Medicare products are expected to be the fastest growing insurance sector over the next 10-years. At the same time, Boomers are transforming care delivery, from aging-at-home services to convenience-driven alternate sites of care such as retail clinics, telemedicine and wearables to anti-aging nutraceuticals. Opportunity abounds. What’s clear is the need to understand Boomers – what’s important to them, what truly matters to them, and why they do what they do – has never been more important. For marketers this means a shift in orientation from brand promotion to individual inspiration, from features and functions to emotional appeals that move people to act and engage. It’s about connecting with Boomers around personal, relevant motivations and deep, sometimes even unconscious desires, like freedom, happiness, renewed goals, or simply the ability to enjoy life. A quick snapshot of 75+ million Boomers ages 51 to 69: ... Read More


Find More, Spend Less, Take Control: Leveraging Technology to Improve the ROI on Risk Adjustment

Due to changing market dynamics, there is increasing pressure for risk-bearing organizations to improve the effectiveness of their risk adjustment programs. Several trends present pervasive challenges—for example, increasing number of risk-adjusted lives, rising coding intensity factor, and heightened focus on compliance. Risk adjustment departments are constantly being asked to do more with less. Organizations that can leverage risk adjustment as a strategic asset and effectively utilize technology will be best positioned to achieve accurate risk and revenue capture while simultaneously decreasing costs. Streamlining Risk Adjustment with Technology As organizations seek to modernize their risk adjustment operations, there are several high value technology initiatives they can explore. Rather than blindly reviewing charts across the entire membership, organizations can use natural language processing (NLP) technology on medical records to help identify risk adjustment gaps, both for additional HCC capture and for potential deletes. Health Fidelity has been able to consistently demonstrate with our clients that NLP-assisted coding delivers superior results as compared to human-only reviews, both when our clients are conducting the coding and when our coders provide the coding capacity.... Read More


Evaluating the Results of the Enrollment Seasons

The annual review and selection of health insurance for one’s self and family has become an American tradition. During these annual enrollment periods (AEP’s, but referred to under various names), employees, Medicare recipients, and those in the individual and family markets conduct their own variations of the due diligence necessary to assure they will be in the right plan in the coming year. While consumers are pondering their options, health insurers will spend millions in the attempt to attract, retain, and enroll new members. As we near the end of the enrollment seasons, Deft Research will be fielding major national studies geared to evaluate the degree of success these efforts have produced. The research season starts with “shopping and switching” studies published in the first months of the new year, looking at the individual and family plan (IFP) market and at the individual market for Medicare-related insurance. What to look for when diagnosing AEP results Here are some of the factors Deft Research will be tracking and evaluating in 2018. Timing of Consumer Shopping. In the past, the number of seniors ... Read More


Special Offer for Medicare Market Research

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FINAL REPORT Impact Evaluation: Medicare Advantage Transition from RAPS to EDS

Christie Teigland, Vice President of Advanced Analytics, is an expert in the design and implementation of statistical studies focused on comparative effectiveness, predictive analytics, and performance measure development and testing. She advises clients on research protocols designed to answer questions about intervention and treatment effectiveness, predict relative risk of adverse health events, and the impact of regulatory and system changes on outcomes, Star ratings and costs. Prior to joining Avalere, Christie served as Senior Director, Statistical Research at Inovalon where she managed performance measure development projects awarded by the National Committee on Quality Assurance (NCQA), URAC and other organizations. In 2014-15, she directed an impactful study investigating disparities in outcomes in dual eligible and disadvantaged Medicare beneficiaries. Dr. Teigland was invited to serve on the newly formed National Quality Forum (NQF) Disparities Standing Committee in 2015. She served as co-chair of the Pharmacy Quality Alliance (PQA) Measures Update Panel and participates in the PQA risk adjustment panel. Dr. Teigland was Vice President of 2020 Initiatives at Leading Age New York and Director of Special Projects for the Foundation for Long Term Care where she directed the development of innovative technology solutions to advance the use of data-driven decision making to improve outcomes and reduce healthcare costs. ... Read More


The Business of Managing Health Over Healthcare for Health Plans

Payment models for healthcare in the US are at the crossroads. The predominant fee-for-service (FFS) model is widely recognized as a major contributor to wasteful spending and a barrier to improving healthcare delivery. To promote value and progress toward achieving the Triple Aim of an improved experience of care, better health for populations, and lower costs, health plans are turning to payment innovations centered on value. Value-based payment (VBP) programs tie healthcare provider compensation to measurable improvements in quality of care, patient health outcomes, patient experiences, and cost, often in a risk-bearing relationship. Such arrangements are shifting the focus of health plans from strictly managing of healthcare (resource-oriented and cost-containment in a provider fee-for-service contract) to improving the overall measurable health status of the member (outcomes-oriented and value-based under provider risk-bearing contracts). Becoming an organization focused on value requires strong population health management capabilities, good provider relationships with measures that support shared goals, applied health analytics, and updated payment administration competencies. Underlying tools must enable accurately priced contracts and performance- based contract payments. Yet, transforming into an organization that truly achieves such health value management requires modernization of technology, re-engineering of traditional processes, and an internal/external cultural makeover. Let’s break it down.... Read More



Over the past several years, a shift towards value-based care has begun in the US healthcare system. Within value-based care, incentives and policy structures exist to prevent risk selection, where insurers try to avoid enrolling high-risk members who may be costly to cover. Risk adjustment seeks to project and correct for costs incurred by health plans to treat members of varying risk levels. The Centers for Medicare & Medicaid Services (CMS) first introduced risk adjustment with Medicare Advantage, which has been using CMS’s Hierarchical Condition Category (HCC) models to risk adjust since 2004. Medicare Advantage enrollment has been steadily growing and is expected to reach 22 million by 2020. With the move towards value-based care—fueled not only by the Patient Protection and Affordable Care Act (ACA), but also the Department of Health & Human Services’ (HHS)—a bold goal was made to have 90% of CMS payments linked to value-based care and 50% under APMs by 20181. Given this shift, risk-based payments have become more common. Today, risk adjustment also impacts Managed Medicaid plans, Qualified Health Plans under the ACA, Accountable Care Organizations, and provider groups that share risk with their health plan partners. With value-based model enrollment growth, risk adjustment is becoming increasingly important to a health plan’s success. At the same time, market dynamics are putting pressure on the risk adjustment environment.... Read More


Part 2: The Strategic Implications of MACRA

Part 2 of the Successful Health and Wellness MACRA article series explores the strategic implications of the MACRA legislation The passage of MACRA guaranteed an imminent transition to value-based care that will impact most, if not all, clinicians. As a result, the clinical behavior that has fostered success under a fee-for-service payment model will no longer be sustainable. Amidst all the uncertainty surrounding healthcare reform, MACRA is here to stay. Clinicians and hospitals must determine what their future strategy will be in response to the legislation. While MACRA driven change is something clinicians can’t avoid, employed and independent physicians remain unaware of the law and its implications for their practices. The Deloitte Center for Health Solutions 2016 Survey of U.S. Physicians found that 21 percent of self-employed or independent physicians say they are somewhat familiar with MACRA, compared to nine percent of physicians employed by hospitals, health systems, or medical groups.[... Read More


Top 5 Actionable Uses for Marketing Analytics

As the health insurance industry continues to become more competitive and the consumer becomes more discerning, strong business analytics can be the key to both differentiating your plan, and making a positive impact to your bottom line. Today’s Medicare audience is evolving just like any other segment of the population and demanding a better consumer journey. This journey needs to be personalized both from a messaging and media standpoint. And it needs to be available to consumers when they’re ready to engage — whether it’s via traditional media such as Direct Mail and DRTV, or newer channels such as mobile Facebook ads, Over the Top streaming, or pay per click ads on Google or Bing. With all of these mediums to communicate your message and the hyper growth of business analytics, it can be hard to focus on the data that truly matters. “Big Data” can translate into more data than a marketer needs and is able to synthesize and use. The crucial point is to identify “Actionable Data” and focus in on the KPI’s that will help improve your consumer’s journey and your bottom line.... Read More


Analyzing Provider Behavior Patterns to Improve Medical Record Retrieval Success

Medical record retrieval is a crucial component of any risk adjustment or HEDIS® project, yet it is perhaps one of the most difficult. Retrieval is labor intensive, consumes time and resources, and requires great patience and persistence. Is there a way for health plans to increase their retrieval success rate without simply throwing more money at the problem? How can they ensure they’re getting the best return on investment (ROI) in their retrieval initiatives? The key is to analyze provider behavior patterns and re-direct resources to where they can be the most productive. Certain metrics, when analyzed in combination, can reveal where your retrieval approach may need refinement. The Key Metrics... Read More


Thinking Inside the Box with a Provider Decision Quadrant

Sophisticated data analytics can process billions of claim code line edits through the course of the day, helping payers identify hundreds of providers with aberrant billing patterns with each pass of the data. However, this is just the first step in a resource-intensive process to determine whether fraud, waste, and abuse (FWA) have actually occurred—and then, what to do about it. The next step is to answer several challenging questions: How egregious is the behavior? Are some behaviors worse than others? What’s the proper course of action to take in each instance? When it comes to answering these critical questions, a provider decision quadrant can help.... Read More


Walking the Line: Balancing Claims, Premiums, and Compliance for Medicare Advantage Plans

By Amy Cogsdill, Medicare Subject Matter Expert at Discovery Health Partners Medicare Secondary Payer (MSP) is a multi-pronged issue for Medicare Advantage plans. If plans aren’t monitoring the effects of MSP on medical and pharmacy claims as well as premiums from CMS, they could be hurting their bottom line—to the tune of millions of dollars. MSP also introduces compliance responsibilities that plans must regard or else face possible consequences. This requires a balancing act to ensure primacy information is correct for members with other insurance and to verify that claims are paid and premiums are collected in accordance with the member’s primacy. Plans should work to identify inaccurate primacy information and build processes that can help correct these errors so they can ensure accurate payments all around. Let’s look further at each area. Premium It’s important to realize that CMS primacy information is not always correct. Medicare Advantage plans should be reviewing CMS information each month to verify primacy to identify underpaid premiums as well as overpaid premiums. What’s your motivation to verify premium underpayments? Your bottom line! ... Read More


CMS Publication of Prevalence of Chronic Conditions

Prevalence and Medicare utilization and spending are presented for the 19 chronic conditions listed below. Information is presented for (1) U.S. counties, (2) U.S. states, including Washington, DC, Puerto Rico, and the U.S. Virgin Islands, and (3) hospital referral regions (HRR) and is available for the years 2007-2015. The data are available in two Excel file formats. The “Reports” allow users to compare geographic areas to national Medicare estimates. The corresponding “Tables” are traditional excel files that can be exported into other programs.... Read More


The Hidden Cost of Inadequate Health Coverage

The fuss over ObamaCare produces confusion and obscures some important realities that deserve our attention. Much of the political debate creates a polarizing force like a centrifuge, splitting the pros and the cons into opposing camps that line up behind positional opinions about whether healthcare is a right or not. For those opposed to the taxpayer shouldering the financial burden of providing healthcare to those without insurance coverage, the less the taxpayers must fork out to subsidize the uninsured the better. All the while, there is an implied assumption on the part of the entitlement crowd that just providing insurance coverage for the uninsured is the end game. In my opinion, we are all laboring under serious misunderstandings of the reality of the healthcare system and the way the costs are absorbed by society. I was looking for some solid research about the cost of the uninsured, and I came across a powerful and highly useful study from way back in 2003 when the early debate about universal coverage was just beginning. The approach they took to analyzing the problem still has significant value today, and what it says helps shed light on the misunderstandings referenced above. In a preface to the third chapter of the book Hidden Cost, Value Lost*, there is this revealing assertion from their research: The health care services received by uninsured individuals that they do not pay for themselves are picked up or “absorbed” by a number of parties, including:... Read More



HITRUST Certification validates Talix’s commitment to meeting key healthcare regulations and protecting sensitive private healthcare information SAN FRANCISCO – November 8, 2017 – T Talix, Inc., a premier provider of healthcare risk adjustment and quality solutions for value-based care, today announced its Coding InSight platform and Health Risk Assessment (HRA) application have earned Certified status for information security by the Health Information Trust (HITRUST) Alliance. With the HITRUST CSF Certified Status, these solutions meet key healthcare regulations and requirements for protecting and securing sensitive private healthcare information. HITRUST CSF Certified status indicates that Coding InSight and HRA have met industry-defined requirements and are appropriately managing risk, and places Talix in an elite group of organizations worldwide that have earned this certification. By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the HITRUST CSF helps organizations address these challenges through a comprehensive and flexible framework of prescriptive and scalable security controls.... Read More


Matrix Medical Network to Acquire LP Health Services

SCOTTSDALE, Arizona, October 23, 2017 – Matrix Medical Network (Matrix) announced that it has reached an agreement to acquire LP Health Services, – formerly the healthcare division of LifePlans, Inc. -- from Munich American Reassurance Company. Based in Scottsdale, AZ, Matrix is the leading provider of in-home, facility and community-based risk adjustment and care management services to health plans and risk-bearing providers. LP Health Services is an innovative partner to Medicare Advantage and Managed Medicaid health plans across the country, delivering solutions such as community and post-acute assessments, programs that help close quality care gaps, and services aimed to engage hard-to-reach members. These capabilities, combined with Matrix’s established Medicare Advantage programs and expanding services to the Medicaid market, position Matrix to offer the most complete and comprehensive set of quality and revenue solutions in the industry.... Read More


Nuance and Talix Team to Improve Care Quality and Risk Adjustment at the Point of Decision Making

New Quality and Risk Adjustment Solution from Nuance Combines AI and Coding to Deliver Context-Aware, Personalized Clinical Guidance to Providers BURLINGTON, Mass. and SAN FRANCISCO, October 11, 2017 – Nuance Communications, Inc. and Talix, Inc. today announced a reseller agreement to deliver a new patient-focused solution to support better outcomes and risk adjustment through decision support and automation. As a result of this agreement, Nuance introduced a new Nuance Quality and Risk Adjustment solution that combines Talix’s risk adjustment coding technology with Nuance’s artificial intelligence (AI)-powered Computer-Assisted Physician Documentation (CAPD) solutions. This new offering from Nuance will enable population health specialists, care providers and coders to quickly and easily find and close coding gaps at the point of care, and properly code high value risk adjustment opportunities. With the emergence of new care and payment models, providers are shouldering an increasing amount of accountability and financial risk while also needing to provide comprehensive care and disease management across the continuum of care in a dynamic, value-based environment. As care increasingly shifts toward an ambulatory setting, effective population health management strategies that proactively identify and assess high-risk patients, and improve... Read More


Episource Acquires Peak Payer Solutions, Expanding Capabilities into Health Risk Assessments and Clinical Services

Acquisition brings together Peak’s prospective in-home health assessments and retrospective chart audit capabilities with Episource’s best-in-class Risk Adjustment and HEDIS/Stars services and technology offerings LOS ANGELES, CA., September 25, 2017 – Episource announced today that it has signed a definitive agreement to purchase Peak Payer Solutions, a provider of risk adjustment chart audits, and in-home health risk assessments for health care payers. Peak has a nationwide network of over 750 healthcare providers across all 50 states.... Read More


Where Have All the Workers Gone? An Inquiry into the Decline of the U.S. Labor Force Participation Rate

The following abstract describes an alarming trend in the National Labor Force. The trend itself is of grave concern not just because of its implications for national labor reasons but also because of the inferred health causes it calls out. The fact that the U.S. lacks a national healthcare policy that promotes population health strategies and elevates the visibility of the social determinants of healthcare represents an alarming failure of our government. Continued politicization of funding of affordable healthcare demonstrates that the federal government does not adequately grasp the essential fact that universal access to routine healthcare is directly connected to the health of the economy. Forget about philosophical or political posturing about "healthcare as a right" versus "healthcare as a priviledge". Ensuring that "everyone is in the pool" with healthcare is a top priority that ranks above party affiliation and political agendas. This requires statesmanship and leadership on behalf of a "health-taxed" nation. Kevin Mowll, Executive Director of the RISE Association ... Read More


LA Care CEO Statement on the Graham-Cassidy Health Care Bill

L.A. Care is strongly opposed to the Graham-Cassidy health care bill, which is worse for L.A. Care members – and all of California – than the Repeal and Replace bill passed by the House in May and the bill that was defeated in the Senate in August. What is it?* The Graham-Cassidy bill is a last ditch effort by several Republican Senators that lumps Medicaid and the subsidies for the Exchange into block grants in 2020, leaving it to the states to decide how to allocate funding between Medicaid and the Exchange. It moves the funding formula for the block grants to a method that penalizes the states that expanded Medicaid, like California. Due to these changes, the Medicaid expansion population would be essentially eliminated by 2027. It also eliminates the mandate for individuals to have health insurance – a move that could destabilize the Exchange. This bill will fundamentally alter the federal/state partnership that has been in place since Medicaid’s inception since 1965. These changes will not only impact those who gained coverage through Medicaid expansion under the Affordable Care Act (ACA), but also for mothers, children, developmentally disabled and elderly in nursing homes – all who have limited incomes. According to a recent Avelere study, California would be the hardest hit under this proposal, with a reduction in federal funding between $50 billion to $78 billion by 2027.... Read More


Dual Eligible Medicare Switchers Prefer High-Touch Service

Find out what makes Dual Switchers different from Non-Duals. Deft Research's 2017Dual Eligible Shopping and Switching Study provides a closer look at their shopping and switching behavior during the Medicare AEP. Member experience for Duals is also included and compared to Non-Dual and Low-Income Non-Dual seniors. This study helps health insurers and their agencies understand the key characteristics of Dual Eligible switchers. The Infographic highlights these key characteristics and what shopping channels they prefer along with their member satisfaction. Infographic insights include: Impact of including a phone call in your marketing strategy Importance of an in-person meeting Satisfaction with hospitalization costs... Read More


MACRA Mini Series Overview: Part 1 of 4

Spurred by the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, the healthcare industry is in the midst of an unprecedented transformation. The ACA was passed in an effort to increase access to health insurance and healthcare, while simultaneously improving the quality of healthcare and slowing the growth of healthcare costs.i President Donald Trump has made continued healthcare reform an immediate focus of his presidency, leaving the future of the ACA uncertain. While the future of the law is unknown, it is unlikely the pace of healthcare transformation will slow because reform efforts like the Medicare Access and CHIP Reauthorization Act (MACRA) are expected to move forward as planned.ii MACRA represents the most sweeping change to physician payment for Medicare services in over two decades. With Medicare accounting for $618.7 billion, or 20 percent of national health expenditures, MACRA is guaranteed to have a substantial and immediate impact on both hospitals and physicians.iii In reacting to the implementation of MACRA’s Quality Payment Program (QPP), physicians will need to examine their existing organizational structure, evaluating their relationships with hospital partners. This five part article series examines how MACRA functions as a driving force for the evolving hospital-physician relationship. Part 1 provides an overview of the legislation and Part 2 explores the strategic implications of the legislation, while Part 3 looks at what the legislation may mean for hospital-physician alignment. Part 4 examines the legislation’s financial implications and Part 5 will wrap things up, providing you with some next steps for your organization. ... Read More


If You Believe You Are Healthy Then Why Change?

New proprietary research from Wunderman Health has discovered that most people - regardless of the severity of their condition and unhealthy lifestyles - believe they are much healthier than they actually are. This misperception creates a challenge: how can marketers inspire action when action is not perceived as necessary. Building on the webinar presented by Wunderman Health, Advertising Age and Modern Healthcare earlier this year, the Wunderman “Health Inertia” Report takes a closer look at this phenomenon and how marketers can disrupt it. Health Inertia - New research into the clash of perception versus reality and how traditional marketing approaches reinforce, rather than change, the behavior we call Health Inertia. Emotional Influence - How marketers can use content to tap into individuals' perceptions, emotions and unconscious desires to disrupt Inertia.​​​​​​​ Analytics in Action - Advanced analytics techniques like rapid mass experimentation (RME) that can be leveraged to create the personal, emotionally-intelligent connections that inspire action. Download the full report here.... Read More


How The 360-Degree Patient View Drives Data- Driven Care Decisions

It’s no secret. The way most of us make important healthcare decisions is fundamentally flawed. Rather than conducting the type of rigorous research befitting a potentially life-and-death decision, which would allow us to make the most informed decision, we ask people close to us for advice or recommendations. Why do we do this? Because when we start to peel the onion, we quickly experience a data avalanche of disparate and disconnected data points, a wide array of information that may or may not be relevant to our individual situation, but nothing resembling “the truth,” and often nothing valuable enough to help us make a decision. And we get overwhelmed. This isn’t unique to patient care decisions. Similarly, clinicians across the care continuum need access to timely, relevant insights in order to see a true 360-degree view of the patient, ensuring that care decisions are based upon the most pertinent, complete and timely patient data. Bringing together disparate data sources enables highly granular, patient-level insights for the successful transition from volume to value. Across the United States, healthcare organizations of all types are impacted by evolving regulations and policies at both the state and federal level. To remain compliant, they must have an infrastructure in place that offers the flexibility to adapt quickly alongside new standards and requirements. Platforms that include advanced technologies, such as Natural Language Processing (NLP), Machine Learning (ML) and other forms of Artificial Intelligence (AI), empower clinicians and organizations to meet the unique and varying requirements of regulatory bodies and ultimately improve patient care, outcomes and wellness.... Read More


Why Prepay Cost Avoidance and Post-pay Recovery Must Co-exist

Health plans see value in prepayment cost avoidance Health plans are making a concerted effort to focus more of their payment integrity resources on avoiding inaccurate claims payments up front, rather than recovering erroneous payments on the back end. There is general agreement that this creates more value for a plan. When done successfully, prepayment cost avoidance allows the plan to avoid 100% of the claim cost (vs. the portion they can recover) and it reduces downstream administrative costs associated with recovery. I think we all can agree that having to work a claim multiple times is obviously more expensive than having to work it once. In addition to financial benefits, prepayment cost avoidance can help health plans positively affect relationships with providers by reducing the burden on them to rework claims that are the responsibility of another payer. I recently saw a statistic that said providers incur an additional 20% - 30% of the cost of any claim they have to rework. Your providers would welcome a reduction in that cost. Meanwhile, a focus on cost avoidance makes your members more accountable for ensuring that correct eligibility information is on file. Particularly in an area like coordination of benefits, members should feel more compelled to be proactive about providing the health plan with accurate, current information so their claims will be paid promptly without fuss. Why the cost avoidance shift is happening now.... Read More


How Health Plans Can Help Providers Understand What’s Driving High Volumes of Chart Requests

Why it’s More Important than Ever for Health Plans and Providers to Work Closely Together Audits. Reviews. HEDIS. Star ratings. No matter what, health plan record requests are growing by leaps and bounds each year. And the stakes are high for health plans to ensure they receive medical records in a timely way. We also know that the large volume of requests and submission deadlines can put a drain on provider resources. High volumes of medical record requests make it more important than ever for providers and health plans to work cooperatively and collaboratively. Here’s some helpful information health plans and payors can share with their providers to help them understand what’s driving high volume requests for medical records and how providers can be prepared. Types of Health Plan Reviews: MRA, HEDIS, ACA and MRR There are three primary health plan reviews that receive the most focus: Medicare Risk Adjustment (MRA), Healthcare Effectiveness Data and Information Set (HEDIS) reviews, and Affordable Care Act (ACA) Medical Records Retrieval (MRR). While there are other ad hoc requests related to fraud, waste, and abuse (e.g., Risk Adjustment Data Validation, Medicaid, etc.), these three health plan reviews cause the most provider abrasion. Medical practices are getting hammered by them.... Read More


EMR Integration and Interoperability: The Need is Now

You don’t need special glasses to see that yesterday’s big focus on EMR data entry has been eclipsed by today’s quest for EMR integration and interoperability to bring together and share disparate types of healthcare data from multiple systems. The need is now, given that Meaningful Use is in the rear-view mirror for most and the value-based payment challenges of MACRA, MIPS, and APM initiatives are either underway already or on the immediate horizon. Fee-for-Service models are quickly giving way to new value-over-volume models where providers and ACOs are taking on greater risk in hopes of seeking greater rewards. The pillars of meaningful use – care coordination, patient engagement, and information exchange – remain part of the evolving landscape. New MACRA requirements are creating the need for more data review, exchange, and reporting from more savvy EMR users in more sophisticated EMR systems. Navigating the MACRA requirements and assuming and managing increased risk sharing necessitate having meaningful data presented at... Read More


Where to Now? True North Again

By Kevin Mowll, Executive Director of the RISE Association The failure of the Republicans to repeal, replace, or wreck ObamaCare is a wakeup call for everyone, not just Republicans. While the RISE Association steers away from purely political commentary, the lesson of this protracted political mess needs to be called out for the sake of putting our priorities straight around public policy regarding healthcare reform. In the attached Wall Street Journal article, which suggests that bipartisan solutions are the only remaining way forward, the author proffers hope that the blistering truth will be obvious to all the participants in the 7-year-long fracas around repeal and replace. The bloodied players may still brood in frustration that their political wills were not enough to win, but the author wonders if cooler heads will prevail. I, for one, am not so sanguine; yet I can only hope. The lesson I take away from the many years of wrangling is that the ObamaCare political football games demonstrates that political wills are not the way forward. They lose sight of the True North issue at hand. Rather, the failures of both political parties in arriving at a bipartisan solution signals the fact that what is good for America is good healthcare policy, not political prowess over rivals. Governing from the fringe is not sustainable in a democracy. ... Read More


It’s not Obamacare anymore. It’s our national health-care system.

By Drew Altman and Larry Levitt July 29 Drew Altman is president and chief executive of the Henry J. Kaiser Family Foundation. Larry Levitt is senior vice president of the Kaiser Foundation. Republicans failed to repeal and replace the Affordable Care Act early Friday because of divisions within their own ranks, and because they tried not only to repeal and replace the ACA but also to cut and cap the Medicaid program, generating opposition from many red-state governors and their senators. But most of all, they failed because they built their various plans on the false claim — busted by the Congressional Budget Office — that they could maintain the same coverage levels as the ACA and lower premiums and deductibles, while at the same time slashing about a trillion dollars from Medicaid and ACA subsidies and softening the ACA’s consumer protection regulations. Had they succeeded, they would have won a big short-term victory with their base, which strongly supports repeal, but suffered the consequences in subsequent elections as the same voters lost coverage or were hit with higher premiums and deductibles. ... Read More


Unraveled: Prescriptions to Repair a Broken Health Care System

A book review by Kevin Mowll, Executive Director, The RISE Association Drs. Willam Weeks and James Weinstein authored a book whose stories come straight from the office practice histories of two seasoned and concerned physicians. The anecdotes serve to make concrete the doctors’ illustrations of what is currently wrong with the U.S. healthcare system. These stories anchor the analysis and recommendations in human and empathetic terms, making it clear what gets lost in “wonkish” policy debates, and instead, bring it down to real people: patients, families, doctors, and caregivers. In this story-telling mode, nothing is lost in the acute description of the malfunctioning system, outdated incentives, perverse outcomes, and holistic view of what needs to be done to put things back on track. The insights captured in this book were acquired at a high personal cost. In some cases, the painful experiences were borne by the authors themselves. Yet their eyes remained focused on arriving at powerful diagnoses of the systemic ... Read More


Critical Call Center Metrics For Health Insurers

Positive customer experience is critical to the longevity of any business. A company’s call center plays a major role in creating and maintaining that positive customer experience. Historically, many top e-commerce organizations worldwide haven’t shown great interest in displaying call center phone numbers on their homepage, nor have they rely on assisted sales. However, a shift is occurring in that philosophy as businesses rely on call centers to increase revenues through improved sales and conversion, and provide insights on customer interactions otherwise unavailable. This applies to health insurers and Medicare Advantage plans as well. As such, measuring and understanding call center metrics is a major focus. Business models that require phone assistance for their customers should set up clear processes from the beginning to monitor call center metrics. Managing to the five call center metrics below for your business can provide improvements were it matters most. Specific benefits we have seen with Medicare Advantage providers ... Read More


The Whole is Greater Than the Sum of its Parts

By April Gill, Vice President of Analytic Solutions, Welltok When it comes to risk adjustment and quality, we have long known there is valuable information sitting in silos across the healthcare ecosystem – within EMRs, in various point solution databases such as care management or disease management service providers and even inside the often disconnected departments of America’s health plans. The ever-present challenge is to bring it all together in a meaningful way. And now, with the continual shifts in the political and regulatory environment including the move from fee-for-service to value-based care and incentivized or bundled payment models, it is more important than ever to solve for this and invest in a comprehensive and integrated approach. Let’s explore how 5 key disciplines – when strategically merged together – can help your organization learn and improve over time and, ultimately, drive enhanced long-term success.... Read More



Members' decisions to switch carriers or plans is generally decided based on their experience with the plan throughout the year. Understand who those members are who are likely to shop and switch during the AEP and target them appropriately. (Download Graphic)... Read More


Step Up Your Game: How to Improve Risk Adjustment Coding Accuracy

by Amanda Watkins June 23, 2017 The Office of Inspector General (OIG) sets the bar for coding accuracy at 95 percent, but you can’t achieve that goal without a comprehensive approach that gets it right from the beginning. Are you following best practices to ensure accurate code capture, or is there room for improvement? Here are some concrete steps you can start implementing today to step up your risk adjustment game. 1. Develop a standard set of coding guidelines based on CMS and your own coding approach. The Centers for Medicare & Medicaid Services (CMS), the International Classification of Diseases (ICD) book, and the American Hospital Association’s (AHA) Coding Clinic provide a wealth of information related to coding guidelines. However, they can’t account for every diagnosis scenario that a coder comes across in a medical record. To lessen confusion for your coders, agree ahead of time on your philosophy of diagnosis capture across the “gray” areas of coding guidelines, such as your approach to signatures, specific diagnoses, and code capture from a past medical history, condition list, or medication list. Document your coding guidelines, and have them available for reference throughout the coding season.... Read More


Physician Specialists Gain More Opportunities for Medicare Bonus Payments Tied to Quality

By Avalere Physician specialists have more than 700 measures available for reporting under the Merit-Based Incentive Payment System (MIPS) through Qualified Clinical Data Registries (QCDRs), according to new research by Avalere Health, an Inovalon Company. MIPS is the value-based physician payment program created under the Medicare Access CHIP Reauthorization Act (MACRA) of 2015. Under MIPS, physicians must report on three areas to receive bonus payments: performance against quality measures, practice improvement activities, and implementation of meaningful use components. One reporting option is a QCDR, a tool to collect data that was established by the Centers for Medicare & Medicaid Services (CMS) in 2014. In June, CMS released the 2017 QCDR list, which included 113 total registries, an increase of 61 percent from the 69 approved registries in 2016. The increase in QCDRs makes 478 more measures available for reporting to clinicians, bringing the total to over 700. Beginning this year, clinicians participating in MIPS must report on six quality measures to be eligible for a bonus payment. According to Avalere, the expanded list of QCDRs offers clinicians flexibility in meeting these reporting requirements by allowing them to report on measures more relevant to their specialty. QCDRs may also be a valuable vehicle to fill measure gaps for specialties where measures have not yet been developed. “Some physicians have expressed concern about the lack of meaningful specialty-focused quality measures available for reporting,” said Nelly Ganesan, a senior director at Avalere. “The QCDRs are one way to alleviate some of that concern.” Avalere experts also note that the lengthy and resource-intensive process involved in measure development ... Read More



A research whitepaper by Randy Herman, Founder and CEO of Deft Research THE IMPORTANCE OF PRODUCT PREFERENCE To better understand the impact of health insurers’ marketing and outreach strategies, Deft Research annually surveys seniors during and after Medicare’s Annual Election Period (AEP). The resulting data is the basis for the recently released 2017 Medicare Shopping and Switching Study (MSS). For this year’s study, we followed a panel of 630 seniors throughout the AEP, and we surveyed 2,222 additional seniors after the end of AEP. In total, 7,612 survey responses were obtained and analyzed. This Executive Research Brief focuses on shopping patterns and product preference behavior observed throughout the AEP as well as the practical implications of product preference on marketing strategies.... Read More


Health Plan Focus on Cost Reduction Drives Fresh Look at Payment Integrity

A White Paper by Discovery Health Partners As cost reduction continues to take center stage in healthcare, payment integrity is in the spotlight. Increasingly, health plan executives are recognizing the power of payment integrity functions to add significant value to a health plan’s bottom line by improving the plan’s ability to recover or avoid improper claims payments and improve accuracy of premium revenue. As a result, they are taking a closer look. Payment integrity (also known as payment accuracy) ensures that claims are paid correctly – by the responsible party, for eligible members, according to contractual terms, not in error, and free of wasteful or abusive practices. It may include functions such as coordination of benefits, claims analytics, data mining, and subrogation, among others.... Read More


Three Compliance-Minded Steps to Take for 2018 Marketing and Sales

By Regan Pennypacker Is it me, or is time flying by? Applications are done, bids are in, new plans are in planning stages, and existing plans are getting ready for the launch of the next benefit year. The 2018 model materials were released late last month, and any second now, we should see the release of the 2018 Medicare Marketing Guidelines (MMG). The industry is expecting additional Summary of Benefits guidance to be incorporated in the MMG by the Centers for Medicare & Medicaid Services (CMS) as my colleague Diane Hollie noted in her article on the CMS Spring Conference. We are also interested to see if any modifications are made to CMS’ draft MMG language on Additional Marketing Fees as Betsy Seals pointed out in her article. Time will tell! What is the compliance professional to do to help sales and marketing professionals prepare while we are in this holding pattern for the finalized guidance? Three things:... Read More


Guidance on the 2016 HHS-Operated Risk Adjustment Data Validation Program

By Jessica Smith, May 11, 2017 The Affordable Care Act (ACA) market has been quite a struggle for health plans since it started. Change is never easy for most organizations who have been running a business in the same fashion year after year. Risk adjustment really threw health plans a curve ball when it came to the functional operations and internal validations required to be in place to effectively run this program. The effort around establishing a best-in-class risk adjustment program was underestimated right from the start. This, along with many other variables, is what is causing the staggering financials seen across the industry.Last week, the Centers for Medicare & Medicaid Services (CMS) announced the 2016 Health and Human Services Operated Risk Adjustment Data Validation (HHS-RADV) would be conducted as a pilot year in the same aspect as the 2015 HHS-RADV. This announcement came two days after the final risk adjustment data submissions were due to be submitted to the EDGE server for 2016 dates of service. The announcement that came from CMS on May 3, 2017, was not an overwhelming surprise and was graciously welcomed by health plans. Since the deadline to submit to the EDGE server was completed prior to the announcement, the health plans submitted their information under the assumption the HHS-RADV would function in its entirety, which included having the financial penalties applied, if necessary. So, working under that assumption, health plans marched forward utilizing lessons learned from prior years in managing the data they were sending for risk adjustment to ensure it was complete and accurate. These pilot years allow CMS and health plans to create a refined auditing process, understand benchmarks, and ensure the validation process is working as it was intended. ... Read More


Keep M.E.A.T. on Your List for a Healthy Audit

By Jeanmarie Loria, Advize Health, LLC If you’re reading this article, chances are you already know what HCC Coding is – but we’ll give you a refresher anyway. Hierarchical Condition Category (HCC) and Risk Adjustment Coding is a CMS-mandated payment model. This model works to identify those with chronic and other serious illnesses and prescribes a risk factor score to each patient, taking into consideration their ailments and other demographics. With every payment model comes a specific set of audit and review requirements that must be met to maintain the integrity of the system, and this is where MEAT (Monitor, Evaluate, Assess/Address, Treat) comes in handy. In a face to face visit M.E.A.T. maybe found in the chief complaint, history of present illness, review of systems, physical exam, assessment and/or plan.... Read More


Getting It Right: True North in Healthcare Reform

The movement to repeal and replace "ObamaCare" created so much political noise that clear thinking has been hard to come by. The 2010 legislation that created the marketplace for individuals and small business (the Affordable Care Act or ACA), has almost evolved into a political Rorschach test. The more that politicized options and alternatives to repealing, replacing, or repairing it were discussed, the harder it was to put into focus the original problems the legislation was designed to address. Nevertheless, the rancorous divisions over what needs to happen to fix problems in the individual insurance market remain a distraction from the real issue at hand: the cost of healthcare weighing down the economy and what we need to do to fix it. With all the intense debates swirling around this topic, an impression emerges that “solving the ObamaCare issues” is something that must be accomplished as an isolated matter, discrete and independent of other problems. The heated debates concentrate on the mechanics and tactics required to solve the "uninsured problem", the "under-insured problem", and for some, the federal budget problems created by the subsidies for low-income enrollees in these plans. This single-issue mono-vision obscures a reality that must be addressed. This perspective completely misses the fact that something is going on that is far more corrosive to the wellbeing of all of us as consumers of health care, as taxpayers, and as a nation: something that overshadows the tug ‘o war over ObamaCare. The critical and overlooked issue is that health care expenditures in the U.S are at least twice as expensive as other nations, which consume so much of the national economy... Read More


Repealing Obamacare Isn't Top Priority for Americans

House Republicans plan to hold a vote today on the Trump administration's plan to repeal and replace Obamacare (ACA). Having apparently won the support of more senators, House Majority Leader Kevin McCarthy was confident they now had the 216 yes votes required to pass the bill, saying: "Do we have the votes? Yes. Will we pass it? Yes.” Although a win for the Republicans here would be seen a great triumph for President Trump - delivering on one of his campaign's main promises - recent figures from the Kaiser Family Foundation suggest that for the American public, repealing the ACA isn't actually such a high priority. When asked how they would rate a number of health care issues in terms of importance, the most pressing matter for respondents was revealed to be 'lowering the amount individuals pay'. As the infographic below shows, in comparison to the 63 percent of respondents in support of putting lower personal costs at the top of Trump's health care agenda, repealing Obamacare is seen as being far less important, with a total of 32 percent. This chart shows the health care issues the U.S. public think President Trump should prioritise.... Read More


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


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Find More, Spend Less, Take Control: Leveraging Technology to Improve the ROI on Risk Adjustment

Due to changing market dynamics, there is increasing pressure for risk-bearing organizations to improve the effectiveness of their risk adjustment programs. Several trends present pervasive challenges—for example, increasing number of risk-adjusted lives, rising coding intensity factor, and heightened focus on compliance. Risk adjustment departments are constantly being asked to do more with less. Organizations that can leverage risk adjustment as a strategic asset and effectively utilize technology will be best positioned to achieve accurate risk and revenue capture while simultaneously decreasing costs. Streamlining Risk Adjustment with Technology As organizations seek to modernize their risk adjustment operations, there are several high value technology initiatives they can explore. Rather than blindly reviewing charts across the entire membership, organizations can use natural language processing (NLP) technology on medical records to help identify risk adjustment gaps, both for additional HCC capture and for potential deletes. Health Fidelity has been able to consistently demonstrate with our clients that NLP-assisted coding delivers superior results as compared to human-only reviews, both when our clients are conducting the coding and when our coders provide the coding capacity....
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Medicare products are expected to be the fastest growing insurance sector over the next 10-years. At the same time, Boomers are transforming care delivery, from aging-at-home services to convenience-driven alternate sites of care such as retail clinics, telemedicine and wearables to anti-aging nutraceuticals. Opportunity abounds. What’s clear is the need to understand Boomers – what’s important to them, what truly matters to them, and why they do what they do – has never been more important. For marketers this means a shift in orientation from brand promotion to individual inspiration, from features and functions to emotional appeals that move people to act and engage. It’s about connecting with Boomers around personal, relevant motivations and deep, sometimes even unconscious desires, like freedom, happiness, renewed goals, or simply the ability to enjoy life. A quick snapshot of 75+ million Boomers ages 51 to 69: ...
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RISE Risk Adjustment Academy: CMS & HHS Risk Adjustment 101 and HCC Coding Accuracy

Designed as an introduction or refresher that covers all the bases when working with Medicare Advantage or on commercial health insurance exchanges lines of business. The workshop program is a holistic orientation to the risk adjustment panorama and deep dive into HCC coding for accuracy. With a mix of health plan and provider audiences, a powerful environment for interaction and collaboration is built over two-days. You will gain insight, tips, and best practices to build upon your knowledge of risk adjustment, coding, and documentation.


Upcoming Webinar

Protecting Risk Adjusted Revenue in Small and Mid-Tier Health Plans

If you’ve ever heard the phrase “working without a net” then you’ve heard a phrase that accurately describes the status of risk-adjusted revenue for small and mid-tier health plans. And when you’re working without that net, you’ve got to secure every dollar possible. Easier said than done given the inherent complexity of the encounter management lifecycle and the constant changes and updates that continue to vex managed care plans of all types. What’s required is a simple, best practice approach to encounter data management that is built to serve the needs of health plans regardless of their size. Implementing a best practice approach for small and mid-tier managed care health plans to protect and grow risk-adjusted revenue begins by joining Edifecs for this impactful, actionable webinar.


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