Charles Baker, VP, Compliance Solutions Compliance belongs at the strategic decision-making table to ensure the seamless integration of regulatory guidelines into the fabric of effective programs. For years, compliance in the health insurance sector, especially regarding government programs, has been synonymous with regulatory oversight. Compliance departments have
Read More →The Centers for Medicare & Medicaid Services (CMS) took a significant step towards advancing health equity with the finalization of Parts C and D Enrollment Guidance. This strategic move aligns with CMS’s ongoing commitment to prioritize health equity, a dedication outlined in its comprehensive strategic plan and Framework for
Read More →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 →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 →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
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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
Read More →It’s crucial for health plans and plan sponsors to verify the accuracy and timeliness of benefit documents, such as Certificates of Coverage, Summary Plan Descriptions, and Evidence of Coverages, as they finalize annual changes to benefit plan designs. Some plans have discovered during audits by a Department
Read More →CMS has initiated routine program audits by sending engagement letters to Medicare Advantage organizations, prescription drug plans and Medicare-Medicaid plans. Are You Audit-Ready? If your plan receives an engagement letter, are you prepared to respond within 15 business days, or do you feel nervous and hope you
Read More →Plans should begin using the updated IDN no later than May 2, 2023 CMS updated an Office of Management and Budget-approved standardized Notice of Denial of Medical Coverage (or Payment), also known as the Integrated Denial Notice (IDN). Medicare health plans, including Dual-Eligible Special Needs plans (DSNPs),
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