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),
Read More →Medicare Advantage organizations may not have gotten the outcome they were hoping for in CMS’s recently finalized Risk Adjustment Data Validation rule, but industry experts say they weren’t surprised by the position CMS ultimately took after years of pressure to close out RADV audits and recover identified
Read More →If you plan to enter the value-based insurance design (VBID) market, it’s important to understand the goal of the program in order to make decisions on how to structure it. VBID is a strategy that minimizes or eliminates out-of-pocket costs for high-value services in defined patient populations.
Read More →In a sweeping proposed rule for the 2024 contract year, CMS last month took a strong stance on multiple aspects of the Medicare Advantage program, from misleading marketing and prior authorization to quality gains incentivized by the Star Ratings. As plans digest the many changes proposed in
Read More →Exceeding 950 pages in its initial prepublication version, CMS’s most recent rule proposing policy and technical changes for contract year 2024 is the Biden administration’s most complicated and sweeping Medicare Advantage and Part D rule to date. Following a comprehensive request for information issued last summer on
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