Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight
There is no shortage of concern when it comes to awareness of first tier, downstream and related entity (FDR) oversight. In fact, during a recent webinar hosted by John Gorman, Executive Chairman at GHG, on "The Top 10 Things Killing Your Organization", we shared survey results showing the number one Compliance Program risk, from a health plan's perspective, is FDR oversight.
A number of compliance specialists recently asked us about a CMS condition that either they have received as part of a program audit, or have heard about others receiving. Specifically, the condition pertains to the failure to provide evidence that a Plan Sponsor's FDR employees received fraud, waste and abuse (FWA) training within 90 days of hiring or contracting and annually thereafter.
The citations previously referenced in this condition include 42 CFR § 422.503(b)(4)(vi)(C) and 42 CFR § 423.504(b)(4)(vi)(C), as well as the Compliance Program Guidelines, Section 50.3.2 (dated 1/1/2013). In summation, the CFR required MA organizations to establish and implement effective training and education, and the sub-regulatory guidance supported the regulation, also stating that:
- Sponsors may choose to tailor the training;
- Sponsors must provide the FWA training directly or provide FWA training materials to their FDRs; and
- Sponsors may have FDRs access CMS' standardized FWA training and education module
It is important that all Plan Sponsors are aware of the regulation change made effective as part of the Final Rule released May 24, 2014. In summary, 42 CFR § 422.503(b)(4)(vi)(C)(3) now states as follows: "A MA organization must require all of its first tier, downstream, and related entities to take the CMS training and accept the certificate of completion of the CMS training as satisfaction of this requirement. MA organizations are prohibited from developing and implementing their own training or providing supplemental training materials to fulfill this requirement." The corresponding update was also made to Part 423 for Part D.
For some organizations, this is business as usual. However, for those organizations that were providing their own training and delivering to their FDRs, this is no longer permissible as of 1/1/2016.Therefore, it is recommended that organizations implement this new requirement now. Make sure that any policies and procedures documenting this process are updated, especially since the Compliance Program Guidelines require update. For reference, the Medicare Learning Network is here and the link to the web based training courses is near the end of the page.
Have Questions? Contact me directly at rpennypacker@ghgadvisors.com
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Gorman Health Group's solution, the Online Monitoring Tool (OMT™), streamlines vital compliance activities, such as the implementation of new requirements and corrective actions. Read our recent White paper to learn more.
The external audit program process is fully customizable according to your organization's needs and can encompass both internal and delegated functions, CMS audit protocol, as well as the inclusion of other audit elements that are not part of the current protocol (e.g. enrollment, credentialing, member services). Don't let CMS be the first to tell you where your deficiencies are. Visit our website to learn more >>
Gorman Health Group's Summary and Analysis of the 2016 Draft Call Letter and the Medicare Advantage (MA) Advance Notice is now available. Download it today >>
Value-Based Care: HHS Sets Timeline for Transition
The Health & Human Services Department (HHS) recently announced an accelerated time frame with regards to its efforts to transition the Medicare Fee-for-Service (FFS) payment system over to alternative reimbursement models. Not to be outdone and following on the heels of the HHS announcement where a private coalition of some of the nation's largest healthcare systems and payers announced an initiative to move from FFS payments to so-called value-based payment by 2020. This coalition, called the Health Care Transformation Task Force, was proposed by Richard Gilfallin, a former Medicare official and Chief Executive of Trinity Health, a Catholic system that operates in 21 states.
While there is widespread agreement amongst healthcare leaders and policy makers that the U.S. healthcare system needs to see a significant shift away from volume-based reimbursement to one that incentivizes providers for meeting quality measures, clinical outcomes, and financial savings, the announcement can also leave us shaking our collective heads and wondering how to meet a goal when, to date, it has been so randomly undefined. As stated by Dr. Timothy G. Ferris, who is leading the effort on behalf of Partners Healthcare, "It is really easy to agree on the big-picture stuff, but it gets more complicated when you get into the details." And therein lies the challenge. To repeat a well-worn phrase, the devil is in the detail.
Providers have been willing participants in the various CMS and CMMI initiatives; some willing, some dragged kicking and screaming, have stepped up to the plate to join the bandwagon. While we have made progress, we have fallen short of expectations. Roughly, 3%, 220 of approximately 6,690, of entities that were approved to participate in bundled payments moved forward to implement the new payments. Medicare Shared Savings Program (MSSP) participants have shown some quality improvements and saved Medicare approximately $417 million year one with the first 220 Accountable Care Organizations (ACOs); but this number is under 1% of the Medicare's FFS budget. Several of the original Pioneer ACOs have dropped out to pursue programs, such as MSSP, that offer less risk. A red flag in the new time line, and one that has affected the above initiatives, is poorly defined quality indicators and what truly constitutes value. With an accelerated time line to achieve a shift to volume-based payments, we should focus on lessons learned and steps needed to provide a roadmap to success.
Presently, alternative payment models account for approximately 20% of Medicare payments, and HHS expects to see that percentage rise to 30% by 2016 and to 50% by 2018. This same shift is already taking place within our commercial counterparts. The Blue Cross trade association reported last summer that 20% of their providers had contracts that prioritized quality over quantity, and Aetna reports that 28% of its reimbursements are now in value-based agreements and expects that number to rise to 75% by 2020. What steps do Medicare providers need to start thinking about to promote a similar shift?
- Partnerships: Some of the greatest partnerships in history, Batman & Robin, Abbot & Costello, Laverne & Shirley, have achieved much more together than on their own. As we look around for partners for ACOs, bundled payments, etc., we want to find providers that share our philosophy, geography, goals, and ideas. We need to do our due diligence and ensure we have established, clear-cut terms, methodologies in care, investments, and cost-savings; we also need to establish accountability up front.
- Consistent focus on the value of the opportunity: Involves understanding the change is not the flavor-of-the-month strategy, there will be expenses, and that collaboration is required to succeed.
- Strong leadership and governance: The shift to value-based reimbursement is dependent upon fostering a cultural change from the top down. Culture has its roots in the governance and leadership of the organization. There must be a unified approach around transparency, accountability, and effective outcomes. The key is to balance the upfront expenses and short-term impact to reach long-term success.
Furthermore, much speculation has been given on the change being provider-driven in order to meet the goals. With consumer savvy, newly aged-in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their health care dollar. The new beneficiary is aging in from a world of patient engagement, incentive, and rewards programs, and will expect the same level of service. As HHS promotes "Better Care, Smarter Spending. Healthier People. Why It Matters?", an idealist would say it matters because we are all in this together….a realist would say, "Thanks HHS…but what are the quality measures, and how soon can I have them?" Additionally, the realist will also operate from the belief that there is no one perfect model but that different payment models apply to different treatment pricing scenarios.
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Here at Gorman Health Group, we can help you decide what payment models are appropriate to your unique circumstance and support your implementation efforts. Contact us today.
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Countdown to Final Submit
Today is the final day for current or potential plan sponsors to submit their Medicare Advantage and/or Part D application for a new contract or service area expansion (or service area expansion for 1876 Cost Plans). By now, many of you have already hit final submit and are either celebrating or working on known deficiencies. Or, perhaps you are still waiting for documentation or a final quality check of your submission before you feel confident to submit. Here are a few of the things we learned this year along the way.
- CMS has not updated their Part D readme file to include the FDR chart noted in 3.1.1C. It seems a bit redundant to the information entered in the Part D Data section of HPMS, but to each his or her own. CMS provides no template for that chart so we can imagine either it is overlooked upon initial submission by the applicant, or it is submitted in varied forms.
- Despite making reference to an additional webinar to be held after the second user call, no webinar was scheduled nor was any announcement made to correct that statement. However, CMS staff demonstrated timely responsiveness to posed questions both directly sent to application contacts as well as through the DMAO mailbox.
- With an industry push for quality (read: limited) network establishment, applicants can expect a high level of scrutiny on exception requests. If providers are available in a service area, CMS has stated that applicants should not even submit an exception request, so put those pencils down and step up contracting efforts.
You have until 8:00 PM Eastern Time tonight to submit your application. There should be a good sense of what potential deficiencies exist, so maintain the momentum to fill those gaps. Embrace the reality that CMS may certainly identify additional gaps in the submission. Ensure that your team has time built into your implementation plan to address any additional deficiencies.
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We've assisted scores of organizations through every step of the application process, from gathering the right data, completing the application, submitting, and responding to follow-up questions. Contact us today to ensure a smooth, compliant process.
Registration for the Gorman Health Group 2015 Forum is now open! Attendees can expect timely, actionable advice on the trends shaping health care from notable speakers, including Barclay's analyst, Joshua Raskin, and regulatory guidance directly from Jennifer Smith, a Director in the Medicare Parts C and D Enforcement Group at the Centers for Medicare & Medicaid Services (CMS). Register your team for The Gorman Health Group 2015 Forum today!
Operational Assessment — time for a “Check-Up"
It's time for an operational assessment.
Here's why….
An operational assessment is an opportunity to review your day to day operations to ensure processes are accurate, running efficiently and most importantly, compliant. Over time employees tend to reinvent the wheel - they stray from the documented processes and before you know it, the way it's being done is now the accepted "norm". If management isn't close to the work being performed or not working with a "sleeves rolled up" attitude, then you may be unaware of exactly what's going on in your operational areas. You may believe the staff is doing "this" but they're actually doing "that".
Here's another reason .…
You don't know what you don't know.
GHG's Operational Assessment starts with a period of discovery through observation and interviews. We get people talking. Individuals will have a chance to demonstrate and explain their role and tasks within the operational area. It's through this review and discovery phase we uncover the good, the bad, and the ugly. Typically, an operational assessment will consist of reviewing processes, policies & procedures, production reports and performance metrics, training materials, and systems.
The only thing you have to fear….
Organizations shouldn't fear finding gaps or process failures — they should fear not finding them. Assessments are meant to identify problems, make best practices corrections, and implement changes for excellence; there are no blame games.
Don't delay….
There's no time like the present for an operational assessment. The benefits of improved operational performance can be compelling, including better performance, efficiencies, and increased revenue.
Achieving excellence is a process. Begin the journey with a Gorman Health Group Operational Assessment and we will guide you on the road to excellence.
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Let GHG check the box in each and every operational area of your organization. Our team of veteran experts can assist in AEP preparation, transmitting of timely and accurate membership information, recommending staff levels and utilization, and maintaining and improving all enrollment processes. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open. Join us April 7-9, 2015 at the Gaylord National Resort and Convention Center in National Harbor. Register today >>
Private label health plans - a tool for increase market capture and improved patient outcomes
Private label health plans or co-branded health plans are joint efforts between like minded health plans and provider organizations interested in enhancing market share, achieving improved patient outcomes, minimizing duplication of services and achieving financial accountability. In its purest form, a private label health plan combines the strengths of the participating providers such as reputation, innovative practice patterns, trusted referral patterns and coordination of care techniques with those of the participating health plan such as benefit design, network design, contract administration and other insurance plan core competencies.
Most often, a private label enterprise has as its core characteristics, a value based limited network in which the participating providers agree to, and adhere to, mutually designed clinical and financial performance targets which are intended to optimize patient outcomes and financial performance targets ultimately leading to increased provider and health plan profitability. Benefit plans are customized to maximize in network access, member engagement and minimize out of network referrals. The insurance partner, in addition to providing the basic insurance administrative and medical management insurance functions, contributes by offering access to data and technology often unavailable to providers otherwise.
Private label health plans are a potentially attractive option for health plans that are already working with Accountable Care Organizations , (ACO's) and large Integrated Health Systems, (IDS) who control all, or a majority of, the resources necessary to achieve continuity of care ranging from primary care to end of life care.
Large self insured Employers that labor under legacy self insured insurance programs for their retiree populations are potential customers for private customized private label benefit plans and value based networks because they offer the Employer greater control over benefit offerings, defined employee or retiree contribution and medical cost.
At the Gorman Health Group we have a history of supporting Medicare and Medicaid Health Plans and Provider organizations on innovative approaches to network development, healthcare pricing and model of care development, as well as working with ACO's on achieving improved financial performance and member engagement.
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Need our help? Interested in starting a dialogue on Private label plan development, value based network formation or optimization of ACO performance? Take the first step and call us at 202-364-8283 and ask for me directly or one of our senior subject matter experts or contact us via the GHG website. We are here to help.
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
ACOs — There must be a pony in here someplace
We've all heard that story. Now, CMS is in that proverbial barn and with the proposed rules, have doubled down on the time they're taking to look for ACO success at managing risk. Does it make sense given that only two current ACOs have gone to the two-sided risk model? My guess is that is not what they are really looking for in just another three years.
CMS is really looking at how many beneficiaries are in the fee-for-service Medicare world and they're taking the long view. So, that's the 70% who can't be absorbed overnight into Medicare Advantage. It wasn't hard to think that CMS would change how payment formulas could be adjusted to affect success especially when they were given a quick stake of 5 million fee-for-service beneficiaries who are served by 330 ACOs with another 89 added on January 1. First, CMS always does that. Second, getting to those numbers in just three years took years in the various editions of Medicare managed care. So, there just might be something here.
Another point, for now ACOs have a political advantage. Just follow the ying and the yang between fee-for-service and managed care when the White House changes. Republicans have fed managed care but Democrats have looked for ways to avoid insurance companies and entice provider entities. Nothing could be clearer; the ACA was passed in 2010 by the Dems, funding for the ACA came from Medicare Advantage and "ACO" is nomenclature born in the ACA. Also, the additional three-year term extends ACOs into the next administration and, just maybe, provider-operated organizations will evolve into viable risk bearing entities.
Further, the advances in data management and technology along with their combined effects are telling CMS that a sweet spot is developing for a population-based approach to managing chronic conditions, the current Holy Grail. Mega investments in IT by HHS and micro changes in capability to manage and share individual health information will help. But other changes also include diverse things like developing methods to avoid penalties for readmissions. Care management programs are actually touching patients who are no longer in the hospital by the hospital. All of these are encouraging a long view and the belief that there is a nearby tipping point. So, why not keep ACOs going?
Finally, CMS has committed to care coordination and value-based services with a myriad of programs and demonstrations that encircle the underpinnings of ACOs. The latest and largest is the $670 million Practice Transformation demonstration aimed at engaging 150,000 physicians and 5 million beneficiaries. The CMS long view understands that none of these work overnight and that waiting for 70% of the Medicare population in fee-for-service to be absorbed into Medicare Advantage is beyond myopic. So, make comments on these proposed rules, expect more tweaks, and expect evolution. CMS will continue building the infrastructure to deal with this entrenched population. Clearly, ACOs are in the mix for some time to come.
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From ACO-type incentives to bundled payments and contract capitation, to full professional and global capitation — where the potential is promising, we can help design and implement these arrangements. Visit our website to learn more >>
Our team of veteran executives can help your ACO evaluate the options, manage the workflow to achieve either a Medicare Advantage contract with CMS or a risk contract with an existing MA plan, and continue to achieve improved outcomes. Contact us today to get started >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
New Year's Resolutions for Your Organization!
Every January 1st we have the opportunity to reflect on our prior year. We make lists of all the things we want to do or maybe do better in the upcoming New Year. The typical resolutions are lose weight, quit smoking, save money, exercise more, eat healthier, create a budget or plan a trip. The practice of evaluating our personal life is a good way to celebrate our accomplishments while thinking about ways we can improve in the New Year.
Our professional, workplace life should be no different. Now is the time to evaluate current practices. Take time to list all your departments' processes and functions. Evaluate each one. Is the process working well? Is it efficient? Is there room for improvement? Should it be replaced?
The future of organizations will rely on operational cost management. Each department within an organization should be continually looking for process efficiencies to reduce costs, and ways to boost productivity.
If you think this sounds overwhelming, use GHG's simple tool to start the operational evaluation process. It can be as simple as Keep, Fix or Replace.
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GHG has experienced consultants that can assess and review the operational areas of your organization. We can review current processes and look for efficiencies to improve outcomes and better compliance. Make a resolution to improve your organization's operational areas — GHG can help make it happen in 2015. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
ICD-10 Transition — Ready or Not?
It's a New Year and there are 262 days left until the October 1, ICD-10 implementation deadline. The road to ten has been very challenging with respect to "Go or No-go" implementation timelines. Due to several delays, many organizations literally stopped transition efforts and redirected funding budgets to other priority projects.
The big day is coming! Currently, it is a known fact that CMS is operating under the October 1, 2015 scheduled deadline. It is now crunch time and with the compliance deadline set organizations have minimal time to complete the transition. Thoughtful planning, and executing conversion plans, will overall make the difference between a successful transition and missing the deadline.
What happens if your organization is not fully ready?
What is your plan for remediation?
The transition does not have to be painful. Timing is everything. Health plans and organizations, such as providers, clearinghouses and vendors can still benefit by using the time left to focus and implement additional readiness and deployment strategies for the code switchover.
The International Classification of Diseases, Tenth Revision (ICD-10), consists of two new areas, clinical modification (ICD-10 CM) for diseases and procedural coding system (ICD-10 PCS) and will replace ICD-9. The switch in code sets will provide expanded detail for inpatient, ambulatory and managed care organizations to better define medical conditions. The conversion is a significant change to the standard healthcare coding systems.
So what exactly are the differences between ICD-10 and ICD-9?
- ICD-9 codes have three to five numeric digits, while ICD-10 has three to seven alphanumeric digits - the switch in 2012 to HIPAA 5010 transaction standards for electronic claims paved the way for practices and payers to be able to accommodate ICD-10 changes
- CMS will transition all diagnosis codes from 13,000 old codes to approximately 68,000 codes included in the ICD-10 version
- ICD-10 has more specificity with a lot more codes, which provide more detail and granularity than the old codes
- Diagnosis Procedure Codes Systems (PCS) will increase from 3,000 ICD-9 to 87,000 ICD-10 PCS
Based on these changes, transition to ICD-10 requires extensive detailed planning, and comprehensive readiness efforts organizational-wide. It's virtually more than just a coding function. Diagnosis codes affect almost every core functional and operational process, system and reporting. Failure to prepare for the conversion will have dramatic impacts on financials and ultimately the member experience.
By leveraging in-depth regulatory interpretation and guidance with complete operational knowledge base Gorman Health Group provides ICD-10 best practices through financial analysis and impact assessment, which includes people, process and technology. Gorman Health Group will identify gaps between current operational "as is" process flows and recommend future optimal "to be" process flows required for the implementation. The analysis will highlight the impact on margins by line of business and measured through people, process and technology. Additionally, risks and potential return on investments (ROI) for the identified gaps can be provided.
Gorman Health Group ensures end-to-end operational process re-design including but not limited to the following functions:
- Claims
- Benefits & Product
- Configuration
- Codification and mapping
- Contracting
- Division of Financial Responsibility (DOFR)
- Prior Authorization
- Provider Pricing
- Quality Control
- Revenue Cycle
- Reporting and Analytics
- Metrics
- Vendor Alignment
- Vendor Management and Oversight
- All Other Hand-offs "Operational" Areas
If you are behind the eight ball and not exactly on track let us proactively work with you on an expedited readiness plan, contingency plan development, post-production support, post-transition analysis, knowledge transfer, monitoring and reporting. Gorman Health Group includes some of our industry's most experienced and proficient ICD-10 and operational subject matter experts.
Make your New Year's resolution to stay on track with transitioning to ICD-10. Time is running out and October will be here before you know it.
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At Gorman Health Group, we maintain the country's largest staff of senior operations consultants. Our team assists dozens of health plans every year in scrubbing their member data and can translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
Star Ratings: The Moving Target
Recently announced changes to the Star ratings program continue to present Star Ratings as a moving target for Medicare Advantage organizations. While the Centers for Medicare & Medicaid Services' (CMS') recent memo and request for comments on the 2016 Star Ratings program changes illustrates CMS' continued commitment to rapidly driving better care for patients, better health for communities, and lower costs, the proposed changes will simultaneously usher in a new era of accountability and integration within Medicare Advantage health plans.
CMS announced plans to reintroduce three previously-removed measures (breast cancer screening, beneficiary access, call center/TTY), add the long-awaited CMR completion rate measure, retire three HEDIS measures (two LDL screening measures and the LDL control measure), and make a lengthy list of changes to existing measure specifications in the 2016 ratings. CMS also laid the groundwork for the 2017 addition of measures related to asthma, depression and opiod-overutilization.
Since the new 2017 Star measures will likely be officially announced as 2016 Display Measures later this year, and will be computed based upon services provided throughout 2015, the 1st quarter of the year is an optimal time for plans to adjust population health tactics for 2017 Star Ratings success. With the nature and extent of the 2016 and 2017 changes, Medicare Advantage organizations will want to be very strategic as workstreams are developed or adjusted to accommodate CMS' proposed changes.
Given the complex clinical and social issues associated with asthma, depression and overuse of opiods, integrated activities and coordinated services among providers, clinical teams, case managers, and retail pharmacies will help plans achieve Stars success. Executive leaders will want to understand the nature of CMS' new focus areas, and operational and budgetary decision-makers will want to be poised to rapidly understand the changes, as well as deploy new or adjusted tactical workstreams in early 2015 to best ensure Stars success.
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Our team of experts can help you develop or enhance care coordination within your programs and processes. Contact us today, and let's work together to help your plan achieve 4 Stars.
GHG can evaluate your Star Ratings approach, and identify tactics you can begin implementing immediately, to integrate initiatives, eliminate redundancies, and build an enterprise-wide Star management structure. Visit our website to learn more >>
Registration for the Gorman Health Group 2015 Forum is now open and our Early Bird discount has been extended to January 16. Enter promo code EarlyBird30 at checkout to receive your 30% discount. Register today >>
Data Smog - CMS's Clear Vision for the Future of Data & Analytics
We all feel a little bit like hoarders with the vast amount of data we collect and store. We can also agree that it's a challenge to utilize that data for its best purpose and integrate it appropriately across an organization.
Recently in an article, Niall Brennan, the Centers for Medicare & Medicaid Services' (CMS) first Chief Data Officer, said their view about the role of data and analytics is changing. CMS has adopted a core mission to improve data collection and dissemination due to the substantial growth of both the number of data users as well as the vast amount of data it collects.
It's not just about collecting and storing data anymore, it's about aggressive analytics. CMS recognizes the importance of data analytics and the proper use of all that information but continues to struggle with numerous data sources and various systems that don't share data. Mr. Brennan is tasked to optimize and maximize data created by CMS's systems for all users.
This recent announcement is a good reminder for health plans to also take a look at how they collect, analyze, and utilize data. Health plans need to ensure their data is accurate, analyzed diligently and utilized appropriately for it to be relevant. The success of your organization relies on clean accurate records and meaningful data. Accurate data = optimal revenue.
CMS's new vision has elevated the importance of the data and analytics role within an organization. What was once considered a behind the scenes supporting role has now taken center stage. Get ready for your curtain call, the world of data and analytics is changing.
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GHG has experienced Consultants that can help with your Data Analytics. We can review your data architecture and assess processes to look for efficiencies and opportunities. Let us help you optimize your analytics and get all that data under control. Visit our website to learn more >>
John Gorman, GHG's Executive Chairman together with colleagues, Glenn Ellerbe, and Mae Regalado, Senior Consultant, gave an in-depth discussion on the end-to-end management of data from noting identified gaps in data processing, concerns regarding data completeness and accuracy, plus shared procedural practices and audit metrics ensuring workflows are best in-class." Access the recording here >>