Industry Ducks Bullets in 2016 Medicare Advantage Rate Proposal

Friday, February 20th after close of business, the Centers for Medicare and Medicaid Services (CMS), released its 2016 Advance Notice of Medicare Advantage Payment, known affectionately as “the call letter.”

This one was the most anticipated in years, and the industry unexpectedly ducks bullets in it, in risk adjustment, Star Ratings, and elsewhere. It’s got a few unicorn farts in it, and a couple puffs of Chanel No. 5 as well.

Overview of Long-Term Care Services and Support for Seniors

The Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) delivers the first descriptive results from an in-depth study of Long-Term Care Providers.

The data comprised of surveys from interviews with adult day services centers,  residential care communities, and the records obtained from the Centers for Medicare & Medicaid Services on home health agencies, hospices, and nursing homes.

Risk Adjustment Data Validation (RADV) Audits Just Got Real

Last night the second-largest Medicare Advantage plan in the country, Humana, filed an SEC document detailing a US Department of Justice investigation into the company’s risk adjustment coding and data collection practices.  The investigation is an extension of a 2010 physician-led whistleblower action under the False Claims Act.  The company has over 3.2 million Medicare

CMS Releases Part D Drugs and Formulary Requirements

The long awaited revision to the Prescription Drug Benefit Manual Chapter 6 is hot off the press. Many of the changes have been published previously by CMS in Best Practice guidance or communicated in the course of CMS compliance audits.

CMS Releases the 2015 Audit Protocol: Critical Next Steps to Avoid Becoming A Casualty of Reasonable Expectations

On February 12th, CMS released the 2015 Audit Protocol. The question on everyone’s mind is – what does this mean for 2015? Well, it means a few things. Outlined below are some of the most impactful changes, as well as the “why” behind the change, and the trends that continue to emerge.

1. CMS has initiated a new audit cycle – this means that even if your Organization was audited in 2012, 2013, OR 2014, your Organization could be audited again this year.

Countdown to Final Submit

Today is the final day for current or potential plan sponsors to submit their Medicare Advantage and/or Part D application for a new contract or service area expansion (or service area expansion  for 1876 Cost Plans). By now, many of you have already hit final submit and are either celebrating or working on known deficiencies. Or, perhaps you are still waiting for documentation or a final quality check of your submission before you feel confident to submit.

In 2015 a Slap on the Wrist Can Be the Kiss of Death

It is truth that in the second term of Democratic administrations, scores get settled between Washington regulators and business partners of the Federal government.  2015 will be no different for our favorite agency, the Centers for Medicare & Medicaid Services (CMS).  It’s already on a pace for 2015 to be the toughest year ever in enforcement actions against Medicare Advantage plans.  And generally speaking, the regulatory bar is rising faster than anyone imagined.  Consider:

Review of ICD-10

The International Classification of Diseases 10 (ICD-10) is widely recognized as a diagnostic coding system that will replace ICD-9. Each disease within the ICD-10 has its own corresponding code as well as detail to include the signs and symptoms, complaints, and associated diagnostic procedure.1 The upcoming transition to the ICD-10 is being viewed by many as a sweeping transition that will present both opportunities and challenges for various healthcare organizations.

Medicare Secondary Payer (MSP) is all about the money.

Money going out as a result of paying claims as primary payer when it’s possible you should be paying as secondary payer. CMS reduces plan payments for members with MSP, shown on the Monthly Membership Report (MMR) as an MSP adjustment (reduction).

Kaiser Family Foundation & CCF Release 50-State Survey on Medicaid and CHIP

It’s time again for the release of the annual 50-state survey on Medicaid and CHIP enrollment, eligibility, cost-sharing and renewal policies conducted by the Kaiser Family Foundation’s Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families.