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MedHOK Strategic Insights Blog

Notification Relief for Plans on Part C External Reviews

A little bit of the burden on external reviews has been lifted from Medicare Advantage (MA) plans by the Centers for Medicare and Medicaid Service (CMS). Effective Jan. 1, 2019, CMS is removing the requirement for plans to notify enrollees upon forwarding Part C denial cases to the Independent Review Entity (IRE).

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Enrollment Changes Hitting Medicare Advantage

With welcome season in October upon us, Medicare Advantage (MA) health plans are preparing for two major enrollment-related changes. One offers great opportunities for plans to increase enrollment while another may bring limitations.

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Plans Win Big on Risk Adjustment Lawsuit – But Don’t Get Too Excited


Medicare Advantage (MA) plans won a huge victory on September 7 when a federal judge set aside a 2014 healthcare rule that set much stricter standards on plans in terms of reporting on over-payments in the program. The lawsuit arose when the Centers for Medicare and Medicaid Services (CMS) established a rule that required plans to return over-payments within 60 days of identifying them. If they did not, they would be presumed in violation of the False Claims Act, which carries the threat...

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Medicare Advantage Medicaid Status Report Best Way to Track True Medicaid Status

In response to our blog last week on Medicaid dual status identification, we had a number of people inquire as to the best way to determine correct dual eligible statuses for their Medicare Advantage members.

We note that determining correct dual status is more and more important these days because:

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CMS Begins to Move Again on Encounter Data Transition

There has been notable flux in the Centers for Medicare and Medicaid Services’ (CMS) effort to retire the old Risk Adjustment Payment System (RAPS) of encounter submission in favor of the HIPAA 837-based Encounter Data Processing System (EDPS). After setting a definitive sunset for RAPS in 2020 a few years ago, CMS suspended the phaseout due to some gaps on its end (numerous report issues) but especially due to the likely major revenue reduction plans would see because most had not planned...

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FAQ Memo Helps Plans Train Providers on Cost-Sharing Hold Harmless Obligations

A great Centers for Medicare and Medicaid Services (CMS) memo issued in July 2018 (link here) as well as other CMS literature (links here and here) help take the mystery out of plan and provider obligations to hold certain dual eligibles (those in both Medicare and Medicaid) harmless from certain cost-sharing. To this day, the rules are little known and Medicare beneficiaries regularly receive bills for cost-sharing they don’t owe and are balance billed.

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Effort to Rein In Drug Costs Means Major New Initiatives in Medicare Advantage and Part D

While drug costs have been relatively moderate of late, the Centers for Medicare and Medicaid Services (CMS) is ever mindful of the drug world’s increasing share of overall drug costs, especially as Americans age. As such, CMS and its parent, the Department of Health and Human Services (HHS), have announced two key initiatives to reduce overall drug costs and trends in Medicare Advantage and Part D.

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Recent Audits Point to a Few Key Audit Policy Changes

As informal information trickles in on 2018 audits, we wanted to share with you two trends that we are hearing through the grape vine.

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ACO Changes Draw Unfair Fire

The Trump administration announced recently that it plans on curtailing one payment model in the Accountable Care Organization (ACO) pilot – the Medicare Shared Savings Program (MSSP). Since the broader ACO program (after the Pioneer pilot) started, ACOs have had the ability to gain bonuses if they improve costs and quality or gain greater bonus if they also take on so-called downside risk. Over 80 percent are governed under the softer arrangement.

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Will Fax Machines Be Relegated to the Dustbin of History?

Up until a few months ago, I had this decade-old fax machine sitting in my personal office at home. It was relatively modern – the individual sheet paper type, not the roll style. I just didn’t want to part with it, until one day it fell from my desk and was no more. It was then that it dawned on me I hadn’t used it for years.

It seems, though, doctors have an even stronger affinity for their fax machines. They still dominate the healthcare authorization landscape as tens of thousands of...

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