CMS Gives EDPS Transition Some Breathing Room

CMS published the final call letter for 2018 yesterday, April 3, which included a welcome accouncement regarding the transition from RAPS to EDPS-based RAF scores. Citing numerous public comments on the subject, CMS throttled back the speed with which they plan to switch over to an encounter-based methodology. Instead of the blended rates originally contemplated, they announced that the more modest blend of 85% RAPS to 15% EDPS would be used in 2018, allowing more time to improve the reliability of the encounter data methods. While the RISE data collaboration study was not cited, we believe that the educational value of our study, along with our communication and advocacy of a more moderate approach by CMS, contributed to the confidence with which plans and other interested parties spoke up during the open comment period. Once again, we owe thanks to the folks at Avalere and Inovalon, as well as at AHIP, for the collegial and professional collaboration. Also, we want to thank the health plans that actively participated in our study for making this work possible. ... Read More


Why Does Risk Adjustment Need Technology?

Cognitive computing. Machine learning. Natural language processing. Two years ago, few people in the risk adjustment world had ever heard of these terms, and yet today they are becoming synonymous with risk adjustment. What are these technologies? Why do we even need them in risk adjustment? Traditional risk adjustment just isn’t efficient Traditionally, risk adjustment has been done manually: Coders comb through thousands of pages of patient charts and look for documented chronic conditions. But this isn’t the most effective or efficient process. It is time consuming and costly, and it doesn’t make good use of coders’ expertise. When I coded this way, It was frustrating that I had to spend so much time organizing my work before I could actually start doing it. Additionally, coders are often beholden to the slow and disruptive chart retrieval process.... Read More


Take Aways from RISE Nashville Summit

The 11th Annual RISE Nashville Summit continued the event’s tradition of yearly growth. The return to downtown Nashville was widely applauded by attendees, who were glad to be back near Broadway’s nighttime funk and fun. While festive, this year's event occurred in the wake of the new administration in Washington, D.C., and the healthcare themes surrounding the "repeal and replace" of the Affordable Care Act (ACA) cast a long shadow. In contrast to the upbeat, confident notes struck by last year’s keynote speaker Senator Tom Daschle, this year’s sobering keynote address by Howard Fineman, NBC/MSNBC political analyst, The Huffington Post Media Group global editorial director, and bestselling author, was an assessment of the pluses and minuses of our new president. Mr. Fineman's remarks indicated that the political alliances in power will seek to undo what Senator Daschle viewed as "irreversible” a year ago.... Read More


The Future of Medicare Advantage Provider Directory Requirements

By Shelley Segal, Principal at Medicare Compliance Solutions Through their first round of Medicare Advantage (MA) online directory audits, CMS has made it clear to health plans they will continue to aggressively identify and pursue instances of non-compliance by using a host of oversight methods. The results from the first round identified significant errors and many of the findings suggest that, at a minimum, there will be increased frustration from members and may significantly prevent access to care. The intent of the new regulations has been to afford beneficiaries and their care givers the protection and tools needed to make the most informed decisions about their healthcare coverage. My favorite analogy used thus far has been “What if your GPS was correct less than 50% of the time?” ... Read More


21st Century Cures Act: Medicare Advantage Impact

Review of Relevant Provisions with Expert Insight. March 2017. PULSE8 is privileged to bring you a summary of key Medicare Advantage program requirements within the 21st Century Cures Act. The bill was signed into law on December 13, 2016 by President Barrack Obama. Key Medicare Advantage Requirement Update Announcements: Issuance of Risk Adjustment Methodology Change Requirements (Expanded Detail Below) Order for a Temporary (through 2018) Stay of Plan Termination for 5-Star Program Underachievers Mandate to Allow Medicare Advantage Enrollment for ESRD Beneficiaries Implementation of a 3-Month Open Disenrollment Option for All Beneficiaries RISK ADJUSTMENT METHODOLOGY CHANGE REQUIREMENTS: Full Impact to be Phased-In over Payment Years 2019 through 2022 ACCOUNT FOR AN INDIVIDUAL’S TOTAL NUMBER OF CONDITIONS The Cures Act instructs the Secretary of Health and Human Services to improve the determination methodology of a beneficiary’s health status by factoring in the count of an individual’s total conditions. Furthermore, additional adjustments are to be applied as an individual’s total number of conditions increases. In practice, these changes will raise risk capitation payments, on a sliding, “HCC count per beneficiary” scale. Pulse8 foresees the development of a multiplier variable applied to an individual’s calculated HCC risk factor. The multiplier ... Read More


Winning in Risk Adjustment Five Steps for Health Plan Executives to Boost Coding Accuracy and Efficiency

Executive Summary An educational whitepaper, courtesy of Talix As the healthcare industry continues to shift from volume-based to value-based reimbursement, health plans are moving to change the way they do business. Recognizing that the cost of and incentives associated with traditional fee-for-service care are unsustainable, they are expanding their risk-based contracting efforts and seeking out more innovative ways to help providers deliver better care at a lower cost. For these payer organizations, accurate and timely risk adjustment is crucial to their success, as it has a direct impact on both plan revenue and care quality. The stakes are high and will only continue to grow. In today’s highly regulated, competitive and increasingly quality-focused market, payers must look to technology for cost-effective ways to expand their risk adjustment strategies. This white paper outlines the risk adjustment challenges health plans face and how technology-enabled data analytics can help plans tackle the problem and master risk adjustment through five proven steps for improved coding efficiency, productivity and accuracy. A Changing Marketplace... Read More


And the Money Kept Rolling In...

By Julie Mason, Principal, Medicare Compliance Solutions Several days ago, CMS announced the 17 Medicare Advantage (MA) plans subject to civil monetary penalties (CMPs) based on their 2016 audit findings. Until this year, the months of February and March in the MA space meant the application season. Now, based on CMS’ March 1 memo on CMPs, it is the application-and-enforcement actions season. Unlike past years, when CMS posted audit-based enforcement actions on a rolling basis throughout the year, they are now holding public notification of audit-based CMPs until the first quarter of the following year. (Although the CMS memo didn’t explicitly address timing of intermediate sanctions—e.g., freezing of enrollment and marketing—one should presume those actions will be imposed and announced on a more immediate basis.) This change in process allows CMS to evaluate all audits simultaneously (grading on a curve?), and that can’t happen until the end of audit season, typically November or early December. Add a couple of months for decision-making by CMS and the twenty layers of review required to issue just about anything, and that brings us to deep into the first quarter of the next year. So what does this mean for MA plans scheduled for a 2017 audit, or the many MA plans who suspect they’re on the 2017 audit hit-list? For one, it means that audited MA plans may not know until well after the audit closes whether they will be sanctioned. Following a CMS audit, there is often a fair amount of conjecture amongst senior management regarding whether the audit findings are significant enough to result in sanctions or enforcement actions. It’s not a fun exercise, and will be more protracted now that sanctions are announced in one fell swoop in the first quarter of the following year. For all MA plans, it means there won’t be a clear window on CMS’ approach to enforcement during the current year. And with a new and unpredictable administration in place (sort of), we will all be looking for clues. The March 1 memo stated that sanctions and enforcement actions for regulatory violations identified through sources other than audits would continue to be posted to the CMS website “within the normal timeframe after notification to the sponsor,” which typically has been within a few days or so. But non-audit related sanctions and enforcement actions are few and far between, or at least they have been up until now. ... Read More


RISE Survey on Member Engagement

Final Report on Consumer Engagement in Healthcare Now Available Many enterprises have the need to better engage members and patients. Enterprise goals may be straightforward, like collecting HRA data; or, more complex like driving smoking cessation. There are many ways to interact with members, and enterprises often know little about which approaches are most effective. The RISE Association sponsored a 2016 survey of its membership designed to break new ground by identifying benchmarks for member and patient engagement efforts, and the results are now in. Many groups focused on driving engagement are small. Among responding enterprises, almost half of all teams dedicated to consumer engagement have only 1 to 5 FTE’s and manage a median budget of $3.7MM/year. 12.2% top 20 FTE’s. The largest departments are more than 3x more likely to routinely use consumer marketing techniques, like A/B testing, than the smallest groups, which implies real differences in engagement sophistication and resources. Nearly 90% of respondents reported growing interest from senior leaders, while only half report growing budgets, so there is a need to do more with less. Respondents report that working with clinicians is 6x more effective than texting. This highlights the prevailing wisdom that physicians and care managers are the most effective influencers of decisions; and at the same time, it highlights the immaturity of text as a channel in healthcare communications.... Read More


Final Report: RISE RAPS EDS Data Study

The final report for the RISE RAPS EDS Data Collaboration Study is complete and available for download and distribution. This completes more than a year of work involving 8 MA Organizations with over 30 H contracts, covering more than one million members. It has been presented at a briefing on Capitol Hill in Washington D.C. by Tom Kornfield from AHIP, Dr. Christie Teigland from Avalere and Arati Swati from Inovalon. ... Read More


Listen to Webinar on RISE RAPS/EDS Data Study Report

Originally broadcast on February 21 at 1:30 p.m. ET Dr. Christie Teigland, from Avalere, and Arati Swadi from Inovalon, presented the findings from the RAPS / EDS data collaboration study. The collaboration, sponsored by the RISE Association, involved eight Medicare Advantage companies with 30 H-contracts and over one million MA members. ... Read More


ACA Marketplace Update

Filing extension may not be enough to keep insurers in individual market By Virgil Dickson | February 21, 2017 Modern Healthcare Article Health insurers are pleased the Trump administration wants to give them seven extra weeks to file rates for individual-market plans in 2018. But that move does little to settle their uncertainty about whether to offer plans at all. Their anxiety has been heightened by the Republican drive to repeal and replace the Affordable Care Act and by a pending House Republican lawsuit to block certain payments to insurers. Carriers say they need to know the rules of any new system before they can design plans and set rates.... Read More


What Do Voters for Trump and Who Have ACA Coverage Want?

Take a listen to this 5 minute video from a Kaiser Foundation focus group made up of people with ACA coverage who voted for Trump. It will sound awfully familiar to those providing qualified health plans in the marketplace, no matter which member voted for any particular candidate.... Read More


ObamaCare: How Will We Repeal and Replace It?

RISE presented a four-person expert panel that delivered a powerful, jam-packed 90-minute program on this hot topic. If you missed this one and have an interest in better understanding what is likely to happen, what is doable and what isn’t, then you should list to the recording of our webinar below. Lisa DiSalvo began with a thorough and compelling outline of proposals on policy currently under consideration, competing for favor in the jockeying process now underway in the new administration in Washington, D.C. Following her presentation was Richard Lieberman analyzing the political context and outlook for solving the challenge posed by the incoming administration that wishes to achieve many of the same goals as ObamaCare while spinning their own preferences into the recipe. ... Read More



Avalere analyzed data from eight Medicare Advantage Organizations (MAOs) representing 1.1 million beneficiaries in more than 30 unique plans operating across the country to understand the impact of shifting the determination of plan risk scores from the Risk Adjustment Processing System (RAPS) to the new Encounter Data System (EDS). Centers for Medicare and Medicaid Services (CMS) intends to transition gradually to EDS-based payments, starting with 10 percent of the payment based on EDS in 2016, increasing to 25 percent in 2017 and 50 percent in 2018. ... Read More


Kaiser Health Tracking Poll: November 2016

Health Care in the 2016 Election Many factors were important to voters’ choices in the 2016 presidential election, with over two-thirds of voters stating that the direction the country is headed (82 percent), jobs and economy (75 percent), and health care (68 percent) were a “major factor” in their vote. Majorities also cite foreign policy (63 percent), terrorism (61 percent), immigration (58 percent), and candidates’ personal characteristics (56 percent for Clinton’s and 54 percent for Trump’s) as “major factors.” When voters are asked to select the “biggest factor” in their vote for president, the direction of the country (31 percent), Donald Trump’s personal characteristics (15 percent), jobs and the economy (15 percent), and Hillary Clinton’s personal characteristics (12 percent) rank above health care (8 percent).... Read More


Repeal the ACA? Not So Easy to Do

Here is an interactive article posted by the New York Times on December 3, 2016. It does a nice job of succintly telling the story with visual, interactive cards. It begins... Republicans plan to repeal much of the Affordable Care Act, sometimes referred to as Obamacare. But the law’s parts are interdependent, and removing some aspects while keeping others will be very difficult.... Read More


Remarks by Andy Slavitt: Keeping Medicare’s Promise with MACRA

DECEMBER 1: CMS Blog Below are prepared remarks by Andy Slavitt, CMS Acting Administrator before the MACRA MIPS/APM Summit, Washington, D.C. on December 1, 2016. So, you decided to come to Washington to see what was new and how things might be changing… I am sure we did not disappoint.... Read More


Payment and Delivery System Reform in Medicare: A Primer on Medical Homes, Accountable Care Organizations, and Bundled Payments

Nov 17, 2016 by Susan Baseman, Cristina Boccuti, Marilyn Moon, Shannon Griffin, and Tania Dutta Kaiser Family Foundation The Affordable Care Act (ACA) established several initiatives to identify new payment approaches for health care that could lead to slower spending growth and improvements in the quality of care. Many of these new delivery system reforms are currently being implemented and tested in traditional Medicare. This Primer describes the framework and concepts of three broad alternative payment models—medical homes, ACOs, and bundled payments—and reviews their goals, financial incentives, size (number of participating providers and beneficiaries affected), and potential beneficiary implications. It also summarizes early results with respect to Medicare savings and quality.... Read More


Has Healthcare Reform Failed?

October 25, 2016 By Kevin Mowll, Executive Director, The RISE Association News articles announce retreats of large insurance companies from the public health insurance exchange markets, leaving many geographic areas served by only one insurance company option, and ask whether "Obamacare" is coming unraveled. Other postings point to the financial losses that these companies have suffered.... Read More


RISE RAPS EDS Collaboration: Inovalon Presentation

The RISE technical business partner, Inovalon and their subsidiary, Avalere, conducted a RISE webinar on June 23, reporting their findings in the analysis of 2014 RAPS and EDS data for the RISE collaboration. Their slide presentation is provided below: ... Read More


HCC Coder Survey: Profile of the Community

Early in 2016, RISE was approached by one of the association sponsors, Apixio, about conducting a survey of the HCC coder community. They wanted a better picture of the way the coders work and the tools they use in their jobs. As a technology company, of course, Apixio was keen to understand to what extent the community is comfortable with and uses technology in their daily jobs. RISE felt that this would be a useful survey as a mirror back to the HCC coding community about themselves and how their peers work. RISE supplied a mailing list of known HCC coding members for the purpose of inviting them to participant in this study. No marketing was permitted, just the profiling survey. Here are the results, which we promised we would share with you. We hope you find it of interest. Please let us know if you have questions and we will facilitate getting answers for you. ... Read More


RISE to Publish RAPS to EDPS Findings: Get the Scoop!

Those of us who participated in the call with CMS on Thursday morning heard that there are problems rolling out this transition from RAPS to EDPS and that CMS is closely focused on the issue. However, the healthplans included in the RISE RAPS to EDPS transition data collaboration are already way ahead on this topic. I am very pleased to announce that RISE will be publishing the results of our study shortly... Read More


Some Notes on the RISE Nashville Summit 2016

by Kevin Mowll, Executive Director of RISE. The bigger this annual event gets, the more difficult it is to summarize all the themes and nuggets of information. Perhaps the most useful place to start is with the keynote address by Senator Tom Daschle and some of the key ideas that emerged from the RISE Advisory Board meeting on Sunday, with thanks to Denise Tortora, our RISE / Healthcare Education Associates senior vice president of marketing for her notes, as well.... Read More


Open Enrollment Trends: Selected Statistics prior to the Final Enrollment Deadline

Data as of February 1, 2016 By Niall Brennan, CMS Blog Open Enrollment ended on January 31 with about 12.7 million Americans having selected plans through Health Insurance Marketplaces, including 3.1 million signed up through State-based Marketplaces and over 9.6 million through the platform. This does not include about 400,000 people who signed up on the New York ... Read More


CMS Found to Underpay for Duals with Chronic Conditions

A new analysis by Avalere finds that the Centers for Medicare and Medicaid Services (CMS) underpay Medicare Advantage (MA) plans for the costs of treating individuals with multiple chronic conditions. CMS uses a risk adjustment model to determine its payments to plans based on the expected healthcare costs of each plan’s enrollees. This process is known as risk adjustment. Avalere finds that CMS’s risk adjustment model under-predicts costs for individuals with multiple chronic conditions by $2.6 billion on an annual basis. CMS last updated the model in 2014 and has indicated that it will make changes to the model intended to improve its accuracy for certain Medicare-Medicaid “dual eligibles” in 2017.... Read More


News Flash! CMS Delays MA Sweeps Deadline by Three Weeks

We have a report that CMS extended the sweeps deadline by 3 weeks today. An executive at one of our RISE affiliated health plans met with CMS on Monday and explained the impact of the new 410 edit which caused a surge in rejects for 2014 RAPS data. CMS graciously decided to rescind the edit and allow everyone an extra 3 weeks. ... Read More


Is Ambiguity Our Friend Any More? (Redux of July 15)

By Kevin Mowll, Executive Director of the RISE Association HCC coding is a rigorous and demanding science, as I have learned from the coding workshops RISE has put on for coders. There are admitted “grey zones” where different coders come up with different conclusions on which codes are allowable and which are riskier bets. This ambiguity allows payers with higher tolerances to “sail closer to the wind” when it comes to policy decisions regarding HCC coding. It permits them to harvest more diagnoses and the revenue that they bring, which does all kinds of good things for maintaining rich plan benefits and lower premiums to compete in the market. Isn’t that a good thing? Well, maybe not.... Read More


ICD-10 Coding and GEMs

By Tim Buxton, MBA, CPC, CIC, COC, CRC, CCS, CHP The General Equivalence Mappings (GEMs) are a series of crosswalks created by CMS to help all organizations dealing with the ICD-10 transition translate from ICD-9 to ICD-10 quickly and easily. Unfortunately, many organizations have simply installed the GEMs into their coding or billing systems without understanding the implications of doing so. This is an invitation for inaccurate coding. The GEMs cannot be relied upon for complete and accurate coding. All coders should rely upon the ICD-10 book(s) or an officially certified electronic resource when selecting ICD-10 codes. Coders should utilize the process they were taught at the beginning of their training: seek the diagnostic terminology in the index, review the tabular for any special notes and to confirm code selection, then assign the code. There are nearly 70,000 diagnosis codes in ICD-10. The vast majority of these (over 90%) are different in their specific language than ICD-9 codes. According to the AAPC, a recent study noted 445 instances when a single ICD-9 code can map to more than 50 possible ICD-10 codes; and 210 instances where a single ICD-9 code can map to more than 100ICD-10 codes (Healthcare Business News, Nov. 2015). It is impossible for an automated system to accurately and correctly assign ICD-10 codes. CMS concurs with this recommendation. In their GEMs FAQ document, the organization notes that,... Read More


Keep Us in the Loop!

Have you changed jobs? Changed titles? New phone number? You can edit and update your profile with RISE so we can keep you informed about all the webinars and cool benefit updates for members. ... Read More


Where To Now on the HIX Marketplace?

It appears that there is a popular backlash against the reforms that HHS wants to conduct in the HIX marketplace outlined in their proposed rules. The following Modern Healthcare article suggests that the overriding issue that the public is concerned about is achieving some kind of stable path for premiums and the elimination of the big swings from one year to the next. HHS, in contrast, is trying to impose some restrictions and uniformity like CMS did in the Medicare Advantage world: regulations around what a provider network can look like, standardized benefit packages (not just actuarial values), and so on. The payer community objects to such restrictions which, they claim,... Read More


CMS Comes Out with EDS Filtration Logic

CMS has just published the final version of the filtration logic for the EDS data submissions. This is the long-awaited set of specs for the risk adjustment community in Medicare Advantage plans. You should have this coming to you now via your HPMS system. Feel free to contact me if you do not have the pdf document and I can e-mail it to you. ... Read More


A Brief Introduction to ACO Quality Measures

Tim Buxton, MBA, CPC, CIC, COC, CRC, CCS, CHP December 14, 2015 Affordable Care Organizations (ACO’s) are much in the news; but what is an ACO, and how can we measure its success? ACO’s have been established as interwoven healthcare entities with the intent to coordinate high quality care at a cost savings. They treat traditional Medicare patients, and are compensated by sharing in the savings the ACO achieves for Medicare. One CMS measurement of an ACO achieving its goals are the application and requirement for reporting of Quality Measures. Each ACO must demonstrate that it has met certain requirements regarding the care and satisfaction of its patients.... Read More


The Health Insurance Exchanges RADV Audit Process

By Tim Buxton, MBA, CPC, CIC, COC, CRC, CCS, CHP. For health plans (insurers) participating in the Health Insurance Exchanges (HIX), one important aspect of the program is the Risk Adjustment Data Validation (RADV) audit. RADV audits have existed for several years in the Medicare Advantage program, but there are several important differences in the HIX (“Commercial”) sphere. While the 2015 Commercial RADV audits were indefinitely delayed and ultimately foregone, HHS has indicated its intention to begin ... Read More


Laura Sheriff from USMD Joins RISE Board

We are extremely pleased to announce that Laura Sheriff is joing the RISE Executive Advisory Board. Laura is Director of RAF/HCC Management in the Population Health Management department for USMD, a physician led medical group in Irving, Texas. This unique health care home consists of over 250 physicians and associate practitioners, 2 hospitals, 4 cancer treatment centers, and more than 50 primary care clinics serving the Dallas-Fort Worth metropolitan area. Laura's participation in the RISE Board expands even further the representation and active contribution of providers in the governance and strategic direction of the RISE association as well as the conference programs offered by our sister company, Healthcare Education Associates, who produce roughly 40 healthcare conferences each year. ... Read More


Gamification: The Realities of the Health Insurance Exchange Marketplace

I just returned from the fall Risk Adjustment Forum in Ft. Lauderdale with a greater appreciation of the perils of risk adjustment in the HIX marketplace in contrast with the Medicare Advantage world. Then right on the heels of that, we noticed the headlines in Modern Healthcare that United HealthCare is having second thoughts about remaining in the HIX game due to $425M in losses. Imagine that your HIX program invested a “chunk of change” in risk adjustment activities like you might under a Medicare Advantage plan... Read More


Risk Adjustment on the Health Insurance Exchanges

Tim Buxton, MBA, CPC, CIC, COC, CRC, CCS, CHP October 26, 2015 In early 2014, DHHS introduced the concepts of Risk Adjustment for the Health Insurance Exchanges (HIX). Despite the intervening months, there remain a large amount of confusion and some lingering questions regarding the details of this program. Risk adjustment exists in the HIX sphere (also known as Commercial or HHS Risk Adjustment) for the same purposes that it was instituted into Medicare Advantage: to protect against adverse selection and mitigate the financial impact of healthy versus unhealthy members. Without the incentive of risk adjustment, health plans have traditionally selected for healthier members, who cost them less. ... Read More


Insights from the HCC Coding Accuracy Workshop: Physician Engagement

I had the opportunity to participate in the RISE Risk Adjustment Academy workshops in Boston on October 21 and 22. Both workshops were great and I found myself taking a lot of notes. As I absorbed the information from the HCC Coding Accuracy program in particular, I realized some insights about HCC coding that were new and exciting to me. One of the ideas was about the frequent disconnect between physicians and coders. Others brought up this topic before but it received extra attention in our workshop and was clarified for me by Donna Malone, one of our terrific faculty members from the Tufts Health Plan in Boston. The physician mind is focused on the associated process of evaluating, treating and managing the health conditions presented by each patient. The chart documentation provided by the physician is all framed in the language of diagnostic phrasing and language... Read More


Update on RISE RAPS / EDS Industry Collaboration with Inovalon

Closing Off Contracting Shortly! The industry collaboration that RISE has pioneered with several healthplans is making significant progress with business partner, Inovalon, under Jason Rose's leadership. There are several MAOs now confirmed for participation in the joint study project, some in final contracting stages, putting the aggregated MA membership at roughly 500,000 and climbing. Given the CMS announcement that they plan to publish the final MAO-004 filtration guidance in December, we have taken a few more weeks to recruit as many healthplans into the project as possible. The project support provided by Inovalon has enabled us to continue discussions with plans that expressed interest and bring them onto the project. We will be wrapping up recruitment by approximiately October 31... Read More


Former Head of CMS Berwick Says, 'Things Will Never Go Back'

Medscape Multispeciality Interview: Don Berwick, MD, a pediatrician by training, has been at the very center of US healthcare policymaking for many years. He served as president and CEO of the Institute for Healthcare Improvement (IHI) before heading the Centers for Medicare & Medicaid Services (CMS). Then he entered politics, running for governor of Massachusetts in 2014. In this Medscape interview, Dr Berwick discusses these roles and his take on a variety of pressing issues in healthcare. Medscape: What do you think you accomplished as CMS administrator?... Read More


Top 10 Highlights from the Massachusetts Health Care Cost Trends Hearing

Check in with Rosemarie Day as she reports on the state of Massachusetts and how their evolving healthcare reform movement is faring. A former speaker at RISE California, Rosemarie has a distinctive authority based on her experience at The Connector in the original formation of the public insurance exchange several years ago. By Rosemarie Day | October 8, 2015 | Blog, Blog & Press Massachusetts led the nation in insuring more people and is now attempting to tackle its rising health care costs ... Read More


A Risk Adjustment Education Webinar Series from Richard Lieberman

The only comprehensive risk adjustment education series for health plans, exchange issuers, ACOs and risk-bearing provider groups from Mile High Healthcare Analytics A true deep dive into the critical issues facing risk adjustment programs today. This is not a high-level 101 version of risk adjustment, it is aimed at decision-makers looking for practical advice on how to optimize their operations quickly. Delivered online, this is the perfect series to fit into your busy schedule and to avoid expensive travel costs.... Read More


The Certified Risk Adjustment Coder (CRC)

The Certified Risk Adjustment Coder (CRC) is the only certification testing competencies for coders under all risk adjustment models. As risk adjustment payment models gain more momentum, it is important for coders to demonstrate expertise in diagnosis coding for proper risk adjustment determinations. Professionals with the CRC certification demonstrate proficiency with documentation review, determining conditions that qualify for coding, assigning the proper ICD-9-CM diagnosis codes ... Read More


Industry Collaboration on RAPS / EDPS Transition Project

RISE and Inovalon continue to receive great feedback on health plans interesting in participating in the project to quantify potential risk that helps prepare for an uncertain transition from a 100% RAPS to a 100% EDS-based system. The goal of this project is to collaborate as colleagues within an industry, in conjunction with the policy and regulatory oversight body of CMS, to better understand challenges in achieving transition from a 100% RAPS to a 100% EDS-based system. Further, to best achieve this transition, an Inovalon is providing a detailed comparison of analytical outputs for RAPS and EDS data. Inovalon will provide an aggregate national benchmark that will be formally published and shared with CMS leadership in addition to providing individual health plans with their plan-specific analyses. If you are interested in joining the project or would like more details, we are actively seeking additional health plans to participate over the next few weeks. Please contact Kevin Mowll or Jason Rose for details:... Read More


The Fourth Martin L Block Award for Clinical Innovation & Excellence

At the RISE Nashville summit in March, 2016, our third special recognition award was presented in an annual recognition for clinical innovation and excellence at the RISE national program. The 2016 award winner was Dr. John Broderick from Landmark Health in Albany, NY... Read More


Is There a Benchmark for HCC Prevalence in Medicare Advantage?

I received an inquiry from a Medicare Advantage plan asking if I knew of any resource that would show the prevalence rates of HCC codes among Medicare Advantage populations. The notion was to obtain something as a benchmark against which a plan could gauge their own prevalence from risk adjustment work for reasonableness. ... Read More


How to Choose an Initial Validation Auditor

The Health Insurance Exchange Marketplace has already pre-sented a number of challenges to the Qualified Health Plans (QHPs) or issuers on and off the exchange. The latest obstacle to overcome is the Initial Validation Audit (IVA) and the required selection of a qualified IVA vendor. The intent of the IVA, quite simply, is to ensure that the membership and risk adjustment information being sent to HHS for payment is accurate and com-plete. The purpose of this white paper, therefore, is to help QHPs know what to look for (and what to avoid) when selecting their IVA vendor.... Read More


Hewitt Moten Memorium

We lost a great friend when Hewitt Moten passed away suddenly. A frequent speaker at many Healthcare Education Associates conferences and an active member of RISE, Hewitt brought enthusiasm and intelligence to any room. Through his presence and charisma, he contributed greatly to a sense of community among the risk adjustment professionals. Along with so many of our sponsor partners, RISE and Healthcare Education Associates want to express our wishes of consolation and comfort to Hewitt's family and friends. Together we are sponsoring a memorium drive to support the future education of his two surviving daughters. If you feel called to contribute, please click through to the following website to make a donation to that fund. ... Read More


RISE Industry Collaboration on RAPS to EDS

Today we broadcasted a webinar that presented the RISE Industry Collaboration on the Medicare Advantage migration from a RAPS-based method over to an encounter data system (EDS) for creating the Risk Adjustment Factor (RAF Score) beginning in 2016. This collaboration is an industry-wide effort to gage the effect of switching to an EDS method and how that impacts the CMS premium levels for MAOs. Inovalon has offered to serve as the technology partner supporting this analysis, and our presentation today walks the audience through the purpose and methodology proposed. We aim to identify MAOs that want to participate by August 31 so we can commit the resources to conducting and completing the study by the end of December this year. ... Read More


Dear Doctor: the OIG Thinks We Owe Them $12.2 B

The Department of Health and Human Services has done some numbers on payment accuracy for federal programs. Well, "inaccuracy" is actually what they were talking about. Among a short list of "high-error" programs, Medicare Advantage Part C gets tagged with an 8.5% improper payment rate, which translates into $12.2 B estimated for payment year 2014 (down from their estimated 15.4% error rate in 2009). ... Read More


Is Ambiguity Our Friend Any More?

I have heard from some plans that they relish the flexibility that ambiguity grants them to “sail closer to the wind” when it comes to policy decisions regarding HCC coding. It permits them to harvest more diagnoses and the revenue that they bring, which all kinds of good things for maintaining rich plan benefits and lower premiums to compete in the market. Isn’t that a good thing? Well, maybe not.... Read More


News Update on CMS RADV Findings

Center for Public Integrity Publishes Latest News on RADV Audits Fred Schulte published the most recent article in his continuing series regarding the Medicare Advantage risk adjustment data validation audits. Check out the article: Based upon the results from a Freedom of Information Act filing and subsequent court order, it appears that CMS has released some information that previously was unavailable to the public regarding four healthplan audits, in addition to one recently released regarding PacifiCare of Washington. The key issue here is the CMS findings regarding the failure of chart audits to validate the diagnosis originally submitted to CMS in RAPS data. ... Read More


RISE Sponsor Directory

I have been asked this question several times. We compiled the attached directory so you would have access to that information at your finger tips. All you need to do is click on this link and you can download the directory. We will update and revise as changes occur, so keep checking in with us: ... Read More


Fred Schulte Asks, "Why Not Extrapolate?"

If you have missed his series of articles in the Center for Public Integrity website, you will want to make his acquaintence with his appearance on an National Public Radio article (see link below). I received a call from Fred last week and we explored the issue of extrapolation penalties for Medicare Advantage RADV audits. In short, Fred's contention is that there is "upcoding" of procedure codes for FFS Medicare billing that is subjected to OIG audits and subsequent extrapolation penalites, which should be the same standard applied to diagnostic "upcoding" under Medicare Advantage. This means that any errors discovered in a RADV audit would be subject to a penalty that is extrapolated across the whole population: chart audit confirmation of diagnostic codes would have zero tolerance for non-validation. ... Read More


CMS Pushes Ahead on Value-Based Payment

See the video of the Modern Healthcare interview with Dr. Patrick Conway, CMS Chief Medical Officer and Assistant Deputy Director. He articulates the CMS accelerated and crystallized vision of practice transformation. The commentary includes the topics of diffusion of these methods into Medicaid and the private sector, as well as the evolving ACO model. There has been some big fallout of ACOs, but he indicates that it is expected that a certain failure rate is inherent in the innovation process. Good interview. Check it out.... Read More


Best In Class Case Study

The case study I cited in my blog below, called "Where Coding Takes Us", appears on pages 4 and 5 of the whitepaper. The actual joint presentation of this case study by Lesley Weir from Censeo and Jennifer Pereur from Hill Physicians Medical Group, conducted on the second day of the RISE Risk Adjustment Forum in New Orleans on May 14th. Censeo has made a recording of this presentation available for download at the link below. It was very well received, based on the evaluations that Healthcare Education Associates collected, so I was not alone in my appreciation. It is worth mentioning that both Lesley and Jennifer are members of the RISE Executive Advisory Board, Lesley having been a longstanding member for many years and Jennifer, our newest board member. ... Read More


CMS RADV Q&A Document

I noticed the link to the CMS RADV Q&A that Tam Pham mentioned today in her webinar presentation on CMS RADV PRocess Overview and Best Practice ... Read More


Where Coding Takes Us

Risk Adjustment and Controversy: Risk adjustment is a payment tool that is coming under greater levels of scrutiny, particularly given some recent journalism that presented a very slanted view of the practice as it relates to the popular Medicare Advantage program that provides health coverage to roughly 30% of Medicare beneficiaries. While this series of articles is critical of the health insurance industry, it mixes a string of worthwhile and valid points with a large dose of bad information and invalid accusation ( Putting this into perspective requires more than tough soundbites. It requires some understanding of what the government and the industry are really trying to do and how they are going about it. ... Read More


RFI Efforts

We have had several health plans come to us asking for some help, not only with their RFPs for certain services, but also for conducting the initial RFI search process. That only makes sense. Our sponsoring vendors are happy to receive inquiries that invite discovery about the array of services they offer. While most of our sponsors concentrate in risk adjustment or Stars-related services, they have many other capabilities beyond that which are not always evident in our grid of services we post on the RISE site. So by all means, ask and we will do our best to assist you in your due diligence process for whatever outsourcing needs you have. As momma used to say, "If you don't ask, you're never gonna know". ... Read More


Medicare Advantage Money Grab: More whistleblowers allege health plan overcharges

Jim Swoben and I have been exchanging LinkedIn postings. We agree that, where there is fraud involved, let the hammer fall. However, where this series of articles by Fred Schulte goes involves some expanded definition of what is fraud and what is appropriate risk revenue management. That is where we are going to disagree about this, as Jim and I have discussed. So let's first get our terms and definitions straight. Fraud involves intentional and knowing extraction of funds to which you are not entitled, perhaps even through careless negligence as a responsible and accountable player. ... Read More


Redefining Member Engagement

Today, it is especially critical for Health Plans to develop a solid plan and execution strategy for driving member engagement and loyalty. Health Plans acknowledge that it is more cost effective to retain first year members as opposed to enrolling new members. In order to increase member retention rates, it is imperative to begin to effectively engage each member at the point of enrollment. In-home health assessments are typically the first engagement effort Medicare Advantage Plans provide to their members, post-enrollment. These health assessments are not only focused on collecting ... Read More


Capitated Doc Is Indicted in First MA Upcoding Criminal Case in S. Fla.

If you have been sleeping under a rock, you may not be aware of this risk adjustment legal case in Florida. Otherwise, you are wondering how it will turn out and what it will reveal about what really went on in Del Rey, Florida. The question is really about what was done by whom, where were legal lines crossed and who all is going to end up paying the piper. ... Read More


News Flash: Booking Hotel Space for New Orleans Risk Adjustment Forum

Due to the popularity of the Risk Adjustment Forum for Health Plans the Roosevelt New Orleans has sold out, thus an overflow room block been established. Do not delay book your room today as the overflow block will sell out rapidly. The overflow hotel is located just blocks from the Roosevelt. ... Read More


Another Resource for Preparing for the AAPC CRC Exam

RISE fully supports the new AAPC certificate program for risk adjustment, the CRC credential. Of course, AAPC provides study and preparation tools. We also want you to know that there is a program offered by Medical Audit Resource Services, Inc. (MARSI), a leader in HCC coding, auditing and consulting services. They provide a very thorough and comprehensive online certification course in HCC coding and auditing. This course will also prepare students for the CRC exam. The curriculum contains approximately 40 hours of instruction, training materials, worksheets, quizzes and tests.... Read More


RISE Nashville 2015 Hit a Home Run!

What a pleasure to report on last week’s event at the Gaylord Opryland convention center! First, it was the largest event in HEA’s 9 year history featuring RISE. We had over 850 registered in contrast with 600 last year and 450 the year before. Needless to say, we were thrilled with the turnout. Aside from scale, however, what really stood out was the content and speakers in a combination of general sessions (chaired by Nathan Goldstein from Censeo Health) and four concurrent breakout sessions that covered several themes ... Read More


Marketing & Sales 2015 Summit

The 8th annual marketing and sales summit was well attended at the Sheraton downtown Nashville. The buzz of appreciation was definitely there! We had a great set of speakers and panel discussions, plus a two-track structure breaking out into marketing topics (chaired by Gene Devine from Cavulus) and sales (chaired by Brooke Ivey from the Bloom Insurance Agency). There were so many provocative and stimulating presentations that stood out as memorable, not the least of which were some noted below. I was only able to be in one place at one time, so I intend no slight to those not mentioned. Not the Same Old Game... Read More


Is There a Grey Zone in HCC Coding?

In an insurance world where financial underpinnings are tied to risk, the industry tries to create a science of risk assessment (in the generic sense) so they can price against it with confidence. This has worked historically for life insurance, for example, and in the indemnity health insurance markets, as well. But in today’s health care world, there are points of confusion about risk adjustment coding used to calibrate premiums, as in Medicare Advantage, or to redistribute them, as in the health insurance exchanges. When I mention the idea of “areas of grey” in risk adjustment coding, this is not to say that the coders I met are terribly confused. ... Read More


Is FFS the Benchmark for Coding Accuracy?

Risk adjustment is taking some heat. Approaches pursued by Medicare Advantage Organizations (MAOs) receive criticism voiced by several actors, not the least of which are in governmental oversight. One of the concerns voiced is that there is a significant difference in the amount of diagnostic codes associated with members of MA health plans in comparison with Medicare beneficiaries still in Original Medicare.... Read More


Health Insurance for the Poor Sometimes Trumps Politics

The editorial board of the NY Times posted this article highlighting the ideological tensions that have yielded in 28 states but not in the other 22 over the issue to expand Medicaid to the poor. While "Obamacare" has been a litmus test to separate the Reds from the Blues in so much political drama recently, several Red states have found ways to directly overlook the schism in the interest of the low income citizens.... Read More


AAPC Risk Adjustment Certification Launced

RISE Supports the AAPC's New Certificate The large national coding certification company has launched its latest certificate program, risk adjustment coding. For those involved in risk adjustment coding for some time, the medical coding certificates for provider office practices and other settings did not fully embrace the work they were doing. Now a standardized program of study and preparation is available through AAPC, including an online training... Read More


Does the Public Believe the Headlines?

This article is very disturbing. It is so easy to hate insurance companies and assume that this is all true without understanding the more complex story. I think we risk getting the "baby thrown out with the bath water" if we cannot spell out the value of risk adjustment and accountable care, compared with the failings of FFS healthcare. ... Read More


Smart Analysis of CMS Advance Notice

Pulse8 provides a valuable summary and keen analysis of the advance notice, featuring key insights they want to call to our attention. Their analysis parses out some critical factors that you really need to understand and to which you should pay attention. I recommend that you download this and spend some time digesting its crucial take-aways. ... Read More


Following Up on the 2016 CMS Advance Notice

Mintz Levin Alerts MA Organizations About Fraud Risks In the article written by Tara Swenson of Mintz Levin and published in the National Law Review recently, there are some worthwhile points to note. First, that CMS is now viewing the population of Medicare Advantage members as being no different than those beneficiaries in Original FFS Medicare, on the whole. Therefore, the logic goes, the aggregate payment level show be equivalent to the "old school" AAPCC model used before the year 2000 (BIPA era, for the old schoolers). This has some very important implications I will talk about below. ... Read More


Conference Discounts for Groups

Did I Mention Group Discounts for the Healthcare Education Associates' Conferences? If you open up the brochures, there is a note under the registration section that reads: PLEASE NOTE: Groups must register at the same time to receive the applicable discount. ... Read More


New Technology Demonstration

Tyrula’s Ask: We are looking for about 6 Medicare Advantage plans to confirm that the identified major sources of frustration can be solved with RAMP. We are looking for feedback to incorporate into the product. We’d ask you to use it for 4 to 6 weeks. We would start by identifying and getting member data for 2 to 4 practice sites. We’ll provide all the necessary training. After implementation, we require an hour a week to discuss the project and a few hours at the end of the program for structured feedback. ... Read More


The RISE Academy

Where can you get a comprehensive picture of how key areas of our accountable care movement work? Think about it. People that are new end up sitting next to someone else who has been there a little bit longer. Call it "sit-by-Susie" training. Is that really going to get people up to speed with a comprehensive view of what field they are working in and how their jobs fit in? What's more, when you hire people "with experience", what kind of confidence do you have that they really have the background you need? ... Read More


High Deductibles: How Does That Get Us to Triple Aim?

This is one of the things that really makes me cranky: high deductible health insurance plans. Haven't we learned anything in the last 30 years? Putting a big financial hurdle in front of healthcare consumers is the old indemnity trick that only makes sense in the short term. But what about achieving the longer term Triple Aim? Or does the prevalence of this type of benefit design now mean that, in our heart of hearts, our insurance companies really do not believe it? ... Read More


HHS Sets Goals for Expanding New Medicare Payment Models

Dr. Patrick Conway spoke at length about the direction CMS is taking to move the health care industry forward, weaning off of the reliance on fee-for-service reimbursement. The vision expressed lays out a spectrum of payment methodologies that ramp up towards more population health-oriented models. It is a progression through which CMS wants to navigate with providers, driving with the weight of the HHS checkbook to move the needle. The graphics published in the article are great visuals. ... Read More


Accountable Care: How Wide Is the Gulf?

A very smart fellow recently said to me, essentially, that ACOs that are founded on outdated legacy structures are doomed to fail. I have been thinking about this ever since. The real question he poses is whether some organization, purpose-built around a specific mission, can re-invent itself to fulfill a different mission or whether it is a prisoner of its own legacy. ... Read More


CMS' rewards programs can impact Medicare Advantage organization's bottom lines

Tom Wicka, CEO of Novu, writes an interesting article on Medicare Advantage plan design strategy that is worth an attentive read. His suggestions are well-taken. However, to fully appreciate why this is such a shift in CMS policy, it is worth stepping back for a moment to consider what this is all about. Let's face it: ... Read More


Final Rule on 2015 CMS Broker Compensation

This whitepaper is for Medicare Advantage health plans (MA) and those who are responsible for incentive compensation to external agent/brokers and internals sales reps. MA plans are required to follow marketing guidelines that outline how plans can market to Medicare beneficiaries. In this paper we review common challenges we see MA plans having with MIPPA rules ... Read More


Video: Dr. Atul Gawande on End of Life Care

Dr. Gawande speaks about a topic that eventually becomes highly personal and relevant in everyone's life. This short Modern Healthcare video is an interview with Dr. Gawande about his new book. ... Read More


What's Up with Healthcare?

Maybe healthcare is confusing and, for some, a mystery that befuddles. Sometimes it is hard to gain perspective. Yet in certain ways, these five reasons for optimism are ones that help to make it clearer and even worthwhile. Be sure to check Rosemarie's blogs from time to time. She is a frequent speaker at our HEA conferences and an expert on Health Insurance Exchanges. ... Read More


Update on CEU Credits for RISE Risk Adjustment Forum

AAPC and AHIMA Coders That Attended in Coral Gables. All H239 Certificates were sent out for the main conference, and the workshops, as well. However, due to some confusion, there are separate certificates for each. ... Read More


CMS Posts MAO-004 Report

Take a look at the attached report. It will give you the direction that the industry has been waiting for from CMS.... Read More


CMS Risk Adjustment Participant Manual 2006

This is an extremely valuable reference tool from 2006 for everyone involved in risk adjustment.... Read More


Open Enrollment: Election Results and What Really Matters

With the election results just one week old and the next open enrollment for health insurance exchanges only three days away, I took a look at whether these types of events have affected each other... Read More


OIG Posts 2015 Work Plan

... Read More


Coding and Documentation Takes Center Stage

RISE members are hungry for insights and guidance about coding in this world of risk adjusted health insurance. In particular, the coders are asking for opportunities to learn from those who have a grasp on deciperhing the complex and specific ... Read More


RADV Best Practices User Group Meeting 10/29

The first meeting took place, setting in motion a forum for exploring and sharing best practices regarding RADV programs. The scope of the user group embraces everything from risk mitigation, program design and strategies, to preparation and execution of the business... Read More


November 17-18 Risk Adjustment Overflow Hotel Announced!

Due to the popularity of the Risk Adjustment Forum the Westin Colonnade has sold out, thus an overflow room block been established. Do not delay book your room today as the overflow block will sell out rapidly. The overflow hotel is located just blocks from the Westin Colonnade. ... Read More


RAPS / EDS User Group Report

The RISE User Group aims to find out the answer to this question. It involves complexity that is difficult to appreciate until you dig in deeper. There are a lot of variables that cause different healthplans to come to different conclusions.... Read More


The HIX Marketplace Soon Opens for Business Version 2.0

Rosemarie Day comments on what to expect as we get to the second open enrollment season for the Health Insurance Exchanges Marketplace. The expectations are that this season will be different from last year in significant ways,... Read More


CMS RAPS Submission Dates

CMS Publishes the RAPS submission deadlines for dates of service (with thanks to RISE Sponsor, Advance Health)... Read More


RAPS / EDS User Group Sets Out a Course

CMS is using an encounter data submission (EDS) data extract to replace RAPS, and drive the calculation of HCC risk scores as well as related premium revenue for Medicare Advantage members.... Read More


2015 AEP: Final Checklist for Broker Compensation (recording available)

As the former Medicare guy, one thing I learned about broker distribution is that you need to really stay on top of the CMS regulations about payment. It can get out of hand and pile up, compounding problems year on top of year.... Read More


Sales Compliance Webinar: recording available

Our Medicare Sales user group put their fingers on CMS marketing and sales compliance updates. They identified this as one key area where a webinar would really help them prepare for the upcoming AEP season.... Read More


Call for RAPS / EDS User Group Members

RISE is issuing a call for members to join a user group to get our bearings on the impact of the CMS changes from a RAPS-based data submission process to an EDPS methodology. This is a practical work group that will gather data and develop shared metrics to compare the effects of the conversion on future CMS premiums. ... Read More


Exchanges and Narrow Networks

Rosemarie Day is blogging regularly about the world of Health Insurance Exchanges. This piece addresses the narrow provider network strategy: how it is being utilized in plan designs, how it plays out for consumers, and the implications going forward.... Read More


CMS Ponies Up More for Healthcare Innovation

Today, Health and Human Services Secretary Sylvia Mathews Burwell announced new prospective awardees to test innovative care models, bringing the total amount of funding to as much as $360 million for 39 recipients spanning 27 states and the District of Columbia. ... Read More


HIX Product Management & Marketing

Although marketing to individual consumers has been the essence of the Medicare product segment, this is a whole new game with the Health Insurance Exchange marketplace. The reformed market rules and zero-sum risk adjustment methodology is layered on top of a direct to consumer segment where most purchases are channeled through an online shopping experience.... Read More


Updated Review of 2015 CMS Rules for Broker / Agent Compensation

In the paper we describe the existing rules that have been tricky, which will be reinforced in 2015. We then dig into compensation examples which illustrate changes in 2015. Each example is linked back to the verbiage from the proposed rules and previous year’s rules.... Read More


Top 4 Lessons Learned in HIX Round One

The Health Insurance Exchange marketplace has gone through its first cycle of open enrollment and everyone is trying to read the tea leaves. Rosemarie Day is a national expert on this topic and has the “scars” to prove it from the early days of the Massachusetts foray into health care insurance market reform. ... Read More


Medicare RADV User Group

After talking with colleagues at our RISE Nashville conference as well as the risk adjustment forum in Chicago at the end of May, we were encouraged to create a user group for the risk adjustment leadership of Medicare Advantage plans. These representatives included plans that had been through a RADV audit as well as those who hadn’t yet.... Read More


CMS National Training Program Update for June 2014

The CMS National Training Program is celebrating its 18th year of excellence in providing consistent, accurate, and reliable information about the programs that are administered by the Centers for Medicare & Medicaid Services. ... Read More


The Risk Adjustment Forum for Health Plans

This event, set at the Fairmont Hotel in Chicago, was one of the most powerful and productive risk adjustment events I have attended: The presentations were strong and meaty with content The scope of the topics was geared perfectly to the target, including both Medicare and Health Insurance Exchange domains The questions and answers were often vigorous and plumbed deeper and more keenly than expected... Read More


CMS Publishes Rich Data on Disease Prevalence, Cost and Utilization

Today, the Centers for Medicare & Medicaid Services (CMS) is releasing its first annual update to the Medicare hospital charge data, or information comparing the average amount a hospital bills for services that may be provided in connection with a similar inpatient stay or outpatient visit. CMS is also releasing a suite of other data products and tools aimed to increase transparency about Medicare payments. The data trove on CMS’s website ... Read More


Medicare Sales User Groups

We got a lot of encouragement at our Medicare Marketing and Sales Summit in March to create a user group for the Sales leadership of Medicare Advantage plans.... Read More


Broker Commissions and CMS Regulations

Earlier in 2014, CMS proposed new rules for Broker/Agent Compensation. The proposed rules included a startling decrease to what plans could pay Broker/Agents for renewals. This initial proposal created a lot of concern about the adequacy of renewal commissions and what impact the change would have on the stability of agent / broker distribution channel. ... Read More


Mastering the CMS Program Audit Process Recap

Our recent Compliance and Audit Operations summit in Baltimore, Mastering the CMS Program Audit Process, headlined by CMS leadership and featuring Medicare Advantage health plan leaders, received an impressive turn-out and remarkable audience response.... Read More


CMS News Link

It is worth capturing this URL and looking it over from time to time. For example, here is some news for Medicare Advantage Plans: • Expanded prevention and health improvement incentives: The final rule expands rewards and incentive programs that focus on encouraging participation in activities that promote improved health, efficient use of health care resources and prevent injuries and illness.... Read More


HHS Update on Health Insurance Marketplace

HHS took stock of the Health Insurance Marketplace (HIX), reflecting activity through April 19, 2014. With all the speculation and political spin reported, depending on the biases of the source, it is good to have some reliable statistics on what has transpired so far. While it is still premature to make any iron-clad predictions, the preliminary information gives us something more concrete than the assumptions used to create the product offerings in the first place.... Read More


CMS Innovations Website

The Innovation Center develops new payment and service delivery models in accordance with the requirements of section 1115A of the Social Security Act. Additionally, Congress has defined – both through the Affordable Care Act and previous legislation – a number of specific demonstrations to be conducted by CMS.... Read More


Peak Health Solutions Webinar on the Impact of the 2015 Final Notice of Methodological Change on Medicare-Advantage Plans

The 2015 final notice is no slim read; CMS packed a lot into it, as they always do. The nail-biting and white-knuckled anticipation is over and now the red-eyed bid development process goes into hyper-drive. Richard Lieberman’s insightful comments help plans navigate each CMS nuance as they apply the rules to each individual contract. ... Read More


RISE Nashville 2014 Recap

The annual RISE conference in Nashville was attended by more than 600 people, about 50% more than last year, and garnered a lot of praise as a valuable and productive event. Healthcare Education Associates is still combing over the evaluations and the feedback to tease out all the comments and suggestions, but it is clear it was a big hit.... Read More


Review of 2015 CMS Proposed Rules for Agent/Broker Compensation White Paper

Keith Kraemer, President of EvolveSPM, produced a white paper for RISE members that teases out the regulations and makes them clearer and more understandable. He provides us with an insight into how they work as well as the pitfalls in understanding and making our broker / agent payment processes operational. ... Read More


Product Design, Pricing & Risk Adjustment on the HIX Recap

Product design, pricing & risk adjustment on the Health Insurance Exchanges (HIX) This was a perfect opportunity to gather together as the 2015 bid cycle is shaping up for the deadlines of March 15th for plan benefit changes and May 15th for rate filings: Comparing notes with one another on the financial planning picture for the Health Insurance Exchanges Taking stock of enrollment trends so far, despite a rocky start in many states... Read More


ACO Growth Summit Recap

The 2014 ACO Growth Summit conference (which just concluded on Tuesday) was well-attended and represented ACO players from coast to coast. I was particularly impressed by the active and engaged audience: they were clearly attending because they were intent on picking up some pearls of wisdom from the extraordinary speakers which included administrative leaders and physician groups from both Medicare and Commercial ACOs. ... Read More


Health Insurance Exchange Summit Recap

I am reminded of a famous Mark Twain quote, “Reports of my demise are greatly exaggerated”, when it comes to the public noise about the roll-out of the Affordable Care Act After two days of a powerhouse lineup of speakers and attendees, the RISE-Sponsored2nd Annual Health Insurance Exchange Summit, was officially closed this week in Las Vegas.... Read More


The New Face of RISE

RISE is getting a new start. We have had a huge success with the original focus on risk adjustment, revenue management and quality of care connection. And as we go along, we find that so many things are interconnected. It is bit difficult to draw a circle around those topics and hold them in isolation.... Read More


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Latest Posts

CMS Gives EDPS Transition Some Breathing Room

CMS published the final call letter for 2018 yesterday, April 3, which included a welcome accouncement regarding the transition from RAPS to EDPS-based RAF scores. Citing numerous public comments on the subject, CMS throttled back the speed with which they plan to switch over to an encounter-based methodology. Instead of the blended rates originally contemplated, they announced that the more modest blend of 85% RAPS to 15% EDPS would be used in 2018, allowing more time to improve the reliability of the encounter data methods. While the RISE data collaboration study was not cited, we believe that the educational value of our study, along with our communication and advocacy of a more moderate approach by CMS, contributed to the confidence with which plans and other interested parties spoke up during the open comment period. Once again, we owe thanks to the folks at Avalere and Inovalon, as well as at AHIP, for the collegial and professional collaboration. Also, we want to thank the health plans that actively participated in our study for making this work possible. ...
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Take Aways from RISE Nashville Summit

The 11th Annual RISE Nashville Summit continued the event’s tradition of yearly growth. The return to downtown Nashville was widely applauded by attendees, who were glad to be back near Broadway’s nighttime funk and fun. While festive, this year's event occurred in the wake of the new administration in Washington, D.C., and the healthcare themes surrounding the "repeal and replace" of the Affordable Care Act (ACA) cast a long shadow. In contrast to the upbeat, confident notes struck by last year’s keynote speaker Senator Tom Daschle, this year’s sobering keynote address by Howard Fineman, NBC/MSNBC political analyst, The Huffington Post Media Group global editorial director, and bestselling author, was an assessment of the pluses and minuses of our new president. Mr. Fineman's remarks indicated that the political alliances in power will seek to undo what Senator Daschle viewed as "irreversible” a year ago....
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Upcoming Conference


Qualipalooza: The 2nd Annual RISE Quality Leadership Summit 

This unique event incorporates three conferences presented side-by-side: the Star Ratings Strategic Planning Forum, the HEDIS Forum, and the CAHPS, HOS & Member Survey Forum. Register for one conference for an in-depth examination of a single area, or design your own event by opting for the all-access pass and choosing the sessions from each conference which correspond exactly to your interests.


Upcoming Webinar

The Impact of Quality Incentive Models in Medicaid Markets


Thirty-one of our fifty states now have Medicaid managed care, and several markets are expected to implement managed care in the next few years. More than $160B in Medicaid spending occurs through the Managed Care Organizations. As more and more states seek to do more with less, increasing accountability for health quality outcomes is placed on health plans. Join this webinar to learn the typical quality payment approaches states use, issues often faced by health plans under each model and what states are expected to do with payment models tied to quality performance in light of near term Medicaid reform efforts.


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