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
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
The 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.
360° Risk Adjustment: A Strategy for Success in the Value-Based Care Era
In this webinar, attendees will discover that when risk adjustment is treated as a priority – not just as an actuarial exercise – and brought into the organization’s long-term strategy, it can be properly leveraged as an asset to drive growth and advance the organization’s mission of keeping patients healthy. Risk-bearing entities who embrace a 360° approach to risk adjustment will outpace their competitors in the transition to value-based care models.