grind stone working to meet all the waves of operational changes and requirements related to Medicare, Medicaid, Obamacare, and Health Care Reform – you literally don’t even have time to glance upward to the skies. Understandable. But it can cost you.

Financial Impacts of Unscrubbed Data

We have written many articles on the importance of maintaining accurate, reliable data. Data is everywhere and in many versions. Health plans need to be very careful to input only that information coming from a reliable source of truth. In government programs, that reliable source of truth is prescribed to be information contained within the government’s systems. “Scrubbing” data means reconciling against that reliable source of truth.

CMS 2015 Oversight and Enforcement Conference – Compliance Edition

The pessimist complains about the wind.  The optimist expects it to change.  The realist adjusts the sail. -William A. Ward

Those who had the opportunity to view or attend the Centers for Medicare & Medicaid Services (CMS) annual Audit & Enforcement Conference & Webcast better start thinking about which group of folks you will be a part of: pessimists, optimists, or realists.  In order to maximize your success, you best classify yourself in the realist bucket ‒ quick.

Takeaways from Accountable Physician Groups’ Annual Summit

Twice a year I get the honor of speaking to the California Association of Physician Groups’ (CAPG) annual summit and DC policy meeting.  CAPG represents accountable, capitated physician groups, and now has members in 39 states.  They’re always among my favorite speeches given how sophisticated the audiences are.  Here’s a few takeaways from my talk last week on “The Future of Government Programs”:

CVS Health is Serious About Growing its Clinic Business

CVS Health is serious about growing its clinic business. On Monday, USA TODAY reported that CVS Health plans to acquire Target’s pharmacy and clinic business for $1.9 billion.

Healthcare reform is producing a surge in newly insured people seeking care, and hospitals are under severe pressure to keep pace.

Implementing a new PBM? What you need to know.

Now that the smoke has cleared and the ink is dry on the formulary/transition and bid submissions, it’s okay for plans to breathe for a couple of weeks. Then—if you’re implementing a new Pharmacy Benefit Manager (PBM)—it’s time to roll up your sleeves and get started with conceptualizing and developing a road map for the next six months. It’s important to start early and work steadily to make decisions, create processes, and complete training.

HRADV: What you don’t know could cost you millions

Now that the 2014 EDGE server submission is complete, it will soon be time to audit a large sample of the data. Are you ready?

MLR: Don’t Miss Your Target

As the ink dries on 2016 bids for Medicare Advantage (MA) plans, one important question remains…What to do with summer vacation?  Drinks by the pool or a family trip to Disney?

Reality check!

Re-Evaluating Your Plan’s QI Evaluation and the Process Behind It.

This is the time of year when most plans have either completed, or are in the process of completing, their annual evaluation of their Quality Improvement (QI) Program Description and Work Plan for operating year 2014.  In the 12+ years I have worked for Gorman Health Group (GHG), I have seen a range of evaluations – from great evaluations to those that are just a couple of pages without content.  Let’s examine some mistakes and discuss some industry happenings that are often missed in the overall QI world.  Before we go on to discuss, let’s remind ourselves what the Centers for Medicare &am