It’s Time to Review Your Risk Adjustment Vendor Contracts

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



Increased Medicare Beneficiary Complaints About Third-party Marketing Leads to New Requirements For Agent/Broker Training & Testing Guidelines

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

CY 2023 Medicare Advantage and Part D Marketing and Communications Final Rule and Impact to Medicare Advantage Dual Eligible Special Needs Plans

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



Medicare Advantage Plans Completing Applications For New Markets or Service Areas Must Build-out Provider Networks at the Same Time

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

Top Ten Steps for Exclusion Monitoring Compliance

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