Medicare Advantage - Articles

End-Stage Renal Disease Risk Model Updates for 2023
October 24th, 2022 - Aimee Wilcox
For the first time, ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans beginning in 2021. Since that time, CMS has been working to revise the program to reduce costs, improve quality, and drive benefits. Effective January 1, 2025, one such change will include a definition change for "oral-only drugs." Why is Medicare changing the definition of these drugs and how will that be a driving force in advancing care models for ESRD in the future?
Calendar Year 2023 Medicare Advantage and Part C & D Payment Policies
August 9th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year CMS publishes an Advance Notice of the upcoming years Medicare Advantage (MA) Capitation Rates and Part C and Part D Payment Policies and asks for comments related to it. Each of the comments are carefully reviewed and responded to and often are impactful to changes seen between the Advance Notice and final publication referred to as the Rate Announcement. With health equity as a primary focus for 2023, CMS announced some policy changes that may impact your organization.
Medicare Advantage (MA) Benchmarking Policies Are Headed for Change
July 12th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
More than 43% of Medicare beneficiaries are not enrolled in Medicare Advantage plans, which were established to control costs and improve quality. However, as noted in the March MedPac Report Executive Summary of 2021, these plans average an estimated 104% of Medicare Fee-For-Service (FFS) spending. How does CMS plan to manage Medicare Advantage plans now?
Medicare FFS Beneficiaries Average 2 or More Chronic Conditions
April 19th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Medicare Advantage plans were created in an effort to improve patient health outcomes, quality of healthcare services, and reduce costs by managing chronic health conditions better than traditional Medicare plans. According to a CMS-published report from 2018, the average Medicare FFS beneficiary suffers from at least two chronic health conditions with a per capita cost of $2,067. Can you guess how many suffer from six or more chronic conditions?
Will CMS Allow Medicare Advantage Organizations to Risk Adjust from Audio-Only Encounters? 
July 13th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
While audio-only telehealth services became a covered benefit during the PHE, CMS put limitations on using the data from those encounters for risk adjustment scoring. Medicare Advantage (MA) plans cannot use the information from these encounters to be scored for risk adjustment; however, it can be used for risk adjustment scoring of ACA plans.
Are You Aware of the 2021 Star Rating System Updates?
November 5th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:  Quality of ...
Special Needs Plans Help Beneficiaries and Risk Adjustment Reporting
October 22nd, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
It is no secret that Medicare and Medicaid are steadily moving towards their goal of value-based health care. Medicare Part C (Medicare Advantage) identifies and rewards payers, and subsequently their providers, for increasing the efficiency and quality of care they provide to Medicare...
Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately
July 21st, 2020 - Aimee Wilcox
We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
August 20th, 2019 - Aimee Wilcox
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial. As any company who has billed Medicare services can attest, the one-year timely filing ...
Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage
July 26th, 2019 - Namas
Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky. In their notice, Anthem states: "Effective for all commercial ...
Now is Your Chance to Speak Up! Tell CMS What You Think!
June 13th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
CMS is asking for your input, we all have ideas on how we would change healthcare documentation requirements and get rid of the burdensome requirements and regulations if it were up to us, so go ahead, speak up! Patients over Paperwork Initiative is being looked at to help significantly cut ...
Risky Business The CMS HCC Risk Model
July 27th, 2018 - Terry Ketchersid, MD, MBA
Today's catchy title may invoke memories of that risqué movie from the 80's starring a young Tom Cruise famously dancing in his "tighty whities." But today's post is not about that type of risk. Instead we are going to spend some time with a risk adjustment model that's quietly become...
OIG Reviews Medicare Advantage Claims
February 1st, 2018 - Wyn Staheli, Director of Research
On January 16, 2018, the OIG released a report of their findings on claims data for Medicare Advantage plans. While it appears that there were not significant issues, they did find that: "Types of potential errors included inactive or invalid billing provider identifiers; duplicated service lines; missing required data; inconsistent dates; ...
Creating a Culture of Compliance in 2018
January 26th, 2018 - Sean M. Weiss, CHC, CEMA, CMCO, CP MA, CPC-P, CMPE, CPC
This year (2018), health care organizations (Hospitals, Health Systems and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency....
MACRA facts that every clinician should know [Infographic]
November 11th, 2016 - Adam Smith
MACRA is here and the new program is going to sunset several (un) popular programs such as Meaningful Use and the Value Based Payment Modifier model. Everybody who is anybody is busy discussing about MACRA and its ramifications. But as with any big updates the myths are jostling for space with the...
How group practices are surviving the value based payment model in 2016!
June 3rd, 2016 - Adam Smith
As the healthcare industry undergoes dramatic transformation, group practices are facing a lot of turbulence to their financial structuring. Moving away from fee-for-service business models to value-based reimbursement setup is a daunting endeavor, but, that’s where the industry is heading...

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