Stand Tall Amongst Competition: Key to Success in Medicaid is Clear

Health plans diligently strive to be the best and first choice for delivering excellent healthcare services.  Many seek accreditation with various organizations such as the National Committee for Quality Assurance (NCQA), the Utilization Review Accreditation Commission (URAC), and, most recently, the Malcolm Baldrige National Quality Award (MBNQA) as confirmation they provide their members with the utmost quality healthcare services.

The $64,000 Question in Star Ratings

As we wrap up the 2nd quarter, health plan leaders across the country are beginning to ask their Star Leaders the $64,000 question:  “Are we on track to achieve a 4-Star Rating this year?”

CMS 2015 Spring Conference

Some important points came out of the Centers for Medicare & Medicaid Services’ (CMS’) Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast; the presentations and videos of the event can be found here in CMS’ Event Archives.  If you did not have a chance to attend or watch it live, please watch the videos for important changes pertaining to many aspects of the MA-PD program.  Speakers addressed Part C and Part D call letter updates, policy and technical changes, Quality Impr

You’re Doing it Wrong in Care Management

An important paper recently released in the American Journal of Managed Care shattered the notion that care management can save money on high utilizers. The article reviewed recent studies of the effectiveness of health plan care management programs and found that, while many studies show significant savings, more rigorous studies concluded that savings were “limited or nonexistent.”  Mind. Blown.

19 Lessons from 19 Years

Nineteen years ago this week, I left the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS) and the Office of Managed Care, to launch what would become Gorman Health Group. Time has flown, the company has grown, and my backside sewn with hard lessons about our industry and government health programs. Here are 19 lessons I’ve learned in those 19 years.

Next Generation Accountable Care Organization

With the NextGen model, the Centers for Medicare & Medicaid Services (CMS) is attempting to respond to some of the criticisms of the first two Medicare ACO models: the Pioneer demonstration program and the Medicare Shared Savings Program (MSSP) authorized under the Affordable Care Act (ACA). CMS says that the NextGen model represents:

The Risk in DIY: CMS Mandated Material

“Do It Yourself”, or DIY, has been the rave for years now.  From social media sites like Pinterest to television networks like HGTV, Americans have become fond of this philosophy.  Now, I am a big believer in being self-sufficient and must say that I have been sucked into marathon viewings of DIY shows often (Nicole Curtis of Rehab Addict is no joke!).  And, while I have seen my share of success stories, more often than not, I see DIY projects result in complete frustration from those attempting to DIY and very costly mistakes.

The Medicare “Doc Fix”

The “doc fix,” as just passed by the House of Representatives, would fix the annual sustainable growth rate (SGR) calculation by eliminating it.  The SRG was enacted nearly 18 years ago as a way to tie physician compensation under Medicare to the growth in the national economy.  It has never worked well, and Congress has had to override it 17 times to prevent sizeable cuts to Medicare’s physician payment rates.  The current SGR cut is about 21% and will take effect March 31 of this year.

Is the “NUNCMO” Nightmare Keeping You Up at Night?

The recent MAPD Help Desk Memo, dated 3/3/15, advises that on March 8, 2015, “The Centers for Medicare & Medicaid Services (CMS) will be performing a clean-up to process “73” transactions that contain NUNCMO (Number of Uncovered Months) value from the extraneous NUNCMO row that was removed in Phase 1 multi-phase NUNCMO data clean-up which occurred on March 23, 2014.  The effective start date of this transaction will be the preceding Part D enrollment start date.”