Current Trends For Payers

As more and more provider organizations enter into risk-sharing agreements, provider engagement programs are experiencing a surge in participation. Provider engagement programs improve the collaborative relationship between plans and providers to keep documentation up-to-date for CMS submission. It's essential for plans to offer a variety of delivery methods to suit the provider's practi...

NLP is an AI technology that is being used in healthcare IT for clinical documentation and medical coding. For medical coding, the program identifies diagnoses codes for HCC risk adjustable categories and flags it for a medical coder to review.  In robust medical charts that span up to thousands of pages in length, this enables coders with an automated way to identify diagnoses codes for review, h...

The intention for developing RADV audits was to develop a checks and balances to ensure reimbursement payment accuracy for Medicare Advantage Organizations (MAOs). There’s a history of CMS addressing payment accuracy in the Medicare space that dates back to the 80’s with the prospective payment system, PPS, and in the late 90’s with the Balanced Budget Act. The first RADV audit for MAOs wasn'...

There is a distinct advantage to enrollment technologies that are built specifically for CMS's enrollment and dis-enrollment regulations for Medicare Advantage and Part D.  One such specification includes the Application Programming Interface (API) integration of the CMS MARX database for the validation of eligibility for Medicare Part A, B and D. This is a unique function that allows for rea...

In this bonus episode, we welcome Stars expert, Megan Piotrowski, for an in-depth review of the recent Star Ratings release. On October 13, 2023, the 2024 Medicare Advantage and Part D Star Ratings were published on Medicare Plan Finder, largely representing Measurement Year 2022 data submitted to CMS.  We discuss the variables that influenced performance and why it's the second year in a row...

In this episode, we discuss the significant changes in the weight of Star measures, with the reversal of the 2022 Final Rule—many measures are returning to their previous weights. In response to the 2022 Final Rule, plans made significant investments to enhance the member experience in areas like customer service and developing digital platforms. The 2023 Final Rule has recently announced the remo...

As stewards of healthcare, health plans are responsible for managing the care of its members. This includes working with providers to capture member conditions accurately and comprehensively via medical charts and coding. This improves member outcomes and optimizes the plan's risk adjustment revenue which ultimately reduces member costs.  The scope of a prospective risk adjustment program is...

Best practices for Medicare and Medicare Advantage marketing and ads continue to evolve as greater numbers of seniors integrate digital activity, such as online news and Facebook, into their daily routines. While the goal of any campaign is to stop-the-scroll and convert, there are marked differences for achieving this across generational cohorts. Current research on Medicare markets tend to be ve...

CMS Interoperability and Patient Access Final Rule was developed to connect healthcare technology systems  so members can access their own data. All CMS-backed plans—Medicare Advantage plans, Medicare plans and ACA plans will be required to provide a patient access API, a provider API, and a payer-to-payer data exchange system. An API is an application program interface. An API is like an electric...

Technology is essential for today's care management operations, yet it's important to recognize that technology can either help or hinder the business. At its best, technology offers a reduction in the basic cost of doing business through streamlined workflows, automation and digital processing of administrative functions. But, at its worst, improperly designed technology can cause waste...

Social determinants of health (SDoH) is an important variable to consider when interacting with Medicare Advantage populations and as the healthcare system increases its use of digital technologies, such as telehealth visits, online prescriptions and digital communications, digital inequality is becoming a forefront issue within SDoH. Digital inequality examines populations to determine internet a...

“The goal is to support consumers in making informed decisions about which plan to choose” HEDIS hones in on 5 domains of care and measures whether the healthcare services rendered are actually improving conditions. The domains include effectiveness of care, access or availability of care, experience of care, utilization and resource use, and information about the health plan. In the domain of acc...

"The operating infrastructure of health plans rely on technology to expedite processes, scale, react quickly to regulatory changes and changes in the market." Technology debt is the cost of maintaining legacy software systems over time, often built in hard code. Updates and workarounds are expensive and the process for implementation is slow, but there's also the opportunity cost, b...

It’s hard to imagine a time when claims were submitted on paper. In 2003, Medicare required electronic submission of all claims via an electronic data interchange (EDI) for auto-adjudication. This means claims are processed, paid, and have a status update without human contact. Plans should aim for an auto-adjudication rate in the high 90’s, but some systems still struggle with this benchmark. The...

The concept of marketing segmentation isn't new, but what may be new, is the idea of generational segments within the Medicare market. Until recently, messaging to the senior market has involved painting  a picture of a peaceful and relaxing retirement. The Silent Generation, born between 1925-1945, responded very favorably to this messaging. And many of the older Baby Boomers, born between 1...

“One area of opportunity that a lot of health plans overlook, is taking a step back and looking at data that’s right in front of them with a new perspective..” The weight of the CAHPS survey has steadily increased over the years from 8% in 2014 to 32% of the overall Star Rating in 2021. Scoring is complex and there’s no one size fits all strategy. Two health plans the same size can do the same thi...

“It ’ s essential to accelerate the speed and time for gaps to identify them faster and proactively.” In the context of risk adjustment gaps, there are two overarching goals—to identify and accurately predict member conditions. To do this, health plans are reliant on the amount and quality of the data they have—primarily sourced from clinical and claims data. Plans need this data to produce intell...

“There’s a whole new range of possibilities for interacting with members through digital medium.” Marketing and communications in the Medicare Advantage space have evolved significantly in the past five years. Leaving behind a one-size-fits-all outreach approach, today’s best practice is messaging for a journey of one—targeting unique individuals or groups of individuals with similar needs. For ex...

"The only way to proactively identify and manage members with rising risk is by connecting care teams with real time data, analytics, and predictive models." In this episode, we explore the origins of care management, reactive versus proactive models of care, ways to coordinate care with real-time data, practical uses for data and analytics for diagnosis and treatment, as well as the ide...

“Maintain the spirit of continual improvement across the organization. Even though there is uncertainty, CMS rewards heavily for improvement year over year.”   2021 was the first year that CMS shifted away from clinical metrics and skewed the weight towards member experience. Health plans will need to address matters such as how well members understand their benefits, the ease of the experience su...