On July 27, 2023, CMS released the HPMS memorandum “Announcement of the Part D Formulary and Benefit Administration Validation Audit” which will impact Medicare Advantage Prescription Drug Plans. The CMS training is presented by the Medicare Part C and D Oversight and Enforcement Group, Division of Audit
Read More →The metrics related to the average number of retrieved charts and coded charts per unit of time (day, week or month) are crucial for effective project planning and successful completion of any retrospective chart review program. By monitoring these metrics, managed care organizations can gauge the efficiency
Read More →Per the CY 2023 Final Rule published on May 9, 2022, CMS requires applicants to demonstrate a sufficient network of contracted providers to care for beneficiaries before approving their application. Additionally, for CY 2024, CMS adopted regulations explicitly stating that applications may be denied if network adequacy
Read More →Foreword from report issued July 18, 2023 by CMS’ Medicare Parts C and D Oversight and Enforcement Group: Read full report here The Medicare Parts C and D Oversight and Enforcement Group (MOEG) in the Centers for Medicare & Medicaid Services (CMS) has historically released an annual
Read More →The Department of Health and Human Services, Office of Inspector General (OIG) continues to actively audit Medicare Advantage Risk Adjustment programs, with a focus on diagnosis codes at “high risk of being miscoded.” Between Feb. 2021 and May 2023, OIG issued 25 audit reports that uncovered significant
Read More →A high-performing risk adjustment member engagement program is crucial for healthcare organizations to accurately assess and document the health status of members. Here are four steps for health plans to take now that will enhance risk score accuracy, improve care coordination and achieve better outcomes. Clearly Identify
Read More →Medicare-Medicaid plans (MMPs) report monitoring and performance measures consistent with the three-way contracts with states, the Medicare-Medicaid capitated financial alignment model core reporting requirements, and state-specific reporting requirements. For the 2023 performance measure validation (PMV) cycle (covering data reported for the 2022 measurement year), CMS will select
Read More →As we count down to the third quarter, it’s time for plans to review year-to-date progress against 2023 risk adjustment roadmaps and determine if any course corrections are needed. Here are four proactive steps health plans should take now to avoid the frenzied fourth-quarter push: Evaluate completion
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The proposed rule, Ensuring Access to Medicaid Services, includes changes to existing requirements and introduces new requirements. The proposed regulations advance CMS’s efforts to improve access to care, quality and health outcomes; the regulations are intended to promote health equity across fee-for-service (FFS) and managed care delivery
Read More →Since 2021, the OIG has issued 24 audit reports, and four of the reports have been published so far in 2023. These audits identified more than $400 million in overpayments, with approximately 72% of audited HCCs not validated / supported within the medical documentation The Office of
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