Trusted vendor relationships are crucial for Managed Care Organizations (MCO’s) to deliver outstanding service, care and value to members, providers and regulators. These relationships, which are foundational for successful risk adjustment programs, provide prospective in-office and in-home assessments, extra bench strength on retrospective projects, data submissions, audit
Read More →CMS in a recent bulletin unveiled a “suite of new resources” aimed at guiding states and CMS in their oversight of Medicaid and CHIP programs, including managed care programs. Two items of particular interest to managed care organizations in a July 6 Center for Medicaid and CHIP Services
Read More →CMS recently announced a change that impacts enrollment information for Medicare Advantage and Part D plans. The new race and ethnicity data will be required for all enrollments after January 1, 2023. CMS plans to use the race and ethnicity data to better track and solve disparities
Read More →The Centers for Medicare and Medicaid Services (CMS) reported an increase in Medicare beneficiary complaints associated with third-party marketing organizations (TPMOs). In 2020, CMS received 15,497 complaints related to marketing, and in 2021 there were nearly 40,000 complaints. CMS analyzed the complaint data and determined that two
Read More →According to the CMS fact sheet released April 29, 2022, there are about 4.1 million dually eligible beneficiaries receiving Medicare services through Medicare Advantage (MA) dual eligible special needs plans (D-SNPs). Based on the final rule for MA and Part D marketing and communications (CMS-4192-F), there are several
Read More →The Centers for Medicare & Medicaid Services (CMS) requires that all health plans have written standards for access to care timeliness and member services. Your health plan is required to: Most states have a standard set requirement for primary and specialty care access and availability. Is your
Read More →Are you ready for CMS universe testing for this fall’s Timeliness Monitoring Project (TMP) project? Are you ready for a CMS program audit? CMS will perform the yearly Timeliness Monitoring Project in three waves of data requests beginning in September 2022 and ending in October 2022. This
Read More →Medicare Advantage (MA) health plans that submitted CY 2023 applications are addressing network deficiencies AT THE SAME TIME they’re planning initial applications for new markets or service area expansion for CY 2024. Provider network submissions for CY 2024 will be due to CMS in February 2023. Plans have started
Read More →The Office of Inspector General (OIG) has the authority to exclude individuals and entities from participation in federally funded healthcare programs for many reasons, including a conviction for Medicare or Medicaid fraud. The OIG maintains a list of excluded individuals and entities, the List of Excluded Individuals/Entities,
Read More →Shifts in the managed care landscape have reinforced the need for health plans to engage providers to drive accuracy of risk scores at point of care. As health plans and providers adopt value-based reimbursement and risk-sharing models, ensuring accuracy of risk scores becomes an increasingly integral part
Read More →
