This year’s RISE National was jam-packed with information about Medicare Advantage, managed care, compliance, risk adjustment, quality, member engagement, technology, and data analytics that health care professionals can bring back to their organizations. Here are eight memorable quotes from just a few of the 45 sessions we attended, as well as those heard in hallway chats, during our three days in Nashville.
On DOJ fraud investigations
“Ten to 15 years ago there were not very many cases involving the Medicare Advantage program. There was a blindness by prosecutors when it came to Medicare Advantage. We knew about Part A and Part B and Part D and knew there was something in between. We didn’t understand Medicare Advantage and risk adjustment … Why the change? Why are we pursuing Medicare Advantage now? ... It’s where the money is.”
- Edward C. Crooke, assistant director, civil division, fraud section, United States Department of Justice
On Change Healthcare cybercrisis
“Most insurers other than Change Healthcare and UnitedHealth Group are sitting on their hands and hoping it is going to go away…Hope is not a strategy. Our crisis in health plan operations is like a volcano bubbling in Iceland.”
- Melissa Smith, founder, senior advisor, Newton Smith Group
“Should we allow one entity to have this much ability to disrupt the industry if it goes down…No one should have so much power to disrupt the industry…. A really important step is to understand your ecosystem. What is your dependency on a single vendor in your organization? What is your contingency plan and recovery plan? How do you communicate to members?
- Rex Wallace, founder & principal, Rex Wallace Consulting
During the pandemic, I said never waste a good pandemic and develop telemedicine flexibilities. Now I would say never waste a cybercrisis…Shore up your budget, review your technology, create true resiliency so you can rise above this faster, better, and more securely.”
- Ana Handshuh, principal, CAT5 Strategies
On Day 1 takeaways
The OIG, DOJ, CMS central office gave us a road map. Let’s be mindful of the guidance. They are putting out work plans, always telling us exactly what they look for. Pay attention and keep working hard. Color in the lines.
- Kaleb Holt, Medicare program director, Select Health, RISE National 2024 co-conference chair
"DOJ and OIG kicked off day one with sobering reminders of their commitment to delivering the best care and value to Medicare beneficiaries. They will continue to hold plans and their associated vendors accountable for ethical business practices and ensuring the continued success of the MA program.
While much of the focus often lands on the health plans, this is a great time for solution providers to also take action to ensure their programs and solutions are compliant to best support plans and their members ethically and legally.
- Reva Sheehan, senior director, customer insights, mPulse
Scrutiny in the Medicare Advantage space is increasing and that doesn’t just apply to health plans. Provider groups, as well as vendors, can expect more oversight as well, pushing them to consider where automated tools can help with accurate data capture and reporting to ensure compliance. Recent news on cyber-attacks, inappropriate prior authorization denials, and continued risk adjustment upcoding highlight the importance for all managed care leaders to champion ethical corporate culture to cultivate trust. The time is now to take meaningful action by managed care leaders to persuade stakeholders of the business value of compliance, and ensure they have the tools in place to be successful.
- Melissa James, CPC, CPMA, CRC, risk adjustment, senior consultant, health language, Wolters Kluwer Health
To move forward from data access and resiliency disruptions, health plans should consider dedicated training and education on how they can work together with providers and vendors to develop and implement more robust security and disaster recovery measures to manage risk, optimize costs, and safeguard equitable patient care.
- Courtney Breece, associate vice president of product, Inovalon