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# GHG Advisors

Government-Sponsored Healthcare Consulting

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## Posts

- [Set Your Plan Apart with an OTC Benefit](https://ghgadvisors.com/set-your-plan-apart-with-an-otc-benefit/) - Two of the buzz phrases most frequently heard in the health care community now are “value-based care” and “social determinants of health” (SDOH). Health plan leaders must leverage both to compete. SDOH are particularly important in Medicare and dual-eligible populations, and Medicare Advantage and Part D plans are uniquely positioned to address SDOH through provider
- [The CMS Spring Conference Has Come and Gone!](https://ghgadvisors.com/the-cms-spring-conference-has-come-and-gone/) - The Centers for Medicare & Medicaid Services (CMS) held its annual spring conference, and although it was a shortened conference this year with four areas of discussion as well as a keynote address by Demetrios Kouzoukas, Principal Deputy Administrator for Medicare and Director of the Center for Medicare, they did cover some important changes about
- [Taking the Pulse of Your Population](https://ghgadvisors.com/taking-the-pulse-of-your-population/) - How well do you know your members? Member segmentation, or stratification, is the foundation of your population health management strategy. Member wellness, healthcare facility utilization, and provider patient management are some of the metrics that not only meet the needs of accrediting bodies (e.g., NCQA) but also help you manage your member population efficiently, and
- [3 Steps for Success: 2020 Material Creation and Review Season](https://ghgadvisors.com/3-steps-for-success-2020-material-creation-and-review-season/) - It’s late Friday afternoon before Memorial Day weekend and the Centers for Medicare & Medicaid Services (CMS) has gifted us with the Contract Year 2020 model materials memo! Although most organizations wait until the bids are in, we are seeing some plans get a head start on their materials this week. Last year there were multiple
- [Why Member Experience? And Why Now?](https://ghgadvisors.com/why-member-experience-and-why-now/) - Recently, I was having a drink with a friend in the industry, and I started talking about our member experience roadmap. My friend made the mistake of asking me why I was bringing this up now – weren’t there more important things to be worrying about, such as developing the right product or Star Ratings?
- [CMS Seeks Comments to Proposed Audit Protocol Changes](https://ghgadvisors.com/cms-seeks-comments-to-proposed-audit-protocol-changes/) - In a HealthPlan Management System (HPMS) memo dated August 20, 2019, the Centers forMedicare and Medicaid Services (CMS) announced they are seeking comments totheir proposed changes to the current program audit protocols, which expire in2020. All protocol areas have updatesand clarifying language to the Audit Process and Data Request documents. Noteworthychanges include: Compliance
- [March 25, 2021 - Star Ratings Updates: A Focus on Member Experience](https://ghgadvisors.com/webinar-star-ratings-updates-member-experience/) - March 25, 2021 STAR RATINGS UPDATES A Focus on Member Experience Webinar Recent updates from CMS have led health plans to revisit their Star Ratings strategies and recalculate their path forward. Specifically, the increased weighting of member experience measures means that MA plans will need to consider Star Ratings and member experience in nearly every
- [With Switching Down, MAOs Seek ‘Untapped’ Market Segments](https://ghgadvisors.com/switching-down-maos-seek-untapped-market-segments/) - AIS Health recently spoke with GHG's Vice President, John Selby, about his analysis of the 2021 Medicare Annual Election Period.
- [CMS Program Audit Universes and Protocol Changes Tabled Until 2022](https://ghgadvisors.com/cms-program-audit-universes-protocol-changes-tabled-until-2022/) - The Centers for Medicare and Medicaid Services (CMS) recently released the 2021 Program Audit Memo, which announced that it will start sending engagement letters in March of 2021, and will continue to do so through July of 2021. CMS also announced that it will continue to use the 2020 protocols for program audits in 2021. CMS
- [CMS Releases New Notice of Denial of Medical Coverage](https://ghgadvisors.com/2206-2/) - On February 19, 2020, CMS released a new OMB-approved Notice of Denial of Medical Coverage (NDMC), also known as the Integrated Denial Notice (IDN), for Medicare Advantage plan use. While CMS encourages plans to begin using the new form as soon as possible, it must be implemented by April 1, 2020. The form and instructions
- [CMS Announces COVID-19 Mailbox for MA Plans](https://ghgadvisors.com/3-25-industry-alert/) - In case you missed it, CMS announced a COVID-19 mailbox for Medicare Advantage plans to submit policy and benefit related questions. View it here: https://ma-covid19-policybenefits.lmi.org/covid19mailbox GHG’s experts are also here to answer any of your Coronavirus-related questions—don’t hesitate to reach out for support.
- [CMS Publishes Revised COVID-19 Guidance](https://ghgadvisors.com/cms-publishes-revised-covid-19-guidance/) - CMS has published additional guidance related to COVID-19 for MA and Part D sponsors, including expanded benefit offerings, telehealth information, Model of Care flexibility and more. This announcement revises and replaces an initial memo released on March 10. Reach out to us at ghg@ghgadvisors.com with any questions.
- [Health Service Delivery Tables Deadline is Fast Approaching](https://ghgadvisors.com/health-service-delivery-tables-deadline-is-fast-approaching/) - CMS requires MA plans to maintain a compliant network at all times. We understand that your plan may have deployed your network analytic teams to support other functional areas due to the pandemic; however, the mid-June deadline to submit Health Service Delivery (HSD) tables for CMS review is fast approaching. Based upon the data in
- [CY2021 Marketing Models, Standard Documents, and Educational Material](https://ghgadvisors.com/cy2021-marketing-models-standard-documents-and-educational-material/) - While we await the associated HPMS memo, CMS had uploaded the CY2021 materials to their website. You can preview them here: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/MarketngModelsStandardDocumentsandEducationalMaterial
- [OMB-Approved 2020 Program Audit Protocols](https://ghgadvisors.com/omb-approved-2020-program-audit-protocols/) - CMS has published the OMB-approved 2020 Program Audit Protocols, available for download here: https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/ProgramAudits CMS also announced a possible reprioritization of the 2020 program audits in an effort to complete them later this year. Sponsors should review the new protocols and prepare for any changes in data reporting, process, etc. Reach out to Tina Bailey,
- [CMS Resumes Parts C and D Program Audit Activities for 2020](https://ghgadvisors.com/cms-resumes-parts-c-and-d-program-audit-activities-for-2020/) - CMS is resuming Medicare Parts C and D program audit activities for 2020. As of yesterday, all engagement letters for 2020 audits have been distributed. Contact Tina Bailey, CCEP with any questions or support with an upcoming audit. Program audit info here: https://www.cms.gov/Medicare/Compliance-and-Audits/Part-C-and-Part-D-Compliance-and-Audits/ProgramAudits
- [CHART Model Team to Host Informational Webinar](https://ghgadvisors.com/8-17-industry-alert/) - The Community Health Access & Rural Transformation (CHART) Model team is hosting a webinar TOMORROW, Tuesday, August 18, from 1:00 – 2:30 PM EDT. To promote better health outcomes for the approximately 57 million Americans living in rural communities, including millions of Medicare & Medicaid beneficiaries facing unique challenges (i.e., limited transportation options, shortage of health
- [2022 Advance Notice Part I Released, Heavy Focus on Risk Adjustment](https://ghgadvisors.com/dlr-industry-alert-draft-from-9-16-newsletter/) - On September 14th, CMS published the 2022 Advance Notice Part I, with particular emphasis on Risk Adjustment. One key takeaway from this announcement is that CMS will push forward with their plan to implement and fully phase in the use of 100% of encounter data using the 2020 CMS-HCC model. Read the memo here. GHG
- [It's the Most Wonderful Time of the Year...To Think About Your 2019 CPE Audit](https://ghgadvisors.com/its-the-most-wonderful-time-of-the-year-to-think-about-your-2019-cpe-audit/) - For most Plan Sponsors, the holidays are not a time of respite or reflection; they are a time for looking forward to the upcoming calendar year. This is when Compliance begins its tradition of annual audit work plans and getting those audits approved via committee and the governing body. While in the midst of all
- [Changes Are Ahead for C-SNPs and D-SNPs](https://ghgadvisors.com/changes-are-ahead-for-c-snps-and-d-snps/) - The Centers for Medicare & Medicaid Services (CMS) announced yesterday that beginning in 2020, all current Chronic Condition Special Needs Plans (C-SNPs) must submit their Model of Care (MOC) to CMS annually for evaluation and approval by the National Committee for Quality Assurance (NCQA). The approval will last for one year, and plans must continue
- [Modernizing Part D & Medicare Advantage to Lower Drug Prices](https://ghgadvisors.com/modernizing-part-d-medicare-advantage-to-lower-drug-prices/) - The Centers for Medicare & Medicaid Services (CMS) has done it again. While everyone was still in a turkey-induced coma after Thanksgiving, they released a 185-page document of proposals/bombshells called Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of-Pocket Expenses. The document provides proposals that will help contain costs for both
- [Tips for 2020 Product Development](https://ghgadvisors.com/tips-for-2020-product-development/) - It’s the middle of January, and the Medicare Advantage (MA) world now knows whether you were a winner, loser, or maintaining status quo from the 2019 Annual Election Period (AEP). This last year was a great one to test the waters with strong benefit strategies and aggressive sales and marketing techniques. We saw several of
- [HHS Proposed Bill Could Revolutionize Current Rebate Pricing Model](https://ghgadvisors.com/hhs-proposed-bill-could-revolutionize-current-rebate-pricing-model/) - Removal of Drug Rebate Safe Harbor Protection The U.S. Department of Health and Human Services (HHS) issued the proposed rule to remove the safe harbor protection rebates involving prescription pharmaceuticals on January 31, 2019. The proposed rule is looking to disrupt the current incentive structure of the drug payments, particularly to Pharmacy Benefit Managers (PBMs).
- [New Medicare Opioid Management Initiatives](https://ghgadvisors.com/new-medicare-opioid-management-initiatives/) - The Centers for Medicare & Medicaid Services (CMS) held a webinar on December 27, 2018, to help providers understand the new guidance for prescribing opioids to Medicare beneficiaries – and if you didn’t listen in, you missed a good one. Here is the fact sheet for reference. My first thought was, “Can’t we just leave
- [Better Billing, Better Consumer Experience](https://ghgadvisors.com/better-billing-better-consumer-experience/) - The Medicare Advantage market is heating up – a trend that’s expected to continue, according to a new Kaiser Family Foundation report. In 2019, there will be 417 more MA plans than this year. Fourteen new carriers will offer plans in 26 states, with only five carriers exiting the market. As market competition in MA
- [Top 10 Changes - Draft Medicare Communications and Marketing Guidelines](https://ghgadvisors.com/top-10-changes-draft-medicare-communications-and-marketing-guidelines/) - Centers for Medicare & Medicaid Services (CMS) has released the draft Medicare Communications and Marketing Guidelines (MCMG) for 2020. Of the CMS draft MCMG changes, here’s our top 10: Plans must include a toll-free TTY number when a telesales number is listed in the same font size as the other phone numbers. This requirement no
- [You Can NO LONGER Be on Autopilot! Live or Let Die to the Nationals!](https://ghgadvisors.com/you-can-no-longer-be-on-autopilot-live-or-let-die-to-the-nationals/) - This past Annual Election Period (AEP) was more active than in past years, and the results show it. There were more than 600,000 net new Medicare Advantage (MA) enrollees this AEP. The following chart shows the AEP growth of the 10 largest parent organizations. The top three – UnitedHealthcare, Humana, and Aetna – had significant
- [Population Health and Care Management](https://ghgadvisors.com/population-health-and-care-management/) - The term “population health” began emerging in U.S. health care circles around March 2003 when David Kindig and Greg Stoddart co-authored an article in the American Journal of Public HealthCare Management entitled “What is Population Health?” In the article, the authors provide a working definition for population health as “the health outcomes of a group
- [Feasibility Studies](https://ghgadvisors.com/feasibility-studies/) - Two of the most common questions plans ask are: “Where should we be offering products?” and “What products should we be offering?” A feasibility study can really help make that picture clearer. For plans looking to either expand or become a health plan in 2021, this should be done as early in the process as
- [The Medicare Plan Finder (MPF) Tool AND its Much Needed Make-over](https://ghgadvisors.com/the-medicare-plan-finder-mpf-tool-and-its-much-needed-make-over/) - Starting this AEP Medicare beneficiaries will have a new experience when researching Medicare Plans on medicare.gov. The site is much more user friendly and provides a much cleaner user experience. The picture below displays the new home page you will see when you enter the site. It’s hard to believe that the original MPF, one
- [In the Midst of AEP…Don’t Lose Sight of the Upcoming Application Season Compliance Solutions](https://ghgadvisors.com/in-the-midst-of-aepdont-lose-sight-of-the-upcoming-application-season-compliance-solutions/) - In mid-October, CMS will release the online Calendar Year 2021 Notice of Intent to Apply (NOIA). The NOIA must be submitted to CMS by November 12, 2019 if organizations plan to submit an application for the 2021 plan year, either for a new contract or contract expansion, including the following: It’s that time again…time to
- [New Membership Preparation From a Clinical Perspective](https://ghgadvisors.com/new-membership-preparation-from-a-clinical-perspective/) - How do plans get ready for new membership as the new enrollment period starts? When you are trying to plan for the future at times it is best to look back at the past….past data, past experiences, trends and your past mistakes as well. As AEP rolls around it’s time to look back at the
- [Compliant Coding and Documentation:  Minimize Compliance Risk with CMS through HCC audit programs](https://ghgadvisors.com/compliant-coding-and-documentation-minimize-compliance-risk-with-cms-through-hcc-audit-programs/) - Was your plan selected for this year’s Medicare Part C Contract-Level Risk Adjustment Data Validation (RADV) audit of 2014 dates of service? Have you participated in a Department of Health & Human Services (HHS) Office of Inspector General (OIG) audit related to risk adjustment submissions? Does your plan participate in the Affordable Care Act (ACA)
- [Three Ways to Retain Your Members for 2020](https://ghgadvisors.com/three-ways-to-retain-your-members-for-2020/) - It’s the Annual Election Period (AEP) and now is a really difficult time to turn your thoughts away from what’s right in front of you, but a strong retention program can be the difference between achieving your enrollment goals or missing them. Member retention is key to long-term success. Net growth does not happen with
- [Blending Network Strategy & Product Strategy](https://ghgadvisors.com/blending-network-strategy-product-strategy/) - As more and more health systems and provider organizations successfully manage the shift from volume-based patient care to value-based population health management, health plan strategic planning should be blending network strategy with product strategy as a key factor in the ability to achieve clinical and financial goals. The majority of providers are savvy at managing
- [2020 Readiness Checklist](https://ghgadvisors.com/2020-readiness-checklist/) - On October 3, 2019 the Centers for Medicare & Medicaid Services (CMS) released the 2020 Readiness Checklist highlighting critical operational and contractual requirements for Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), Medicare-Medicaid Plans (MMPs), and Cost Plans. The readiness checklist is released annually and, when used as a “self-assessment,” can be an effective tool
- [The OEP Is Almost Upon US! Are YOU Ready?](https://ghgadvisors.com/the-oep-is-almost-upon-us-are-you-ready/) - January 1, 2020, Medicare Advantage (MA) enrollees have a one-time opportunity to switch their plan, similar to a grace period, and the opportunity ends March 31. Both new MA enrollees and existing enrollees have the ability to switch plans. This is a chance for MA plans to win and lose enrollment! To make sure you
- [Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance](https://ghgadvisors.com/cms-announces-organization-determinations-appeals-grievances-guidance/) - On December 30, 2019, the Centers for Medicare & Medicaid Services (CMS) announced updates to the Parts C & D Enrollee Grievance, Organization/Coverage Determination and Appeals Guidance, which became effective as of January 1, 2020. Noteworthy changes are summarized below: In Section 10.5.3, the guidance was expanded to include more detail about verbal notifications. This section
- [OIG Cracks Down on Chart Reviews in Medicare Advantage Risk Adjustment](https://ghgadvisors.com/oig-report-medicare-advantage-risk-adjustment-chart-reviews/) - On December 10th, 2019, the Department of Health and Human Services Office of Inspector General (OIG) released a report, which evaluated how Medicare Advantage Organizations (MAOs) used chart reviews to increase risk adjustment payments for Medicare Advantage (MA) beneficiaries in the 2017 payment year (2016 Dates of Service [DOS]). While the Centers for Medicare and
- [CMS is Changing the Medicare Advantage Risk Adjustment Model… Will Your 2021 Revenue Be Impacted?](https://ghgadvisors.com/2021-medicare-advantage-risk-adjustment-advance-notice-part-1-analysis/) - On January 6, 2020, the Centers for Medicare & Medicaid Services (CMS) released Part I of the 2021 Advance Notice of Methodological Changes for Medicare Advantage Capitation Rates and Part C and Part D Payment Policies (the Advance Notice), which contains key information about proposed updates to the Part C CMS-Hierarchical Condition Categories (HCC) risk
- [5 Key Takeaways for Product Leaders from the Advance Notice](https://ghgadvisors.com/key-takeaways-product-strategy-cms-advance-notice-proposed-rule/) - The news is out and one thing is clear: CMS is proposing significant changes across all focus areas for Medicare Advantage (MA) plans in the 2021 Advance Notice and 2021/2022 Proposed Rule. On top of that, CMS has announced that there will be no draft or final call letter this year. Instead, items typically released
- [Feeling the Madness! The 2020 CMS Program Audit Cycle Begins](https://ghgadvisors.com/2020-cms-program-audit-cycle-begins/) - This March, sports will not be the only excitement—health plans are gearing up to receive audit notices as we enter the second year of the four-year Program Audit Cycle. The ball is in your court… Your team’s readiness depends on review of the current audit protocols and practice, practice, practice. Are you performing “mock” auditing
- [Remote Work in Challenging Times—Steps to Survive and Thrive](https://ghgadvisors.com/working-remotely-work-from-home-covid-19-coronavirus-disease/) - For many professionals, like those of us at Gorman Health Group (GHG), we were working from home (i.e., remotely) before the words “Coronavirus” or “COVID-19” were ever spoken. Prior to social distancing and “shelter in place” orders, 43% of US employees worked remotely at least some of the time. Surveys are currently underway to determine
- [Dramatic Changes to the Telehealth Benefit Due to COVID-19](https://ghgadvisors.com/telehealth-benefit-expansion-covid-19-coronavirus-disease/) - Over the last week, the Centers for Medicare and Medicaid Services (CMS) has released several documents providing guidance and relief to healthcare organizations amidst the COVID-19 pandemic. First, CMS broadened access and greatly relaxed regulations around telehealth services for Medicare beneficiaries. Through this expansion, Medicare can temporarily pay providers for telehealth visits for Medicare beneficiaries
- [Strategies to Support Value-Based Reimbursement During Uncertain Times](https://ghgadvisors.com/value-based-reimbursement-strategies-covid19-coronavirus-uncertainty/) - As we are all experiencing a new normal in our personal and professional lives during the COVID-19 pandemic, the ability to keep up with the ever-changing clinical and regulatory environment in healthcare has made even the most seasoned healthcare executive feel as if they were swimming against the current. Providers and Accountable Care Organizations (ACOs)
- [As the Bid Submission Timeline Approaches, So Does the Release of PY2021 Model Documents](https://ghgadvisors.com/2021-bid-submission-material-development-timeline-approaching/) - It’s that time again… the frantic whirl of both bid submission and material development in anticipation of the upcoming plan year and sales/enrollment activities. If you are a health plan with multiple contracts and/or plan benefit packages (PBPs), you know how daunting material development and review can be. If not delayed, the Centers for Medicare and
- [6 Tactics for Better Agent/Broker Management During COVID-19](https://ghgadvisors.com/agent-broker-management-tactics-during-covid19/) - On May 29, 2020, the Centers for Medicare and Medicaid Services (CMS) released the Contract Year 2021 Agent and Broker Compensation Rate, Referral/Finder’s Fees, Submissions, and Training and Testing Requirements. While the compensation rate increases are a welcome update for agents/brokers, it is important to explore these changes in the context of COVID-19 and how the standard Medicare
- [Building a Successful Social Determinants of Health Strategy](https://ghgadvisors.com/building-successful-social-determinants-health-strategy/) - For those who have worked on the healthcare frontlines—in hospitals, provider offices, and even patients’ homes—the challenges of social determinants of health (SDOH) have been less of an emerging trend or buzzword and more of a longstanding problem that desperately needs to be addressed. Health plans have also grappled with this issue on a massive population
- [CMS' Proposed Addendum to Part C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance](https://ghgadvisors.com/cms-proposed-addendum-enrollee-grievances-organization-coverage-determinations-appeals-guidance/) - On July 7, 2020, the Centers for Medicare and Medicaid Services (CMS) distributed a draft addendum to address changes to Unified Appeal and Grievance processing for Integrated D-SNPs in the Parts C and D Enrollee Grievances, Organization/Coverage, Determinations, and Appeals Guidance. CMS notes that rules implementing unified grievances and appeals apply only to fully integrated
- [CMS Network Adequacy Changes & the Impact to Medicare Advantage Plans](https://ghgadvisors.com/cms-network-adequacy-changes-medicare-advantage-impact/) - The Centers for Medicare and Medicaid Services (CMS) has afforded Medicare Advantage (MA) plans flexibility in terms of meeting provider network adequacy. These changes lower the percentage of beneficiaries needed to meet adequacy in CEAC, Rural and Micro counties, offer credit towards states with Certificate of Need (CON) laws, and provide the ability for plans
- [Why the OEP is So Important This Year](https://ghgadvisors.com/why-open-enrollment-period-critical-2021/) - With the overwhelming uncertainty due to a global pandemic and a Presidential election year, the entire industry is looking for a crystal ball to shed some light on this year’s Annual Enrollment Period (AEP). Despite this uncertainty, there are a few things we do know for certain: There will be NO large gatherings for member town
- [The Value in Shifting to a Value-Based Care Model](https://ghgadvisors.com/shift-fee-for-service-value-based-care-model/) - The pandemic has shown us that the fee-for-service model was just as fragile as we thought it was. Overnight, providers who had traditionally been reimbursed for the quantity of services provided (rather than better outcomes) found themselves in a devastating situation. The severe and sudden drop in office visits, without another strong source of revenue,
- [How Will Utilization Change After COVID-19?](https://ghgadvisors.com/utilization-change-after-covid19/) - Over the past several weeks, one question in particular has been top of mind for many healthcare systems: how will utilization change in a post-COVID world? By now, we know that we will continue to live with this virus for years to come. As such, we will surely endure periods of shut down, as well as
- [2021 Chapter 2 Enrollment Changes](https://ghgadvisors.com/cms-2021-chapter-2-enrollment-changes/) - With the Centers for Medicare and Medicaid Services' (CMS) recent release of the 2021 chapter 2 enrollment changes, Medicare Advantage (MA) plans now have insight into the many proposals made earlier this year. GHG's Vice President of Sales, Marketing & Strategy, Diane Hollie, summarizes the key changes. Medicare Advantage Plan Options for End-Stage Renal Disease
- [DOJ’s Increased Focus on Risk Adjustment and Compliance](https://ghgadvisors.com/department-justice-focus-risk-adjustment-compliance/) - As the Department of Justice (DOJ) continues its efforts to investigate the diagnosis capture and reporting practices of Medicare Advantage Organizations (MAOs), MAO executives must start to ask, “How can we most effectively report all conditions contributing to a member’s health outcomes while upholding rigorous compliance standards, when official guidance on what is considered ‘compliant’ is unclear?”
- [4 Tips to Expand and Grow Your Enrollment in a Fiscally Responsible Way](https://ghgadvisors.com/4-tips-growing-enrollment-fiscally-responsible-way/) - In the Medicare Advantage (MA) space, we are continually searching for opportunities to grow enrollment, either by adding new products or expanding our service areas. While both are certainly viable methods, it is important to approach the expansion process in a fiscally responsible way. Conducting a feasibility study can help make this process clearer and
- [MA Plans See Lower 2021 Star Ratings on Average](https://ghgadvisors.com/medicare-advantage-plans-average-lower-2021-star-ratings/) - For many, October signals the beginning of Fall with the weather turning cooler and the smell of pumpkin spice in the air. For Stars leaders at Medicare Advantage plans, it means the nerve-racking public release of their Star Ratings. For the past several years, the Star Ratings program has been relatively stable. However, because of
- [2021 Medicare Advantage Readiness Checklist](https://ghgadvisors.com/2021-medicare-advantage-readiness-checklist/) - Every year, CMS releases an annual Readiness Checklist in an effort to remind Medicare Advantage (MA) Plan Sponsors of key contractual responsibilities in the upcoming plan year. The Readiness Checklist is not only a great reminder for existing Sponsors, but is also an excellent guide for plans that are new to the MA market. This
- [Part II of the CY 2022 Advanced Notice: Continued Evolution of the Medicare Advantage Star Ratings](https://ghgadvisors.com/part-2-2022-advanced-notice-continued-evolution-medicare-advantage-star-ratings/) - On October 30, 2020, CMS surprised plans with the early release of Part II of the CY2022 Advance Notice. Per CMS, this earlier-than-anticipated issuance may allow for the early publication of the CY 2022 Rate Announcement. This would provide plans with more time to prepare their bids and would provide some level of certainty during
- [Building A New Provider Network or Planning Your Next Service Area Expansion? Don't Lose Sight of Your Biggest Asset](https://ghgadvisors.com/building-a-new-provider-network-or-planning-your-next-service-area-expansion-dont-lose-sight-of-your-biggest-asset/) - The sun is shining, kids are out of school, and vacation season is in full swing! While our Health Plan Network and Product teams are taking a few deep breaths after application and bid filing deadlines, we cannot rest on our laurels for very long. Summer is the best time to start planning your next
- [Member Engagement — Are you listening to your members?](https://ghgadvisors.com/member-engagement-are-you-listening-to-your-members/) - Member Engagement — Are you listening to your members? Do you understand what prospective members need and want from a health plan? Are you acting on the feedback you receive from your members? If you answered "no" to all or just one of these questions, your health plan may be missing opportunities to engage members
- [Challenges in Network Development](https://ghgadvisors.com/challenges-in-network-development/) - The sun is shining, kids are heading back to school, and fall will be here before we know it. Now is the perfect time to start planning for your network expansion needs. Plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan's
- [Helping Smaller Providers Assess Their Ability to Take on Risk](https://ghgadvisors.com/help-smaller-providers-assess-ability-take-risk/) - We often note that when a team works well together, it can collectively accomplish more than its members alone. Your network providers, especially the individual and small groups, have been inundated with information from all directions on how to prepare for a shift to value-based payment models. This shift can seem overwhelming to a small
- [Big Push on the Super-Committee for a Permanent "Doc Fix"](https://ghgadvisors.com/big-push-on-the-super-committee-for-a-permanent-doc-fix/) - Our industry needs to be watching the workings of the Congressional deficit Super-Committee for obvious reasons: Medicare is one of its biggest targets for reining in Federal spending. Hands-down the biggest issue facing Medicare Advantage is an indirect one: whether the "Supers" will address the Sustainable Growth Rate (SGR) methodology that determines reimbursement for physicians
- [2021 Risk Adjustment Strategy and Program Readiness](https://ghgadvisors.com/2021-risk-adjustment-program-readiness/) - As plans begin to wind down the year, one thing is clear. The COVID-19 pandemic put a strain on the entire healthcare industry and, for risk adjustment in particular, the disruption caused by the pandemic resulted in both adverse consequences (i.e., decreases in preventative encounters such as annual wellness visits) as well as some positive
- [Making Order from Chaos](https://ghgadvisors.com/making-order-from-chaos/) - "Big data" is often described in terms of colorful dashboards and a roomful of SQL programmers. Gorman Health Group (GHG) thinks of it as a symphony of moving parts that all play a role in managing quality healthcare. The year 2014 was the first time since 2005 that saw an increase in Medicare Advantage (MA)
- [Helping Your Providers Assess Their Ability to Take Risk](https://ghgadvisors.com/helping-your-providers-assess-their-ability-to-take-risk/) - We have often noted when a team works well together, it can collectively accomplish more than its members alone. This adage has never been truer than the looming Medicare Access & CHIP Reauthorization Act of 2015 (MACRA) legislation and the steps providers will need to take to make a successful transition. Your network providers, especially
- [Network Exceptions: Why Coordination Between Provider Network Operations & Compliance is Key](https://ghgadvisors.com/network-exceptions/) - As we approach the holiday weekend, health plan Network and Product teams alike are breathing a sigh of relief after the fireworks that came along with this year’s network exception process, application, and bid filing deadlines. A lesson learned by many is there can never be too much oversight in managing provider network data. The
- [New Challenges in Network Development](https://ghgadvisors.com/new-challenges-in-network-development/) - The summer sun is shining and vacation season is in full swing! While our Health Plan Network and Product teams are taking a few deep breaths after application and bid filing deadlines, we cannot rest on our laurels for very long. Summer is the best time to start planning your next service area expansion (SAE)
- [It’s Time to Prepare for Medicare Advantage Provider Network Submissions](https://ghgadvisors.com/prepare-medicare-advantage-provider-network-submissions/) - Network management, directory accuracy, initial applications, service area expansions (SAEs), and the new triennial review process have exposed many Medicare Advantage (MA) plans to serious issues—from policy to process and staffing to technology. As we move into the countdown for network development, expansion, and Health Service Delivery (HSD) submission for 2020, as well as plan
- [In Light of COVID-19, Overcommunication is Necessary](https://ghgadvisors.com/covid-19-coronavirus-disease-member-provider-communications/) - Since COVID-19, otherwise known as coronavirus disease, surfaced in China at the end of last year, consumers have been bombarded with media coverage and corporate communications about the spread of the pandemic, the necessary precautions, the state of the global economy, and changes to operations, most of which has been less than positive. In particular throughout
- [AEP Marketing During COVID-19 ...AND a Presidential Election](https://ghgadvisors.com/2021-aep-marketing-covid19-presidential-election/) - Developing a marketing strategy during a Presidential election year is difficult enough. But adding in the current, and eventually, post-COVID-19 environment, which is unprecedented, makes it even more challenging. As we mentioned in a recent webinar, Medicare Advantage (MA) plans will need to “think outside of the box” when developing and executing a go-to-market strategy
- [New Benefits & Special Enrollment Period (SEP) During a National Emergency](https://ghgadvisors.com/national-emergency-special-enrollment-period-sep/) - Since President Trump declared COVID-19 a national emergency in all 50 states and the District of Columbia, a Special Enrollment Period (SEP) for Medicare beneficiaries is allowed. The SEP runs from March 1st to June 30th. What is a Special Enrollment Period? The SEP exists for Medicare beneficiaries who were unable to make an election during the Open Enrollment
- [Medicare Sales in the Age of COVID-19](https://ghgadvisors.com/2020-medicare-sales-covid-19-presidental-election/) - There’s no doubt about it: COVID-19 will change the way we sell Medicare products. In previous years, health plans relied on agents for seminars, town halls and “kitchen table” sales. This year, plans cannot depend on face-to-face interactions with Medicare beneficiaries to be successful in the upcoming Annual Enrollment Period (AEP). Medicare beneficiaries are one of the
- [Network Development Season is Upon Us](https://ghgadvisors.com/cms-new-network-adequacy-requirements-network-development/) - At this time of year, we would normally be sunsetting summer, sending the kids off to school, and stepping into the splendor of fall. As we move through the seasons of 2020, we have an odd mix of sharing our kitchen table 'office space' and navigating a new normal with our families and co-workers. At
- [Impacts of CMS' 2022 Advance Notice Part I on Risk Adjustment](https://ghgadvisors.com/2022-medicare-advantage-advance-notice-part-1-risk-adjustment/) - On September 14th, 2020, CMS released their Advance Notice Part I for CY2022. CMS published this earlier than in the past to accommodate a potential early publication of the CY2022 Rate Announcement. In light of the uncertainty associated with COVID-19, an early Rate Announcement could benefit Medicare Advantage Organizaions (MAOs) by having information earlier in
- [Strategies to Ensure Accurate Coding and Submission of Upstream Encounter Data](https://ghgadvisors.com/on-demand-webinar-strategies-ensure-accurate-coding-submission-upstream-encounter-data/) - On Demand Webinar: Strategies to Ensure Accurate Coding and Submission of Upstream Encounter Data October 22, 2020 On October 8th, GHG’s SVP of Healthcare Analytics and Risk Adjustment Solutions, Jeff De Los Reyes, moderated a webinar with Austin Bostock of Pareto Intelligence and Meleah Bridgeford of Episource to discuss the future of the regulatory environment,
- [Miss Our Star Ratings Webinar?  Here Are the Top 5 Takeaways](https://ghgadvisors.com/miss-our-star-ratings-webinar-here-are-the-top-5-takeaways/) - With just a few more weeks remaining before the 2018 Star Ratings cycle begins, we are on the cusp of yet another exciting iteration of program changes and updates within the Star Ratings program. In case you missed our Star Ratings webinar, here are our top five takeaways from the session: Silo-busting will be more
- [Webinar Recap: 2019 MCMG Highlights](https://ghgadvisors.com/webinar-recap-2019-mcmg-highlights/) - Thank you to all who came to the GHG webinar regarding the 2019 Centers for Medicare & Medicaid Services (CMS) Medicare Communications and Marketing Guidelines (MCMG). We had a great attendance and are working to answer all of your questions and get a Q&A to all who attended plus the presentation! We wanted to take
- [On Demand Webinar: Four Trends in Supplemental Benefits for 2021 Success](https://ghgadvisors.com/on-demand-webinar-four-trends-in-supplemental-benefits-for-2021-success/) - Supplemental benefits have been a valuable differentiator for Medicare Advantage (MA) plans since the Centers for Medicare and Medicaid Services (CMS) expanded the scope of coverage to certain non-medical supplemental benefits in 2018. Since then, we have seen continued expansion in supplemental benefit adoption and prevalence, which has required MA organizations (MAOs) to become even
- [On Demand Webinar: Four Lessons Learned from the 2020 AEP Results](https://ghgadvisors.com/on-demand-webinar-2020-medicare-advantage-annual-enrollment-period/) - On April 14th, Diane Hollie of Gorman Health Group was joined by George Dippel from Deft Research for a thoughtful, data-driven discussion about the enrollment outcomes of the 2020 Medicare Advantage (MA) Annual Enrollment Period (AEP). With support from a recent analysis on the AEP data by Pareto Intelligence, the webinar presentation explored the many
- [AEP Sales Strategies for a Pandemic & Presidential Election](https://ghgadvisors.com/on-demand-webinar-2020-aep-sales-strategies-pandemic-election-year/) - JULY 14, 2020 On Demand Webinar: AEP Sales Strategies for a Pandemic & Presidential Election On June 30th, GHG hosted a panel discussion with Bill Stapleton of HPOne, Dwane McFerrin of Senior Market Sales, and Tom Richert of Blue Cross and Blue Shield of Louisiana to discuss the challenges of selling during an election year
- [CMS Shares Key Information Surrounding MA Organizations & COVID-19](https://ghgadvisors.com/cms-shares-key-information-surrounding-ma-organizations-covid-19/) - On March 10, 2020, CMS issued key information via HPMS memo on the responsibilities and flexibilities afforded to Medicare Advantage organizations and Part D sponsors related to disasters and emergencies resulting from COVID-19. A declaration by the Governor of a State is one of the triggering events for the special requirements related to Part A\B
- [Key Components in Shared-Risk Pool Reporting](https://ghgadvisors.com/key-components-in-shared-risk-pool-reporting/) - When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs) and Accountable Care Organizations (ACOs), as well as providers teaming up
- [Preparing Your Care Management Team for Optimal Performance](https://ghgadvisors.com/preparing-your-care-management-team-for-optimal-performance/) - As many plans are preparing to write a new Model of Care (MOC) for a new service area, an expanded service area, or redlining or revising an existing document, many plans miss the opportunity of evaluating the readiness of their Care Management team for change. The critical part of this team? The leadership. I would
- [CMS MA Proposed Rule: Star Ratings Updates](https://ghgadvisors.com/cms-ma-proposed-rule-star-ratings-updates/) - Last week, the Centers for Medicare & Medicaid Services (CMS) released a Proposed Rule allowing expanded access to telehealth services for Medicare beneficiaries, streamlining appeals processes for beneficiaries in Dual Eligible Special Needs Plans, helping CMS recover improper payments to plans based on Risk Adjustment Data Validation audits, and continuing to increase the stability and predictability
- [Medicare Advantage 2020 Proposed Rule](https://ghgadvisors.com/medicare-advantage-2020-proposed-rule/) - It’s been a long wait since the passage of the Bipartisan Budget Act in February, but the 2020 Medicare Advantage (MA) proposed rule is finally here. Perhaps the biggest opportunity for plans is the shift that makes telehealth a basic benefit, which means the digital revolution that brought us things like ATMs on every corner,
- [Inside MA-PD Premium Trends](https://ghgadvisors.com/inside-the-ma-pd-premium-trends/) - With the release of the 2019 landscape files, benefit information and Star Ratings data, now is the time to update your market analyses to understand trends in your current and potential markets. Nationwide, 2019 monthly premiums for Medicare Advantage Prescription Drug Plans (MA-PDs), excluding Special Needs Plans (SNPs) and Medicare-Medicaid Plans (MMPs), range from $0
- [Readiness Checklist Outlines Key Operational Requirements](https://ghgadvisors.com/readiness-checklist-outlines-key-operational-requirements/) - The Centers for Medicare & Medicaid Services (CMS) published its annual Readiness Checklist via HPMS memo on 10/2/2018. As in prior years, the checklist provides a high-level overview of key operational requirements for the coming plan year. Plan Sponsors must communicate any at-risk requirements to their CMS Account Managers. Here we summarize important things to
- [The 2019 Star Ratings Are Out!](https://ghgadvisors.com/the-2019-star-ratings-are-out/) - The 2019 Star Ratings are out! While our experts crunch the numbers and analyze the data, here are a few “fast facts:” Of the 360 contracts rated in both 2018 and 2019, 80 earned higher overall ratings in 2019 compared to 2018 90 earned lower overall ratings in 2019 than in 2018 190 maintained the
- [Bundled Payments Report Issued](https://ghgadvisors.com/bundled-payments-report-issued/) - Bundled payments capitate medical care at the episode level. It is one of the few “value-based” approaches the Centers for Medicare & Medicaid Services (CMS) and the Innovation Center have fielded that works. But it doesn’t work for the taxpayers, at least not yet. If you stop and think about it, the whole Prospective Payment
- [Three Reasons to Invest in the Open Enrollment Period](https://ghgadvisors.com/three-reasons-to-invest-in-the-open-enrollment-period/) - The Open Enrollment Period (OEP) is back with some new rules. Starting January 1, 2019, Medicare Advantage (MA) enrollees have a one-time opportunity to switch their plan, similar to a grace period. This opportunity ends March 31. Both new MA enrollees and existing enrollees have the opportunity to switch plans. This is a new opportunity
- [Why Investing in Your Staff Will Benefit Your Members](https://ghgadvisors.com/why-investing-in-your-staff-will-benefit-your-members/) - I started my career working in social services. I wanted to change the world, as many of us do in our youth. When my family needed health insurance, I applied for a job with a health insurance company. It was an unexpected career change, but I was fortunate as I had an amazing mentor who
- [Streamline Your Medicare Enrollment](https://ghgadvisors.com/build-a-better-medicare-advantage-enrollment-experience/) - Large Medicare Advantage carriers invested a median of $11.25 per member per month in marketing in 2015, and spent a median of $17.44 on account and membership administration, according to a Sherlock Company analysis. With that kind of spending, the last thing a carrier needs is for seniors to become confused and frustrated by the enrollment
- [Senate Approves Bill to Address Opioid Epidemic](https://ghgadvisors.com/senate-approves-bill-to-address-opioid-epidemic/) - On Monday, the Senate approved a bill to address the opioid epidemic by a vote of 99 to 1. Three months ago, the House passed their own opioid legislative package by a vote of 396 to 14. Both chambers overcame their usual partisan politics to turn 70 separate bills into a comprehensive legislative package that
- [Taking Advantage of Reimbursement Increases & New Benefit Opportunities for MA?](https://ghgadvisors.com/are-you-capitalizing-on-reimbursement-increases-for-medicare-advantage-plans/) - The Centers for Medicare & Medicaid Services (CMS) has provided increases in reimbursement to plans, and Gorman Health Group believes this trend will continue for Medicare Advantage (MA) for the immediate future. So how are you taking advantage of this? Are you increasing your service area? Are you entering MA for the first time? Are
- [Network Development in the Era of Relaxed Supplemental Benefit Regulations](https://ghgadvisors.com/network-development-in-the-era-of-relaxed-supplemental-benefit-regulations/) - As we saw in this year’s Centers for Medicare & Medicaid Services (CMS) regulations, Medicare Advantage (MA) plans are gaining greater flexibility to design and offer new types of benefits to service their members. While the information was provided after many plans had already put significant time into their Contract Year (CY) 2019 bids, we
- [The CMS Fall Conference Highlights](https://ghgadvisors.com/the-cms-fall-conference-highlights/) - The Centers for Medicare & Medicaid Services (CMS) annual fall conference never misses in providing important information for Sponsors. This year’s conference was held in Baltimore on September 6, 2018. Conference materials can be found on the Compliance Training, Education & Outreach website here. CMS covered many areas, but here I’m focusing on two key
- [Barriers to the New Opioid Care Coordination Safety Edit for 2019](https://ghgadvisors.com/barriers-to-the-new-opioid-care-coordination-safety-edit-for-2019/) - The Contract Year (CY) 2019 Call Letter and Centers for Medicare & Medicaid Services (CMS) expectations for all sponsors to implement a real-time opioid care coordination safety edit at the time of dispensing as a proactive step to engage both patients and prescribers about overdose risk and prevention will require: Implementing a point of sale
- [How to Avoid Network Development & Expansion Pitfalls](https://ghgadvisors.com/how-to-avoid-network-development-expansion-pitfalls/) - Network management, directory accuracy, service area expansions (SAEs), and the new triennial review process have placed many Medicare Advantage (MA) plans in flux and exposed serious issues – from policy to process to staffing and technology. As we move into the countdown for network development and expansion for 2020, a review of lessons learned will
- [CMS Takes Action to Lower Drug Prices, Permits Step Therapy](https://ghgadvisors.com/cms-takes-action-to-lower-drug-prices-permits-step-therapy/) - I have been known to utter “holy cow” in my day, and the recent Centers for Medicare & Medicaid Services (CMS) Health Plan Management System (HPMS) memo allowing step therapy for Part B drugs was the reason for my most recent exclamation. Who saw this coming? The first sentence of the memo reads, “CMS is
- [Top 10 Changes – NEW Medicare Communications and Marketing Guidelines (MCMG)](https://ghgadvisors.com/top-10-changes-new-medicare-communications-and-marketing-guidelines-mcmg/) - Gorman Health Group will conduct a webinar on the new guidelines in the next couple of weeks, but we wanted to get this out right away as the Centers for Medicare & Medicaid Services (CMS) has rewritten the Medicare Marketing Guidelines (MMG) for 2019. A lot of information is the same but just condensed –
- [Focus on Rural Population: What Your Plan Still Has Time to Do](https://ghgadvisors.com/focus-on-rural-population-what-your-plan-still-has-time-to-do/) - Here we are at the end of July already! Time flies, especially when we are busy preparing for enacting our bid submission approvals and planning for rollout of plan year 2019 activities and new members. It is not too late to still enhance this year’s activities and positively affect our members within the remaining five
- [Trump Administration Alarms PBMS with First Drug Pricing Initiative](https://ghgadvisors.com/trump-administration-alarms-pbms-with-first-drug-pricing-initiative/) - The Department of Health and Human Services (HHS) issued its blueprint for dealing with the high price of prescription drugs in May, and the administration is finally undertaking a number of initiatives to operationalize the proposals. So far, as seen from the updates below, the proposals will have the biggest impact on pharmacy benefit managers
- [Prep for the 2019 Medicare Communications and Marketing Guidelines](https://ghgadvisors.com/prep-for-the-2019-medicare-communications-and-marketing-guidelines/) - I am shocked the 2019 Medicare Marketing Guidelines (MMG) did not come out last Friday since that is when I started vacation. But no… a week later, we are still waiting, and now the wait really starts to impact the development of our marketing strategies and tactics. In reviewing the April 12, 2018, Centers for
- [House Passes Opioid Bill](https://ghgadvisors.com/opioid-bill-passes/) - Surprise, the House actually passed a bipartisan healthcare bill on June 22 that had support from almost all members of both parties. H.R. 6, Support for Patients and Communities Act, is a comprehensive opioid bill that combines more than 58 individual bills intended to address the national opioid epidemic. The bipartisan bill passed 396-14 with
- [Benefits are Submitted. What’s Top of Mind for 2019 Marketing & Sales?](https://ghgadvisors.com/benefits-have-been-submitted-whats-the-buzz-for-2019-marketing-and-sales/) - Now that benefits have been submitted, the emphasis is turning to Sales and Marketing. When speaking with different Medicare Advantage plans across the country, you start to hear different things about what is going to be important for Marketing and Sales this Annual Election Period (AEP) and Open Enrollment Period (OEP). Here is some of
- [Population Health Management Tactics to Succeed in Medicare Advantage](https://ghgadvisors.com/population-health-management-tactics-to-succeed-in-medicare-advantage/) - Population health. Many of us in the industry speak those words often without truly thinking about what it really means to us as a health plan or as a provider group, and often times, what it means to our data collection and analysis processes. For many Organizations today, success in the Medicare Advantage market space is
- [Changes for How Biosimilars are Reimbursed](https://ghgadvisors.com/changes-to-how-biosimilars-are-reimbursed/) - Biosimilars have finally been accepted by the popular crowd. Coverage year 2019 (CY2019) is going to see some changes for how biosimilars are being reimbursed. In 2015, the first biosimilar product, Zarxio (filgrastim), was approved in the U.S. An approved biosimilar is a medication that has been shown to be highly similar to a Food
- [Three Costs of Marketing Material Errors](https://ghgadvisors.com/three-costs-of-marketing-material-errors/) - Now that bids have been submitted and the Centers for Medicare & Medicaid Services (CMS) is in the process of finalizing their posted models (check the dates on those versions, people!), it’s time to think about material development and review. If you are in Compliance or Product Development, chances are you have some responsibility for
- [The 2019 Model Marketing Materials Are Posted. Ready for What's Next?](https://ghgadvisors.com/the-2019-model-marketing-materials-are-posted-are-you-ready/) - As we await the Medicare Communications and Marketing Guidelines (MCMG), The Centers for Medicare & Medicaid Services (CMS) released the 2019 Model Marketing Materials which includes standardized outreach and educational materials for Medicare Advantage Plans, Medicare Advantage Prescription Drug Plans, Prescription Drug Plans, and 1876 Cost Plans. Bids are due in a little over a week.
- [Blending Network Strategy and Product Strategy](https://ghgadvisors.com/blending-network-and-product-strategy/) - As more and more health systems and provider organizations successfully manage the shift from patient care to population health management, long-term health plan strategic planning should be blending network strategy with product strategy as a key indicator of the ability to achieve clinical and financial goals. The majority of providers are savvy at managing pay
- [CMS Audit Annual Report Highlights Importance of Mock Audits](https://ghgadvisors.com/cms-audit-annual-report-highlights-importance-of-mock-audits/) - Imagine you are the Compliance Officer of your health plan, and you see the email from the Centers for Medicare & Medicaid Services (CMS) announcing you have been selected for a program audit. Did you take the opportunity in the months leading up to this day to confirm your organization can pull compliant universes? Did
- [2018 Audit & Enforcement Conference: Program Audit Changes on the Horizon](https://ghgadvisors.com/2018-audit-enforcement-conference-program-audit-changes-on-the-horizon/) - On Monday, I provided some highlights of last week’s conferences during our weekly Insider call. The Centers for Medicare & Medicaid Services (CMS) hosted the Spring Conference on May 9 and the Audit & Enforcement Conference on May 10. The Program Audit tools and methodology continue to evolve. The agency gave the industry a heads
- [President Trump unveils a Blueprint to Lower Drug Prices](https://ghgadvisors.com/president-trump-unveils-a-blueprint-to-lower-drug-prices/) - On May 11, 2018, President Trump unveiled his Blueprint to Lower Drug Prices and Reduce Out-of-Pocket Costs entitled “American Patients First”. The President emphasized lowering drug prices as one of his greatest priorities during the campaign and promised to use the federal government’s purchasing power to negotiate lower drug prices to protect consumers, in particular
- [Lack of Staff: Biggest Hurdle to Success](https://ghgadvisors.com/lack-of-staff-biggest-hurdle-to-success/) - Staffing continues to be a major hurdle in the healthcare industry. A recent poll conducted by Gorman Health Group showed that 38% of respondents believed the biggest hurdle to success in their organization was lack of knowledgeable staff or lack of staff. What is the meaning of success? Is it reaching financial targets? Meeting and
- [Integrated OTC Benefits: A Prescription for Customer Satisfaction](https://ghgadvisors.com/integrated-otc-benefits-a-prescription-for-customer-satisfaction/) - Most over-the-counter products and medications like pain relievers, allergy medications, heartburn drugs and topical antimicrobials were once available only by prescription. In OTC form, these drugs are FDA approved and often equally effective as prescription drugs at a fraction of the cost. Yet their OTC status has long meant these drugs are not covered under
- [CMS June Network Submission Deadline Fast Approaching](https://ghgadvisors.com/cms-june-network-submission-deadline/) - In early February, there was a bit of a scramble when several plans received notices they had approximately a week to submit their Health Service Delivery (HSD) tables for a network adequacy review. Fortunately, for some, the communication should have indicated the gates were open for plans wanting to test adequacy and receive technical feedback.
- [Latest Audit Enforcement Actions Issued by CMS](https://ghgadvisors.com/latest-audit-enforcement-actions-issued-by-cms/) - Like clockwork, the Centers for Medicare & Medicaid Services published the enforcement action notices issued to sponsors related to 2017 program audits. Additional detail regarding conditions, audit scores, and enforcement is expected to be included in the 2017 Program Audit Enforcement Report, which the agency hopes to release before their conferences taking place May 9-10.
- [Audit Engagement Letters Will Start in March](https://ghgadvisors.com/cms-begins-sending-audit-engagement-letters-in-march/) - If you did not have the pleasure of being part of a Centers for Medicare & Medicaid Services (CMS) Program Audit in 2017, don’t be caught off guard if you receive your invitation this year. Audit engagement letters will start going out this month. CMS has made few changes to the 2018 CMS program audit
- [CMS Focus: Compliant Independent Review Entity Data](https://ghgadvisors.com/cms-focus-compliant-independent-review-entity-data/) - The focus on compliant Independent Review Entity (IRE) data should come as no surprise to Part D sponsors. In December 2016, the Centers for Medicare & Medicaid Services (CMS) released the Health Plan Management System (HPMS) memo, Compliance and Enforcement Actions Related to Part D Auto-Forwards, indicating sponsors with inordinately high auto-forward rates were subject
- [Data Universes - Friend not Foe](https://ghgadvisors.com/medicare-advantage-implementation-its-all-about-asking-the-right-questions/) - Data universes are not new in the Medicare Advantage and Part D space. The Centers for Medicare & Medicaid Services (CMS) requires data universes for a variety of purposes, including program audits and timeliness monitoring. Gorman Health Group has communicated time and time again the importance of pulling accurate universes as well as continuous review
- [CMS Reports Medicare Advantage Provider Directories Continue to be Plagued with Inaccuracies](https://ghgadvisors.com/cms-new-review-estimates-medicare-advantage-provider-networks-are-plagued-with-inaccuracies/) - The Centers for Medicare & Medicaid Services (CMS) issued its Round Two online provider directory review, and the results were dismal. Plans reviewed showed an overall inaccuracy average higher than Year One plans. We can try to marginalize the results and say the average inaccuracy found by location was 48%. Nevertheless, the fact remains that
- [HEDIS Deadlines Approaching](https://ghgadvisors.com/hedis-deadlines-approaching/) - It’s HEDIS® time again! Health plans should have data collection and audit activities in full swing for Healthcare Effectiveness Data Information Set (HEDIS®) 2018. High-performing plans will have started the hybrid chart collection and medical record review. January 31 is the National Committee for Quality Assurance (NCQA) deadline for the HEDIS® 2018 Roadmap. This document
- [CMS Announces Changes to the Network Review Process for Medicare Advantage Organizations](https://ghgadvisors.com/cms-announces-changes-to-the-network-review-process-for-medicare-advantage-organizations/) - As anticipated, the Office of Management and Budget (OMB) approved the Centers for Medicare & Medicaid Services’ (CMS’) move to network adequacy reviews on a three-year cycle, unless there is a triggering event that would reset the timing of a Medicare Advantage Organization’s triennial review. What does that mean for Medicare Advantage plans? Initially, CMS
- [CMS Timeliness Monitoring Underway](https://ghgadvisors.com/cms-timeliness-monitoring-underway/) - The Centers for Medicare & Medicaid Services (CMS) timeliness monitoring is currently underway at organizations with active contracts in 2017 and 2018, with a few exclusions, such as Medicare-Medicaid Plans and organizations that underwent a program audit in 2017 and did not have any invalid data submissions in key audit areas. Is your organization excluded?
- [Second NOIA Deadline Approaching](https://ghgadvisors.com/second-noia-deadline-approaching/) - Applicants looking to enter Medicare Advantage, Part D, or the Medicare-Medicaid Plan space have two deadlines to submit a Notice of Intent to Apply, commonly referred to as a “NOIA,” for contract year 2019: November 13, 2017, and January 26, 2018. The first submission allows the Centers for Medicare & Medicaid Services (CMS) team to
- [Provider Network Management New Year’s Resolutions for 2018](https://ghgadvisors.com/provider-network-management-new-years-resolutions-for-2018/) - Many of you and your teams are in the frantic, end-of-year trenches renegotiating current provider agreements or working on contracting new providers for a service area expansion, and it is easy to lose sight of all the changes swirling around the provider network arena. As we head into 2018, we would encourage you to incorporate
- [Three Considerations For Those Entering Medicare Advantage](https://ghgadvisors.com/three-considerations-for-those-entering-medicare-advantage/) - Every few months the industry hears news of new players getting into the Medicare Advantage (MA) game. And why not? According to the Kaiser Family Foundation, more than 19 million Medicare beneficiaries are enrolled in MA plans this year. Either someone is building from the ground up or purchasing an existing structure, such as CVS
- [Pressure Test your 2019 Expansion Strategy in 3 Steps](https://ghgadvisors.com/test-your-new-expansion-or-products-before-go-to-market/) - Do it now! Get your benefit strawman, enrollment projections, and financial goals developed before benefit season begins! Step 1: Market Analysis – Hopefully you have already performed this step before you submitted the Notice of Intent to Apply (NOIA), but if not, it’s not too late. A market analysis typically includes the following: Penetration analysis
- [Benefit Administration Testing – From a Compliance, Audit, and Best Practice Perspective](https://ghgadvisors.com/benefit-administration-testing-from-a-compliance-audit-and-best-practice-perspective/) - In 2016, 41 million individuals (72 percent of all Medicare beneficiaries) were enrolled in Medicare Part D. Of those enrolled, 60 percent were in stand-alone Prescription Drug Plans (PDPs), and 40 percent were in Medicare Advantage Prescription Drug plans (MA-PDs). Plan sponsors must adjudicate pharmacy claims for the Part D benefit in accordance with their
- [Start Planning For 2019 Medicare Advantage Growth](https://ghgadvisors.com/start-planning-for-2019-medicare-advantage-growth/) - By Diane Hollie Here are three planning questions you need to ask yourself right now: Are you losing market share because you are not offering the right products or product mix? How could the profitability of your Medicare Advantage (MA) enrollment change if you expanded your service area? Is now the time to begin offering
- [The 2019 Application - Key Dates](https://ghgadvisors.com/the-2019-application-deadline-approaching/) - As a follow up to my last article on the Notice of Intent to Apply, I give you an enhanced chart of 2019 application activities outlining things you should have been doing or should be in the middle of now. Thanks to the Centers for Medicare & Medicaid Services (CMS) for creating a base, published
- [CMS Notice of Intent to Apply](https://ghgadvisors.com/cms-notice-of-intent-to-apply-2/) - The Centers for Medicare & Medicaid Services (CMS) Annual Call Letter calendar marks November 13, 2017, as the first due date for the Notice of Intent to Apply. It is expected the Center for Medicare will release a reminder memo this month outlining the details. In general, the agency requires a Notice of Intent to
- [Beyond Obamacare: Congress Takes on Many Medicare Bills](https://ghgadvisors.com/beyond-obamacare-congress-takes-on-many-medicare-bills/) - By Olga Walther Congress moved beyond considering the Affordable Care Act (ACA). From potential changes to the Medicare Advantage (MA) program to necessary extensions of already existing Medicare programs, Congress had a busy working week moving the healthcare agenda. CHRONIC Care Act Following the announcement there would not be a vote on Graham-Cassidy,
- [How to Make Your Next MA-PD Plan Implementation a Success](https://ghgadvisors.com/how-to-make-your-next-ma-pd-plan-implementation-a-success/) - By John Gorman Friends of mine built a house. They indicated it was the most stressful event, full of decisions they didn’t know they needed to make, and struggled to agree. The timeline they hoped for was not reality and had to be reworked. While they said they were stronger having gone through the process
- [Planning For Growth](https://ghgadvisors.com/now-is-the-time-to-start-planning-for-2019-medicare-advantage-growth/) - By Regan Pennypacker Here are three planning questions you need to ask yourself right now: Are you losing market share because you are not offering the right products or product mix? How could the profitability of your Medicare Advantage (MA) enrollment change if you expanded your service area? Is now the time to begin offering
- [Now Is The Time To Start Planning For 2019 Medicare Advantage Growth](https://ghgadvisors.com/now-is-the-time-to-start-planning-for-2019-medicare-advantage-growth-2/) - Here are three planning questions you need to ask yourself right now: Are you losing market share because you are not offering the right products or product mix? How could the profitability of your Medicare Advantage (MA) enrollment change if you expanded your service area? Is now the time to begin offering an MA plan?
- [Three-Year Network Adequacy Review for Medicare Advantage Plans](https://ghgadvisors.com/three-year-network-adequacy-review-for-medicare-advantage-plans/) - If the Centers for Medicare & Medicaid Services (CMS) knocked on your door today, would you be ready to submit a compliant provider network within 60 days? CMS estimates the proposed three-year network adequacy review for Medicare Advantage (MA) plans would mean just that for approximately 304 MA plans for calendar year 2019. Normally this
- [10 CMS Program Audit Risks](https://ghgadvisors.com/10-cms-program-audit-risks/) - Program audits and oversight activities must be designed with many factors to balance: accuracy, consistency, efficiency, and in an effort to be least disruptive to a plan sponsor. Correspondingly, a plan should be tailoring its response to these audits with those same factors in mind. A colleague and I outline ten common risk areas we
- [Addressing Key Questions on the 2018 Medicare Marketing Guidelines](https://ghgadvisors.com/key-questions-concerning-the-2018-medicare-marketing-guidelines/) - We had a fantastic turnout for our webinar last week on the 2018 Medicare Marketing Guidelines (MMG). Something I’ll reiterate is that the MMG are for everyone. Nilsa Rudisill and I had plenty of spirited discussions when working to narrow down the content to fit in a single hour. We know your time is valuable, and we
- [2018 Medicare Marketing Guidelines](https://ghgadvisors.com/2018-medicare-marketing-guidelines-finally/) - It was a hot summer night when the Centers for Medicare & Medicaid Services (CMS) released the final version of the calendar year 2018 Medicare Marketing Guidelines (MMG), and a few hot summer days have passed while the industry digests the changes. Don’t make the mistake and only share the MMG with sales and marketing;
- [Digital Marketing in the Medicare Advantage World](https://ghgadvisors.com/digital-marketing-in-the-medicare-advantage-world/) - “Internet shopping rates have surpassed the rates of all other shopping activities.” As marketers, we have heard for years now that omnichannel is the way to go and that baby boomers are online. But we still see a lack of focus on digital in many Medicare Advantage marketing strategies. Deft Research’s “2016 Age-in Study” shows
- [Rising Drug Costs Continue to be a Concern](https://ghgadvisors.com/rising-drug-costs-continue-to-be-a-concern/) - During the presidential campaign, Donald Trump highlighted the need to address rising drug costs, stating the drug industry was “getting away with murder.” Several recent high-price drug increases for HIV/AIDS drugs, hepatitis C drugs, and the EpiPen®, among others, have also raised Congressional, state, and public concern about the issue. During the campaign, Trump discussed
- [Three Reasons Why Pre-AEP Marketing Is Critical](https://ghgadvisors.com/three-reasons-why-pre-aep-marketing-is-critical/) - One of the reasons healthcare marketing is so interesting is that it’s never static for long. Once you think you have it figured out, something changes in the mix. Pre-Annual Election Period (AEP) marketing is one of those phenomena that changes the mix in AEP marketing. If a pre-AEP marketing strategy is not in your
- [Three Compliance-Minded Steps to Take for 2018 Marketing and Sales](https://ghgadvisors.com/3-compliance-minded-steps-to-take-for-2018-marketing-and-sales/) - Is it me, or is time flying by? Applications are done, bids are in, new plans are in planning stages, and existing plans are getting ready for the launch of the next benefit year. The 2018 model materials were released late last month, and any second now, we should see the release of the 2018
- [Final Benefit Submission Is Done. Top 5 Items To Focus on Now!](https://ghgadvisors.com/final-benefit-submission-is-done-top-5-items-to-focus-on-now/) - Benefits were submitted on June 5, 2017. Too many times we see health plans wait until the last minute to complete important information. This tends to lead to incorrect mailings and advertising getting into the marketplace with costly errata mailings occurring. Gorman Health Group recommends you start with a strong work plan in place to
- [Top Challenges in Provider Data Management](https://ghgadvisors.com/top-challenges-in-provider-data-management/) - While health plan provider directory inaccuracies have been at the forefront of the news, regulatory agencies, and consumer protection agencies, the directories are only the tip of the iceberg in how difficult provider data management is for health plans. Plans continue to gather information on providers in a multitude of ways and from a variety
- [Marketing Takeaways from CMS’ Spring Conference](https://ghgadvisors.com/marketing-takeaways-from-cms-spring-conference/) - Although the Centers for Medicare & Medicaid Services (CMS) Spring Conference is typically thought of as a “compliance” conference, there is always important information that comes from the conference which affects Marketing. It is important to understand the information coming today instead of waiting for a CMS memo or the Medicare Marketing Guidelines (MMG). It
- [Highlights from 2017 CMS Audit and Enforcement Conference](https://ghgadvisors.com/highlights-from-2017-cms-audit-and-enforcement-conference/) - The Centers for Medicare & Medicaid Services (CMS) hosted their annual Audit and Enforcement Conference on Thursday, May 11, and addressed the following topics: 2017 Program Audits Audit Protocol Updates: Compliance Program and Medicare Medicaid Plan Medication Therapy Management (MTM) Panel 2016 Program Audit and Enforcement Report Timeliness Monitoring Civil Money Penalty (CMP) Methodology The
- [Checklist for Developing Your Marketing Plan for 2018](https://ghgadvisors.com/checklist-for-developing-your-marketing-plan-for-2018/) - Developing a new marketing plan each year is a “clean slate” opportunity to look at your marketplace and develop strategies to meet your goals. Gorman Health Group has seen how baby boomers are beginning to change the landscape of Medicare marketing, and it is important not to be left behind. We have developed a checklist
- [Tips for a Multicultural Marketing Strategy](https://ghgadvisors.com/tips-for-a-multicultural-marketing-strategy/) - We are all familiar with the 5% language threshold requirement by which the Centers for Medicare & Medicaid Services (CMS) mandates Medicare Advantage Organizations (MAOs) to make specific marketing materials available in any language that is the primary language of at least 5% of an MAO’s service area. This is the bare minimum. With 8%
- [The Importance of Accurate Provider Data and Network Adequacy](https://ghgadvisors.com/the-importance-of-accurate-provider-data-and-network-adequacy/) - For almost two years, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data integrity is at the forefront of the
- [The Achilles Heels of Part D in Program Audits: FA and CDAG Administration](https://ghgadvisors.com/the-achilles-heels-of-part-d-in-program-audits-fa-and-cdag-administration/) - This may seem like the movie “Groundhog Day,” but Formulary Administration (FA) and Coverage Determinations, Appeals, and Grievances (CDAG) continue to hobble plan sponsors’ Centers for Medicare & Medicaid Services (CMS) program audit results. Failure to properly administer their CMS-approved formulary continues to plague plan sponsors. As a result, enrollees experience inappropriate denials of coverage
- [Three Important Tips to Make Sure Your Bid Process Is Successful This Year](https://ghgadvisors.com/three-important-tips-to-make-sure-your-bid-process-is-successful-this-year/) - Now that applications are completed, it’s time to get started on developing bids for 2018. In our experience working with many health plans, we have seen a wide range of strategies for developing bids over the years. Some of the strategies have worked very well, but many times we are working to improve or develop
- [CMS Puts Plans on Notice with Recent Enforcement Actions](https://ghgadvisors.com/cms-puts-plans-on-notice-with-7-3-million-in-civil-money-penalties/) - The Centers for Medicare & Medicaid Services (CMS) Program Audit reviews a subset of contractual requirements every year, and each year, leadership wants to know how they fared compared to others, when they are due for an audit notice, and what some of the most pervasive conditions were identified. How many of you, dear compliance-minded
- [Adjusting Star Ratings for Audits and Enforcement Actions](https://ghgadvisors.com/adjusting-star-ratings-for-audits-and-enforcement-actions/) - Within the Draft Calendar Year 2018 Call Letter, the Centers for Medicare & Medicaid Services (CMS) acknowledged the valuable comments received from the industry related to the use of audit findings and enforcement actions in the Star Ratings Program. As a result of those comments, CMS proposes a revision of the Beneficiary Access and Performance
- [Perhaps a Visit to the Physical Therapist Is in Order – Make Sure Your CDAG Process Is Not a Weak Spot](https://ghgadvisors.com/perhaps-a-visit-to-the-physical-therapist-is-in-order-make-sure-your-cdag-process-is-not-a-weak-spot/) - Coverage Determinations, Appeals, and Grievances (CDAG) remain a compliance Achilles heel for many Part D sponsors. The Centers for Medicare & Medicaid Services (CMS) has noticed! Challenges with interpreting CMS regulations and guidance and operational restrictions have the potential to create a very costly gap. CMS is increasing scrutiny of this area in 2017. CMS
- [Teaming with Providers: Collaboration to Achieve Results](https://ghgadvisors.com/teaming-with-providers-collaboration-to-achieve-results/) - When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs). As health plans continue adapting to
- [How to Maximize Your Medicare Advantage Website Strategy](https://ghgadvisors.com/how-to-maximize-your-medicare-advantage-website-strategy/) - How was your Annual Election Period (AEP)? Have you evaluated your performance? Do you need to enhance your sales and marketing strategies? Now is the time to recognize and appreciate your 2017 successes as well as confront your shortcomings. There are several moving parts to a successful sales and marketing strategy, one being your Medicare
- [Current Trends in Retiree Health Coverage Expected to Continue Under a Trump Administration](https://ghgadvisors.com/current-trends-in-retiree-health-coverage-expected-to-continue-under-a-trump-administration/) - The landscape for retiree healthcare is not expected to change significantly under a first Trump term. However, several Republican proposals, if enacted, could incent group members to shift to the individual market over time. Background - According to the September 2016 Kaiser Health Foundation (KFF) – Health Research & Educational Trust (HRET) Health Benefits Survey,
- [A Vendor's Oversight is Never Done](https://ghgadvisors.com/a-vendors-oversight-is-never-done/) - There are many industry voices adding their perspectives about the new administration and changes to come. However, the Compliance Officers I know do not have the luxury of stopping and truly considering the potential impact as they are managing the continuous pressures of their daily directives. Today I address a group of very industrious Compliance
- [January Release of the Draft MMG - Perfect Timing](https://ghgadvisors.com/january-release-of-the-draft-mmg-perfect-timing/) - It’s still January, and, yes, the Centers for Medicare & Medicaid Services (CMS) has released the draft 2018 Medicare Marketing Guidelines (MMG). Perfect timing! The Annual Election Period (AEP) has come and gone, and here we are once again, having post-mortem discussions on what went right, what went wrong, and where to go from here.
- [It’s Product, Benefit, and Premium Time for 2018](https://ghgadvisors.com/its-product-benefit-and-premium-time-for-2018/) - Whether you are just updating your current product benefits, are offering a new plan benefit package (PBP), new product, or service area, or are new to Medicare Advantage altogether, now is the time to start planning for the 2018 bid submission. It is best practice in the bid process to utilize a working team approach,
- [Opportunities for Growth in the New Administration](https://ghgadvisors.com/opportunities-for-growth-in-the-new-administration/) - "Opportunities are like sunrises. If you wait too long, you miss them." ―William Arthur Ward With the new administration coming into power this month, there is a lot of conjecture over what might happen. Overall consensus is the one business segment that is the most stable is Medicare Advantage. Trump is a supporter of Medicare
- [2017: Taking Stock to Inform Next Steps](https://ghgadvisors.com/2017-taking-stock-to-inform-next-steps/) - As the end of 2016 approached, it made for a good time to look back on developments that have impacted us over the past year. The most impactful changes related to 2016 decisions are to come, however, a few important lessons learned over the past year are worth additional reflection. This is especially true if
- [Reflections on the Basics of Delegation Oversight](https://ghgadvisors.com/reflections-on-the-basics-of-delegation-oversight/) - Imagine entering University and enrolling into Advanced French Language and Literature, a 300-level class, with no previous knowledge or study of the French language. As your professor welcomes you into class with bonjour, bienvenue, ça va, you have no idea how to reply. Now imagine sticking with that course for the full semester, trying to
- [Preparing For The 2017 Call Center Monitoring](https://ghgadvisors.com/preparing-for-the-2017-call-center-monitoring/) - On November 16, 2016, the Medicare Drug Benefit and C & D Data Group of the Centers for Medicare & Medicaid Services (CMS) issued the “2017 Part C and Part D Call Center Monitoring and Guidance for Timeliness and Accuracy and Accessibility Studies”. In an effort to ensure continued call center compliance in 2017, CMS
- [Internal Controls - Taking the "Risk" out of Risk Adjustment](https://ghgadvisors.com/internal-controls-taking-the-risk-out-of-risk-adjustment/) - Risk adjustment has become more and more of a “hot topic” these days. The critical implications and takebacks that occur with submitting unsupported diagnosis information and data inaccuracies are staring to become more real for a lot of health plans. This year, the Government Accountability Office (GAO) took aim at the lackluster auditing around risk
- [Preparing for the 2018 Medicare Advantage and Part D Application Season](https://ghgadvisors.com/preparing-for-the-2018-medicare-advantage-and-part-d-application-season/) - On October 31, 2016, the Centers for Medicare & Medicaid Services (CMS) posted the 30-day releases of the 2018 Medicare Advantage and Part D new application and service area expansion instructions for public comment. While this is not an annual process for each Sponsor, it is a yearly undertaking for Gorman Health Group. It is
- [PBM-Supported Part D Measures Impact Quality Bonus Payment Revenues](https://ghgadvisors.com/pbm-supported-part-d-measures-impact-quality-bonus-payment-revenues/) - Regulatory time frames around coverage determinations and appeals have existed since the inception of the Part D benefit. Timely access to medications has been a hallmark of the “member protective” stance the Centers for Medicare & Medicaid Services (CMS) has taken since Day 1. So how is it, even 10+ years into the delivery of
- [First Year Communication – Building Loyalty and Trust](https://ghgadvisors.com/first-year-communication-building-loyalty-and-trust/) - How can you deliver customized and personalized products, services, and experiences to members? You and your team need to begin with understanding your membership. Defining your membership by both value and their needs provides line of sight to information that will influence loyalty and trust. Questions that should be asked by you and your team
- [CMS Provides Reminders on Key Dates in the MA-PD Application Process](https://ghgadvisors.com/cms-provides-reminders-on-key-dates-in-the-ma-pd-application-process/) - Open Enrollment for the Affordable Care Act Marketplaces and the Annual Election Period for Medicare is underway. But this month also marks the start of required Centers for Medicare & Medicaid Services (CMS)-facing activities necessary for the application process. Regan Pennypacker, Senior Vice President of Compliance Solutions at Gorman Health Group, points out “for many
- [CMS Releases New Guidance on Coverage Determinations & Redeterminations](https://ghgadvisors.com/clear-but-aggressive-guidance-on-outreach-for-coverage-determinations-and-redeterminations-four-things-to-review-today/) - On October 18, 2016, the Centers for Medicare & Medicaid Services (CMS) issued enhanced guidance on outreach attempts to support coverage decisions in its memo titled “Guidance on Outreach for Information to Support Coverage Decisions.” In recent years, CMS Program Audits have consistently identified the failure of plans to have documented sufficient outreach attempts when
- [Open Enrollment for the Health Insurance Marketplace Begins: Issuers and Enrollees Forge Onward with the Chaos](https://ghgadvisors.com/open-enrollment-for-the-health-insurance-marketplace-begins-issuers-and-enrollees-forge-onward-with-the-chaos/) - Beginning next week, consumers will start actively enrolling in the Health Insurance Marketplace for the fourth year of the Affordable Care Act (ACA). The open enrollment period for the Marketplace begins November 1, 2016, and runs through January 31, 2017. Consumers who would like to actively enroll for January 1 coverage are encouraged to enroll
- [Directory & Provider Data: How Small Inaccuracies Could Lead to Big Risks](https://ghgadvisors.com/directory-provider-data-how-small-inaccuracies-could-lead-to-big-risks/) - For the past year, the Centers for Medicare & Medicaid Services (CMS) has been publishing information and proposing new regulations regarding the criticality of ensuring beneficiaries not only have access to care, but access to accurate information with which to make informed decisions about their healthcare coverage. Data Integrity is at the forefront of the
- [MACRA Final Rule: CMS Announces Flexible Approach](https://ghgadvisors.com/macra-final-rule-cms-announces-flexible-approach/) - No doubt sighs of relief could be heard from across the industry when the Centers for Medicare & Medicaid Services (CMS) announced its flexible approach to next year’s reporting requirements under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS took these flexibilities even further in its final rule released last Friday. Below
- [AEP Marketing: It's Not Too Late](https://ghgadvisors.com/aep-marketing-its-not-too-late/) - It’s Not Too Late… To Make Your Marketing Lead and Sales Goals. During Presidential election years, it can be difficult to book media time, especially with direct response television. If you live in an area with hotly-contested political races, you may be finding it hard to break through the clutter to get the number of
- [MedPAC Meeting Highlights](https://ghgadvisors.com/medpac-meeting-highlights/) - The Medicare Payment Advisory Commission (MedPAC) held a public meeting last week and had a full plate of a variety of topics from Accountable Care Organizations (ACOs) to Medicare Part B drug payment issues. Some takeaways: - The Woes with ACOs: MedPAC found that in 2015, the Centers for Medicare & Medicaid Services (CMS) paid
- [The 2017 Star Ratings: A Contrast Between Macro Versus Micro](https://ghgadvisors.com/the-2017-star-ratings-a-contrast-between-macro-versus-micro/) - The more things change, the more they stay the same. Despite the many, often significant, changes amidst plan-specific 2017 Star Ratings, there is a surprising amount of stability in the 2017 Star Ratings. Stable performance is evident at the macro level: The 2017 average Star Rating is 4.00 (down only slightly from 4.03 in 2016).
- [2017 Readiness Checklist – Valuable Tool or an Exercise in Redundancy?](https://ghgadvisors.com/2017-readiness-checklist-valuable-tool-or-an-exercise-in-redundancy/) - Some people are list makers and wholeheartedly embrace the value of checklists. They utilize lists to manage tasks, stay focused, and ensure high-quality results. A publication by the Institute of Health’s Committee on Quality of Health Care in America, titled “To Err is Human: Building a Safer Health System,” lays out the value of checklists
- [Plan Now for Performance](https://ghgadvisors.com/plan-now-for-performance/) - As 2016 comes to a close, planning for next year should be well underway. Bids are in, and budgets for the current year are being evaluated against reality before next year's strategies are finalized. As the ACA continues to evolve, CMS has been busy with new programs and more oversight. A plan or provider has
- [CMS Releases Long-Awaited Civil Money Penalty Calculation Methodology](https://ghgadvisors.com/cms-releases-long-awaited-civil-money-penalty-calculation-methodology/) - On September 13, 2016, the Centers for Medicare & Medicaid Services (CMS) quietly released its long-awaited proposed methodology on the calculation of Civil Money Penalties (CMPs). The memo describes the calculation method of CMPs for Medicare Advantage Organizations (MAOs), Prescription Drug Plans (PDPs), Cost Plans, and Programs of All-Inclusive Care for the Elderly (PACE) plans
- [Part D Benefit Administration Continues to be Important Monitoring for CMS](https://ghgadvisors.com/part-d-benefit-administration-continues-to-be-important-monitoring-for-cms/) - Your Pharmacy Benefit Manager (PBM) may have already provided to you their benefit testing pan for 2017. Based on many years of experience, that is not going to be enough. In the September 12, 2016, memo entitled "Contract Year 2016 Part D Formulary Administration Analysis (FAA)", the Centers for Medicare & Medicaid Services (CMS) reiterates
- [Hot Takes on Medicare Advantage and Part D in 2017](https://ghgadvisors.com/hot-takes-on-medicare-advantage-and-part-d-in-2017/) - The Centers for Medicare & Medicaid Services (CMS) released its annual Medicare Advantage (MA) and Part D "landscape files" with data on plans and bids for 2017. It's a picture of programs that are rock-solid and driving insurers' revenues and earnings, offering better supplemental benefits for no increase in price for two-thirds of beneficiaries. Interestingly,
- [Sales Oversight — Essential Guidelines](https://ghgadvisors.com/sales-oversight-essential-guidelines/) - All agents are expected to comply with the Centers for Medicare & Medicaid Services (CMS) regulations and guidelines, federal and state laws, and health plan rules, policies, and procedures. But what does that mean, and how can health plans enable their employed sales staff and contracted agents to stay compliant while achieving target goals and
- [Double Your Value: Three Critical Ways CMS Audit Readiness and the Member Experience Program Intersect](https://ghgadvisors.com/double-your-value-three-critical-ways-cms-audit-readiness-and-the-member-experience-program-intersect/) - What do the Centers for Medicare & Medicaid Services (CMS) program audits and member experience programs have in common? At their core, both activities are looking out for and protecting Medicare health plan members. CMS, in their oversight role, is responsible for ensuring Medicare Advantage (MA) and Prescription Drug Plan (PDP) members receive all the
- [Star Ratings Plan Preview #2:  2017 Trends to Improve 2018 Scores](https://ghgadvisors.com/star-ratings-plan-preview-2-2017-trends-to-improve-2018-scores/) - With the Centers for Medicare & Medicaid Services (CMS) release of 2017 2nd Plan Preview Star Ratings and updated 2017 Technical Notes, the Star Ratings "busy season" is officially in high gear. Though our clients are already reaching out to us to understand how to enhance existing programs and best leverage staff to improve their
- [Strive For Progress, Not Perfection, Because It Doesn't Exist](https://ghgadvisors.com/strive-for-progress-not-perfection-because-it-doesnt-exist/) - This week was a productive one for CMS and Compliance professionals. The 2015 Part C and Part D Program Audit and Enforcement Report was published on September 6, and the 2016 Fall Conference took place on September 8. Highlights of the report include the publication of the most common conditions. CMS provided the frequency of
- [MACRA Flexibility Proposal](https://ghgadvisors.com/macra-flexibility-proposal/) - As we enter the last stretch of the year, many questions remain on what to expect from the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) come January 1, 2017. With the final rule due in November, much of the industry is quick to point out the
- [An "October Surprise" in Medicare Advantage Star Ratings](https://ghgadvisors.com/an-ugly-october-surprise-in-medicare-advantage-star-ratings/) - Each year, one of the most anticipated announcements in the Medicare Advantage (MA) industry is the Star Ratings and program technical guidance for the coming year from the Centers for Medicare & Medicaid Services (CMS). This year's includes an "October Surprise:" a little-known methodological change that could force dozens of 4- to 5-Star-rated plans to lose their hard-fought
- [Keep the End in Mind as 2017 Readiness Approaches](https://ghgadvisors.com/keep-the-end-in-mind-as-2017-readiness-approaches/) - According to Author Stephen Covey, in his book The Seven Habits of Highly Effective People, you should "begin with the end in mind." This means to start with a clear understanding of your destination so you know where you're going and understanding where you are now so the steps you take are always in the
- [2018 Proposed Notice of Benefit and Payment Parameters (NBPP) Summary](https://ghgadvisors.com/2018-proposed-notice-of-benefit-and-payment-parameters-nbpp-summary/) - This year, some of the biggest industry leaders such as Aetna and UnitedHealthcare have exited the Affordable Care Act (ACA) marketplace. The outlook for the longevity of Obamacare looked grim without some drastic changes coming down from the Department of Health and Human Services (HHS) to balance the deficits seen by health plans as they
- [Star Ratings: Medication Management Is Not Just for D Ratings Anymore!](https://ghgadvisors.com/star-ratings-medication-management-is-not-just-for-d-ratings-anymore/) - As a pharmacist and Star Ratings Senior Consultant for Gorman Health Group, whenever I am asked to provide insight on how to achieve or maintain Star Ratings success, the conversation has been limited to the "D" part of the metrics, and the folks involved with Medicare Advantage (MA) and Healthcare Effectiveness Data and Information Set
- [How to Efficiently Conduct an Audit](https://ghgadvisors.com/how-to-efficiently-conduct-an-audit/) - Audits from regulatory bodies swarm around an organization like bees. And like a bee, upon first sight we do not think of the value they bring, but instead we first think of the sting that is to come. A key aspect of an effective compliance program is to ensure there is an effective system for
- [Evolution Through Strategy: Pinpointing Growth Opportunities](https://ghgadvisors.com/evolution-through-strategy-pinpointing-growth-opportunities/) - My last article explained the choice of Medicare Advantage (MA) health plans to evolve or disappear. Evolution is certainly the preferable choice, so let's examine the steps needed to do so. As with any company, you need to identify your target customer. State of the Art Membership accounting helps an existing determine strategies around expansion
- [CMS Announces Expansion of the Medicare Advantage Value-Based Insurance Design Model](https://ghgadvisors.com/cms-announces-expansion-of-the-medicare-advantage-value-based-insurance-design-model/) - The Centers for Medicare & Medicaid Services (CMS) announced plans to expand the Medicare Advantage (MA) Value-Based Insurance Design (VBID) model to more states and more conditions in 2018 without the experience of the first year's launch, which begins in January 2017. The schedule underlines the Administration's goal of rapidly expanding the use of innovative
- [Lessons on the Audit Front](https://ghgadvisors.com/lessons-on-the-audit-front/) - The regulatory scrutiny continues. The Centers for Medicare & Medicaid Services (CMS) 2016 Compliance and Program Audits are in full swing, and it is readily apparent plan sponsors must be "audit ready." CMS' intent to hold plan sponsors accountable to comply with Medicare standards and ensuring beneficiary protection is evident. Plan sponsors must be ready
- [Evolution or Extinction](https://ghgadvisors.com/evolution-or-extinction/) - "The Theory of Evolution has two main points," said Brian Richmond, curator of human origins at the American Museum of Natural History in New York City. "All life on Earth is connected and related to each other," and this diversity of life is a product of "modifications of populations by natural selection, where some traits
- [Medicare Advantage Pays Hospitals Less than Medicare](https://ghgadvisors.com/medicare-advantage-pays-hospitals-less-than-medicare/) - Researchers at Stanford University conducted a study of hospital payments by Medicare Advantage (MA) plans, Fee-for-Service (FFS) Medicare, and commercial insurers in 2009 and 2012 and found MA plans pay lower prices than FFS for most (but not all) types of admissions and in most (but not all) geographic areas. The study found: MA plans
- [First Plan Preview of 2017 Star Ratings Data](https://ghgadvisors.com/first-plan-preview-of-2017-star-ratings-data/) - It's official — the Star Ratings busy season is officially underway. The Centers for Medicare & Medicaid Services (CMS) recently notified plans of the first preview period for the 2017 Star Ratings data. Although CMS did not introduce any surprises or unexpected measure changes as part of the first plan preview, plans have only a
- [Complaints — Make Sure They Are the Gift that Keeps on Giving](https://ghgadvisors.com/complaints-make-sure-they-are-the-gift-that-keeps-on-giving/) - Have you ever received a gift you knew had value, but you just weren't sure how to use it to its full potential? Complaints are very much like that. We need to change our view of complaints and consider them to be gifts from our members that need to be opened and cared for as
- [Aligning With MACRA: Infrastructure And Initiatives That Yield Results](https://ghgadvisors.com/aligning-with-macra-realizing-a-positive-roi/) - The Centers for Medicare & Medicaid Services (CMS) had almost 4,000 responses from providers and health plans regarding the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). With almost 1 million provider groups potentially impacted by the proposed rule, small groups and individual practitioners (primary care physicians (PCPs) and specialists) are being forced to
- [Teaming with Providers: Incentives to Achieve Results](https://ghgadvisors.com/teaming-with-providers-incentives-to-achieve-results/) - When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly we have proven that adage true in healthcare as can be seen with the success of integrated delivery systems, Independent Physician Associations (IPAs), and Accountable Care Organizations (ACOs). As health plans continue adapting to
- [Retail Healthcare -  An opportunity for success](https://ghgadvisors.com/retail-an-opportunity-for-success/) - Are you providing your members and potential members the opportunity to speak with you in person? In the age of technology, we are forgetting how to serve our customers without them having to pick up the phone or log into a website. For some, this way of doing business fits the population they serve. It's
- [Meeting CMS Halfway: The 2016 Audit and Enforcement Conference](https://ghgadvisors.com/meeting-cms-halfway-the-2016-audit-and-enforcement-conference/) - On June 16, the Centers for Medicare & Medicaid Services (CMS) held their third annual Medicare Advantage & Prescription Drug Audit and Enforcement Conference and Webcast. At the heart of this conference is the CMS Program Audit. Agency experts as well as Sponsor participants presented to an in-person and webcast audience on expectations, process enhancements,
- [Risky Business. Are You Ready for MACRA?](https://ghgadvisors.com/are-you-ready-for-macra/) - It turns out Uncle Sam has a plan. He tried mightily to bend that stiff cost curve. He threw everything he had at it — fixed prices, automatic reductions, sophisticated relative value schemes. He could not do it. Turns out the pen (or mouse) is mightier than the sword because almost all of the Medicare
- [Star Ratings: 10 Years, 10 Lessons](https://ghgadvisors.com/star-ratings-10-years-10-lessons/) - The Star Ratings program celebrates its 10th birthday this year. In honor of the first decade of quality ratings systems within managed care, and to celebrate the many lessons we've learned during these formative years of the Star Ratings program, here are 10 of our top lessons from the first 10 years of the program.
- [Technology and Vendor Implementations](https://ghgadvisors.com/technology-and-vendor-implementations/) - As with all program and technology initiatives, the short- and long-term successes realized as a result of the investments made rely on the critical stages of vendor transitions, data and system readiness, and project management - A well-oiled Vendor and Program Implementation Initiative. Quite often, our health plan and provider clients have multiple projects running
- [2015 Risk Adjustment/Reinsurance Payments Published](https://ghgadvisors.com/2015-risk-adjustmentreinsurance-payments-published/) - Risk adjustment was designed as part of Obamacare to offset the impact of the underwriting process being eliminated to allow those individuals with pre-existing conditions to obtain health insurance. Now a health plan's risk is assessed after the member is enrolled. Health plans need to ensure the risk of their organization is reflected completely and
- [Advancement in Analytics](https://ghgadvisors.com/advancement-in-analytics/) - It's all about the numbers! As the Centers for Medicare & Medicaid Services (CMS) tries to quantify more and more aspects of government-sponsored healthcare, metrics are a critical component. Metrics are needed to measure quality programs, returns on investment in patient care, redistribution of staffing and financial resources, as well as benchmarking. The Medicare Access
- [Is Your Sales Distribution Strategy Up for the Challenge?](https://ghgadvisors.com/is-your-sales-distribution-strategy-up-for-the-challenge/) - It's already July, and time is ticking! Do you have your sales distribution strategy completed and management staff in place? With the Annual Election Period (AEP) just a few months away, finalizing your distribution channel, creating sales training, developing telemarketing scripts, and hiring management to oversee all these tasks must be completed now. In addition,
- [Why Is Conducting a Part D Operational Assessment so Important?](https://ghgadvisors.com/why-is-conducting-a-part-d-operational-assessment-so-important/) - Medicare Part D is a complex program that is continually in motion. The Centers for Medicare & Medicaid Services (CMS), in an attempt to provide clarity to stakeholders, actively publishes updated guidance to sponsors to assist in process improvement and encourage optimal beneficiary outcomes and experience. Keeping up with Health Plan Management System (HPMS) memos,
- [Medicare Program Audits — Four Things Operations Should Be Doing Today](https://ghgadvisors.com/medicare-program-audits-four-things-operations-should-be-doing-today/) - Do you think the Centers for Medicare & Medicaid Services (CMS) program audits are stressful? We often make it worse for ourselves than it already is. Imagine being in the audit webinar pulling up a case and having CMS say that case was to be excluded from the universes. Instead of showing your department, processes,
- [Health Plans Need to Start Talking About Disparities in Care](https://ghgadvisors.com/health-plans-need-to-start-talking-about-disparities-in-care/) - On the heels of a recent groundbreaking RAND report on racial disparities in Medicare Advantage (MA), the US Department of Health & Human Services' Office of Civil Rights (OCR) issued a regulation that requires serious attention in health plans participating in MA, Part D, Medicaid, and ObamaCare. It's a game-changer in advancing health equity and
- [The Evolution of Healthcare.gov — It's Time to Play Ball!](https://ghgadvisors.com/the-evolution-of-healthcare-gov-its-time-to-play-ball/) - Now that the Federally-Facilitated Marketplace (FFM) is paying Issuers directly from the FFM system versus the Issuer's system, we are participating in a different type of ball game. Issuers now need to shift gears and begin thinking about how they can impact a timely and accurate payment of Advanced Premium Tax Credit (APTC), Cost Sharing
- [Medicare Marketing Guidelines Summary of Changes — Have They Left You Scratching Your Head?](https://ghgadvisors.com/medicare-marketing-guidelines-summary-of-changes-have-they-left-you-scratching-your-head/) - On June 10, 2016, the Centers for Medicare & Medicaid Services (CMS) announced the release of the 2017 Medicare Marketing Guidelines (MMG) for Medicare Advantage Organizations (MAOs) and Part D Sponsors. Added language, clarification, and new requirements seem to be the theme with the recent updates. So how do these changes affect business as we
- [The MSSP Final Rule](https://ghgadvisors.com/the-mssp-final-rule/) - On June 6, 2016, the Centers for Medicare & Medicaid Services (CMS) released the final Medicare Shared Savings Program (MSSP) Rule, making some significant improvements to the MSSP program. The two notable changes are the use of regional factors when resetting Accountable Care Organizations' (ACOs') benchmarks and a new incentive to transition to the two-sided
- [Avoid the Sharp Edges and Prepare for Your Next CMS Audit](https://ghgadvisors.com/avoid-the-sharp-edges-and-prepare-for-your-next-cms-audit/) - How can a health plan steer clear of the sharp edges for which the Centers for Medicare & Medicaid Services (CMS) will be looking? I'd like to focus on the clinical side of both Organization Determinations, Appeals, and Grievances (ODAG) and Special Needs Plan Model of Care (SNP MOC) and being prepared for your next
- [AEP Marketing and Sales Readiness — Do You Pass the Quiz?](https://ghgadvisors.com/aep-marketing-and-sales-readiness-do-you-pass-the-quiz/) - The following are questions Gorman Health Group would ask when conducting an assessment on marketing and sales strategies and execution plans for our Medicare Advantage clients. Take the quiz today and see if you are on track for a successful Annual Election Period (AEP). If you have answered "no" to any of these questions and
- [The Formulary Season](https://ghgadvisors.com/the-formulary-season/) - It's the formulary season, and you should be in the home stretch for your Health Plan Management System (HPMS) submission. What's on the formulary and what changes were made to the formulary are among the top reasons why members either enroll in or disenroll from a health plan. Manufacturer price increases over the past two
- [How do health plans increase brand recognition and improve brand loyalty?](https://ghgadvisors.com/how-do-health-plans-increase-brand-recognition-and-improve-brand-loyalty/) - It is believed brands who engage on social media channels enjoy higher loyalty from their consumers. So why should health plans and health professionals engage in social media? Social media provides a key opportunity for health plans and health professionals to build relationships with Medicare beneficiaries through social media, develop trust, and collaborate to design
- [Why Do We Make Simple Things So Difficult?](https://ghgadvisors.com/why-do-we-make-simple-things-so-difficult/) - Time and time again, we encounter "the coolest workarounds" ever invented within the government programs space. Said a different way, we encounter staff who are stuck inventing ways to accomplish the regulatory burden upon their shoulders when they don't have the right processes and tools to efficiently do their job. The manual effort and workarounds
- [The Path to Value: The MACRA Quality Payment Program](https://ghgadvisors.com/the-path-to-value-the-macra-quality-payment-program/) - To quote Yogi Berra, "If you come to a fork in the road, take it." Great, but exactly which fork do I take when faced with multiple options? That is the question many provider-led organizations are asking today. On April 27, 2016, the Centers for Medicare & Medicaid Services (CMS) unveiled key provisions of the
- [Why are the Dual Eligible Demos Such a Hot Mess?](https://ghgadvisors.com/why-are-the-dual-eligible-demos-such-a-hot-mess/) - There's no avoiding the steady stream of bad news facing the Centers for Medicare & Medicaid Services (CMS) financial alignment demonstrations for dually eligible beneficiaries. Enrollment is declining, beneficiaries are opting out at epic rates, and leading states like California are slowing their efforts despite crushing budget realities. Dozens of health plans have invested millions to participate in what's
- [Tag, You're It…RADV Selection Has Begun](https://ghgadvisors.com/tag-youre-itradv-selection-has-begun/) - The data submissions have been completed, and the Risk Adjustment Data Validation (RADV) selection process has begun. Are you prepared for what the RADV has in store for you? In April 2016, the U.S. Government Accountability Office (GAO) released a report titled, "Fundamental Improvements Needed in CMS's Effort to Recover Substantial Amounts of Improper Payments."
- [Are Your Members Giving Your Plan A Thumbs Up?](https://ghgadvisors.com/are-your-members-giving-your-plan-a-thumbs-up/) - It's that time of year when health plans are designing their benefit packages for the upcoming selling season, setting goals for their sales team, and implementing strategies to achieve greater success than the year before. But have health plans lost sight of what really matters to membership growth? Are health plans thinking about their current
- [The Effect of the New Part B Drug Payment Proposal on Medicare Advantage and Part D](https://ghgadvisors.com/the-effect-of-the-new-part-b-drug-payment-proposal-on-medicare-advantage-and-part-d/) - It's no secret drug costs have skyrocketed in the past decade, and drug payment policymakers face an uphill battle in figuring out how to curb this exponential growth. The Centers for Medicare & Medicaid Services (CMS) has already taken a beating on its proposal to test a new alternative payment design to pay for drugs
- [Latest Sherlock Benchmarks Confirm Medicare Advantage is a Miserable Beast to Manage](https://ghgadvisors.com/latest-sherlock-benchmarks-confirm-medicare-advantage-is-a-miserable-beast-to-manage/) - The geniuses at Sherlock Company, whose benchmarks on health plan administrative standards are considered the gold standard, have released their 2016 findings and the numbers paint a clear picture: Medicare Advantage (MA) is a miserable beast of a product. It's complicated and labor- and capital-intensive, requiring tremendous patience for executives and investors alike. First: Sherlock's
- [What a Clinton Administration Could Mean for Government Health Programs](https://ghgadvisors.com/what-a-clinton-administration-could-mean-for-government-programs/) - So the people spoke and we are heading for an epic cagematch smackdown general election between reality TV star Donald Trump and former Senator and Secretary of State Hillary Clinton. And you're asking, what's going to happen to Medicare, Medicaid and ObamaCare? The answer is plenty -- below the waterline and out in the states.
- [An Important Component of MACRA: Quality Measures Development Plan](https://ghgadvisors.com/an-important-component-of-macra-quality-measures-development-plan/) - The Centers for Medicare & Medicaid Services (CMS) recently released a proposed regulation that will implement the payment incentives through the Merit-Based Incentive Payment System (MIPS) and Alternative Payment Models (APMs) as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). An important component of these new incentives is the Quality Measure
- [What Is Driving Growth in Your Plan?](https://ghgadvisors.com/what-is-driving-growth-in-your-plan/) - It's May, so if you have not formalized your sales and marketing strategy for this Annual Election Period (AEP), now is the time. At our recent Gorman Health Group 2016 Forum, Carrie Barker-Settles and I had a very insightful discussion with Forum participants about what is driving growth in plans today. First, membership data analysis.
- [50/50 Just Won't Cut It — You Have to Commit 100%. The Top 5 Components for Successful, Compliant, Committed Operations](https://ghgadvisors.com/5050-just-wont-cut-it-you-have-to-commit-100-the-top-5-components-for-successful-compliant-committed-operations/) - If you weren't able to make it to the Gorman Health Group 2016 Forum this year, you missed a dynamic time. More than just relevant topics, it included engaged participants who added a wealth of depth to our discussions. The topic garnering a lot of audience participation was "Can Operational Efficiencies and Compliance Co-Exist?" The
- [3 Key Aspects from State of Compliance](https://ghgadvisors.com/3-key-aspects-from-state-of-compliance/) - They say people fear public speaking more than death. I can tell you from public speaking experience, it is far preferable than death (though if you could bring me back like the red witch did Jon Snow, that could be one heck of a ride). Having an audience of friendly faces is also a huge
- [Medicaid Final Rule Aligns the Program with MA and Exchange Regulations](https://ghgadvisors.com/medicaid-final-rule-aligns-the-program-with-ma-and-exchange-regulations/) - The Centers for Medicare & Medicaid Services (CMS) issued the final Medicaid "mega-rule," a huge regulation that makes changes to every part of the current managed care rules. Although the final rule makes some tweaks based on the comments received from the industry, it largely adopts the proposals released last May. The new changes will
- [The ABCs of Member Satisfaction](https://ghgadvisors.com/the-abcs-of-member-satisfaction/) - Member satisfaction. Customer centricity. Member retention. Consumer experience. Regardless of the term used, the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) survey measures continue to be the common denominator by which the Centers for Medicare & Medicaid Services (CMS) measures a health plan's success, creating a positive member experience. CAHPS® survey responses now represent
- [Where is Healthcare Now? The Long March to Value-Based Care.](https://ghgadvisors.com/where-is-healthcare-now-the-long-march-to-value-based-care/) - "Why won't the Centers for Medicare & Medicaid Services (CMS) let health plans gather some health information at the point of sale? How is CMS going to use the data they are collecting? What is CMS going to do when the first round of Accountable Care Organizations (ACOs) comes to an end?" At the Gorman
- [Takeaways from the Gorman Health Group 2016 Client Forum](https://ghgadvisors.com/takeaways-from-the-gorman-health-group-2016-client-forum/) - The Gorman Health Group 2016 Forum concluded last week with over 200 of our closest clients and partners. There was great news and rough news, so here are a few takeaways: The playing field of government programs continues to expand rapidly, with improving revenue outlook across the board: We're sticking by our projections of over 29 million
- [CMS Addresses Risk Adjustment Methodology](https://ghgadvisors.com/cms-addresses-risk-adjustment-methodology/) - It was great to see so many people attend the HHS-Operated Risk Adjustment Methodology Meeting in person last week at the Centers for Medicare & Medicaid Services (CMS) headquarters in Baltimore, MD. My blog from the end of March, which can be accessed here, addressed many key points from the HHS-Operated Risk Adjustment Methodology white
- [Issues to Watch in Government Health Programs in the Next Few Months](https://ghgadvisors.com/issues-to-watch-in-government-health-programs-in-the-next-few-months/) - Last week was an exciting time for the policy world with the release of the Final Medicare Advantage (MA) Payment Rate and Call Letter. Here are some other notable stories we are watching develop in the next few weeks: Part B Payment Model: On March 8, 2016, the Centers for Medicare & Medicaid Services (CMS)
- [What's Good for Obamacare Is Good for Medicare Advantage, and Vice Versa](https://ghgadvisors.com/whats-good-for-obamacare-is-good-for-medicare-advantage-and-vice-versa/) - I'm really excited to join Gorman Health Group (GHG) after more than 30 years at the Centers for Medicare & Medicaid Services (CMS), and I'm especially excited about the GHG Forum next week in Fort Worth. If you are sitting on the fence, now is a great time to jump in. Make no mistake —
- [Reconciliation just got more complicated](https://ghgadvisors.com/reconciliation-just-got-more-complicated/) - The time has arrived when health plans will start receiving a monthly automated Health Insurance Exchange (HIX) 820. For most health plans, this will occur in April 2016; others, who aren't fully ready yet, will transition in June 2016. So all of the Finance departments throughout the U.S. should be rejoicing they do not have
- [CMS Largely Holds Firm on Most Proposed MA Payment & Policy Changes for 2017](https://ghgadvisors.com/cms-largely-holds-firm-on-most-proposed-ma-payment-policy-changes-for-2017/) - On April 4th, the Centers for Medicare & Medicaid Services (CMS) issued the Final Notice of Methodological Changes for Calendar Year (CY) 2017 for Medicare Advantage (MA) Capitation Rates, Part C and Part D Payment Policies, and 2017 Call Letter. This is the final notice of changes in rates of payment and overall policy. CMS
- [To Everything There Is a Season: Marketing Materials](https://ghgadvisors.com/to-everything-there-is-a-season-marketing-materials/) - There is a season for every activity within your organization: one for bids, one for applications, one for data validation. We are soon to come upon marketing material season, when a flurry of activity usually gets underway in Marketing Communications and Compliance Departments nationwide. Here are three reasons to ramp up: Now more than ever,
- [Engaging Providers in Quality](https://ghgadvisors.com/engaging-providers-in-quality/) - According to a recent study by researchers from Weill Cornell Medical College, and as recently reported in Health Affairs, medical practices in four common specialties (cardiology, orthopedics, primary care, and multi specialty practices) spend an average of 785 hours per physician and $15.4 billion annually reporting quality measures to Medicare, Medicaid, and private payers. As
- [Risk Adjustment Methodology: Reviewing Proposed and Current Model Improvements](https://ghgadvisors.com/risk-adjustment-methodology-reviewing-proposed-and-current-model-improvements/) - On Thursday, March 24, 2016, the Centers for Medicare & Medicaid Services (CMS) released a white paper regarding the risk adjustment methodology. There has been a lot of criticism and discussion about the U.S. Department of Health & Human Services (HHS) risk adjustment program working appropriately. As indicated in the 2017 Notice of Benefit and
- [Is the Honeymoon Over? Issuers Begin Receiving Direct Payment from the FFM System of Record](https://ghgadvisors.com/is-the-honeymoon-over-issuers-begin-receiving-direct-payment-from-the-ffm-system-of-record/) - Although the financial hit may have been delayed a few months, it is still inevitable. Issuers will be moving from the driver's seat when it comes to being paid for their members within the Federally-Facilitated Marketplace (FFM). Beginning in April 2016, FFM Issuers will feel the financial impact of being out of synch with the
- [2017 ACA Applicants and Network Transparency](https://ghgadvisors.com/2017-aca-applicants-and-network-transparency/) - The National Association of Insurance Commissioners (NAIC) completed their review of provider network rules and published a draft of a new Model Rule. This is the first update of network rules in over 20 years. NAIC convened a committee of regulators, health plans, and consumers to provide input to the development of the draft document.
- [CMS Proposes New Part B Prescription Drug Payment Model](https://ghgadvisors.com/cms-proposes-new-part-b-prescription-drug-payment-model/) - On March 8, 2016, the Centers for Medicare & Medicaid (CMS) released a proposed rule which aims to test a new alternative payment design to pay for drugs covered under Medicare Part B. Medicare Part B covers prescription drugs administered in a physician's office or hospital outpatient department. Currently, covered Part B drugs fall into
- [Four Easy Ways to Lose Revenue](https://ghgadvisors.com/four-easy-ways-to-lose-revenue/) - Times are busy. We are all doing more with less these days. Sometimes we don't put processes in place to make sure functions continue when our focus is elsewhere. Here are four easy ways you could be losing revenue: Member Experience and Claims Payment: Not storing all diagnostic codes for your provider and facility claims.
- [2016 Annual Election Period (AEP) Medicare Advantage (MA) Enrollment Growth Slows Compared to 2015](https://ghgadvisors.com/2016-annual-election-period-aep-medicare-advantage-ma-enrollment-growth-slows-compared-to-2015/) - The number and share of Medicare beneficiaries enrolling in MA plans continue to increase, but the pace of growth is beginning to decline. Currently, there are nearly 18 million Medicare beneficiaries enrolled in MA health plans across the country. This includes all individual and group plan enrollment. Approximately 32% of Medicare beneficiaries are now in
- [MA Plans' Must-Fix: the Member Experience](https://ghgadvisors.com/the-member-experience/) - Now more than ever, it's clear to us health plans and their stakeholders will thrive or die based on the member experience they provide. The member experience, especially with drug benefits, now represents more than half of a health plan's Star Rating in Medicare Advantage (MA), with millions in bonuses and bid rebates hanging in the
- [Another Health Plan Cuts Commissions — Is there a trend developing?](https://ghgadvisors.com/another-health-plan-cuts-commissions-is-there-a-trend-developing/) - Is there a trend developing with health plans and their offerings under the Affordable Care Act (ACA)? Raising rates, high-risk members, and cutting agent commissions continue to be challenges for all health insurance companies offering plans under the ACA. Some of the big plans still in the game say it's too early to bail out,
- [CMS' Recent Enforcement Actions Show Agency Means Business in 2017](https://ghgadvisors.com/cms-recent-enforcement-actions-show-agency-means-business-in-2017/) - As we predicted, the Centers for Medicare & Medicaid Services (CMS) is off to an aggressive start on the compliance front in the last year of this administration and shows no signs of slowing down with $832,250 worth of fines levied in the month of February alone. The list of enforcement actions released comes with
- [Provider Directory & Network Adequacy Highlights in the 2017 Draft Call Letter](https://ghgadvisors.com/provider-directory-network-adequacy-highlights-in-the-2017-draft-call-letter/) - The Centers for Medicare & Medicaid Services (CMS) has emphasized the wide-scale monitoring efforts underway with respect to network adequacy and provider directory monitoring and the direct impact it has on not only the plan's ability to provide timely and adequate access to care, but the impact it has on the decision-making ability of the beneficiary
- [CMS gears up for major quality performance program overhaul for ACA program](https://ghgadvisors.com/cms-gears-up-for-major-quality-performance-program-overhaul-for-aca-program/) - The Centers for Medicare & Medicaid Services' (CMS') recent issuance of the 2017 Letter to Issuers in the Federally-facilitated Marketplaces and Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule affirms the agency's plans to elevate the importance and transparency of quality performance by Qualified Health Plans
- [Star Ratings: Moving the Needle](https://ghgadvisors.com/star-ratings-moving-the-needle/) - Now more than ever before, plans must streamline their Star Ratings programs to meet member expectations while encompassing all aspects of care delivery and breaking down internal silos. This requires innovation amidst a backdrop of the ever-changing Centers for Medicare & Medicaid Services (CMS) landscape. CMS continues to treat Star Ratings as an ever-evolving, dynamic measurement
- [Operations Mistakes Will Be Costly — Highlights of the 2017 Draft Call Letter](https://ghgadvisors.com/operations-mistakes-will-be-costly-highlights-of-the-2017-draft-call-letter-2/) - There was a time when operational areas were shooting for 98% accuracy as the "golden" number. In today's age of data and focused audits, even 99% may not be enough. The Call Letter doesn't have many surprising new risk areas for Operations. No new crazy regulations to ponder how we can possibly implement them. Instead,
- [Final Rule: The Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017](https://ghgadvisors.com/final-rule-the-patient-protection-and-affordable-care-act-hhs-notice-of-benefit-and-payment-parameters-for-2017/) - The anticipation is finally over — the "Patient Protection and Affordable Care Act; HHS Notice of Benefit and Payment Parameters for 2017 Final Rule" has arrived. This annual document provides health plan issuers the rules and requirements to develop plans and operational processes for the upcoming year. Since the Affordable Care Act (ACA) was enacted,
- [The Good, the Bad, and the Ugly!](https://ghgadvisors.com/the-good-the-bad-and-the-ugly/) - Regarding the New Proposed Medicare Marketing Guidelines (MMG) Taking a quick read of the proposed 2017 MMG, our marketing team had some initial thoughts about the proposed changes we would like to share. The Good It's only February, and we have the proposed 2017 MMG. This is great for us "Marketers" since we can
- [CMS Releases New Medicaid Rule, OMB in Final Review](https://ghgadvisors.com/cms-releases-new-medicaid-rule-omb-in-final-review/) - Last week, the Centers for Medicare & Medicaid Services (CMS) finalized the new Medicaid rule — a 653-page proposal requiring Medicaid managed care organizations (MCOs) to enhance their network adequacy, establish quality ratings, set a medical loss ratio (MLR) threshold of 85%, and develop a robust managed long-term care program. The new Medicaid rule has now
- [Noteworthy Evolution for Star Ratings in 2017 MA Draft Call Letter](https://ghgadvisors.com/noteworthy-evolution-for-star-ratings-in-2017-ma-draft-call-letter/) - Last week's release by the Centers for Medicare & Medicaid Services (CMS) of the 2017 Medicare Advantage (MA) Advance Notice of Methodological Changes and Call Letter ended the mystery surrounding potential policy and payment changes on the horizon. As our Founder and Executive Chairman, John Gorman, recently noted: "There's a lot to like — and
- [Compliance Highlights of the CY 2017 Draft Call Letter](https://ghgadvisors.com/compliance-highlights-of-the-cy-2017-draft-call-letter/) - According to the Centers for Medicare & Medicaid Services (CMS), the Call Letter activities follow four major themes: improving bid review, decreasing costs, promoting creative benefit designs, and improving beneficiary protections. This means implementing creativity and doing more with less while enhancing the beneficiary experience. To borrow from one of the earliest reality shows, this
- [There's a Lot to Like and to Fear in the 2017 Medicare Advantage Call Letter](https://ghgadvisors.com/theres-a-lot-to-like-and-to-fear-in-the-2017-medicare-advantage-call-letter/) - On Friday after the close, the Centers for Medicare & Medicaid Services (CMS) released the 2017 Medicare Advantage (MA) Call Letter with proposed policy and payment changes. There's a lot to like — and much to fear. On payments, CMS came in with higher-than-expected rates that make clear the long walk in the desert from cuts
- [What to Watch: The Fiscal Year 2017 budget](https://ghgadvisors.com/what-to-watch-the-fiscal-year-2017-budget/) - President Obama released the Fiscal Year 2017 budget last Tuesday, which contains many significant proposals to government healthcare programs. Although both the Senate and House's budget committees already rejected hearings from the President's budget chief and unsurprisingly declared the bill "dead on arrival," the proposals do contain many bipartisan provisions with significant cost savings. One
- [10 Years of Star Ratings: Lessons Learned](https://ghgadvisors.com/10-years-of-star-ratings-lessons-learned/) - The year 2016 marks the tenth year Medicare Advantage (MA) plan performance data has been collected for evaluation under the Centers for Medicare & Medicaid Services' (CMS') Star Ratings program. While we await the "new news" from CMS about new Star Ratings measures and other program updates in the impending Advance Notice, we thought it
- [Is Value-Based Insurance Design All It's Cracked Up To Be?](https://ghgadvisors.com/is-value-based-insurance-design-all-its-cracked-up-to-be/) - There continues to be a lot of buzz about value-based insurance design (VBID). VBID is the idea that consumers' out-of-pocket medical costs should be based on the value of a service to their health and not the price. Health Affairs defined VBID as "an approach that attempts to improve the quality of care by selectively
- [This Is the Year to Get It Right](https://ghgadvisors.com/this-is-the-year-to-get-it-right/) - Five consecutive years of very similar audit protocol, continuous partnering with sponsors to identify improvements, and numerous best practice/common conditions memos. Where are you in audit readiness? Did you evaluate the items in the 2016 Readiness Checklist sent in November? I will get back to that! In the meantime, the Centers for Medicare & Medicaid
- [Star Ratings Update:  MedPAC Votes to Eliminate Double Bonuses](https://ghgadvisors.com/star-ratings-update-medpac-votes-to-eliminate-double-bonuses/) - Star Ratings is already a hot topic in 2016, and we're only one month into the new year. In most recent news, the Medicare Payment Advisory Commission (MedPAC) unanimously voted last month to eliminate the double bonuses associated with Star Ratings, while also virtually unanimously voting to exclude diagnoses collected during in-home assessments from the
- [Breaking the Incompatibility Barrier — Four Keys to Merging Operational Productivity and Compliance](https://ghgadvisors.com/breaking-the-incompatibility-barrier-four-keys-to-merging-operational-productivity-and-compliance/) - Can compliance and efficiency co-exist in Operations? Is there a "right" balance between the two, or could it be more of an intertwining of the two? If you have been in Operations long enough, you have been told you have to increase efficiency, reduce staff, and improve handle time or auto-adjudication rates. What you probably
- [Risk Adjustment: Proposed Changes & New Regulations](https://ghgadvisors.com/risk-adjustment-proposed-changes-new-regulations/) - At Gorman Health Group (GHG), we pride ourselves on having our fingers on the pulse of what continues to be a complex and volatile government programs environment. Whether it is fact or fiction, our clients and our peers look to us to interpret and filter through the official announcements, the breaking news, the propaganda, and
- [To File or Not To File, That Is the Question](https://ghgadvisors.com/to-file-or-not-to-file-that-is-the-question/) - We've made it clear through this blog the Centers for Medicare & Medicaid Services (CMS) is throwing down the gauntlet in terms of ensuring Medicare Advantage provider networks are adequate. The biggest change to the 2017 application process supports this initiative. For Service Area Expansions, CMS is requiring current service area network data at the
- [Sales 2017 Readiness — Are You Maximizing Your Sales Potential Today?](https://ghgadvisors.com/sales-2017-readiness-are-you-maximizing-your-sales-potential-today/) - Here we go again, planning for the upcoming selling season. Every year it seems to approach more quickly than the year before. Are you ready? If the answer is no, or you are not sure, here are a few critical items to consider as you create your 2017 Annual Election Period (AEP) strategy: Market Analysis
- [New AHC Model Supports Better Care, Smarter Spending & Healthier People](https://ghgadvisors.com/new-ahc-model-supports-better-care-smarter-spending-healthier-people/) - The Centers for Medicare & Medicaid Services (CMS) Center for Medicare & Medicaid Innovation (CMMI) recently announced the Accountable Health Communities (AHC) Model, which will examine whether systematically identifying and attempting to address health-related social needs of Medicare and Medicaid beneficiaries through referral and community navigation services can impact healthcare costs, reduce inpatient and outpatient
- [Network Adequacy Top of Mind for CMS](https://ghgadvisors.com/network-adequacy-top-of-mind-for-cms/) - The Centers for Medicare & Medicaid Services (CMS) continues to reinforce its focus on health plan provider networks with several recent announcements. The release of the new Network Management Module (NMM) within the Health Plan Management System (HPMS) is the tool CMS will utilize for monitoring network adequacy. The NMM functionality allows both CMS and
- [Top Tips for Star Ratings Success in 2016](https://ghgadvisors.com/top-tips-for-star-ratings-success-in-2016/) - Amidst our rapidly-changing industry landscape, the Star Ratings program essentially serves as a "Medicare Advantage stress test," measuring a plan's ability to master the operational complexities encountered while improving the quality of care and general health status of Medicare beneficiaries through member-pleasing experiences. At any given time, there are multiple Star Ratings cycles in play.
- [Issues That Will Define Government Health Programs in 2016](https://ghgadvisors.com/issues-that-will-define-government-health-programs-in-2016/) - The new year brings a slew of issues that will define government-sponsored health programs. Here's what we're watching closely, not necessarily in this order. Opportunities have never been greater in Medicare, Medicaid, and ObamaCare, but execution risk is rising fast. If this was an easy business, we'd be out of business. Drug Pricing: Prospects for a legal fix in
- [New Hospice Policies Could Mean Big Changes for MA](https://ghgadvisors.com/new-hospice-policies-could-mean-big-changes-for-ma/) - Medicare's hospice care is garnering much attention and starting the evolution process this year. The Centers for Medicare & Medicaid Services (CMS) issued several new regulations changing hospice payments, and these regulations come with big implications for Medicare Advantage (MA) plans as well. Last month, the Senate Committee released a policy options paper, discussing solutions
- [Health Insurance Marketplace — What's Contributing to the 2016 Enrollment Growth?](https://ghgadvisors.com/health-insurance-marketplace-whats-contributing-to-the-2016-enrollment-growth/) - On December 22, 2015, the Centers for Medicare & Medicaid Services (CMS) released a snapshot report of the Health Insurance Marketplace Open Enrollment, capturing Marketplace enrollment from the beginning of Open Enrollment (November 1) through December 19 (Week 7 of Open Enrollment) for consumers who signed up for health coverage through the Healthcare.gov platform. Not
- [Top Five Operational Resolutions for 2016](https://ghgadvisors.com/five-operational-resolutions-to-live-by-in-2016/) - Did you know only 8% of people who make New Year's Resolutions achieve them? There are many reasons why resolutions are not accomplished. They may have been too aggressive or priorities changed. Sometimes it's because the goal is too vague or there are far too many and a person is unable to focus on them
- [Three Reasons Why Compliance Program Effectiveness Needs Evaluation Now](https://ghgadvisors.com/three-reasons-why-compliance-program-effectiveness-needs-evaluation-now/) - Happy New Year! It's a time when your organization may be evaluating whether or not to submit a new application or a service area expansion. This may be when annual training kicks off once again. You may be reviewing attestations to determine which vendors need to provide you with new documentation. And don't forget to
- [United Healthcare Potential Exit](https://ghgadvisors.com/united-healthcare-potential-exit/) - Last month, United Healthcare (UHC) made an announcement that shocked the industry — it may leave the Health Insurance Marketplace if it can't become profitable by 2017. The company stated it expects to lose $490 million next year due to its participation in the Affordable Care Act (ACA) market. Standing by its comments, UHC pointed
- [Agent Commission: Don't find yourself on the wrong end of the tipping point](https://ghgadvisors.com/agent-commission-dont-find-yourself-on-the-wrong-end-of-the-tipping-point/) - Agent compensation for Medicare Advantage has changed drastically since the implementation of the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008. MIPPA included regulations, for the first time, around Agent/Broker Commission - among many other things. The goal of implementing commission requirements was to ensure there was a level playing field between plans
- [Are You Paying Twice?](https://ghgadvisors.com/are-you-paying-twice/) - Each month, health plans receive files and premium reductions for members deemed to have secondary coverage, which the Centers for Medicare & Medicaid Services (CMS) calls Medicare Secondary Payer (MSP). MSP shifts the burden from Medicare to commercial insurance companies. CMS receives information from a multitude of sources identifying beneficiaries who have other coverage appearing
- [Because They Can](https://ghgadvisors.com/because-they-can/) - The United States Senate conducted the first day of hearings Wednesday, December 9, on the high price of pharmaceuticals. The Special Committee on Aging is investigating the soaring prices of old drugs, including the overnight price hike of Turing's Daraprim from $18 to $750. Every day there is another press release about the egregious increase
- [CMS Clarifies Key Audit Terminology](https://ghgadvisors.com/cms-clarifies-key-audit-terminology/) - Immediate Corrective Action Required (ICAR), Corrective Action Required (CAR), and Observation. These terms have become part of the vocabulary for Compliance specialists, auditors, analysts, managers, directors, and Compliance Officers who so often field questions from Operations. Let's consider the following scenario: Compliance has just completed an internal audit of Claims Operations and has identified findings.
- [Senate passes bill repealing major provisions of Affordable Care Act](https://ghgadvisors.com/senate-passes-bill-repealing-major-provisions-of-affordable-care-act/) - Last week, the Senate passed an Affordable Care Act (ACA) repeal bill, with a vote of 52-47. Although largely symbolic, this marks the first time the Senate has been able to pass such a bill. The Senate voted on a bill previously passed by the House, however, because of the large number of amendments made by
- [Government Shutdown Deadline Nears](https://ghgadvisors.com/government-shutdown-deadline-nears/) - Less than a week remains for Congress to agree on a $1.1 trillion funding bill in order to avert the threat of yet another government shutdown. The deadline to pass this bill is December 11, 2015, although Congress could technically use a stopgap measure to buy an extra week, pushing the deadline to December 18. As previously reported,
- [AEP Is Winding Down, But Your Work Is Not Over!](https://ghgadvisors.com/aep-is-winding-down-but-your-work-is-not-over/) - As the Annual Election Period (AEP) begins to wind down, you have a pretty good idea of where you will end up this AEP. Whether you knocked the socks off your competition or missed your goals, now is the best time to assess your marketing and sales strategies in preparation for 2017! Typically, we all
- [Evolution of Validation: Selecting an Independent Auditor](https://ghgadvisors.com/evolution-of-validation-selecting-an-independent-auditor/) - The Centers for Medicare & Medicaid Services (CMS) audit validation process has evolved over the past few years. Here is what you should know about the changes and how to best prepare to contract with an Independent Auditor, or IA. Let's go back to 2012. CMS was conducting the validation of audited Sponsors' corrective action
- [Update on CMS Spotlight on Provider Directories and Network Adequacy](https://ghgadvisors.com/update-on-cms-spotlight-on-provider-directories-and-network-adequacy/) - As we learned from the 2016 Call Letter, the Centers for Medicare & Medicaid Services (CMS) is placing a renewed focus on Medicare Advantage plans' provider network with emphasis on both online provider directories and network adequacy. CMS plans to monitor compliance of plans' adherence through direct monitoring with additional contract funds and through the
- [Star Ratings:  Preparing for 2016](https://ghgadvisors.com/star-ratings-preparing-for-2016/) - With the Centers for Medicare & Medicaid Services (CMS) release last week of its annual Request for Comments on Enhancements to the Star Ratings program, we now have our first official glimpse into the potential changes which could be introduced in the 2018 Star Ratings. Consistent with CMS' recent about-face on the impact of socio-economic
- [2016 Readiness Review Smaller Size, Bigger Punch.](https://ghgadvisors.com/2016-readiness-review-smaller-size-bigger-punch/) - The Centers for Medicare & Medicaid Services (CMS) released the 2016 Readiness Checklist on Monday, November 9, 2015. The 20-page checklist is full of items CMS is expecting plan sponsors to review and validate it will be compliant for the 2016 calendar year. While CMS won't have an official website for plan sponsors to attest
- [Influencing Your 2017 Star Ratings: It's Not Too Late](https://ghgadvisors.com/influencing-your-2017-star-ratings-its-not-too-late/) - We are officially in the throes of the unavoidable, and much dreaded, 4th quarter Star Ratings "fire drill." While health plan leaders (again) promise their staff and providers this year will be the last a Star Ratings fire drill will be needed, the day-by-day countdown to year-end has officially begun. As even more evidence year-end
- [Is This Payment Real? CMS Launches Policy-based FFM payments Through the HIX 820 in 2016](https://ghgadvisors.com/is-this-payment-real-cms-launches-policy-based-ffm-payments-through-the-hix-820-in-2016/) - If you think your organization has been working from a fire hose these past few years since the launch of the Health Insurance Marketplace, wait until the Centers for Medicare & Medicaid Services (CMS) rolls out policy-based payments to Federally-facilitated Marketplace (FFM) Issuers beginning in 2016. It's not as if the accuracy of member data
- [Proposed Changes to the CMS-HCC Risk Adjustment Model](https://ghgadvisors.com/proposed-changes-to-the-cms-hcc-risk-adjustment-model/) - Policy changes governing risk adjustment in plans for Medicare-Medicaid dual eligibles may soon be coming. In response to concerns about the accuracy of the Centers for Medicare & Medicaid Services (CMS)-Hierarchical Condition Category (HCC) risk adjustment model for predicting costs of dual eligible beneficiaries, CMS recently released a Health Plan Management System (HPMS) memo stating
- [Mergers Pave Way for Good Opportunity to Enter Medicare Advantage Market](https://ghgadvisors.com/mergers-pave-way-for-good-opportunity-to-enter-medicare-advantage-market/) - While the largest insurance companies await their fate at the hands of federal regulators, other plans and investors should pay close attention to the opportunity to acquire divested plans from the two deals. With the shareholders overwhelmingly approving the merger between Aetna and Humana, all eyes are on what the Department of Justice (DOJ) and
- [Is Your Customer Service Ready? Top 5 Lessons Learned in 2015 Rolling into 2016](https://ghgadvisors.com/is-your-customer-service-ready-top-5-lessons-learned-in-2015-rolling-into-2016/) - It's only a few months until we ring in a new year. Time flies, but there is still enough time to ensure we put our best foot forward as we begin 2016. Here are the top 5 lessons learned in 2015 as we roll into 2016 to ensure Customer Service is ready for the New
- [A New Report by Kaiser Family Foundation Found Part D Premiums Will Rise an Average of 13% in 2016](https://ghgadvisors.com/a-new-report-by-kaiser-family-foundation-found-part-d-premiums-will-rise-an-average-of-13-in-2016/) - We blogged earlier this month about Medicare Advantage (MA) premiums showing slight decreases to no decreases across the board for 2016 based on the Centers for Medicare & Medicaid Services (CMS) estimates. But what does the landscape look like for Part D? CMS stated in a September 2015 article, "Premiums in the Medicare Prescription Drug
- [The Transition From RAPS to EDS: New Offering Helps Your Plan Calculate & Define Risk Level](https://ghgadvisors.com/the-transition-from-raps-to-eds-new-offering-helps-your-plan-calculate-define-risk-level/) - In 2016, the Centers for Medicare & Medicaid Services (CMS) will start to transition from utilizing Risk Adjustment Processing System (RAPS) files, to support the Medicare risk adjustment payment, to encounter files. The transition process is gradual, with a weighted percentage being taken for 2016: 10 percent based on the encounter files and 90 percent
- [Relief for Plans Serving Dual Eligibles?](https://ghgadvisors.com/relief-for-plans-serving-dual-eligibles/) - It seems as though the Centers for Medicare & Medicaid Services (CMS) may be taking a detour in their position on the effect of socio-economic characteristics of a plan's enrollees. Last week, CMS announced plans to release a proposal to change Star Ratings for plans with significant low socio-economic beneficiaries, in a forthcoming request for
- [2015-2016 CMS Program Audit Protocols Update](https://ghgadvisors.com/2015-2016-cms-program-audit-protocols-update/) - It's Christmas in October (and Hanukkah, too) if you've been waiting for the revised 2015-2016 Program Audit process and protocols. Let's get right down to it! You'll want to review all 20 documents (made up of the memo, data requests, supplemental questions, templates, and impact analysis layouts) for their significant enhancements and make necessary changes in
- [10 Millon People Expected to Have Marketplace Coverage in 2016](https://ghgadvisors.com/10-million-people-expected-to-have-marketplace-coverage-in-2016/) - The 2016 Health Insurance Marketplace open enrollment is right around the corner, opening on November 1, 2015. With premium rate increases well above 10% for 2016, it's no surprise the 2016 enrollment projections for the Marketplace are estimated to increase by less than a million from the total current 2015 enrollment, bringing the total individuals
- [Considering Network Expansion? The Role Network Adequacy, Risk Adjustment, and Star Ratings Play](https://ghgadvisors.com/considering-network-expansion-the-role-network-adequacy-risk-adjustment-and-star-ratings-play/) - The leaves are changing colors, pumpkins are out on every front stoop, and the brisk weather signifies fall is in full swing. It also means we are in the midst of application season for health plans wanting to expand their geographic footprint. The Centers for Medicare & Medicaid Services (CMS) has put provider networks front
- [MA-VBID Request for Applications Released](https://ghgadvisors.com/ma-vbid-request-for-applications-released/) - The Centers for Medicare & Medicaid Services (CMS) has released the Request for Applications for the Medicare Advantage (MA) Value-Based Insurance Design (VBID) Model, which is an opportunity for MA plans to offer supplemental benefits or reduced cost sharing to enrollees with CMS-specified chronic conditions, focused on the services that are of highest clinical value
- [Data Revolution: The Need for Accurate Data to Drive Quality Analytics](https://ghgadvisors.com/data-revolution-the-need-for-acurate-data-to-drive-quality-analytics/) - The Affordable Care Act (ACA) made a tremendous impact on the healthcare industry. What was once a free-flowing commercial market with very low requirements and data interaction has now transformed—it has morphed into a highly-regulated market heavily dependent on data to deliver quality outcomes for members and to remain financially sound. The processes set forth
- [Healthcare Trends: ICD-10, Mergers, Part B Premiums & MA-VBID](https://ghgadvisors.com/healthcare-trends-icd-10-mergers-part-b-premiums-ma-vbid/) - ICD-10 We are into our third week of ICD-10, and so far, reviews of implementation woes have been mixed. Some reports tout a smooth rollout process, with few problems — at least from the side of payers and clearinghouses. However, providers have noted several issues they are encountering from the transition, such as not being
- [The 2016 Star Ratings:  Finding Calm in the Chaos](https://ghgadvisors.com/the-2016-star-ratings-finding-calm-in-the-chaos/) - All great changes are preceded by chaos, and the Centers for Medicare & Medicaid Services (CMS) release last week of the 2016 Star Ratings certainly introduced a great deal of chaos for Star Ratings teams throughout the industry. With approximately 5% of additional reimbursement tied to ≥4-Star performance, health plan leaders are either taking a
- [Where did your organization fall with CMS' estimates for 2016 & what's next?](https://ghgadvisors.com/5800-2/) - In September, the Centers for Medicare & Medicaid Services (CMS) estimated the average Medicare Advantage (MA) premium will decrease by $0.31 next year, from $32.91 on average in 2015 to $32.60 in 2016. The majority of MA enrollees (59 percent) will face no premium increase. Sounds great, but the reality is most MA and
- [2016 Star Ratings are Working, and the Bar is Rising](https://ghgadvisors.com/2016-star-ratings-are-working-and-the-bar-is-rising/) - The Centers for Medicare & Medicaid Services (CMS) released the 2016 Medicare Advantage (MA) Star Ratings early this year, on Thursday morning. The usual practice is to wait until Friday after the close. It was a shift designed to move markets, and the news was mixed. Overall, Star Ratings are working to improve quality in many areas of health plan
- [ACO vs. Value-Based](https://ghgadvisors.com/aco-vs-value-based/) - Earlier this year, the U.S. Department of Health & Human Services (HHS) set a goal of moving 30 percent of payment for traditional Medicare benefits to value-based payment models by the end of 2016 and 50 percent by the end of 2018. The Center for Medicare & Medicaid Innovation's (CMMI's) Accountable Care Organizations (ACOs) have
- [The MA-VBID Model: Key Takeaways](https://ghgadvisors.com/the-ma-vbid-model-what-you-need-to-know/) - Now that you have digested the Centers for Medicare & Medicaid Services' (CMS) announcement on the proposed demonstration for high-value benefit designs, the clock is ticking on determining an optimal set of benefits prior to the CMS deadline of November 15, 2015. Over 37 organizations are eligible to consider this opportunity, which is based on
- [New Part D Medication Therapy Management Model: Is It Right For you?](https://ghgadvisors.com/new-part-d-medication-therapy-management-model-is-it-right-for-you/) - Drum roll, please…beginning January 1, 2017, the Centers for Medicare & Medicaid Services (CMS) will pay Medicare Prescription Drug Plans (PDPs) to play in Medication Therapy Management (MTM)—and it's all about the money. Where before MTM costs were administrative, there will be two additional payments for plans approved for participation in the model program. The
- [Recommendations Made by the National Quality Forum on Medicaid Measures](https://ghgadvisors.com/recommendations-made-by-the-national-quality-forum-on-medicaid-measures/) - The National Quality Forum (NQF) is a non-profit organization working to evaluate and endorse standardization of healthcare performance measures. Recently, NQF submitted a series of reports to the U.S. Department of Health and Human Services (HHS) outlining recommendations on new measures aimed at improving Medicaid beneficiary quality of care. For the last four years, NQF
- [Healthcare Implications Post Boehner Exit](https://ghgadvisors.com/healthcare-implications-post-boehner-exit/) - House Speaker John Boehner announced last Friday he will resign his seat at the end of October. Following this announcement, House and Senate members immediately announced plans to pass a spending bill preventing a government shutdown by scrapping plans to block Planned Parenthood funding for the time being. Boehner's resignation makes this move possible because
- [Do More Than Survive AEP](https://ghgadvisors.com/do-more-than-survive-aep/) - How quickly another Annual Election Period (AEP) is upon us. This time of year is the perfect time to review your new member onboarding activities and AEP strategy. We all know the sale doesn't end when the application is turned in and membership begins. This is where the rubber hits the road. These are the
- [Star Ratings Plan Preview #2](https://ghgadvisors.com/star-ratings-plan-preview-2/) - It's hard to believe, but it's that time of year again. Yes, it's football season—and it's also the beginning of Star Ratings season. The Centers for Medicare & Medicaid Services (CMS) annual Star Ratings plan preview periods have become as much an annual ritual for Medicare Advantage (MA) plans as the Advance Notice and Call
- [Medicare Advantage Value-Based Insurance Design: Key Considerations](https://ghgadvisors.com/medicare-advantage-value-based-insurance-design-key-considerations/) - The Centers for Medicare & Medicaid Services (CMS) recently announced a proposed demonstration that will test varying benefit designs based on health status. The Medicare Advantage Value-Based Insurance Design (MA-VBID) Model will allow organizations to offer targeted supplemental benefits and/or reduced cost sharing to enrollees with specific chronic conditions to further the goal of improving
- [ACOs Should Run for the Exits and Into Medicare Advantage](https://ghgadvisors.com/acos-should-run-for-the-exits-and-into-medicare-advantage/) - CMS recently released results from the Medicare Pioneer Accountable Care Organization (ACO) Program and the Medicare Shared Savings Program (MSSP). Once again the results are a mixed bag: quality is up, but the ROI for most participants is a joke. The update should have the most sophisticated demo sites running for the exits and into
- [The Medicare Advantage Value-Based Insurance Design (MA-VBID) Model Test](https://ghgadvisors.com/the-medicare-advantage-value-based-insurance-design-ma-vbid-model-test/) - The Centers for Medicare & Medicaid Services (CMS) announced on September 1 a proposed demonstration that will test varying benefit designs based on health status. The overall goal is to improve clinical outcomes while reducing plan expenditures. This demonstration is proposed for seven states: Arizona, Indiana, Iowa, Massachusetts, Oregon, Pennsylvania, and Tennessee. According to the
- [Final Rule for Medicare Prescription Drug Benefit Program Coordination Requirements](https://ghgadvisors.com/final-rule-for-medicare-prescription-drug-benefit-program-coordination-requirements/) - Where has the summer gone? When you get your formulary submission approval email, you breathe a sigh of relief and can relax for…a second. It's time to start planning for Part D Readiness and Benefit Administration testing so when November 15 arrives, you are well on your way to having those completed. For Medicare Advantage
- [The CMS Fall Conference: 4 Ways to Solve the Preparedness Problem](https://ghgadvisors.com/the-cms-fall-conference-4-ways-to-solve-the-preparedness-problem/) - The Centers for Medicare & Medicaid Services (CMS) held their Fall Conference and Webcast on September 10 in Baltimore. The presentations and videos from the event are found on the Compliance Training, Education & Outreach site here. CMS covered various aspects of the Medicare Advantage Prescription Drug (MA-PD) program, but here I've focused on four
- [How to Partner with Key Health Systems in your Service Area to Optimize Benefit Plan Offerings](https://ghgadvisors.com/do-cms-access-availability-standards-impede-innovative-narrow-network-design-in-ma/) - As we anticipate additional information this week on the Centers for Medicare & Medicaid Services (CMS) network adequacy (pilot) audit, we can't help but consider how CMS' rigorous access and availability standards hamper Medicare Advantage (MA) plans' ability to be on the cutting edge of innovative network design. The Affordable Care Act, in comparison, has
- [Government Sends Stark Reminders that Insurers' Biggest Customer is Still the Regulator](https://ghgadvisors.com/government-sends-stark-reminders-that-insurers-biggest-customer-is-still-the-regulator/) - Since we opened our doors 19 years ago, we've preached to health insurers to think of the government as your business partner. This week, we got several reminders that insurers' biggest customers -- Medicare, Medicaid, and ObamaCare -- are still the regulator. As business conditions improve for health plans across these business lines, government expectations
- [Potential Changes in Part C Reporting](https://ghgadvisors.com/potential-changes-in-part-c-reporting/) - The Part C and Part D Reporting Requirements and Supporting Regulations were posted in the PRA Listing on August 24th for review and 30-day comment. Since we are still in this window, this is a great opportunity for Compliance and Operations to review these together. To follow are Part C highlights that merit your attention.
- [Changes for 2015 Part D Reporting Announced by CMS](https://ghgadvisors.com/changes-for-2015-part-d-reporting-announced-by-cms/) - The Centers for Medicare & Medicaid Services (CMS) recently released an updated version of the Contract Year 2015 Part D Reporting Requirements Technical Specifications. Sponsors are required to undergo data validation to have some of their Part D data audited annually. Each Part D Sponsor is required to provide necessary data to CMS to support
- [Teaming with Providers: Together, Everyone Achieves More](https://ghgadvisors.com/teaming-with-providers-together-everyone-achieves-more/) - When a team works well together, the members collectively accomplish more than any of the individuals could have accomplished alone. Certainly, we have proven that adage true in healthcare, as can be seen with the success of integrated delivery systems, Independent Practice Associations (IPAs), and Accountable Care Organizations (ACOs). As health plans continue adapting to
- [The Impact of CMS Changes on MA & FFM 2016 Agent Readiness](https://ghgadvisors.com/the-impact-of-cms-changes-on-ma-ffm-2016-agent-readiness-2/) - Preparing for the 2016 selling season means implementing a strategy that mitigates compliance risks for your organization and empowers your sales force to meet your enrollment targets. In our recent webinar regarding the impact of the Centers for Medicare & Medicaid Services (CMS) changes on Medicare Advantage (MA) and Federally-Facilitated Marketplace (FFM) 2016 Agent Readiness,
- [The Affordability Review — “Reading the Tea Leaves"](https://ghgadvisors.com/the-affordability-review-reading-the-tea-leaves/) - The fall season is a good reality check — back to school, cooler weather, end of summer, and …. Budgeting/financial forecasting. Forecasting is like predicting the future — you have to know how to read the tea leaves and see the efficiencies and interdependencies of your current performance to have a better idea of future
- [Best Practices and Common Conditions of Audit Preparation](https://ghgadvisors.com/best-practices-and-common-conditions-of-audit-preparation/) - As we wait for the 2014 Part C and Part D Program Annual Audit and Enforcement Report to be released, we contemplate the activity that our client partners have experienced during CMS audits, in remediation of identified conditions, and preparation for future activities. This year started a new audit cycle. It has also been a
- [Medicare at 50: Past, Present & Future](https://ghgadvisors.com/medicare-at-50-past-present-future/) - Since its inception on July 30,1965, millions of elderly and disabled Americans have been able to obtain medical care through Medicare. Before Medicare, almost half of all Americans 65 and older had no health insurance. Today that number has dropped to a staggering 2 percent. The accomplishments for Medicare have been noteworthy. These include increased access to
- [2016 Marketing Guidelines: Evolve or Pay](https://ghgadvisors.com/2016-marketing-guidelines-evolve-or-pay/) - There were several significant changes released in the 2016 Medicare Advantage & Part D Medicare Marketing Guidelines (MMGs), all of which communicate the same consistent message from the Centers for Medicare & Medicaid Services (CMS), the focus is on the beneficiary. Possibly one of the more surprising trends was that with the focus on improving
- [MLTSS:  Key to Caring for Duals](https://ghgadvisors.com/mltss-key-to-caring-for-duals/) - We all want to do it: Provide the best healthcare services for our members. For our vulnerable population, this can be complicated, if not near impossible to achieve, given the current healthcare issues at hand. About 9.6 million people in the United States are covered by both Medicare and Medicaid, including low-income seniors and younger
- [EHR Incentive Programs: Improving Access to Care](https://ghgadvisors.com/ehr-incentive-programs-improving-access-to-care/) - The 2014 Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs were developed to provide financial incentives to eligible professionals, eligible hospitals, and Critical Access Hospitals (CAHs) to achieve meaningful use of certified EHR technology with the goal of improving patient care. The programs worked to prompt healthcare providers to adopt, implement, upgrade, or demonstrate
- [At the Intersection of Exhausted and Impossible](https://ghgadvisors.com/at-the-intersection-of-exhausted-and-impossible/) - Today, most employees and employers in all organizations struggle to do more with less…not just health plans. Information flow and the necessity to respond quickly to change have totally transformed existing jobs in the last ten years. There is little opportunity to spend days considering the implications of data and information received. The necessity of
- [Quality Ratings: No National Standard for MCOs…Yet](https://ghgadvisors.com/quality-ratings-no-national-standard-for-mcosyet/) - A recent article noted five major changes in new Medicaid Managed Care rules, one pertaining to a quality ratings system. Many states have quality ratings for managed care plans, but currently there is no national standard. Medicare has a five-star system evaluating private plans, and private plans offered through the Affordable Care Act's (ACA's) Health Insurance
- [Obamacare Reinsurance and Risk Adjustment, Year One.](https://ghgadvisors.com/obamacare-reinsurance-and-risk-adjustment-year-one/) - The much-anticipated "Summary Report on Transitional Reinsurance Payments and Permanent Risk Adjustment Transfers for the 2014 Benefit Year" has been released by the Centers for Medicare & Medicaid Services (CMS). A staggering 99.7% of Issuers were able to successfully submit data. The remaining 0.3% either did not set up an EDGE server or submitted data
- [The Reality of the 2014 Commercial Risk Adjustment Payment Transfer: Forecasted vs. Actual](https://ghgadvisors.com/the-reality-of-the-2014-commercial-risk-adjustment-payment-transfer-forecasted-vs-actual/) - The signing of the Affordable Care Act (ACA) into law threw health insurers into a whirlwind of changes. The guaranteed issue law made it so no enrollee in the individual or small group commercial market would be denied coverage due to their health status. In addition, the rate for all members now had to stay
- [Quick Hits for September Sweeps](https://ghgadvisors.com/quck-hits-for-september-sweeps/) - Unfortunately, Risk Adjustment does not have the luxury of taking the summer off. As CMS continues to stress the criticality of submitting complete, timely and accurate data to support plan payments related to Risk Adjustment, health plans must have year-round processes in place to ensure compliance as well as accurate payment from the government. As
- [CMS to Monitor Access to Care, Defines Provider Network Adequacy Pilot Program](https://ghgadvisors.com/cms-to-monitor-access-to-care-defines-provider-network-adequacy-pilot-program/) - During the Centers for Medicare & Medicaid Services (CMS) Audit & Enforcement Conference & Webinar held on June 16, 2015, CMS provided a glimpse as to how the Provider Network Adequacy (PNA) Pilot Program would begin to monitor beneficiary access to care. The two-pronged approach will evaluate both provider network adequacy and the plan's provider directory.
- [Game Changer:  Key Reforms Proposed in CMS Medicaid Rule](https://ghgadvisors.com/game-changer-key-reforms-proposed-in-cms-medicaid-rule/) - You've got your nose to the grind stone working to meet all the waves of operational changes and requirements related to Medicare, Medicaid, Obamacare, and Health Care Reform - you literally don't even have time to glance upward to the skies. Understandable. But it can cost you. July 27th is the CMS deadline for all
- [Financial Impacts of Unscrubbed Data](https://ghgadvisors.com/financial-impacts-of-unscrubbed-data/) - We have written many articles on the importance of maintaining accurate, reliable data. Data is everywhere and in many versions. Health plans need to be very careful to input only that information coming from a reliable source of truth. In government programs, that reliable source of truth is prescribed to be information contained within the
- [CMS 2015 Oversight and Enforcement Conference - Compliance Edition](https://ghgadvisors.com/cms-2015-oversight-and-enforcement-conference-compliance-edition/) - The pessimist complains about the wind. The optimist expects it to change. The realist adjusts the sail. -William A. Ward Those who had the opportunity to view or attend the Centers for Medicare & Medicaid Services (CMS) annual Audit & Enforcement Conference & Webcast better start thinking about which group of folks you will be
- [AEP Begins in 120 Days. Are your agents ready?](https://ghgadvisors.com/78-days-to-open-enrollment-are-your-agents-ready/) - It's so much more than training. GHG's fully-automated Sales Sentinel™ can take your agents from zero to ready-to-sell in as little as one week, ensuring agents are not only trained, but contracted, licensed, and appointed per CMS requirements. Sentinel can also assist the organization with administrative onboarding functions such as form collection and writing code assignment. See
- [Takeaways from Accountable Physician Groups' Annual Summit](https://ghgadvisors.com/takeaways-from-accountable-physician-groups-annual-summit/) - Twice a year I get the honor of speaking to the California Association of Physician Groups' (CAPG) annual summit and DC policy meeting. CAPG represents accountable, capitated physician groups, and now has members in 39 states. They're always among my favorite speeches given how sophisticated the audiences are. Here's a few takeaways from my talk
- [CVS Health is Serious About Growing its Clinic Business](https://ghgadvisors.com/cvs-health-is-serious-about-growing-its-clinic-business/) - CVS Health is serious about growing its clinic business. On Monday, USA TODAY reported that CVS Health plans to acquire Target's pharmacy and clinic business for $1.9 billion. Healthcare reform is producing a surge in newly insured people seeking care, and hospitals are under severe pressure to keep pace. "This long-term strategic relationship will certainly benefit the patients,
- [Implementing a new PBM? What you need to know.](https://ghgadvisors.com/implementing-a-new-pbm-what-you-need-to-know/) - Now that the smoke has cleared and the ink is dry on the formulary/transition and bid submissions, it's okay for plans to breathe for a couple of weeks. Then—if you're implementing a new Pharmacy Benefit Manager (PBM)—it's time to roll up your sleeves and get started with conceptualizing and developing a road map for the
- [HRADV: What you don't know could cost you millions](https://ghgadvisors.com/hradv-what-you-dont-know-could-cost-you-millions/) - Now that the 2014 EDGE server submission is complete, it will soon be time to audit a large sample of the data. Are you ready? HRADV is the Commercial Risk Adjustment Data Validation that will be conducted annually on the data submitted to the EDGE server. This audit is similar in nature to the Medicare
- [MLR: Don't Miss Your Target](https://ghgadvisors.com/mlr-dont-miss-your-target/) - As the ink dries on 2016 bids for Medicare Advantage (MA) plans, one important question remains…What to do with summer vacation? Drinks by the pool or a family trip to Disney? Reality check! The long hours spent on the bid submission included many spreadsheets with financial projections of loss ratios, per member per month (PMPM)
- [Re-Evaluating Your Plan's QI Evaluation and the Process Behind It.](https://ghgadvisors.com/re-evaluating-your-plans-qi-evaluation-and-the-process-behind-it/) - This is the time of year when most plans have either completed, or are in the process of completing, their annual evaluation of their Quality Improvement (QI) Program Description and Work Plan for operating year 2014. In the 12+ years I have worked for Gorman Health Group (GHG), I have seen a range of evaluations
- [Medicaid Rule Imposes New Standards for Beneficiary Access](https://ghgadvisors.com/medicaid-rule-imposes-new-standards-for-beneficiary-access/) - Per the announcement by CMS on Tuesday, the proposed Medicaid rule would require plans to implement an 85% medical loss ratio (MLR). Implementing an MLR for Medicaid would bring the programs in line with the private health insurance market and Medicare Advantage. However, as mentioned by GHG's Sunmi Janicek, it would not be without challenges.
- [CMS Spotlight on Provider Directories & Network Adequacy](https://ghgadvisors.com/cms-spotlight-on-provider-directories-network-adequacy/) - As we learned from the 2016 Call Letter, the Centers for Medicare & Medicaid Services (CMS) is placing a renewed focus on Medicare Advantage (MA) plans' provider network, with emphasis on both online provider directories and network adequacy. CMS plans to monitor compliance of plans' adherence through direct monitoring with additional contract funds and through
- [Medical Loss Ratio Concern in CMS Proposed Medicaid Rule](https://ghgadvisors.com/medical-loss-ratio-causes-concern-in-cms-proposed-medicaid-rule/) - The much anticipated Medicaid regulation from the Centers for Medicare & Medicaid Services (CMS) has been released, which aims at helping align regulations for managed care plans, creating a dynamic shift in how the Medicaid business will be handled moving forward. One example of the new change is the proposed implementation of the 85% minimum
- [The $64,000 Question in Star Ratings](https://ghgadvisors.com/the-64000-question-in-star-ratings/) - As we wrap up the 2nd quarter, health plan leaders across the country are beginning to ask their Star Leaders the $64,000 question: "Are we on track to achieve a 4-Star Rating this year?" This is, perhaps, one of the most challenging questions that can be posed to any Star Leader at this point in
- [CMS 2015 Spring Conference](https://ghgadvisors.com/cms-2015-spring-conference/) - Some important points came out of the Centers for Medicare & Medicaid Services' (CMS') Medicare Advantage Prescription Drug (MA-PD) Spring Conference & Webcast; the presentations and videos of the event can be found here in CMS' Event Archives. If you did not have a chance to attend or watch it live, please watch the videos
- [Stand Tall Amongst Competition: Key to Success in Medicaid is Clear](https://ghgadvisors.com/stand-tall-amongst-competition-key-to-success-is-clear/) - Health plans diligently strive to be the best and first choice for delivering excellent healthcare services. Many seek accreditation with various organizations such as the National Committee for Quality Assurance (NCQA), the Utilization Review Accreditation Commission (URAC), and, most recently, the Malcolm Baldrige National Quality Award (MBNQA) as confirmation they provide their members with the
- [The Imminent Medicaid Mega-Reg is Gonna be "Epic"](https://ghgadvisors.com/the-imminent-medicaid-mega-reg-is-gonna-be-epic/) - For the last several weeks health policy nerds have been anxiously awaiting the release of the long-awaited Medicaid managed care proposed rule, the first from the Centers for Medicare and Medicaid Services (CMS) in 13 years. We're coming to call it the "mega-reg" here. Friday at the Congressional advisory MACPAC meeting, Commissioners were widely quoting the
- [You're Doing it Wrong in Care Management](https://ghgadvisors.com/youre-doing-it-wrong-in-care-management/) - An important paper recently released in the American Journal of Managed Care shattered the notion that care management can save money on high utilizers. The article reviewed recent studies of the effectiveness of health plan care management programs and found that, while many studies show significant savings, more rigorous studies concluded that savings were "limited or nonexistent."
- [Five Critical Steps to Enhance Revenue & Maximize Growth Potential](https://ghgadvisors.com/five-critical-steps-to-enhance-revenue-maximize-growth-potential/) - Everybody's talking about revenue management and maximizing growth opportunities for health plans, but no one has laid out the steps for successful outcomes…until now. Gorman Health Group (GHG) is giving you our recipe for enhancing your premium revenue and maximizing your growth potential in the following five-step plan: Step 1. Targeted Population/Demographics Different populations have
- [19 Lessons from 19 Years](https://ghgadvisors.com/19-lessons-from-19-years/) - Nineteen years ago this week, I left the Health Care Financing Administration (HCFA), now the Centers for Medicare & Medicaid Services (CMS) and the Office of Managed Care, to launch what would become Gorman Health Group. Time has flown, the company has grown, and my backside sewn with hard lessons about our industry and government health
- [Next Generation Accountable Care Organization](https://ghgadvisors.com/next-generation-accountable-care-organization/) - With the NextGen model, the Centers for Medicare & Medicaid Services (CMS) is attempting to respond to some of the criticisms of the first two Medicare ACO models: the Pioneer demonstration program and the Medicare Shared Savings Program (MSSP) authorized under the Affordable Care Act (ACA). CMS says that the NextGen model represents: A new
- [Claims Leakage and the Path to Avoidance](https://ghgadvisors.com/claims-leakage-and-the-path-to-avoidance/) - All managed care organizations must operate a high-performing Claims Management. With strict medical loss ratios (MLR) as required by healthcare reform, timeliness provisions, payment accuracy, and constant regulatory requirement changes, covering operating costs pose significant challenges. Cost containment whereby eliminating excess, leakage and waste must be top priority. The environment is rapidly changing. It doesn't
- [You've Got Mail: National Sample RADV Audit Scores are In](https://ghgadvisors.com/youve-got-mail-national-sample-radv-audit-scores-are-in/) - By now you may have received your score from the Centers for Medicare & Medicaid Services (CMS) regarding the national sample for Risk Adjustment Data Validation (RADV) audits. Wondering how you compare to your peers or competitors and what the implications of your score are? Factors that should be taken into account regarding your score compared to
- [Spring Fever Focus: Grievances and Appeals](https://ghgadvisors.com/spring-fever-focus-grievances-and-appeals/) - Spring is here, showing us all different signs of renewal. It motivates us to clean out clutter, open those windows, and start the year fresh. Audit season is also upon us, and people are taking a close, hard look at internal processes that surround grievances and appeals processing. Findings in this area keep showing up,
- [How Do You Cross a Threshold to Success When There Isn't One?](https://ghgadvisors.com/how-do-you-cross-a-threshold-to-success-when-there-isnt-one/) - Many plans are reacting to the changes affecting the Star Ratings as described by the most recent release of the 2016 Advanced Notice. One of the most impactful changes is that of the removal of the thresholds for plan year 2016 measures. CMS gave early warning of the removal of the thresholds for many of
- [Gorman Health Group Client Forum Takeaways: Government Programs are Booming, Bar is Rising](https://ghgadvisors.com/gorman-health-group-client-forum-takeaways-government-programs-are-booming-bar-is-rising/) - We just wrapped our best-ever Gorman Health Group 2015 Client Forum at National Harbor with over 200 of our closest clients and partners. There was both great and tough news, so here's a few takeaways, including a couple stunners: For the first time, a prominent Wall Street analyst said he could see a path to 100% Medicare Advantage
- [Risk Adjustment Recap & Keys to Success](https://ghgadvisors.com/risk-adjustment-recap-keys-to-success/) - The 2016 Final Call Letter released on Monday, April 6, confirmed proposed rulings highlighting the following categories: End the Blend; For payment year 2016, CMS will only use the 2014 HCC Risk Adjustment Model. Coding Pattern Adjustment; CMS has increased the adjustment factor for MA coding pattern differences by 0.25 percent, the lowest amount possible under
- [You Got Them . . . Now How Do You Keep Them?](https://ghgadvisors.com/you-got-them-now-how-do-you-keep-them/) - Your plan's marketing and sales efforts have proven fruitful, and the Annual Election Period (AEP) was a success! The question is . . . do you have a member for life? New members are bombarded with information they need to digest and questions they need to answer. And everyone speaks in acronyms, e.g., OOA, OEV,
- [Medicaid Reimbursement Rates and the Future of the Program](https://ghgadvisors.com/medicaid-reimbursement-rates-and-the-future-of-the-program/) - A recent monumental decision by the Supreme Court was just passed, and it will define the way Medicaid providers will be reimbursed now and in the future. Many Medicaid providers, including doctors, hospitals, and healthcare organizations, are already concerned with the low reimbursement rates, but now, due to the 5-4 vote by the Supreme Court,
- [The Risk in DIY: CMS Mandated Material](https://ghgadvisors.com/the-risk-in-diy-cms-mandated-material/) - "Do It Yourself", or DIY, has been the rave for years now. From social media sites like Pinterest to television networks like HGTV, Americans have become fond of this philosophy. Now, I am a big believer in being self-sufficient and must say that I have been sucked into marathon viewings of DIY shows often (Nicole
- [Reenergized After RISE…Now What?](https://ghgadvisors.com/reenergized-after-risenow-what/) - It's the Wednesday after a jam-packed RISE conference, focused on "Best Practices and Actionable Tools for Improving Risk Adjustment and Achieving Exceptional Quality Performance." I am sure I speak for most of my colleagues that attended the Summit when I say, "I'm reenergized, but what should I do first?" The large group sessions and the
- [The Medicare "Doc Fix"](https://ghgadvisors.com/the-medicare-doc-fix/) - The "doc fix," as just passed by the House of Representatives, would fix the annual sustainable growth rate (SGR) calculation by eliminating it. The SRG was enacted nearly 18 years ago as a way to tie physician compensation under Medicare to the growth in the national economy. It has never worked well, and Congress has had
- [Partners Needed](https://ghgadvisors.com/partners-needed/) - I calculated the total amount of civil monetary penalties (CMPs) levied by the Centers for Medicare & Medicaid Services (CMS) last year on Medicare Advantage and Part D plans, and it's a big number: $4,925,150. There were also five suspensions in 2014. Now more than ever, plan sponsors need to assess their Pharmacy Benefit Manager
- [The Model of Care: More than Just a Technical Requirement](https://ghgadvisors.com/the-model-of-care-more-than-just-a-technical-requirement/) - The Model of Care (MOC) represents the backbone of a health plan's operational infrastructure and offers powerful potential through which to drive quality improvement, service excellence and improved health outcomes. Though only required for plans operating a Special Needs Plan (SNP), the MOC is not just a legal or regulatory requirement. The MOC captures and
- [Marry Data to Build Accurate Customer Profiles](https://ghgadvisors.com/marry-data-to-build-accurate-customer-profiles/) - Have you ever played "Pin the Tail on the Donkey" as a kid and found yourself laughing when you got completely turned around and totally missed the donkey? That's what it's like when blindly developing benefits, products, marketing, and sales strategies without understanding what your current and prospective customers look and think like — except
- [Is the “NUNCMO" Nightmare Keeping You Up at Night?](https://ghgadvisors.com/is-the-nuncmo-nightmare-keeping-you-up-at-night/) - The recent MAPD Help Desk Memo, dated 3/3/15, advises that on March 8, 2015, "The Centers for Medicare & Medicaid Services (CMS) will be performing a clean-up to process "73" transactions that contain NUNCMO (Number of Uncovered Months) value from the extraneous NUNCMO row that was removed in Phase 1 multi-phase NUNCMO data clean-up which
- [Network Adequacy Test Submissions for Medicare-Medicaid Plans](https://ghgadvisors.com/network-adequacy-test-submissions-for-medicare-medicaid-plans/) - In follow up to the October 2014 Health Plan Management System (HPMS) memo titled "MMP Network Adequacy Standards," the Centers for Medicare & Medicaid Services (CMS) announced dates in which Medicare-Medicaid Plans (MMPs) and Minnesota Senior Health Options Dual Eligible Special Needs Plans (D-SNPs) can check their network against the MMP standards in the HPMS
- [The Annual Full Replacement COB Files Are on Their Way](https://ghgadvisors.com/the-annual-full-replacement-cob-files-are-on-their-way/) - It's that time of year again when Part D plans will receive full replacement Coordination of Benefits (COB) files from the Centers for Medicare & Medicaid Services (CMS). The Health Plan Management System (HPMS) memo dated 3/6/15 states that the 2015 Full Replacement COB files will be sent to organizations beginning March 19th. Plans will
- [Key Changes to Star Ratings from 2016 Draft Call Letter](https://ghgadvisors.com/star-ratings-are-you-on-the-winning-or-losing-end-of-program-changes/) - Now that the news from last month's 2016 Advance Notice (also known as "the Call Letter") from the Centers for Medicare & Medicaid Services (CMS) has had time to sink in, it's time for the real work to begin. Perhaps even more noteworthy than the long-discussed removal of 4-Star thresholds is CMS' planned interim action
- [Go-to-Market — No Department Left Behind](https://ghgadvisors.com/go-to-market-no-department-left-behind/) - Although the next Annual Election Period (AEP) is a ways off, now is the time to start thinking about product development and overall strategy. In most organizations, the start of the "Go-to-Market" (GTM) strategy discussions begins with the C-Suite, Product Development, and Sales and Marketing. This keen group of professionals works sequestered and siloed for
- [Money Grab: CMS to Rerun Risk Scores, Implement Plan for Overpayment Recovery](https://ghgadvisors.com/money-grab-cms-to-rerun-risk-scores-implement-plan-for-overpayment-recovery/) - Do you know your level of exposure for overpayment recovery from CMS? On March 3, 2015, Cheri Rice, CMS' Director of Medicare Plan Payment Group, released a memo notifying all Medicare Advantage Organizations, PACE Organizations, and certain Demonstrations of its intent to rerun risk scores during the calendar year 2015. If you read this memo
- [Is This Condition For Real? CMS Compliance Program Audit Findings Tied to FDR Oversight](https://ghgadvisors.com/is-this-condition-for-real/) - 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
- [Formulary Submission Reminders](https://ghgadvisors.com/formulary-submission-reminders/) - The reprieve of Plan Sponsors having only one set of calendar year (CY) formularies to maintain is coming to an end. It's that time of year where, in preparation for CY 2016 formulary submission, Plan Sponsors are diligently assessing their formulary and benefit structure to optimize beneficiary access to formulary drugs while leveraging cost containment
- [Industry Ducks Bullets in 2016 Medicare Advantage Rate Proposal](https://ghgadvisors.com/industry-ducks-bullets-in-2016-medicare-advantage-rate-proposal/) - Friday, February 20th after close of business, the Centers for Medicare and Medicaid Services (CMS), released its 2016 Advance Notice of Medicare Advantage Payment, known affectionately as "the call letter." This one was the most anticipated in years, and the industry unexpectedly ducks bullets in it, in risk adjustment, Star Ratings, and elsewhere. It's got a
- [Risk Adjustment Data Validation (RADV) Audits Just Got Real](https://ghgadvisors.com/risk-adjustment-data-validation-radv-audits-just-got-real/) - Last night the second-largest Medicare Advantage plan in the country, Humana, filed an SEC document detailing a US Department of Justice investigation into the company's risk adjustment coding and data collection practices. The investigation is an extension of a 2010 physician-led whistleblower action under the False Claims Act. The company has over 3.2 million Medicare
- [Value-Based Care: HHS Sets Timeline for Transition](https://ghgadvisors.com/value-based-care-health-and-human-services-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
- [CMS Releases Part D Drugs and Formulary Requirements](https://ghgadvisors.com/cms-releases-part-d-drugs-and-formulary-requirements/) - The long awaited revision to the Prescription Drug Benefit Manual Chapter 6 is hot off the press. Many of the changes have been published previously by CMS in Best Practice guidance or communicated in the course of CMS compliance audits. The changes include additions to the sections on Medically Accepted Indications, drugs purchased in another
- [CMS Releases the 2015 Audit Protocol: Critical Next Steps to Avoid Becoming A Casualty of Reasonable Expectations](https://ghgadvisors.com/cms-releases-the-2015-audit-protocol-critical-next-steps-to-avoid-becoming-a-casualty-of-reasonable-expectations/) - On February 12th, CMS released the 2015 Audit Protocol. The question on everyone's mind is — what does this mean for 2015? Well, it means a few things. Outlined below are some of the most impactful changes, as well as the "why" behind the change, and the trends that continue to emerge. 1. CMS has
- [Countdown to Final Submit](https://ghgadvisors.com/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.
- [In 2015 a Slap on the Wrist Can Be the Kiss of Death](https://ghgadvisors.com/in-2015-a-slap-on-the-wrist-can-be-the-kiss-of-death/) - It is truth that in the second term of Democratic administrations, scores get settled between Washington regulators and business partners of the Federal government. 2015 will be no different for our favorite agency, the Centers for Medicare & Medicaid Services (CMS). It's already on a pace for 2015 to be the toughest year ever in enforcement actions
- [Getting Ready for the Bid Season](https://ghgadvisors.com/getting-ready-for-the-bid-season/) - Since the CMS Medicare Advantage January enrollment numbers did not include the last three days of the Annual Election Period (AEP), it is important to utilize the February enrollment file to get the full picture of AEP results. At GHG, we like to develop the reporting in January for directional results and get an idea
- [Medicare Secondary Payer (MSP) is all about the money.](https://ghgadvisors.com/medicare-secondary-payer-msp-is-all-about-the-money/) - Money going out as a result of paying claims as primary payer when it's possible you should be paying as secondary payer. CMS reduces plan payments for members with MSP, shown on the Monthly Membership Report (MMR) as an MSP adjustment (reduction). Money coming in results when research and outreach attempts validate paying as secondary
- [Kaiser Family Foundation & CCF Release 50-State Survey on Medicaid and CHIP](https://ghgadvisors.com/kaiser-family-foundation-ccf-release-50-state-survey-on-medicaid-and-chip/) - It's time again for the release of the annual 50-state survey on Medicaid and CHIP enrollment, eligibility, cost-sharing and renewal policies conducted by the Kaiser Family Foundation's Commission on Medicaid and the Uninsured with the Georgetown University Center for Children and Families. It's clear that the Affordable Care Act (ACA) has broadened Medicaid's base of coverage for
- [2016 CMS Applications: Highlights and Basics](https://ghgadvisors.com/2016-cms-applications-highlights-and-basics/) - This week's CMS industry training on applications was quite informative, and contained many audience questions that you will want to hear. The recording is already available to registrants for those who missed it. There was way too much information for me to summarize, so I have included here a few highlights from the call and
- [How to Maintain the Accuracy & Consistency of Data through an Entire Life Cycle](https://ghgadvisors.com/how-to-maintain-the-accuracy-consistency-of-data-through-an-entire-life-cycle/) - It doesn't matter whether you call it the Annual Election Period (AEP), Open Enrollment Period or Fall Open Enrollment; it's that busy time of the year when beneficiaries are on the move. Now that the dust has settled, it's time to take a thorough look at your member data. Your members are your revenue. Accurate
- [Operational Assessment — time for a “Check-Up"](https://ghgadvisors.com/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
- [Private label health plans - a tool for increase market capture and improved patient outcomes](https://ghgadvisors.com/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,
- [2016 CMS Application Season Begins](https://ghgadvisors.com/2016-cms-application-season-begins/) - Yesterday CMS released the 2016 Part D application, and this afternoon the 2016 Medicare Advantage (MA) application was released. Despite the applications' release dates, potential and current Plan Sponsors should be well under way in the preparation of the upload that is due on February 18th. Aspects of the application that require significant lead time
- [ACOs — There must be a pony in here someplace](https://ghgadvisors.com/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
- [New Year's Resolutions for Your Organization!](https://ghgadvisors.com/new-years-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
- [ICD-10 Transition — Ready or Not?](https://ghgadvisors.com/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
- [Annual Compliance Program Audit: Your Organization's Achilles Heel?](https://ghgadvisors.com/annual-compliance-program-audit-your-organizations-achilles-heel/) - When it comes to auditing throughout the Organization, the truth is that much of the responsibility often falls directly on the Compliance Department. This can be due to many factors, such as lack of resources or lack of cross-functional expertise. However, one of the CMS Compliance Program requirements is that the Compliance Program itself is
- [Star Ratings: The Moving Target](https://ghgadvisors.com/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
- [Data Smog - CMS's Clear Vision for the Future of Data & Analytics](https://ghgadvisors.com/data-smog-cmss-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)
- [Rewards and Incentives: Are We There Yet?](https://ghgadvisors.com/rewards-and-incentives-are-we-there-yet/) - Yes, Medicare Advantage is finally catching up to the rest of the health care industry, and we are now permitted to offer enrollees Rewards and Incentives. On December 4, 2014, CMS released an HPMS memo titled "Rewards and Incentives Program Guidance" which provides additional guidance related to how Organizations must implement Rewards and Incentives Programs,
- [A Christmas Wish List for Claims](https://ghgadvisors.com/a-christmas-wish-list-for-claims/) - Here's what I am wishing for all our health plan clients….an uneventful start to the 2015 Plan Year. By that I mean that all the prescription claims that should adjudicate without rejecting actually do, and the claims that should not pay, reject as expected. Either the beneficiary leaves the pharmacy with their medication or the
- [Federal study raises questions about access to care for people gaining Medicaid coverage under the Affordable Care Act](https://ghgadvisors.com/federal-study-raises-questions-about-access-to-care-for-people-gaining-medicaid-coverage-under-the-affordable-care-act/) - Federal investigators said in a new report that large numbers of doctors who are listed as serving Medicaid patients are in reality, not available to treat them. Patients select their physicians from a list of providers associated with each Medicaid health plan. The investigators, led by the inspector general, Daniel R. Levinson, called the doctors'
- [Hepatitis C virus (HCV) and treatment with  Sovaldi® (sofosbuvir)](https://ghgadvisors.com/hepatitis-c-virus-hcv-and-treatment-with-sovaldi-sofosbuvir/) - The medication Sovaldi® has revolutionized the way HCV is treated and at the same time has shocked health insurance payers and particularly Medicaid prescription drug budgets. With an estimated cost of $1000 or more per pill for a twelve (12) week course of treatment, the cost to treat one person can exceed $84,000. According to
- [Medicare Secondary Payer — A Simple Process with a Big Impact](https://ghgadvisors.com/medicare-secondary-payer-a-simple-process-with-a-big-impact/) - We've heard many organizations say, "We do MSP" or "MSP, it's easy, we've got it covered". MSP processing may not be rocket science but it's a regulated process with steps that need to be executed correctly. The MSP transactions that your organization submits directly affect the monthly payment to your Plan and impact your financial
- [Republican Congress to Use "Inside Baseball" and Courts to Maim ObamaCare](https://ghgadvisors.com/republican-congress-to-use-inside-baseball-and-courts-to-maim-obamacare/) - Blowing in like a flu outbreak as year-end approaches, ObamaCare Derangement Syndrome has enveloped the Capital. Republican leaders in Congress are plotting to use arcane parliamentary procedures and the courts to do further violence to ObamaCare, and by extension, to the millions who have gained insurance through it. While it's red meat for the conservative base, the
- [Medicare and Exchange Risk Adjustment: Data Quality Matters](https://ghgadvisors.com/medicare-and-exchange-risk-adjustment-data-quality-matters/) - Plans/Issuers participating in the Exchange may think they have dodged a bullet because HHS has stated payments will not be adjusted during the first two years of the program as a result of RADV audits. However, other remedies such as prosecution under the False Claims Act may still be applied to non-compliant issuers (health plans).
- [Medicare Advantage Rates for 2016: Chanel No. 5 or Another Unicorn Fart?](https://ghgadvisors.com/medicare-advantage-rates-for-2016-chanel-no-5-or-another-unicorn-fart/) - This week CMS issued a surprise announcement on payment rates for Medicare Advantage in 2016. The 2.02% increase is in line with projections we have been using for 2016, and is also consistent with other projections for Medicare FFS per capita cost growth. But there should be no confusion: this is NOT the final rate,
- [Best Practices in Medicaid Claims Administration and Oversight](https://ghgadvisors.com/best-practices-in-medicaid-claims-administration-and-oversight/) - Every Medicaid operation needs high-performing claims administration. With strict medical loss ratios as required by healthcare reform, ongoing regulatory changes, timeliness, and payment accuracy relevant to provider pricing and benefit administration, covering operating costs poses significant challenges. Claims adjudication must be efficient and cost effective. Claims adjudication is the process of paying or denying claims
- [Exchanges - Risk Adjustment - Ladies and Gentlemen, Start Your Engines](https://ghgadvisors.com/exchanges-risk-adjustment-ladies-and-gentlemen-start-your-engines/) - Seriously, the first question is, "what do you have under the hood for risk adjustment in your health plan?" If you're running a stock claims engine that merely matches up with your enrollment file for CMS Edge Server processing, and you don't have a risk adjustment operation, you may be breathing fumes from your competitors.
- [A Bad Couple Weeks for ObamaCare](https://ghgadvisors.com/a-bad-couple-weeks-for-obamacare/) - It's been a bad couple weeks for ObamaCare. It started with a Republican gorilla-stomp in the midterms, a rout that included several Governors' mansions and state legislatures that essentially froze in place the Medicaid expansion map. Then, in a shocker, the Supreme Court decided to consider King v. Burwell, the case that could undo ObamaCare's
- [The Importance of a Proactive Call Center](https://ghgadvisors.com/the-importance-of-a-proactive-call-center/) - During the AEP we know how critical a role our Member Services team plays. During this time, they are integral to helping prospective enrollees understand the benefits of your Plans, and play an important part in the retention of your current members. Having a strong proactive Member Call Center is crucial in today's environment. Test your call
- [CMS Validation Process: The Silver Lining](https://ghgadvisors.com/cms-validation-process-the-silver-lining/) - We've seen quite a few changes over the past few years in the way that the Centers for Medicare & Medicaid Services (CMS) is approaching the program audit and audit validation process. The most notable trend this year is continued push back of responsibility onto the Organization. In recent sanction reports, CMS states that it
- [CMS Initiates New Program to Support Care Coordination Among ACOs](https://ghgadvisors.com/cms-initiates-new-program-to-support-care-coordination-among-acos/) - Many of you are aware of the recently published Centers for Medicare & Medicaid Services (CMS) Affordable Care Act (ACA) initiative to support care coordination nationwide. CMS announced the availability of a new initiative for Accountable Care Organizations (ACOs) participating in the Medicare Shared Savings Program. The initiative is designed to encourage ACOs to realize
- [12 Years in the Making - Rules Guiding Medicaid Managed Care are Getting a Makeover](https://ghgadvisors.com/12-years-in-the-making-rules-guiding-medicaid-managed-care-are-getting-a-makeover/) - At the Medicaid Health Plans of America (MHPA) meeting last week in Washington, DC, there was a lot of buzz surrounding the upcoming release of an updated Medicaid Managed Care regulation. Per CMS officials speaking at the conference, the last update was 12 years ago! Discussions surrounding the update were focused on three main themes:
- [Little Reason for Optimism in Red State Medicaid Expansion](https://ghgadvisors.com/little-reason-for-optimism-in-red-state-medicaid-expansion/) - For months several Wall Street analysts and others have predicted near-total adoption of the Affordable Care Act's Medicaid expansion by the states. To date, only 27 have, and I see little optimism for more than a handful to do so anytime soon. Red State governors are WAY more entrenched than anyone anticipated, and they're getting
- [The Good, the Bad and the Ugly in Medicare Advantage](https://ghgadvisors.com/the-good-the-bad-and-the-ugly-in-medicare-advantage/) - In the last two weeks there's been good, bad and ugly news for Medicare Advantage (MA) plans. On one hand, the program has never been stronger and quality metrics are surging in the right direction; on the other, the industry is sucking it up on following the rules of its biggest customer, the Centers for Medicare and
- [NY Times article reiterates compliance trends in Medicare Advantage](https://ghgadvisors.com/ny-times-article-reiterates-compliance-trends-in-medicare-advantage/) - As many of you have already read, the NY Times ran a scathing article on October 12th titled "U.S. Finds Many Errors in Medicare Health Plans" shining a light on serious Compliance issues we've all been aware of over the past several years. Is the continued lack of non-compliance really news to anyone in the industry?
- [Exchange 2014 Data Submission Due April 30,2015](https://ghgadvisors.com/exchange-2014-data-submission-due-april-30-2015/) - As we wind down on our inaugural year with Health Insurance Exchanges (HIX), we have seen plans using a variety of approaches in their Risk Adjustment data reporting efforts. Some continue to use the same approaches used for their Medicare programs (chart reviews, provider outreach, in-home assessments, etc). Some have not even begun any retrospective,
- [Noteworthy declines in Star Measures: Ensure a 4-Star Performance](https://ghgadvisors.com/noteworthy-declines-in-star-measures-ensure-a-4-star-performance/) - With 5% of revenue contingent on achieving at least 4 Stars, the stakes have never been higher for Medicare Advantage plans. Within the 40% of plans earning at least 4 Stars in 2015, plan leaders are celebrating their return on investment from quality improvement initiatives and other Stars-impactful activities. But for the 135 plans on
- [Reversing the Trend:  Improving Care Coordination](https://ghgadvisors.com/reversing-the-trend-improving-care-coordination/) - The good news from the 2015 Star Ratings is clear: Medicare Advantage plans held steady or improved in almost 70% of the 46 Part C & D Star measures. But the more subtle message hidden underneath the 15 measures where performance declined in 2015 is similarly clear: health plans have not yet mastered population management
- [They Still Don't Like It](https://ghgadvisors.com/they-still-dont-like-it/) - In the October 8, 2014 memo entitled "Contract Year 2014 Part D Formulary Administration Analysis (FAA)", CMS reiterates their concern with the accuracy of formulary coding. For the April 2013 analysis, 9 out of 88 (10.2 %) plan sponsors were found to have failed FAA, meaning that greater than 20% of the sampled rejects were
- [Application season is here: How's your network holding up?](https://ghgadvisors.com/application-season-is-here-hows-your-network-holding-up/) - Once again we are in the midst of application season for health plans applying to become a Medicare Advantage Health Plan, expanding their MA geographic footprint or getting into the Health Insurance Exchange space. Regardless of the scope or the specific enterprise, network adequacy and accessibility is a major cornerstone of any MA or Exchange
- [The 2015 Ratings are In: Have the Stars Aligned?](https://ghgadvisors.com/the-2015-ratings-are-in-have-the-stars-aligned/) - The Centers for Medicare & Medicaid Services (CMS) has released the 2015 Medicare Advantage Star Ratings, and the Stars seem to be aligning with CMS' goals of the Star Ratings program. For the 40% of Medicare Advantage plans earning at least 4 Stars this year, and thus qualifying for Quality Bonus Payments, these newly-released Star
- [Part D Rejected Claims Continue to be Important Monitoring for CMS](https://ghgadvisors.com/are-you-confident-in-your-current-process-to-review-and-identify-non-compliant-rejected-claims/) - Rejected claim analysis is a year-round activity with special emphasis that should begin before January. Are you confident in your current process to review and identify non-compliant rejected claims? As a Plan Sponsor, whether you delegate all or part of your Part D Drug Benefit set-up to your Pharmacy Benefit Manager (PBM), The Centers for
- [Marketplaces — Your Stars are coming](https://ghgadvisors.com/marketplaces-your-stars-are-coming/) - The Centers for Medicare & Medicaid Services (CMS) has been aggressively working in the background to establish the Star Ratings program for the Marketplaces, thus consumers will have their first quality information by 2017. Selecting a Marketplace health plan will no longer be based only on price or provider. As such, quality ratings will have
- [High Value Network: Generation 4.0](https://ghgadvisors.com/high-value-network-generation-4-0/) - When it comes to healthcare, two truism's are that medical costs are going up along with demand for healthcare services. And when it comes to organic growth of healthcare volume and expenses, government programs represent a major driver, particularly when considering that on a daily basis thousands of baby boomers age into Medicare. During the
- [Does your current Model of Care coincide with the new requirements?](https://ghgadvisors.com/is-it-time-to-submit-your-model-of-care-moc-for-re-approval/) - The Centers for Medicare and Medicaid Services (CMS) revised the Model of Care (MOC) requirements, reducing core clinical and non-clinical elements from 11 to 4. Subsequently, the National Committee for Quality Assurance (NCQA) revised their scoring guidelines and methodology, based on this change. What does this mean for health plans that are scheduled to resubmit
- [Reasonableness — The Last Chance](https://ghgadvisors.com/reasonableness-the-last-chance/) - After four tries, some Marketplace health plan applicants have still failed to meet CMS reasonableness standards for 2015. Some of these applicants complained that they did everything they were told to do but were again rejected. Others are still asking for definition and written standards. Unfortunately, most understand that nothing in writing exists beyond the
- [It's a Marathon - Not a Sprint](https://ghgadvisors.com/its-a-marathon-not-a-sprint/) - Plans will shortly be receiving the Readiness Checklist from CMS. At first glance it looks like just a bunch of boxes to check off and answering yes and no questions. Here's the rub: Starting to figure out whether or not you have 30 boxes of non-readiness to report to your Account Manager is not a
- [Important strategies for a plan's medical management team](https://ghgadvisors.com/important-strategies-for-a-plans-medical-management-team/) - It wasn't too long ago that the clinical staff and practitioners in the medical management arena of health plans only focused on the quality and continuity of care with their members. These objectives were very important, and should continue to be the focus of any medical management team. However, in more recent times, it has
- [Another Flood of Good News for Medicare Advantage](https://ghgadvisors.com/another-flood-of-good-news-for-medicare-advantage/) - Last week the Centers for Medicare and Medicaid Services (CMS) did its annual data dump for the 2015 Medicare Advantage (MA) and Prescription Drug Plan (PDP) bids. Even with MA plans sailing into the worst rate environment in over 15 years, the data offered another flood of good news for the industry. Several takeaways from our
- [Gearing up for 2016 — Look Ahead, Plan Ahead](https://ghgadvisors.com/gearing-up-for-2016-look-ahead-plan-ahead/) - As if you are not busy enough, now is the time to start looking towards both 2016 and the future, to ensure you have the correct products in your marketplace as well as determine whether it is time to either increase or decrease the size of your market. Understanding and really knowing your current membership, plus
- [Bombshells from MedPAC on Medicare Advantage Retention](https://ghgadvisors.com/bombshells-from-medpac-on-medicare-advantage-retention/) - The Medicare Payment Advisory Commission (MedPAC ), the nonpartisan blue-chip Congressional uber-nerds on our favorite entitlement program, met this week and the staff report presented a couple bombshells on retention rates in Medicare Advantage (MA). In the aggregate, the commission noted that in 2012 the voluntary disenrollment rate from plans was slightly below 10%. The vast
- [CMS's Star Ratings Firing Squad Gets Squirt Guns](https://ghgadvisors.com/cmss-star-ratings-firing-squad-gets-squirt-guns/) - Last week, in a surprise move, the Centers for Medicare and Medicaid Services (CMS) reversed its threat to terminate all Medicare Advantage and Part D health plans with 3 or fewer Stars for more than 3 consecutive years. Roughly a dozen health plans were lined up in front of the firing squad as an example
- [Data the Silent Killer](https://ghgadvisors.com/data-the-silent-killer-2/) - As a seasoned veteran in healthcare operations I've seen firsthand the progression of data utilization by health plans. Despite decades of growth we're not there yet. In the 1950s and 60s data processing began to take hold. Unfiltered data was the norm. Not much was done with it. Data validation was in its infancy. Business
- [Why Medicare ACOs Were Always a Bad Deal, and Why They Need an Exit Strategy](https://ghgadvisors.com/why-medicare-acos-were-always-a-bad-deal-and-why-they-need-an-exit-strategy/) - Last week, the tenth of 32 Medicare Pioneer ACOs dropped out of the program. Others are expressing reservations about entering or continuing given the experience of Pioneers and the hundreds participating in the Medicare Shared Savings Program (MSSP). To be clear, it's not all bad news...but most ACOs will need an exit strategy, fast. Medicare
- [Passing Marketplace Reasonableness — One More Chance](https://ghgadvisors.com/passing-marketplace-reasonableness-one-more-chance/) - September 4th was final submission day for Marketplace plans but some worried health plans were asking "what ifs" about their last submission for network access. These plans have re-submitted network updates after two CMS rejections that required correction for failing reasonable access. They have three consecutive wrong guesses on whatever standards CMS believes they have
- [Groundhog Day: CMS Issues Best Practice Memo Related to Common Audit Findings](https://ghgadvisors.com/groundhog-day-cms-issues-best-practice-memo-related-to-common-audit-findings/) - Is it Groundhog Day or does this memo say the same thing as last year? Nope you're not imagining things - In CMS' Memo titled "Common Conditions, Improvement Strategies, and Best Practices based on 2013 Program Audit Reviews" that was released on August 27th, CMS outlines again the industry pitfalls and best practices around common
- [ObamaCare Derangement Syndrome Fades, Medicaid Expands.](https://ghgadvisors.com/obamacare-derangement-syndrome-fades-medicaid-expands/) - Last week's approval of Pennsylvania's Medicaid expansion waiver by the Centers for Medicare and Medicaid Services (CMS) may have been good medicine for ObamaCare Derangement Syndrome among Red State governors. Growing numbers are beginning to see the light and resistance to expansion is beginning to crumble like stale crackers. Expansion momentum is building in Republican-led
- [Em El AR  Passive Statistic or Call to Action?](https://ghgadvisors.com/em-el-ar-passive-statistic-or-call-to-action/) - For many, the medical loss ratio (MLR) is the ratio of the health plan's incurred medical claims to the total premiums earned. However under the Affordable Care Act and for government health programs, the MLR is the ratio of medical claims plus quality improvement costs divided by earned premiums minus federal and state taxes and fees and
- [PA's Corbett is Latest GOP Governor to Take Medicaid Expansion. Will Others?](https://ghgadvisors.com/pas-corbett-is-latest-gop-governor-to-take-medicaid-expansion-will-others/) - Last week the Center for Medicare and Medicaid Services (CMS) announced the approval of Pennsylvania's Healthy Pennsylvania plan to expand Medicaid coverage to more than half a million low-income people, becoming the 27th state to do so under the Affordable Care Act (ACA) and the 9th Republican governor. It's a big step for Governor Corbett,
- [So, what does “Unreasonable Delay" really mean in Federally Facilitated Marketplaces?](https://ghgadvisors.com/so-what-does-unreasonable-delay-really-mean-in-federally-facilitated-marketplaces/) - As expected, CMS has been sending correction notices to health plans about their networks. Also, as expected, some plans have received a second rejection of their response to the first rejection. Now, time is limited since final corrections are due by September 4. Health plans are asking CMS to give them some idea about how
- [The Medicare ACO Demos Are a Mess.  Here's What it Means for Health Plans.](https://ghgadvisors.com/the-medicare-aco-demos-are-a-mess-heres-what-it-means-for-health-plans/) - This week, another Medicare Pioneer Accountable Care Organization Demonstration site, longtime GHG client Sharp Healthcare in San Diego announced it was dropping out. It was the tenth Pioneer to quit the trail, and not for lack of trying. Many of the Pioneers did great on improving quality and reducing costs -- the issue is not the
- [Sales Allegations — What is the best practice?](https://ghgadvisors.com/sales-allegations-what-is-the-best-practice/) - It's just about that time of year again. Yes, you've got it — Sales Allegation time. During AEP, Organizations receive an influx of complaints of alleged sales misconduct "Sales Allegations". And, every year we receive some of the same questions around how these allegations "should" be investigated and closed. The rub is, CMS is all
- [The Clock is Ticking...](https://ghgadvisors.com/the-clock-is-ticking/) - If you are a veteran of Medicare Risk Adjustment reporting, you are probably in high gear planning or implementing year end programs to optimize 2014 and 2015 revenue. But is the same old approach you used last year the right approach for this year? Or maybe you are new to Medicare Risk Adjustment or Commercial
- [Hospice Guidance Turns 180 Degrees](https://ghgadvisors.com/hospice-guidance-turns-180-degrees/) - After 70 Senators signed a protest bill and the hue and cry from hospice providers, patients and prescribers got too loud, CMS rescinded its' previous regs for hospice patients and published new guidance on 7-18-14. Previous guidance required health plans to place prior authorization edits on all medications after a member was identified as being
- [The Model of Care's Interdisciplinary Care Team](https://ghgadvisors.com/the-model-of-cares-interdisciplinary-care-team/) - The Centers for Medicare & Medicaid Services (CMS) has outlined expectations for Model of Care (MOC) for Medicare managed care programs. One of the critical elements of the MOC is the Interdisciplinary Care Team (ICT). CMS has placed greater emphasis on outcomes measures and a well-designed ICT can be a success factor in improving the
- [Health Plan Strategists: Fish Where the Fishes Is -- in LTSS](https://ghgadvisors.com/health-plan-strategists-fish-where-the-fishes-is-in-ltss/) - One of the best pieces of advice I ever got in business was to "fish where the fishes is", and for health plan strategists it holds up. In this Golden Age of Government-sponsored Health Programs, one of the biggest fishing holes is Long-Term Services and Supports, and a new primer from KFF lays out the opportunity beautifully. And
- [Navigators, In-Person Assisters and Brokers](https://ghgadvisors.com/navigators-in-person-assisters-and-brokers/) - The Alliance for Health Reform held a briefing on August 5, 2014 on "Navigating the Health Insurance Landscape: What's Next for Navigators, In-Person Assisters and Brokers?" Consumer enrollment in Qualified Health Plans (QHPs) offered in the Exchange Marketplaces for 2014 was greatly assisted by Navigators, In-Person Assisters (including Certified Application Counselors) and Brokers. 28,000 navigators
- [Outbound Enrollment Verification (OEV) - To call or not to call?](https://ghgadvisors.com/outbound-enrollment-verification-oev-to-call-or-not-to-call/) - With the release of the 2015 Marketing Guidelines, CMS made a few key updates to the Outbound Enrollment Verification (OEV) Process. One of the most significant updates is that CMS now allows organizations to complete the OEV process via direct mail or email (if the beneficiary opted-in for email). This change actually provides significant opportunity
- [Regulatory Oversight of Narrow Network Plans](https://ghgadvisors.com/regulatory-oversight-of-narrow-network-plans/) - The Alliance for Health Reform held a meeting that focused on "Network Adequacy: Balancing Cost, Access and Quality" on July 21. The meeting was very well attended for mid-summer, indicating substantial interest in the trend towards smaller networks particularly in qualified health plans offered through the ACA Exchange marketplaces. Several of the panelists mentioned a
- [American Action Network Promotes Government Subsidies](https://ghgadvisors.com/american-action-network-promotes-government-subsidies/) - The American Action Network (AAN), a 501(c)(4) conservative think tank, has published a report that purports to show that Medicare Advantage (MA) payments will be about 13% less in 2015 than they would have been had the Affordable Care Act not interfered. To get the attention of members of Congress, the report shows the reductions by Congressional
- [It's silly season again, so let's sue the President](https://ghgadvisors.com/its-silly-season-again-so-lets-sue-the-president/) - The Speaker of the United States House of Representatives, one of the most senior elected officials in the US government, has announced that the House is going to sue the President because he has delayed enforcement of a provision of the 2010 health care law; a provision that a majority of that same House has
- [High Performance Health Plan Networks](https://ghgadvisors.com/high-performance-health-plan-networks/) - A Milliman report commissioned by AHIP finds that narrower, high value provider networks can help reduce premiums from 5 to 20 percent when compared to broad network plans. A high value network is one selected on the basis of not only fee schedules, but also overall efficiency and quality metrics. Health plans can make these
- [Hobby Lobby and Corporate Person-hood](https://ghgadvisors.com/hobby-lobby-and-corporate-person-hood/) - The Supreme Court ruled on Monday, in the Hobby Lobby case, that requiring family-owned corporations to pay for insurance coverage for contraception under the ACA violated a federal law protecting religious freedom. This essentially means that some corporations now have religious rights. Although the majority tried to make this ruling as narrow as possible, it
- [Part D and Hospice Rules Mucking Up Beneficiaries' Last Days](https://ghgadvisors.com/part-d-and-hospice-rules-mucking-up-beneficiaries-last-days/) - Last week the Centers for Medicare and Medicaid Services (CMS) met with 30 hospice & healthcare organizations about suspending a new rule intended to avoid duplicate payments for hospice medications. This is a very big deal and the new rule is mucking up many beneficiaries' last days. The National Hospice and Palliative Care Organization described
- [Further Evidence That PBMs are Failing on Government Programs](https://ghgadvisors.com/further-evidence-that-pbms-are-failing-on-government-programs/) - At CMS' oversight and enforcement conference last week Jonathan Blanar, the agency's Deputy Director of Compliance Enforcement, presented the following slide. In this slide, you will see actions CMS has imposed against Medicare health plans in the last two years, and for what reasons. It's further evidence that pharmacy benefit managers (PBMs) are failing Medicare beneficiaries and the
- [4 Points to Ponder from CMS' Oversight and Enforcement Conference](https://ghgadvisors.com/4-points-to-ponder-from-cms-oversight-and-enforcement-conference/) - On June 26, CMS hosted their MA-PD Oversight and Enforcement conference. Not one of the topics was less relevant to the audience than another — they prepared ahead of time to present current, critical information related to their data-driven approach to oversight, best practices and common findings, preparing for an audit and enforcement actions. I
- [PBMs are the Health Plan Industry's Achilles Heel](https://ghgadvisors.com/pbms-are-the-health-plan-industrys-achilles-heel/) - In this Golden Age of government programs, the health plan industry has never had more exposure to the generally poor performance of pharmacy benefit managers (PBMs). Performance metrics in Medicare, Medicaid and ObamaCare are directly tied to PBM execution, and the recent track record of these companies means they are the Achille's Heel of insurers. PBMs historically
- [The state of enrollment: Lessons learned in connecting Americans to coverage](https://ghgadvisors.com/the-state-of-enrollment-lessons-learned-in-connecting-americans-to-coverage/) - Enroll America issued a 92 page report on the lessons learned and best practices from the initial open enrollment on the new Affordable Care Act (ACA) Exchanges. According to the report, 8 million people enrolled in the new qualified health plans (QHPs) and an additional 4.8 million people enrolled in Medicaid and CHIP. The report was
- [Integration of MMP Requirements](https://ghgadvisors.com/integration-of-mmp-requirements/) - MA-PD plans have plenty to worry about with CMS requirements, regulator's issue of the day, or Central Office determining what issue to hang their hat on today, seemingly changing with the shift of the wind. It is a challenge to keep track of it all, but it's a necessity we promote and support. Running like
- [The Impact of Tax Subsidies in the Federally Facilitated Marketplaces (FFM)](https://ghgadvisors.com/the-impact-of-tax-subsidies-in-the-federally-facilitated-marketplaces-ffm-2/) - A recent report released by the Department of Health and Human Services (HHS) found that four out of five persons who qualified for tax credits in the Federally-facilitated Marketplaces paid an average of $82 a month in premiums after tax subsidies for their health coverage. 69 percent of individuals selecting plans with tax credits in
- [Most, if Not All, States Will Be on the Federal Exchange by 2020](https://ghgadvisors.com/most-if-not-all-states-will-be-on-the-federal-exchange-by-2020/) - Correction: June 20, 2014 An earlier version of this article misidentified the state of Washington as preparing to enter into the Federal Exchange. Though the state of Washington is having trouble with its enrollment website, Washington Health Benefit officials have clarified that Washington state has no intention of becoming part of the federal marketplace. As ObamaCare
- [Tuesday Night's Primary Elections Were Huge.  Here's What They Mean for Our Industry.](https://ghgadvisors.com/tuesday-nights-primary-elections-were-huge-heres-what-they-mean-for-our-industry/) - House Majority Leader, Eric Cantor (R-VA) is toast. Trounced in his Richmond district by a nobody Tea Bagger Tuesday night. Cantor gave up his leadership position yesterday. Depending on where you sit politically, either the unthinkable or the inevitable happened. In fact, a Majority Leader hasn't lost incumbency since the office was created in 1899. "The defeat of
- [Aetna Offers a Playbook for Evolution in the Golden Age of Government Programs](https://ghgadvisors.com/aetna-offers-a-playbook-for-evolution-in-the-golden-age-of-government-programs/) - Ralph Giacobbe of Credit Suisse got another terrific "get" hosting Aetna's management team for an insightful discussion last week. I found the takeaways offer a playbook for how to adapt and evolve in the new Golden Age of government-sponsored health programs: Watch Your Wallet: Aetna assumed an accelerating cost trend in 2014 of 6-7%. The company noted
- [The Status of Medicaid Expansion, and Why It Will Keep Getting Better](https://ghgadvisors.com/the-status-of-medicaid-expansion-and-why-it-will-keep-getting-better/) - Medicaid is already the largest insurer on the planet, and the Affordable Care Act (ACA) is driving enrollment faster than anyone imagined. But there are headwinds in covering more Americans through Medicaid, some political, some operational. Here's why it will continue to improve and drive expanded coverage for the uninsured -- and why all insurers
- [Obama Administration Puts Executive Focus on -- Surprise! -- Execution](https://ghgadvisors.com/obama-administration-puts-executive-focus-on-surprise-execution/) - In Washington we say that where a President puts his prize staffers is the best indicator of his priorities. That being the case, two of POTUS' recent staffing moves paint a picture: Obama's #1 domestic priority is smoothing out ObamaCare before the next enrollment period this fall and solidifying the experience of the millions who
- [What's Gained and Lost with an HHS Secretary Burwell](https://ghgadvisors.com/whats-gained-and-lost-with-an-hhs-secretary-burwell/) - My old Clinton Administration colleague Sylvia Mathews Burwell sailed through a confirmation hearing last week. What was expected to result in serious anti-ObamaCare fireworks and soundbite fodder for midterm campaigns ended with a whimper. Her second confirmation hearing was yesterday, and it's a "Washington dog isn't barking" story. It's now looking like she'll cruise through
- [Follow the Leader: United Health Group's Outlook on Government Health Programs](https://ghgadvisors.com/follow-the-leader-uniteds-outlook-on-government-health-programs/) - Ralph Giacobbe at Credit Suisse is a leading health industry analyst and is doing the best work of his career. Today he produced a fantastic recap of his discussion with United Health Group CEO Steve Hemsley and several of his top executives. It included some fascinating insights into the market leader's strategy for government health
- [Pass through payment cuts to providers?](https://ghgadvisors.com/pass-through-payment-cuts-to-providers/) - The Medicare Physician Quality Reporting System (PQRS) has teeth. Says CMS: "Eligible professionals who do not satisfactorily report data on quality measures for covered professional services will be subject to a payment adjustment under PQRS beginning in 2015...Accordingly, eligible professionals receiving a payment adjustment in 2015 will be paid 1.5% less than the MPFS [Medicare
- [POTUS Spikes the Football, but the ObamaCare War-Game Isn't Over](https://ghgadvisors.com/potus-spikes-the-football-but-the-obamacare-war-game-isnt-over/) - Last week as health insurance exchange open enrollment ended, President Obama spiked the football, announcing that 8 million people had signed up, and that the Obamacare debate is "over." He put an exclamation point on it: that millions more had gained coverage through Medicaid expansion and new mandates on employers. Now, any further discussion of repealing ObamaCare
- [Spring Cleaning: Have you thoroughly examined your MSP records yet?](https://ghgadvisors.com/spring-cleaning-have-you-thoroughly-examined-your-msp-records-yet/) - Spring cleaning normally consists of taking a look around our homes and conducting a deep clean. It's a time when we can no longer ignore those often neglected, out of sight jobs that we know we must do in order to maintain a clutter-free, and healthy home. In the government health care space, there is
- [The 2015 Medicare Advantage Final Call Letter = Unicorn Rainbow Farts](https://ghgadvisors.com/the-2015-medicare-advantage-final-call-letter-unicorn-rainbow-farts/) - The Center for Medicare and Medicaid Services' (CMS) release of the final 2015 Call Letter for Medicare Advantage (MA) Monday after the close was a "unicorns farting rainbows" moment. Unicorn rainbow farts bring happiness and joy to all those that observe them, and then dissipate quickly. After a beating at the hands of the ever-more
- [Are ACOs fulfilling expectations?](https://ghgadvisors.com/are-acos-fulfilling-expectations/) - Many of the Medicare Shared Savings program ACOs are now in their second year of operation and some of the Pioneer ACOs are approaching year three. As a result, we are beginning to see published data on which of those ACOs are achieving shared savings. For those ACOs that began operating in 2012, (only ones
- [Member Engagement and Experience are the New Risk Adjustment](https://ghgadvisors.com/member-engagement-and-experience-are-the-new-risk-adjustment/) - In this new era of Star Ratings in Medicare Advantage and Part D, where a 4+ score is now do-or-die, health plan survival comes down to two things: member engagement and the member experience. They're the new risk adjustment when rates in 2014-2015 will be at their lowest levels in more than a decade, and
- [Lighting the Path in the Golden Age of Government-Sponsored Health Programs: Join Us for the GHG Client Forum](https://ghgadvisors.com/lighting-the-path-in-the-golden-age-of-government-sponsored-health-programs-join-us-for-the-ghg-client-forum/) - More than 300 guests will convene on May 1-2 at the Red Rock Casino in Las Vegas for the 2014 Gorman Health Group Forum, our annual strategic retreat for leaders in government-sponsored health programs. This year's gathering promises to be the most actionable, content-packed conference you could attend on how to succeed in this new Golden Age of government business. And when the
- [Innovating in 2014](https://ghgadvisors.com/innovating-in-2014/) - CMS has developed an Innovation Center to address health care payment and service delivery models. It is a great site to find information about current Innovation Model Partners, and a place to share your ideas on how care can be delivered and paid for in ways that will lower care cost and improve quality of
- [2015 Medicare Advantage Draft Rate Notice is a Bear: Messy, Noisy, and Smells Like Roadkill](https://ghgadvisors.com/2015-medicare-advantage-draft-rate-notice-is-a-bear-messy-noisy-and-smells-like-roadkill/) - Friday after the close of business, CMS released the draft 2015 "call letter", the rate announcement for Medicare Advantage. As expected, it's a bear: messy, noisy, and smells like roadkill. It's just about a worst-case scenario for flabby, distracted, uncommitted health plans in Medicare -- the roadkill to come. The table is now heavily tilted against
- [John Gorman Comments on CMS Proposed Rate Cuts in Modern Healthcare Magazine](https://ghgadvisors.com/john-gorman-mentioned-in-modern-healthcare-magazine/) - CMS is scheduled to release initial guidance on Medicare Advantage (MA) rates for 2015 that insurers have estimated could reduce payments by as much as 7 percent next year. Insurers say cuts of that magnitude could cause premium increases and benefit reductions that could severely impact seniors. In a recent article featured in Modern Healthcare Magazine regarding proposed MA rates,
- [ObamaCare's Winners and Losers -- Consumer Edition](https://ghgadvisors.com/obamacares-winners-and-losers-consumer-edition/) - I got my start in DC some 23 years ago as a reporter, and the profession's credo is always to "afflict the comfortable and comfort the afflicted." ObamaCare is the story of a lifetime for enterprising journalists, and the really poignant anecdotes that can shape and move public opinion -- and therefore politics -- are
- [CMS announcement regarding 820 payment files and the interim process poses a new challenge for Issuers in the Health Insurance Marketplace](https://ghgadvisors.com/cms-announcement-regarding-820-payment-files-and-the-interim-process-poses-a-new-challenge-for-issuers-in-the-health-insurance-marketplace/) - It's a rough road ahead for Issuers trying to get paid in the Health Insurance Marketplaces. The latest announcement from CMS on Monday, December 2, 2013 related to payment process changes for the Health Insurance Marketplace present yet one more challenge for Issuers. As GHG predicted several weeks ago, each new phase of the rollout
- [Zombies in Washington!](https://ghgadvisors.com/zombies-in-washington/) - Zombie: (a) a will-less and speechless human only capable of automatic movement who is held to have died and been reanimated. (b) The Sustainable Growth Rate. By means of the Balanced Budget Act of 1997, Congress created the Sustainable Growth Rate, or "SGR" to us who know and love it, a will-less and speechless rule
- [Navigators and Agents Gone Wild](https://ghgadvisors.com/navigators-and-agents-gone-wild/) - Since the October 1 launch of the ObamaCare health insurance exchanges/marketplaces, there's been a growing din over the field conduct of navigators and insurance agents, in the process of enrolling eligibles on behalf of the exchanges or the health plans participating in them. Meanwhile, the associations backing brokers are putting pressure on the Obama administration,
- [Much Progress on Healthcare.gov, But "Back End" Fixes Will Determine Success](https://ghgadvisors.com/much-progress-on-healthcare-gov-but-back-end-fixes-will-determine-success/) - Of the many, many things I gave thanks for last week, there was Jeffrey Zients, the White House management guru brought in to sort out the mess that is the launch of ObamaCare, and for his geek squad working feverishly on the fixes. His long-awaited progress report was released on Sunday, and it's amazingly sanguine
- [Consultant Assessment in the Headlines](https://ghgadvisors.com/consultant-assessment-in-the-headlines/) - Consultants were in the news this week; that doesn't happen often. In this scenario which I will not deeply dive into, a private consulting team was brought on to independently assess the status of a certain federal health insurance enrollment system. Their assessment, after reviewing hundreds of documents and conducting scores of interviews, includes a
- [Medicare Advantage Showcased as the Model for Medicare Reform](https://ghgadvisors.com/medicare-advantage-showcased-as-the-model-for-medicare-reform/) - The National Coalition on Health Care (a nonprofit organization representing 80 organizations who support comprehensive health system change) and the Partnership for the Future of Medicare (a bipartisan organization supporting the long-term security of Medicare) have a new lobbying message — don't kill the golden goose. Recognizing the upcoming budget battles this year and next,
- [What's next for the ACA](https://ghgadvisors.com/whats-next-for-the-aca/) - Here we are on November 15th one day after President Obama unexpectedly delayed a key provision of the Affordable Care Act, which allows insurance companies to continue, for one year, offering health care plans that fall short of the requirements as outlined in the ACA . The next day our "stewards of national well being" elected
- [Pay me now or pay me later: Things to keep in mind when you set your 2014 budget](https://ghgadvisors.com/pay-me-now-or-pay-me-later-things-to-keep-in-mind-when-you-set-your-2014-budget/) - Back in the '80's Fram Oil Filters had an advertising campaign that featured an actor dressed as a mechanic, admonishing viewers to get their oil changed and get a new oil filter, to prevent costly engine damage. "Pay me now or pay me later," he said. When it comes to some key Medicare Advantage functions,
- [There is no cheat sheet for 2014.](https://ghgadvisors.com/there-is-no-cheat-sheet-for-2014/) - Now is the time of year when we all have 12 things to do in the next 30 minutes, plus we are budgeting and we need to write our strategic approach for 2014. We have to learn how to prioritize and focus on what is truly important to our success. Unfortunately, there is no cheat
- [Reading the Stars in Medicare in 2014-2015](https://ghgadvisors.com/reading-the-stars-in-medicare-in-2014-2015/) - Whatever you may think of healthcare.gov, CMS is killing it on the Medicare Star Ratings Quality Demonstration. As we move into the final year of CMS's historic and controversial $8.5 Billion Quality Demonstration, we see clear evidence that quality incentives are working, plans are making major investments to improve their ratings, and quality is improving
- [Live Connects + Motivated Buyers = Better Sales](https://ghgadvisors.com/live-connects-motivated-buyers-better-sales/) - Converting active leads to instant appointments is vital in today's insurance market. Whether you are working in this fall's first open enrollment period outlined in the Affordable Care Act or Medicare's annual open enrollment period, the company that converts immediate leads has an excellent advantage over its competition. Agent Connect is a tool that helps
- [Crisis Averted for Medicare and Medicaid.  Not So for ObamaCare.](https://ghgadvisors.com/crisis-averted-for-medicare-and-medicaid-not-so-for-obamacare/) - So, just hours from national debt default last night, a deal was struck to reopen the government and raise the debt ceiling. Our long national nightmare is over...at least until January 15, when this entire calamity could be repeated by battered ObamaCare dead-enders. It's a crisis averted for Medicare and Medicaid, but not so for ObamaCare.
- [What ObamaCare's Glitches Mean for Health Plan Operations](https://ghgadvisors.com/what-obamacares-glitches-mean-for-health-plan-operations/) - It's been a rough couple weeks for the launch of ObamaCare. The only thing that's kept the Federal exchange's woes off Page 1 this week has been the continuing dysfunction on the Hill. Healthcare.gov traffic will wane, bugs can be recoded and dysfunctional processes redesigned pretty quickly, so we haven't seen anything fatal thus far,
- [Diagnosing the ObamaCare Glitches: Who Farted and Is Pointing at the Dog?](https://ghgadvisors.com/diagnosing-the-obamacare-glitches-who-farted-and-is-pointing-at-the-dog/) - We're fast approaching the end of Week 2 of Obamacare, and like the dysfunction between the Congress and the President, there's still no end in sight. Healthcare.gov underwent major code fixes over the weekend, but is still rejecting logins, failing to load menus and hindering millions of uninsured Americans in 36 states from accessing the
- [Innovation and Quality must go hand-in-hand](https://ghgadvisors.com/innovation-and-quality-must-go-hand-in-hand/) - Plan sponsors are waiting with anticipation for their 2014 Medicare Star Ratings to be released. Just yesterday, Tufts Health Plan in Watertown, Massachusetts released the news that their Medicare Preferred HMO plan was awarded 4.5 out of a possible five stars. It reminds me of the old Ford commercial jingle where they said "Quality is
- [The Shutdown Will Become the Siege of the ObamaCare Teahadists](https://ghgadvisors.com/the-shutdown-will-become-the-siege-of-the-obamacare-teahadists/) - If you're paying any attention to the worsening drama here in DC, dig in because the calendar is not our friend. With the stalemate over the government shutdown ossifying, the Congress just backed into the debt ceiling, which we'll hit in less than two weeks. Now we're going to need a big deal both reopening
- [Healthy Outlook for Medicare Advantage and Part D from CMS in 2014](https://ghgadvisors.com/healthy-outlook-for-medicare-advantage-and-part-d-from-cms-in-2014/) - Last week amid all the ObamaCare drama on the Hill CMS released the 2014 data for Medicare Advantage (MA) and Prescription Drug Plan (PDP) bids. The numbers show a better-than-expected 2013 and a healthy 2014 ahead for Medicare health plans. The market will see new service areas, lower bids, more zero premium plans, and more
- [CBO Analysis of Two Premium Support Options](https://ghgadvisors.com/cbo-analysis-of-two-premium-support-options/) - The Congressional Budget Office (CBO) issued a report on two premium support options for reforming Medicare entitled "A Premium Support System for Medicare: Analysis of Illustrative Options". The two options include a second-lowest-bid option and an average-bid option. The report assumes that they would go into effect in 2018. Medicare Advantage plans would participate in
- [New Conventional Wisdom: A Government Shutdown and New Debt Crisis are Gonna Happen](https://ghgadvisors.com/new-conventional-wisdom-a-government-shutdown-and-new-debt-crisis-are-gonna-happen/) - Health care politics here in Washington are getting curiouser and curiouser by the minute. The new conventional wisdom is that we are careening toward a government shutdown on October 1, and a newly-manufactured debt ceiling crisis a week later, with ObamaCare and every other government-sponsored health program hanging in the balance. Our long national nightmare
- [Wall Street Consensus: 2014 Will Be a Big Growth Year for Payers](https://ghgadvisors.com/wall-street-consensus-2014-will-be-a-big-growth-year-for-payers/) - Since returning from summer vacation I've been making the rounds with friends and spies on Wall Street to see what the nation's checkbook is thinking about the seismic changes coming to our health system starting on October 1. Usually these guys are like long-tailed cats in a roomful of rocking chairs about disruptive events like
- [How Today's Technology Can Shape Tomorrow's Success](https://ghgadvisors.com/how-todays-technology-can-shape-tomorrows-success/) - The reality about technology is you can embrace it or hide from it, but ignoring it can be lethal. Technology should be embraced for its potential solutions rather than shunned for its limitations. Three contemporary examples of successful technology solutions in the insurance industry are warm lead delivery, e-applications and quote engines. Warm lead delivery
- [More House Anarchy = Likelihood of Government Shutdown](https://ghgadvisors.com/more-house-anarchy-likelihood-of-government-shutdown/) - So a week ago the conventional wisdom was that the prospects of an extremist-induced government shutdown on October 1 were infinitesimal. Not anymore. Must. Stop. Underestimating. Wingnuts. The House was scheduled to vote Wednesday on a bill to fund the government after September 30. Right-wing extremists have been demanding that the House refuse to continue funding the
- [Another Pound of Flesh for Government Health Programs This Fall?](https://ghgadvisors.com/another-pound-of-flesh-for-government-health-programs-this-fall/) - With summer drawing to a spectacular close here in Washington, it's abundantly clear that the "train wreck" everyone's expecting won't involve the launch of ObamaCare, but rather an epic legislative pile-up in Congress. With the collision of the debate on Syria, the immigration bill tearing the GOP apart, and now a near-concurrent exhaustion of government
- [What a Difference a Year Makes](https://ghgadvisors.com/what-a-difference-a-year-makes/) - Since the passage of the Medicare Modernization Act, Gorman Health Group has been discussing the value that Medicare Advantage (MA) and Prescription Drug Plans (PDP) offer to both public sector and private sector employers for their Medicare eligible retirees. The value proposition includes FASB/GASB benefits as well as more affordable coverage. A number of employers
- [Agent Oversight Opportunities](https://ghgadvisors.com/agent-oversight/) - The leaves will soon be changing, a sign of renewal. It sounds cliche, but I don't know where this year has gone. There has not been much opportunity to stop and smell the roses while they were still in bloom! CMS has been busy and so have we. I had the pleasure of addressing a
- [Call Center Metrics Reporting Should Be Robust and Actionable](https://ghgadvisors.com/call-center-metrics-reporting-should-be-robust-and-actionable/) - Metrics reporting is as important to insurance call centers as the Law of Large numbers is to an actuary. Call centers use metrics reporting on sales and marketing campaigns to measure individual agent performance, track campaign results and more. Sales and marketing metrics reporting should be robust and dynamic because you can't manage what you
- [Variation in ACA Premiums](https://ghgadvisors.com/variation-in-aca-premiums/) - ACA premiums have been a key topic of discussion this month as more state marketplaces and companies released proposed and final rates for QHPs or "qualified health plans" that will be available on October 1. As discussed in an earlier blog, ASPE released an analysis of rates in July from 10 mostly state based marketplaces
- [Big News:  A Health Care Cost Indicator Went *DOWN*. AGAIN!](https://ghgadvisors.com/big-news-a-health-care-cost-indicator-went-down-again/) - The national average bid for Medicare Part D drug coverage is going down, again. Since 2011, the average bid has declined every year. The amount of each year's reduction, compared to the prior year, has ranged from 1.4% in 2011 to 5.8% in 2013. The 2014 decrease of 4.7%, fits the pattern. So why, you
- [State Marketplace Variation](https://ghgadvisors.com/state-marketplace-variation/) - The Alliance for Health Reform held a briefing entitled "Health Insurance Marketplaces: Different Strokes for Different States". I think the title was an apt description of all the variation that is going on in states that are implementing their own Marketplaces. In many ways, it looks like a natural experiment. Sarah Dash of the Georgetown
- [The survey says...](https://ghgadvisors.com/the-survey-says/) - In May, GHG conducted several marketplace surveys. The initial survey highlighted our clients' top priorities. Here is what the ranking showed as our clients' focal points: STARS Clinical & Financial Alignment Risk Adjustment MLR monitoring We understand that in order to emerge as leaders or at least survivors of the rate reduction and complex regulatory
- [ACOs: Here to stay or gone tomorrow?](https://ghgadvisors.com/acos-here-to-stay-or-gone-tomorrow/) - With the recent announcement by CMS that nine of the 32 Pioneers were dropping out of the program there has been much "Sturm und Drang" about the passing of ACOs into obscurity. A recent article in the Investor Business Daily has gone as far as to predict that not only are all ACOs going to fail,
- [The Market is Working in Part D (Just Like it Will in ObamaCare)](https://ghgadvisors.com/the-market-is-working-in-part-d-just-like-it-will-in-obamacare/) - We've always maintained that Medicare Part D is one of the most successful market-based experiments this country has ever attempted, and that it provides the playbook for ObamaCare's health insurance exchanges. There's further evidence out today of the FACT that the government is capable of creating an insurance market from a green field, regulating the
- [Would the GOP Really Shut Down the Government Over ObamaCare?](https://ghgadvisors.com/would-the-gop-really-shut-down-the-government-over-obamacare/) - As Congress begins its summer recess there's been some hand-wringing in Washington about whether Congressional Republicans will make good on their threat to shut down the Federal government in another game of chicken with President Obama over the Affordable Care Act this fall. Senior members of the GOP are threatening to hold up a continuing
- [A Good Script Doesn't Sound Scripted](https://ghgadvisors.com/a-good-script-doesnt-sound-scripted/) - American film director Steven Spielberg once admitted that the only thing that gets him back to directing is good scripts. Good scripts help give a film structure, purpose and clarity. Good scripts are important in the insurance call center industry, too! A well developed script should do more than comply with the rigors of
- [Cost Sharing in Medicare](https://ghgadvisors.com/cost-sharing-in-medicare/) - The Alliance for Health Reform held a meeting on "Streamlining Cost Sharing in Medicare: The Impact on Beneficiaries" on July 22, 2013 which focused on a number of proposals to modernize Medicare benefits. The Medicare benefit package has not been updated since 1965 and it needs streamlining and improving. Medicare Advantage has already updated many
- [End-of-Life Shows Signs of Life in Congress](https://ghgadvisors.com/end-of-life-shows-signs-of-life-in-congress/) - End-of-life care and planning is something we're passionate about here at GHG, and I've gotten in some trouble over the last couple years in arguing Sarah Palin's "death panels" distortion set the debate back a decade. I may have been too pessimistic, or over-estimated the former half-term Alaska governor's influence: end-of-life planning is showing signs of
- [GHG's Software Sales Sentinel™ Achieves 97% Renewal](https://ghgadvisors.com/ghgs-software-sales-sentinel-achieves-over-90-renewal/) - Gorman Health Group (GHG), is proud to announce that its software, Sales Sentinel™ has achieved a 97% renewal rate, never having lost a client due to performance or dissatisfaction. Sales Sentinel™ supports more than 30 health plan clients across the U.S. and trains more than 30,000 agents each year. Already in 2014, Sales Sentinel™ has 33 clients
- [Leavitt's Take on ObamaCare Mirroring Medicare Part D](https://ghgadvisors.com/leavitts-take-on-obamacare-mirroring-medicare-part-d/) - Former UT Governor and Bush HHS Secretary Mike Leavitt had a terrific op-ed recently in the Washington Post examining similarities and differences between the launch of ObamaCare's health insurance exchanges and implementation of Medicare Part D in 2006. As always, Mike's insights are on-point and a rare constructive voice from the right on how to
- [The Human Cost of Red States' Middle Finger to Medicaid Expansion](https://ghgadvisors.com/the-human-cost-of-red-states-middle-finger-to-medicaid-expansion/) - The Kaiser Commission on Medicaid and the Uninsured is out with a new study illustrating the sickening human cost of the Red States throwing a middle finger to President Obama on the Affordable Care Act's (ACA) Medicaid expansion. Twenty-one states are not expanding Medicaid coverage under Obamacare and would gain considerably more than the 23
- [Not a Narrow Network - A Smart Network](https://ghgadvisors.com/not-a-narrow-network-a-smart-network/) - What we learned in Medicare + Choice is still true today, we don't need narrow provider networks; we need aligned provider networks, aka Smart Networks. We have also learned that narrow networks often cause ill-will with your health systems and uncontrolled leakage. A Smart Network builds a mini-healthcare community similar to an ACO in your
- [GHG Announces New Partnership With BCBSA](https://ghgadvisors.com/ghg-announces-new-partnership-with-bcbsa/) - Gorman Health Group (GHG), is proud to have been selected as a National Partner with the Blue Cross and Blue Shield Association (BCBSA) for its software, Sales Sentinel™. This software facilitates sales agent onboarding, credentialing and ongoing oversight, and it eliminates the labor-intensive agent onboarding process for both your Exchange and Medicare Advantage businesses. Learn more about
- [How to Convert Marketing Calls to Leads and Sales](https://ghgadvisors.com/how-to-convert-marketing-calls-to-leads-and-sales/) - The marketing pieces for your sales campaign have been delivered and the response has been tremendous. Your call center partner must now convert those inbound marketing calls to leads or sales. What should you expect? You should expect an inbound call process that is CMS-compliant. Callers should be fully qualified for eligibility by the call
- [Health Plan's Role in Provider Alignment](https://ghgadvisors.com/health-plans-role-in-provider-alignment/) - Long gone are the days when the provider contracting functions, the medical economics function and the health services/medical management functions within a Health plan could operate in their own separate environment with limited interaction. Health plans today are pressured to provide improved member access to health services at reduced cost while striving for improved treatment outcomes for
- [Tip of the Iceberg](https://ghgadvisors.com/tip-of-the-iceberg/) - Most Americans get their health insurance from employer sponsored coverage. But this coverage has been eroding over the last twenty years. The Clinton health reform discussions realized that it was impractical and fiscally impossible to remove employer contributions from the financing of American health care coverage. And in subsequent health reform efforts, there have been
- [Now the Blood is in the Water](https://ghgadvisors.com/now-the-blood-is-in-the-water/) - Last week, the Obama Administration issued a notice that the Affordable Care Act's (ACA) "pay or play" employer mandate and reporting requirements, which were set to take effect on January 1, 2014, are being postponed until 2015. Now the blood is in the water with all of Washington asking "what's next to be delayed?" It's not even
- [The Seismic Impact of the Baucus Retirement on Health Policy](https://ghgadvisors.com/the-seismic-impact-of-the-baucus-retirement-on-health-policy/) - Senate Finance Committee Chairman Max Baucus (D-MT) stunned Washington recently with his announcement that he was retiring and would not seek reelection in 2014. Next to the Majority Leader, he's probably the most powerful guy in the Senate -- and definitely so on health policy. Attention turned to who's next and what it means for
- [The ObamaCare Enrollment Push Begins](https://ghgadvisors.com/the-obamacare-enrollment-push-begins/) - So we're less than 100 days away from the official launch of outreach and marketing for the new Health Insurance Exchanges, and the enrollment push began in earnest this weekend. It's happening in the face of some tremendous headwinds unlike anything seen since the launch of Medicare Part D in 2006, maybe ever. The Medicare
- [Agent Oversight Improves Quality and Customer Experience](https://ghgadvisors.com/agent-oversight-improves-quality-and-customer-experience/) - If you're like most health plans, you rely on key "glue folks" to keep operations running smoothly. You know the ones: staff members that embrace their role, mind the details and ensure behind-the-scene efforts improve outcomes. They may or may not communicate one-on-one with customers, but their efforts contribute in a positive way to the overall
- [Lessons from Part D for ACA Implementation](https://ghgadvisors.com/lessons-from-part-d-for-aca-implementation/) - It was interesting to hear Mike Leavitt and Mark McClellan compare their experiences in launching the Medicare Part D program in 2005 and 2006 to the challenges facing HHS and CMS in launching the new Health Insurance Marketplaces at a recent Brookings Institution forum. There are so many parallels and yet important differences. The lessons
- [Sea Change at CMS](https://ghgadvisors.com/sea-change-at-cms/) - Administrator Marilyn Tavenner officially named Paul Spitalnic as the CMS chief actuary. I worked with Paul when he first came to CMS to implement the Part D program. He then served as the Director of the Part C and D actuarial group. Paul is very smart and will ably fill the shoes of other distinguished
- [Humana's CEO on Implementing ObamaCare](https://ghgadvisors.com/humanas-ceo-on-implementing-obamacare/) - Reuters got a nice scoop with Humana CEO Bruce Broussard, who took over from the legendary Mike McAllister in January, with an interview on their approach to implementation of ObamaCare in less than 100 days. It was good enough to reprint in full below. A couple impressions: Broussard points out how much the industry wants
- [Lake Wobegone Exchanges](https://ghgadvisors.com/lake-wobegone-exchanges/) - One of the most frequent questions I've been getting on the health reform speech circuit has been what our expectations are for enforcement activity in the exchanges in Year 1 -- and the answer is just about none. For the 16 states launching their own exchanges this Fall, much of the focus will be on
- [Choosing a Call Center? Five Must-Ask Questions](https://ghgadvisors.com/choosing-a-call-center-five-must-ask-questions/) - This fall promises to be one of the busiest in history for health insurers with the flurry of Health Insurance Exchanges (HIE), Annual Election Period (AEP) and the implementation of the Affordable Care Act (ACA). Unanswered calls to insurance companies by potential customers will become forfeited opportunities that may never be reclaimed. Many companies will rely on
- [The Future of Medicare Advantage](https://ghgadvisors.com/the-future-of-medicare-advantage/) - The Alliance for Health Reform and the Kaiser Family Foundation (KFF) sponsored a meeting on the Future of Medicare Advantage (MA) on the day that KFF reported that MA enrollment had reached a historic 28 percent of the Medicare population. A major theme of the conference was whether MA enrollment could be sustained or increased
- [Health Care Innovation Awards Round Two](https://ghgadvisors.com/health-care-innovation-awards-round-two/) - For those of you who applied for the Innovations Awards Program Round One and were denied, or for those of you who didn't apply, CMS/CMMI is providing you with another opportunity to do so. The program is open to virtually any health organization (the exception is that CMS will not entertain proposals that are primarily
- [Every OEV Call Should Be a Welcome Call](https://ghgadvisors.com/every-oev-call-should-be-a-welcome-call/) - In the world of insurance sales, making the right call during a sales presentation and getting the call right for compliance purposes is critical. Outbound Enrollment Verification calls (OEV) calls are not just for an applicant's protection — they're the insurance industry's version of instant replay! Verification calls are "welcome calls" with a new member. A
- [Drugs and Patient Safety - the Disconnect](https://ghgadvisors.com/drugs-and-patient-safety-the-disconnect/) - The recent Washington Post piece published May 11, 2013, on the prescription drug dangers for Medicare patients raises some interesting points about the current prescribing habits of some outlier physicians/prescribers, as well as the lack of a coordinated effort to exclude those same prescribers from participating in Medicare. The use of atypical antipsychotics (identified by
- [Proposed Benefits Manual Changes](https://ghgadvisors.com/proposed-benefits-manual-changes/) - On April 25, 2013 CMS issued a proposed update to the Benefits and Beneficiary Protections Chapter (Chapter 4) of the Medicare Managed Care Manual. The CMS cover letter provides a good summary of the changes that they are proposing to make. Most of the changes are clarifications to existing policy, for example, providing Medicare Advantage
- [Medicare Essential — Is this the future of Medicare?](https://ghgadvisors.com/medicare-essential-is-this-the-future-of-medicare/) - According to The Hill's Elise Viebeck President Obama is receptive to combining Medicare Part A (in-patient hospital) and Part B (outpatient and doctor) deductibles, into a single deductible just like every other insurance scheme in the US. Predictably those to his left complained, maybe because Virginia's Eric Cantor also likes the idea. The impact would
- [Medicare Shared Savings Program Circa 2014](https://ghgadvisors.com/medicare-shared-savings-program-circa-2014/) - Anyone who has paid attention knows that since 2011 more than 200 Medicare ACO's have been operationalized. If you add in commercial ACO's, the number is closer to 400. Still sitting on the fence wondering if ACO's will survive? Consider this, the underlying construct for a Medicare Shared Savings ACO is to promote accountability for
- [QHP Submission Reprieve](https://ghgadvisors.com/qhp-submission-reprieve/) - OK, so maybe reprieve is not the right word, since according to Google it is defined as "a cancellation or postponement of a punishment". If you consider a deadline a punishment, then I suppose this is a reprieve, but I digress. HHS sent out an email Thursday night informing the industry that those issuers who
- [So You Want to File a QHP Application](https://ghgadvisors.com/so-you-want-to-file-a-qhp-application/) - This will be the title of my instructional pamphlet that I envision sitting in a doctor's office, among other great pamphlets such as "Talking to Your Kids about Drugs" and "Depression: Not Just a Hole in the Ground". Many of you reading this may also be in the midst of QHP uploading, on the receiving
- [Health Insurance Premium Guessing Game](https://ghgadvisors.com/health-insurance-premium-guessing-game/) - Health insurance issuers are generating enough fodder for a good guessing game. Will Obamacare increase rates for individual insurance or not? And if so, will the increase be modest or catastrophic. Writing in the April 25 edition of the Washington Post, Ezra Klein reports that the Blues plan that serves the national capital area is
- [Uneven Funding Provides Opportunity for Agent and Brokers in Federal Exchanges](https://ghgadvisors.com/uneven-funding-provides-opportunity-for-agent-and-brokers-in-federal-exchanges/) - It seemed like everyone in Washington last week was discussing the upcoming outreach and enrollment prospects for the federal and state exchanges. Kaiser Family Foundation held a forum on Consumer Assistance that emphasized the uneven funding among states in the first year and the need for coordination among the various types of assistance programs. Several
- [Employer Health Coverage Post Recession](https://ghgadvisors.com/employer-health-coverage-post-recession/) - A new report on employer sponsored health insurance issued by the Robert Wood Johnson Foundation shows some interesting trends in coverage post-recession. "State-Level Trends in Employer-Sponsored Health Insurance" The overall trend in employer health insurance coverage has been on a downward slide for several decades and that trend is continuing. In 2000, almost 70 percent
- [Providers Eying Medicare Advantage](https://ghgadvisors.com/providers-eying-medicare-advantage/) - The March 28 edition of Medicare Advantage News cites a possible trend for provider organizations to sponsor their own Medicare Advantage plans. In the waning days of the old Medicare+Choice program, many provider-sponsored plans came on hard times, so this may seem like an unusual reversal. However, Medicare Advantage lives up to its name, and
- [Pioneer ACOs: Who will stay and who will go?](https://ghgadvisors.com/pioneer-acos-who-will-stay-and-who-will-go/) - Thirty-two Pioneer ACOs sent a correspondence to CMMI in late February, suggesting that they would exit the Pioneer ACO program if CMS did not accept their recommendations for changes to the quality measures employed to determine pay for performance in the Pioneer program. As a group, the Pioneer ACOs suggested to CMMI that because of their
- [Reengineering Service Delivery: Tinkering or redesign?](https://ghgadvisors.com/reengineering-service-delivery-tinkering-or-redesign/) - I am old enough to remember cast iron automobile engines, massive, performance driven by basics such as carburators, distributors and spark plugs. No computer assists, no electronic fuel injection and no computer to monitor and identify performance problems. If the engine ran rough, we adjusted fuel and air mixture.Today's engines are smaller, and have more
- [SGR Cut In MA Rates: To Be or Not To Be](https://ghgadvisors.com/sgr-cut-in-ma-rates-to-be-or-not-to-be/) - With the MA Final Notice due out on April 1, and the 45-Day Notice suggesting the biggest decrease to MA rates in years, the new Congressional Research Service report, which evaluates the HHS Secretary's authority with regard to including or not including an SGR fix in calculating the trend in FFS costs, is of paramount
- [Strange Bedfellows Come to Medicare Advantage's Rescue](https://ghgadvisors.com/strange-bedfellows-come-to-medicare-advantages-rescue/) - If you can say anything about Medicare Advantage (MA), it definitely makes for strange bedfellows in both the private sector and in the halls of Congress. Last Friday the full lobbying fury of the industry was in evidence as three separate groups of legislators appealed to the Centers for Medicare and Medicaid Services (CMS) on
- [What Sequestration Could Mean to Medicare Advantage Claims Payment](https://ghgadvisors.com/what-sequestration-could-mean-to-medicare-advantage-claims-payment/) - Last Friday CMS's Medicare Learning Network released some details on how the sequester will impact Medicare fee-for-service. By extension we see some implications for what it means to Medicare Advantage (MA). The CMS notice offered the following: To All Health Care Professionals, Providers, and Suppliers: Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program — "Sequestration"
- [Impact of the Sequester on CMS Funding](https://ghgadvisors.com/impact-of-the-sequester-on-cms-funding/) - On March 1, 2013, the President issued a sequestration order that cuts $85 billion in federal budgetary resources for FY 2013. By law, on March 27, 2013 Medicare Trust Fund spending will be cut 2 percent and Medicaid will be exempt. Other CMS expenditures are subject to the sequester on March 1, 2013. The CMS
- [Little Good News for Medicare Advantage in Senate Finance Hearing](https://ghgadvisors.com/little-good-news-for-medicare-advantage-in-senate-finance-hearing/) - The Senate Finance Committee held a hearing on Medicare yesterday and received testimony by CMS Medicare chief Jon Blum. Almost a week after the shocking 45-day Notice for Medicare Advantage (MA) and Part D was released, Blum offered little in the way of good news on the 2014 rates. Blum said CMS is committed to ensuring
- [EXCHANGES: Looking for Help](https://ghgadvisors.com/exchanges-looking-for-help/) - CMS has posted a Q&A about their willingness to allow states to partner in plan management activities without submitting a blueprint. This makes a new fourth category of exchanges. So, in addition to state exchanges, partnership exchanges, federally facilitated exchanges, the new fourth category is states willing to cooperate in FFE states. Basically, CMS has
- [Draft Call Letter for 2014](https://ghgadvisors.com/draft-call-letter-for-2014/) - The bad news in the 45 day notice is proposed payment cuts to Medicare Advantage plans for 2014 and big changes to risk adjustment but there is also good news about the reduction in almost all of the Part D benefit parameters. The draft Call Letter, which accompanied the proposed rate announcement, also included some
- [CMS Advance Notice for 2014: This Is What Austerity Looks Like](https://ghgadvisors.com/cms-advance-notice-for-2014-this-is-what-austerity-looks-like/) - CMS's Advance Notice for Medicare Advantage and Part D for 2014 was released after the close on Friday and tanked health plan stocks on Tuesday. It is a shocking, stark portrait of what austerity looks like. There's nothing but bad news in it, and it's worse than anyone expected. Start with an average cut in
- [Exchanges: Sales Agent Certification](https://ghgadvisors.com/exchanges-sales-agent-certification/) - CMS has released a notice seeking comments on their plans for training and certifying sales agents who could enroll persons into the federally facilitated exchanges. To be exact, the notice is about collection of data about the sales agents who are trained and certified for selling coverage offered by qualified health plans on the exchange.
- [Obama Spikes Reform in SOTU Speech. Where Now for Medicare?](https://ghgadvisors.com/obama-spikes-reform-in-sotu-speech-where-now-for-medicare/) - I hope you enjoyed the State of the Union (SOTU) address as much as I did -- it's the Super Bowl of policy geeks. I saw it as an effective rallying tool around a number of the President's goals that will deeply challenge the GOP opposition, like an increase in the minimum wage and immigration
- [Size Does Matter for Medicare Shared Savings ACOs](https://ghgadvisors.com/size-does-matter-for-medicare-shared-savings-acos/) - A recent article in CMS's journal, Medicare and Medicaid Research Review, reinforces our concerns about the prospects for small Accountable Care Organizations (ACOs) in the Medicare Shared Savings Program (MSSP). It appears that size does matter for these provider systems, and that small ACOs are extremely vulnerable to flaws in CMS's gainsharing methodology. According to
- [Some Scary Medicare News in the CBO Report](https://ghgadvisors.com/some-scary-medicare-news-in-the-cbo-report/) - The Congressional Budget Office (CBO) released its new economic outlook yesterday with some interesting predictions on the launch of the Affordable Care Act's health insurance marketplaces (exchanges). But it was some of its Medicare findings that blew my hair back last night: CBO concurred with Medicare trustees that the trust fund will run dry by
- [250,000 Agents in the Federal Exchanges???](https://ghgadvisors.com/250000-agents-in-the-federal-exchanges/) - In a Federal Register notice out yesterday CMS officials are projecting 254,095 health insurance agents and brokers will sign up to sell the "metal plans" in the new federal health insurance exchange (HIX) system. Quarter. Million. Agents. OMG. And the scary part: they face a fraction of the regulatory requirements Medicare sales agents do. "Federally facilitated
- [CBO: Slower Growth in Exchange and Medicaid Enrollment](https://ghgadvisors.com/cbo-slower-growth-in-exchange-and-medicaid-enrollment/) - The Congressional Budget Office released its new economic outlook yesterday and predicts a slower start to enrollment in the new exchanges: 7 million people in 2014 -- down from 9 million last July -- and rising by 2016. The CBO report also estimates that 8 million people will enroll in Medicaid in 2014, so about 15
- [Seven Years in the Wilderness for CMS?](https://ghgadvisors.com/seven-years-in-the-wilderness-for-cms/) - We're coming up on the 7th anniversary of the last Senate confirmation of a CMS administrator. Seven years! There have been a succession of interim or acting administrators since, most notably the brilliant, visionary, and ultimately polarizing Don Berwick. Politico has a great piece out today on why our favorite agency has been in the
- [Let the Games Begin on Medicare Reform](https://ghgadvisors.com/let-the-games-begin-on-medicare-reform/) - Just days after President Obama's full-throated support of defending Medicare from structural reforms in his Inaugural Address, Senator Orrin Hatch (R-UT) yesterday threw down the gauntlet and maintained that reforms are needed in both Medicare and Medicaid in order to reduce the national debt. Hatch, the ranking Republican on the Senate Finance Committee, laid out
- [FFE — Notice of Intent to Apply](https://ghgadvisors.com/ffe-notice-of-intent-to-apply/) - Things should be starting up in the next few weeks for health plans interested in offering products in the FFE. Given the lack of specificity in the final exchange regulation and CMS' pursuit of state help, potential applicants will be in a constant scramble to see who's on first between the states and CMS. So,
- [Obama's Inaugural Hard Line on Medicare/Medicaid](https://ghgadvisors.com/obamas-inaugural-hard-line-on-medicaremedicaid/) - Inauguration Day in Washington is a blessedly nonpartisan event celebrating our messy yet peaceful democracy with great pomp. But President Obama, with renewed certainty, drew a hard line in his inaugural address against entitlement cuts that could fundamentally change Medicare and Medicaid. And in doing so he doubled down with Republicans in the next rounds of the deficit
- [Exchange Activity Kicks Into High Gear](https://ghgadvisors.com/exchange-activity-kicks-into-high-gear/) - With all the activity underway across the states, you'd think we were less than 10 months away from when health plans in the Exchanges begin enrolling or something. Oh wait...HOLY CRAP we're less than a year from launch! The game is on, friends: Minnesota is taking steps to put its health insurance exchange into law,
- [What Happens to Medicare/Medicaid If There's a Government Shutdown?](https://ghgadvisors.com/what-happens-to-medicaremedicaid-if-theres-a-government-shutdown/) - I hate to have to say it, but the "fiscal cliff" debate/debacle last month is going to feel like a speed bump compared to what's coming here in DC on the debt ceiling next month. At the height of its dysfunction right now, the relationship between the President and the Congress points to a near-inevitable government shutdown in
- [The Violence Done to Health Reform by Congress and SCOTUS](https://ghgadvisors.com/the-violence-done-to-health-reform-by-congress-and-scotus/) - As President Obama's second (!) Inauguration approaches on Monday, I was thinking on his signature domestic accomplishment and the violence done to it by 2 years of relentless opposition in Congress and some surgical cuts in the Supreme Court (SCOTUS). John McDonough, the excellent resident health policy geek at Boston.com, beat me to it with
- [2013 Will be a Very Busy Regulatory Year](https://ghgadvisors.com/2013-will-be-a-very-busy-regulatory-year/) - CMS is planning to issue a lot of regulations in 2013 that will impact Medicare Advantage (MA) and Prescription Drug Plans (PDPs) as well as plans that will be offered in the individual and small group market Exchanges. The Medicare Advantage and Part D Advance Notice of Payment Rates and Call Letter will be issued
- [The Claws Will Come Out at CMS in 2013](https://ghgadvisors.com/the-claws-will-come-out-at-cms-in-2013/) - Health plans and other stakeholders in Medicare Advantage and Part D can be assured of one thing by President Obama's reelection: that the claws will come out at the Centers for Medicare and Medicaid Services (CMS) in his second term. Having worked a number of years at the agency I can tell you there is a natural
- [Federally Facilitated Exchanges — Getting States to Help Out](https://ghgadvisors.com/federally-facilitated-exchanges-getting-states-to-help-out/) - The fog has cleared. CMS sees the size of the FFE Mountain and is beginning to put its plans in place to get health plans certified to participate in the FFE by August 2013. While the partnership states have clearly indicated their intention to play a role in reviewing federal requirements for FFE applicants, other
- [American Taxpayer Relief Act of 2012](https://ghgadvisors.com/american-taxpayer-relief-act-of-2012/) - The January 1 legislation to fix the fiscal cliff postpones the scheduled 27 percent Medicare physician fee schedule cut under the Sustainable Growth Rate formula for one year. In order to pay for the doc fix, there are a number of payment reductions to Medicare fee for service providers, especially reductions in hospital and ESRD
- [We Can All Agree On This, I Think](https://ghgadvisors.com/we-can-all-agree-on-this-i-think-2/) - Resources John Gorman and Nathan Goldstein discuss what is next for Government Healthcare in this podcast. Download the recording here.
- [Federally Facilitated Exchanges: The draft application for qualified health plans](https://ghgadvisors.com/federally-facilitated-exchanges-the-draft-application-for-qualified-health-plans/) - In at least 23 states, governors are allowing a "Federal takeover" in the form of a federally facilitated exchange (FFE). Now, CMS has published the first draft of the application that health plans need to complete to become a qualified health plan (QHP) in the CMS FFE. To be sure, the exchange regulation allows individual
- [The Path to a Deal on the Fiscal Cliff](https://ghgadvisors.com/the-path-to-a-deal-on-the-fiscal-cliff/) - Outside the Beltway Bubble it must look like we're about to go all Thelma & Louise off the fiscal cliff. In fact, each day the path to a deal becomes clearer, as brilliantly displayed by our friends at WaPo's WonkBlog. The one thing that is crystal-clear: the final deal will piss off everyone.
- [Medicare Advantage Plans Need the "Doc Fix" More Than Docs Do](https://ghgadvisors.com/medicare-advantage-plans-need-the-doc-fix-more-than-docs-do/) - Predictably, the "Doc Fix" has become a political football in the fiscal cliff discussions here in Washington, and it continues to have huge bearing not just on physicians but Medicare Advantage plans as well. You could say MA plans need the "Doc Fix" more than docs do. The Sustainable Growth Rate (aka the SGR) is
- [Of course they should! (But not for the reason you may think)](https://ghgadvisors.com/of-course-they-should-but-not-for-the-reason-you-may-think/) - The New York Times reports that Hospitals fear they may bear the brunt of Medicare cuts. I should hope so! But not because they are wildly profitable at the expense of efficiency and innovation elsewhere. To be wildly profitable itself is, in my book, no sin. But that's moot in this case: the average hospital
- [What Health Care Federalism Looks Like](https://ghgadvisors.com/what-health-care-federalism-looks-like/) - Insurers are beginning to grumble about the state-by-state variation in Exchange design as implementation bears down on the industry. Fierce Health Payer has a quick summary of the griping here. While I can't blame them for their frustrations (hey, we have to figure out all 50, too!) I do wonder how they would feel about
- [Democrats Painting Themselves Into a Corner on Entitlements in Fiscal Cliff](https://ghgadvisors.com/democrats-painting-themselves-into-a-corner-on-entitlements-in-fiscal-cliff/) - It took no time for Democrats to walk back the growing momentum on an eligibility age increase for Medicare: last week House Minority Leader Nancy Pelosi and prominent Democrats in the Senate slammed the door on that idea. So today several Senate Democrats floated a key Medicare concession to try to get to yes on the fiscal cliff:
- [Health Affairs: Medicare Advantage is Crushing Fee-for-Service](https://ghgadvisors.com/health-affairs-medicare-advantage-is-crushing-fee-for-service/) - Two new Health Affairs studies this month brought further evidence that Medicare Advantage (MA) is crushing traditional fee-for-service Medicare in quality, and that the world's largest experiment in risk adjustment is working in MA. The first study suggests that members of Medicare plans "might use fewer services and be experiencing more appropriate use of services
- [Transition Readiness](https://ghgadvisors.com/transition-readiness/) - As AEP comes to a close on December 7, we are well into the time that organizations need to make sure that new members receive all of their required materials, including their identification cards. Having the annual election stretch to December 31 in the past was certainly to an organization's advantage from a sales perspective,
- [A Half-Trillion from Medicare/Medicaid in Fiscal Cliff Deal?](https://ghgadvisors.com/a-half-trillion-from-medicaremedicaid-in-fiscal-cliff-deal/) - In a recent webinar we predicted that we would see $300-500 Billion in savings from Medicare and Medicaid in a deal to avoid the fiscal cliff. The shapes in the fog are becoming clearer and we'll stand by it: Senate Majority Whip Dick Durbin said this morning on MSNBC's "Morning Joe" that he'd like to
- [Raising the Medicare Eligibility Age and Its Implications in the Fiscal Cliff Negotiations](https://ghgadvisors.com/raising-the-medicare-eligibility-age-and-its-implications-in-the-fiscal-cliff-negotiations/) - You'd never guess from what you see in the news, but the fiscal cliff negotiations are proceeding on two tracks and there is a deal to be done in the coming weeks. One track is public: the screeds in the media and parliamentary chicanery on the Hill, all with the goal of proving their ideological
- [The New Post-Reform Core Capability for Health Plans: Risk Adjustment](https://ghgadvisors.com/the-new-post-reform-core-capability-for-health-plans-risk-adjustment/) - Medicare Advantage and Part D have for years been the world's largest experiments in paying insurers more for the care of sick members while paying less for healthier members, or risk adjustment. Some two dozen states now risk-adjust Medicaid payments to health plans, and the hundreds of Accountable Care Organizations (ACOs) launching this year and next
- [An Old Friend's Newest Challenge: Rein in Massachusetts' Health Costs](https://ghgadvisors.com/an-old-friends-newest-challenge-rein-in-massachusetts-health-costs/) - An old, dear friend of mine and fellow XLHealth Board member, Stuart Altman, was just appointed chief of healthcare cost containment for Massachusetts' ground-breaking reform effort -- a harbinger of things to come nationally as the Affordable Care Act now hurtles toward implementation. The local NPR affiliate did a great interview with Stu that I
- [Election Gives Health Reform the Kiss of Life](https://ghgadvisors.com/election-gives-health-reform-the-kiss-of-life/) - It's hard to argue this wasn't a decisive victory for the President and Democrats in the Senate. What remains to be seen is whether intractable Congressional Republicans will come to the table to get stuff done. While it was a distant #2 issue in exit polls, this election was a de facto referendum on health
- [The Impact of the Election On Medicare Private Plans](https://ghgadvisors.com/the-impact-of-the-election-on-medicare-private-plans/) - Now that President Obama has been re-elected, the Affordable Care Act (ACA) will not be repealed and the ACA provisions impacting Medicare Advantage (MA) plans and Prescription Drug Plans (PDPs) will continue to be implemented. • For MA plans, 2013 will be the last year of the phase-in of the ACA four quartile payment reform,
- [Well, thank God THAT'S over](https://ghgadvisors.com/well-thank-god-thats-over/) - Our long national stimulus for political consultants and media companies has finally ended. What do we have to show for it? An electoral map that is still nearly identical to the national schism during the Civil War, a lot of BuzzFeed slide shows, a "theater of the absurd" moment as Karl Rove blew up Fox's
- [What's at Stake When Death Gets a Makeover](https://ghgadvisors.com/whats-at-stake-when-death-gets-a-makeover/) - A terrific interview with Dr. Tom Smith of Johns Hopkins on end-of-life care and discussion: well worth 3.5 minutes to see what's at stake when death gets a makeover: "hope for the best, plan for the worst." Advancing a frank and open discussion about last wishes is "not so much about saving money but honoring peoples'
- [Public and Private Exchanges](https://ghgadvisors.com/public-and-private-exchanges/) - It appears that Medicare beneficiaries who use the most health care services and are often considered the least able to shop over the internet for health insurance may have been the trailblazers for how health insurance will be purchased in the future. Medicare took a first step in the 1990s when it created a voluntary
- [Open Enrollment and Star Ratings for 2013](https://ghgadvisors.com/open-enrollment-and-star-ratings-for-2013/) - Open enrollment season has started and CMS has posted the star ratings for each Medicare Advantage (MA) plan and Prescription Drug Plan (PDP) on the Medicare.gov website, which is the official site beneficiaries use to get information on their plan choices. Five star plans get a special gold star icon and have special enrollment periods.
- [Obama Enjoys Big Edge in Voter Trust on Medicare](https://ghgadvisors.com/obama-enjoys-big-edge-in-voter-trust-on-medicare/) - Even after that limp first debate performance that wiped out the Democratic convention bounce and tightened the Presidential race across the board, President Obama enjoys a 15-point edge in voter trust on Medicare, clearly a central issue to the campaign and voter turnout on November 6. This represents a six-point increase for Obama since the
- [Fact-Checking the Medicare Advantage Clash at Biden/Ryan Debate](https://ghgadvisors.com/fact-checking-the-medicare-advantage-clash-at-bidenryan-debate/) - Like most, I found the Biden/Ryan debate last week some of the best TV of the election season. Both were well-prepared and spoiling for a fight, and moderator Martha Raddatz did a terrific job. There was one exchange that really got our attention when the topic turned to Medicare Advantage: Rep. Paul Ryan:"7.4 million seniors
- [#DenverDebate](https://ghgadvisors.com/denverdebate/) - Who saw last night's presidential debate in Denver? Certainly there is a great deal of water cooler discussion going on today. Something that irked me was the continual reference to the fact that Medicare would continue to be available for "seniors". Anyone working in the Medicare Advantage arena (whether it's in Medical Management, Sales, Customer
- [Medicare Part D is Crushing It](https://ghgadvisors.com/medicare-part-d-is-crushing-it/) - A bipartisan group came out with another survey showing that Medicare Part D is just about the greatest thing the government's done in a generation. The survey of 2,363 seniors ages 65 and older, conducted by KRC Research and Medicare Today, showed that 90 percent of seniors surveyed are currently satisfied with the Medicare prescription
- [Medicare Advantage in 2013: Stronger Than Ever](https://ghgadvisors.com/medicare-advantage-in-2013-stronger-than-ever/) - CMS recently released the September 2012 enrollment figures and market data on Medicare Advantage (MA) offerings for 2013, and the numbers show a program that's stronger than ever and defying all predictions. It's proof that this industry is capable of adapting to the new market conditions brought by the Affordable Care Act. CMS says Medicare Advantage will
- [Customer Service Week](https://ghgadvisors.com/customer-service-week/) - As it is Customer Service Week and many companies across the country are celebrating the unsung heroes who answer calls and solve problems all day, this seemed like a good time to talk about the pitfalls and problems which can plague customer service centers. We have all had experience with customer service call centers at
- [Affordable Care Act and Insurers of Last Resort](https://ghgadvisors.com/affordable-care-act-and-insurers-of-last-resort/) - From the Detroit News, 9/12/12: Gov. Rick Snyder says his plan to reform Blue Cross Blue Shield of Michigan would make health care more affordable and improve health, but it was met Tuesday by resistance from other insurers, the state's attorney general and a consumer group. Snyder's proposal would convert the state's largest health insurer
- [Romney-Ryan Plans for Medicare Are Kid Stuff Compared to What They'd Do to Medicaid](https://ghgadvisors.com/romney-ryan-plans-for-medicare-are-kid-stuff-compared-to-what-theyd-do-to-medicaid/) - GOP nominees Mitt Romney and Paul Ryan have big plans for Medicare reform, as we've written about here often. But health plans and other stakeholders need to start paying attention to their plans for Medicaid, which are game-changing, would affect millions more Americans, and would take effect much sooner: a recent Bloomberg report found that Romney/Ryan's
- [Medicare Advantage in the Spotlight](https://ghgadvisors.com/medicare-advantage-in-the-spotlight/) - Medicare Advantage (MA) has been in the news quite a lot recently. HHS issued a press release entitled "Medicare Advantage Remains Strong" reporting that since the ACA was passed, MA premiums have fallen by 10 percent and enrollment has risen by 28 percent. Today, 27 percent of Medicare beneficiaries are enrolled in MA plans. HHS
- [More Swing-State Voters Trust Obama on Medicare](https://ghgadvisors.com/more-swing-state-voters-trust-obama-on-medicare/) - We all know seniors vote in huge numbers, and that Medicare has become a centerpiece issue in this Presidential campaign with the selection of Rep. Paul Ryan as the GOP VP candidate. Gallup is out with a new poll showing registered voters in swing states prefer President Obama to Mitt Romney on Medicare. National polls
- [Time to Reauthorize Special Needs Plans](https://ghgadvisors.com/time-to-reauthorize-special-needs-plans/) - Special Needs Plans (SNPs) are a special type of health plan for America's most vulnerable and complex seniors that are set to expire at the end of 2013. Over 500 SNPs serve more than 1.5 million Medicare beneficiaries across the United States. Done well, the SNP significantly improves outcomes and brings down costs thanks to personal
- [Rolling the dice](https://ghgadvisors.com/rolling-the-dice/) - According to the Department of Health and Human Services (HHS), Medicare Advantage (MA) enrollment is anticipated to grow 11 percent. Regardless of the politics behind the message, more beneficiaries than ever will be enrolled in MA products. Most organizations cannot keep up with all of CMS' requirements. As evidenced in their best practice reviews of
- [Selling Season is Nearly Here, Now what?](https://ghgadvisors.com/selling-season-is-nearly-here-now-what/) - Most plans are in the process of onboarding their agents and preparing them to sell. Meanwhile, they've invested marketing dollars across various channels and different media. Now it's time to turn marketing dollars into members. With another AEP just around the corner, here are a few GHG best practice tips to keep in mind this
- [Newbies Slow Dual Eligible Expansion in Key States](https://ghgadvisors.com/newbies-slow-dual-eligible-expansion-in-key-states/) - After last week's AHIP conference on Medicare and Medicaid and MANY coffees and cocktails later, a picture emerged that the only thing slowing the movement of dual eligibles into health plans isn't nervous advocacy groups or overstretched regulators -- it's newbies to the game of caring for the nation's most vulnerable patients. Dual-eligible expansion has
- [We Love Us Some Kitzhaber...Medicaid Reform Genius](https://ghgadvisors.com/we-love-us-some-kitzhaber-medicaid-reform-genius/) - It's happy days for us when Sarah Kliff at WaPo, one of our favorite bloggers, posts a great "get" with Oregon Governor John Kitzhaber, MD -- one of our favorite Medicaid reformers. It was such a terrific interview I wanted to reprint it here, with thanks to both for an illuminating discussion of the way
- [With Presidential Election Static, Senate Slips from GOP's Grip](https://ghgadvisors.com/with-presidential-election-static-senate-slips-from-gops-grip/) - The most frequent question I get is "what will the elections mean to Medicare and Medicaid?" We've said here the Republicans' only hope of repealing the Affordable Care Act and enacting entitlement reform comes from making President Obama a one-termer, maintaining their majority in the House, and retaking the Senate. At the moment the Presidential
- [Romney's Budget Promises on Medicare Cannot Be True](https://ghgadvisors.com/romneys-budget-promises-on-medicare-cannot-be-true/) - The political jiu-jitsu on Medicare since the selection of Paul Ryan as the GOP Vice Presidential candidate has been amazing to watch. Democrats shriek Romney/Ryan will "end Medicare as we know it." Romney/Ryan countered by charging that health reform was funded by $716 Billion in Medicare cuts -- it's Obama who is the threat to
- [Sales Oversight & Thoughts on CMS Updated Agent Training Guidelines](https://ghgadvisors.com/thoughts-on-cm-updated-training-guidelines-from-ghg/) - As you likely noticed, CMS recently released its updated Guidelines for Agent Broker Training and Testing for CY 2013 on August 21. Our in-house compliance experts have cross-walked the new regulations with the old ones from last year and here's our take: for the most part, the updated guidelines should be business as usual. However,
- [I'm a Ryan Fan on Medicare, But He Dropped Some Whoppers at the Convention](https://ghgadvisors.com/im-a-ryan-fan-on-medicare-but-he-dropped-some-whoppers-at-the-convention/) - As we've said here before, we're fans of Rep. Paul Ryan's Medicare reform plans with Senator Ron Wyden (D-OR). Ryan's the first Gen-Xer on a major party ticket, and he's just so freakin' earnest he's hard not to admire. He did a nice job of rallying the faithful in his speech to the Republican National
- [Obama, Ryan, and the Myth of Competition](https://ghgadvisors.com/obama-ryan-and-the-myth-of-competition/) - Both the exchanges at the heart of ObamaCare, and the competing plans in the Ryan Medicare reform proposal rely on competition among health insurance plans to reduce the upward trend in the costs of health care. But health insurance isn't health care. With the consolidation of health care providers that is happening throughout the US,
- [Politics Distort Similarities Between RomneyCare, ObamaCare and RyanCare](https://ghgadvisors.com/politics-distort-similarities-between-romneycare-obamacare-and-ryancare/) - I was quoted in Monday's New York Times story on the success private plans are having in Medicare, pointing out the similarities between RomneyCare, ObamaCare, and RyanCare -- Paul Ryan's proposal for Medicare reform, now receiving unprecedented scrutiny following his selection as Vice Presidential candidate. When you remove the distortion of election-year politics, it's easy
- [Sales Force Oversight Ain't Easy](https://ghgadvisors.com/sales-force-oversight-aint-easy/) - Selling season is nearly upon us, so with that in mind, here are some thoughts to help plans prepare. In this post, I'll detail some sales oversight and reporting best practices we've seen applied with success in a number of plans. When creating an effective agent oversight program, keep in mind that agent oversight requires
- [GOP Piling-on Begins on the Medicare Advantage Star Ratings Demo](https://ghgadvisors.com/gop-piling-on-begins-on-the-medicare-advantage-star-ratings-demo/) - House Republican Committee chairmen began to pile onto rising controversy around the $8.3 billion Medicare Advantage Star Ratings Demonstration this week, first brought to attention by the Government Accountability Office's study of the program commissioned by Senator Orrin Hatch (R-UT) in April. In May, the American Action Forum — an influential conservative think tank here
- [Join us Thursday for First in New Webinar series: Risk adjustment in the exchanges](https://ghgadvisors.com/join-us-thursday-for-first-in-new-webinar-series-risk-adjustment-in-the-exchanges/) - On Thursday July 26th at 1pm ET we'll kick off our new webinar series, "Lessons from Medicare Advantage and Part D", a monthly webinar series around what we've learned in Medicare that can be applied to the exchanges and other aspects of health reform. We'll begin with a deep dive on risk adjustment in the
- [Rising Chorus Urges CMS to Slow Down on Dual Eligibles](https://ghgadvisors.com/rising-chorus-urges-cms-to-slow-down-on-dual-eligibles/) - CMS and at least 20 states are moving hell-bent-for-leather toward enrolling as many as 3 million of the 9 million Dual Eligibles into health plans in the next two years, creating one of the biggest opportunities for payers in history. Now a rising chorus including the Medicare Payment Advisory Commission, the American Medical Association, some
- [GOP's "Reform Repeal Theatre" Costs Taxpayers $48 Million.  WTF?](https://ghgadvisors.com/gops-reform-repeal-theatre-costs-taxpayers-48-million-wtf/) - The House of Representatives again voted to repeal the Accountable Care Act (ACA) last Wednesday, marking the 33rd time Republicans have tried. All 32 previous attempts died in the Senate, as this one will. But the GOP's "Repeal Theatre" comes with a sick price tag: about $48 million and counting, according to a report by CBS News.
- [Medicaid Mattered Most in the SCOTUS Decision](https://ghgadvisors.com/medicaid-mattered-most-in-the-scotus-decision/) - In all of the drama around the recent Supreme Court ruling on the Accountable Care Act (ACA) and the individual mandate, it was the Medicaid eligibility expansion ruling that mattered most. Hands-down, Medicaid was WAY more important: $1 TRILLION and 17 million Americans' access to health insurance is now at stake, potentially millions more when Medicaid
- [Medicare ACO's: Tool for Reducing Medicare costs or something more?](https://ghgadvisors.com/medicare-acos-tool-for-reducing-medicare-costs-or-something-more/) - The June 18th blog by my colleague and friend William MacBain posed a valid question when he asked whether Medicare ACO's are a revolution in healthcare or a side show. My view--it's that and more. To the point that Medicare ACO's will probably have only a minor impact on overall Medicare expenditures, I totally agree but
- [I don't understand.  Why don't Republicans like ObamaCare?](https://ghgadvisors.com/i-dont-understand-why-dont-republicans-like-obamacare/) - During an interview with Judy Woodruff on the PBS News Hour, Sen. John Cornyn (R, TX) paused in his criticism of ObamaCare long enough to praise the Medicare drug program: "We have also seen in the Medicare program with the prescription drug program this has really been one of the few successes we have seen
- [Digital Dewey defeats Truman](https://ghgadvisors.com/digital-dewey-defeats-truman/)
- [The Supremes Say the Mandate is Constitutional. But Voters Get the Final Word.](https://ghgadvisors.com/the-supremes-say-the-mandate-is-constitutional-but-voters-get-the-final-word/) - Washington's best-kept secret since JFK and Marilyn Monroe came out today: the Supreme Court upheld the individual mandate in the ACA in a 5-4 decision made by Chief Justice John Roberts. The President ducked a bullet in the ruling and comes out strong heading into the election on this issue; the decision will galvanize the
- [Supreme Court upholds Romneycare](https://ghgadvisors.com/supreme-court-upholds-romneycare/) - As you have likely heard, Romneycare no, Obamacare, no, the ACA has been upheld by the Supreme Court, with Chief Justice Roberts casting the deciding vote with the liberal block. Health policy implications aside, there are some truly delicious politics here: Obama did not support the mandate in the ‘08 primary. In fact, he was
- [Medicare ACOs:  Revolution or Side Show?](https://ghgadvisors.com/medicare-acos-revolution-or-side-show/) - CMS Deputy Administrator Jon Blum said last Thursday that the agency expects to double the number of ACOs operating in Medicare by the end of this year. That would put the total number of Medicare ACOs at about 130 by January. Assume 130 Medicare ACOs at 15,000 bennies each on average. That's about 2 million
- [Medicare Advantage Enrollment Grows by 10 Percent](https://ghgadvisors.com/medicare-advantage-enrollment-grows-by-10-percent/) - Kaiser Family Foundation just released a Data Spotlight on 2012 Medicare Advantage Enrollment. The report shows that 2012 MA enrollment increased 10 percent from 2011 levels with the addition of 1 million new enrollees. The report also noted that MA enrollment has doubled since 2005. Given the payment cuts in the Medicare Modernization Act and Affordable
- [The Part D Experience: What are the Lessons for Broader Medicare Reform?](https://ghgadvisors.com/the-part-d-experience-what-are-the-lessons-for-broader-medicare-reform/) - The Kaiser Family Foundation sponsored a forum on the Part D program which was enacted in 2003, almost ten years ago. At the time of passage, there were many uncertainties about how the program would fare, e.g. would plans participate, would beneficiaries enroll. The Part D program has had much success in many areas. The
- [Health Affairs Briefing on the June 2012 Issue](https://ghgadvisors.com/health-affairs-briefing-on-the-june-2012-issue/) - Health Affairs sponsored a briefing on the major articles in their June 2012 Issue entitled "Focus on the Care Span for the Elderly and Disabled". "Care Span" is a new term for the full spectrum of services used by the elderly and disabled including acute care, chronic care and long term care services and supports
- [If Mandate Survives SCOTUS, Will GOP States Be Caught Flat-Footed on Exchanges?](https://ghgadvisors.com/if-mandate-survives-scotus-will-gop-states-be-caught-flat-footed-on-exchanges/) - I keynoted the Opal Events Medicare Executive Forum last week and stated there -- as I have here -- that I think there's slightly more than an even chance that SCOTUS will overturn the individual mandate in its ACA ruling later this month. The presentation raised an interesting question: if the mandate survives the Court,
- [Boehner's "Circular Firing Squad" on the ACA](https://ghgadvisors.com/boehners-circular-firing-squad-on-the-aca/) - Politico is out with an astounding story on conservative infighting on the Accountable Care Act (ACA) as the Supreme Court ruling on the Constitutionality of the ACA nears. The story is further evidence of the fact that House Speaker John Boehner doesn't control a GOP caucus -- he's trying to mollify an unruly coalition while
- [Berwick Redux? No Confirmation Planned for Tavenner](https://ghgadvisors.com/berwick-redux-no-confirmation-planned-for-tavenner/) - Senate Finance Committee Chairman Max Baucus told POLITICO that it's "virtually impossible" to see how CMS Acting Administrator Marilyn Tavenner could get 60 votes in the Senate, and therefore he doesn't have plans for a confirmation hearing. Republicans haven't found anything as controversial in Tavenner's background as they did in former Administrator Don Berwick's (the
- [SCOTUS Watch Begins](https://ghgadvisors.com/scotus-watch-begins/) - The US Supreme Court dealt the health plan industry a difficult hand coming out of its oral arguments on the Accountable Care Act's individual mandate in late March. With about five weeks to go until a formal ruling, the Justices will have already made their decision, the draft opinion is circulating around the Court, and the guessing game
- [Times Are A-Changin'...Get Your Team to the GHG Forum June 12-13](https://ghgadvisors.com/times-are-a-changin-get-your-team-to-the-ghg-forum-june-12-13/) - In response to client requests, GHG is holding its first-ever Client Forum June 12-13 in Washington. With so much change in the air in government programs, the Forum is the perfect opportunity to get your team focused on the road ahead. This isn't a disjointed lineup of vendors selling from the podium like at your
- [RIP Harry Gorman, Conservative Agitator, Patriot](https://ghgadvisors.com/rip-harry-gorman-conservative-agitator-patriot/) - I lost my 98-year-old grandfather last week. Harry Gorman was a hugely influential figure with his 2 sons, his 4 grandchildren, and his 7 great-grandchildren. An immigrant Jew who lost most of his family in the Holocaust, he was a husband, father, printer, diamond-cutter, inventor (he invented the cardboard phonograph record, which my contemporaries will recall
- [Democrats Can't Keep Denying Medicare Advantage Demographics](https://ghgadvisors.com/democrats-cant-keep-denying-medicare-advantage-demographics/) - For my entire career I've been baffled by Democrats' resistance to the Medicare risk program (now called Medicare Advantage). I understand that most Dems hate big bad profiteering health insurance companies. What's confounding is why they can't see who the program truly serves: the heart of the party's coalition. America's Health Insurance Plans (AHIP) released
- [Let's Just Say It: the GOP is the Problem](https://ghgadvisors.com/lets-just-say-it-the-gop-is-the-problem/) - Two of Washington's most eminent political observers, Thomas E. Mann of the left-leaning Brookings Institution, and Norman J. Ornstein, resident scholar at the conservative American Enterprise Institute, published an awesome op-ed in today's Washington Post on the truly sorry state of our national politics. And they did something extraordinary: they courageously laid the blame squarely
- [Medicare's Wobbly Solvency](https://ghgadvisors.com/medicares-wobbly-solvency/) - The Medicare Trustees released their 2012 report this week on the fiscal health of our favorite program and concluded that Medicare's Part A Trust Fund won't run out of gas until 2024, the same finding as last year. That's welcome news -- but the conclusion rests on some shaky assumptions, and therefore the day of reckoning
- [Change is here: CMS Finalizes Chapter 13](https://ghgadvisors.com/change-is-here-cms-finalizes-chapter-13/) - It seems like only yesterday that I was submitting comments in response to CMS' draft chapter 13. It was, in fact, way back in April of 2007, when I was a budding young compliance analyst determined to keep a plan on the right track. The review of draft chapter guidance was one of the best
- [I don't often pick fits with the GAO...But when I do, I prefer it's about Medicare Advantage](https://ghgadvisors.com/i-dont-often-pick-fits-with-the-gao-but-when-i-do-i-prefer-its-about-medicare-advantage/) - The non-partisan GAO doesn't much like the demonstration plan that accelerated the MA Quality based payment initiative, known as the Star Rating System. You can read why here, here, or here. For my colleague John Gorman's great summary, visit us over here. I can save you the linkage: the gist is that (much) too much
- [GAO Says Stars Bonus Demo is an $8 Billion Waste](https://ghgadvisors.com/gao-says-stars-bonus-demo-is-an-8-billion-waste/) - The Government Accountability Office released a report yesterday recommending that CMS cancel the Star Ratings Bonus Demonstration, saying it would spend over $8 billion rewarding plans with only average quality improvement. That $8.3 billion -- to be awarded to plans with at least a 3-Star rating -- would offset "a significant portion" of the MA payment
- [Let the games begin](https://ghgadvisors.com/let-the-games-begin/) - By now you should have started your benefit discussion for 2013. With the surprising higher rate coming to plans in 2013 — the competitive juices are flowing across the country. The stakes are high for 2013 and now is not the time to rest on past performances. If I was sitting in the product strategy chair
- [2013 Final Call Letter and Regulations](https://ghgadvisors.com/2013-final-call-letter-and-regulations/) - Along with the Final Rate Notice for 2013, CMS recently published the Final Call Letter and a Final Rule with Comments. These documents include changes to policy and operational guidance for Medicare Advantage (MA) and Part D plans for CY 2013. Our summary of the Final Rate Notice and Final Call Letter Our summary of
- [Delegation Nation](https://ghgadvisors.com/delegation-nation/) - Ongoing monitoring and auditing is a widespread challenge, but they are must-dos according to CMS' compliance program requirements. You have some tools, but not enough to capture the full picture. Responsibilities are spread out between departments and delegated entities. Is the risk assessment just a matter of asking for a list of risks, or is
- [Put down the pitchfork, Mr. Governor](https://ghgadvisors.com/put-down-the-pitchfork-mr-governor/) - Not as discussed as the Mandate, but also under consideration by the Supremes is the provision of ACA that expands Medicaid eligibility under age 65. The States' position is this is a "coercive" expansion. The politics is that the provision is anti-Federalist, forcing the states to spend as wildly as the Feds. Well, the Feds
- [No one has a clue what will happen](https://ghgadvisors.com/no-one-has-a-clue-what-will-happen/) - ... And anyone who tells you differently is trying to impress you. A good friend who clerked for both Alito (when an appeals judge) and Chief Roberts (his first year on the SCOTUS) and his father who is a prominent conservative law school dean and Ambassador agree: it's too close to call. (Not namedropping here,
- [Good to Know](https://ghgadvisors.com/good-to-know/) - Usually CMS leaves us wondering about the benchmark that they have in mind for plans to achieve. But the latest 2013 Draft Call Letter left little to the imagination. It states, "We expected more Part D beneficiaries would be eligible for MTM following changes to the eligibility criteria requirements in 2010. However, the eligibility rate
- [Careful: You might get what you wish for](https://ghgadvisors.com/careful-you-might-get-what-you-wish-for/) - My friend Will Wilkinson has a nice post over at the Economist regarding the politics of the ACA being overturned by the SCOTUS next week. Increasingly, the legal community thinks the law will be upheld, and that it will be the Chief himself who casts the swing vote. Who knows. As many have noted over
- [If You're Not on the Government Programs Bus, You'll Soon Be Under It](https://ghgadvisors.com/if-youre-not-on-the-government-programs-bus-youll-soon-be-under-it/) - The March enrollment numbers are out from CMS and provides some stark evidence that if you're not in government programs, you're not going to be in health care for much longer. Medicare and Medicaid health plan enrollment continues to grow steadily, and is set to explode later this year as several major states begin to move their
- [A Day in the life of the Medicare Compliance Officer](https://ghgadvisors.com/a-day-in-the-life-of-the-medicare-compliance-officer/) - You have so many requirements to follow. You are charged with the interpretation and distribution of the ever-present stream of HPMS memoranda. Operational leadership does not always understand that you can give them the requirements, interpret the requirements, but it's up to them to implement for success. Implementation takes time, often leaving employees performing manual,
- [IPAB is a four letter word](https://ghgadvisors.com/ipab-is-a-four-letter-word/) - The House is taking up a bill to remove Medicare's independent payment advisory board (IPAB) from the Affordable Care Act. Opponents of IPAB call it a death panel and claim it will ration care. That's nonesense, and flies in the face of the legislation that created the IPAB, which prohitits it from ratioining anything. In fact,
- [Don't waste your travel budget](https://ghgadvisors.com/dont-waste-your-travel-budget/) - We're less than three months from the GHG Forum. This is NOT your usual conference. We've developed a unique educational retreat for management teams working in government programs. I'm thrilled at the presentations our faculty are preparing: we're putting our senior consultants on the stage to deliver case studies, war stories and tales of best
- [Right-Wing Senators Offer Competing Medicare Reform Plan](https://ghgadvisors.com/right-wing-senators-offer-competing-medicare-reform-plan/) - Things are getting more and more curious on the Hill as various factions line up to offer their Medicare reform proposals to kick off budget season. Four far-right Senators -- Rand Paul of Kentucky, Mike Lee of Utah and South Carolina's Lindsey Graham and Jim DeMint -- will unveil a plan Thursday that would transition
- [Romney Declines Medicare Coverage, Confirming "1%er" Label](https://ghgadvisors.com/romney-declines-medicare-coverage-confirming-1er-label/) - Gov. Mitt Romney turned 65 this week and, strangely, announced that he won't be signing up for Medicare to stay on private insurance. In doing so he served up another softball for Obama and his opponents for the nomination. The decision puts Romney in a tiny minority: the vast majority of seniors choose to participate in Medicare. Nearly all
- [As GOP's Kamikaze Culture War Continues, the Senate Slips from Its Grasp](https://ghgadvisors.com/as-gops-kamikaze-culture-war-continues-the-senate-slips-from-its-grasp/) - The Wall Street Journal reported on what we've been speculating on: that the GOP's renewed culture war is calling into question the party's ability to recapture the United States Senate this year. "The GOP is facing a tougher fight on a landscape that hasn't stopped changing. In states such as Maine, Nebraska and North Dakota,
- [Stressed? Tell me about it](https://ghgadvisors.com/stressed-tell-me-about-it/) - The Society of Corporate Compliance and Ethics and the Health Care Compliance Association conducted a survey and released their results in a report entitled Stress, Compliance, and Ethics. The survey results address leading causes of stress among compliance and ethics officers. When three of every five respondents agree that they have considered leaving their job,
- [Oregon Leads the Way on End-of-Life Planning](https://ghgadvisors.com/oregon-leads-the-way-on-end-of-life-planning/) - Kaiser Health News is out with a terrific story today on Oregon's progress with end-of-life planning for its seniors. The secret to its success has been a simpler-than-expected solution that a number of states have already adopted or are considering, and it's one of the most encouraging signs of progress in the field since the
- [Word for the day: Volatile](https://ghgadvisors.com/word-for-the-day-volatile/) - Volatile. n. Fickle, inconsistent, easily vaporized. Thanks to the Affordable Care Act, Medicare Advantage finances are going to be volatile. Unwary actuaries may be easily vaporized. The new benchmarks, the "specified amount" under the ACA, are based on which quartile a given county is in. Quartiles are defined by average FFS costs. ACA benchmarks range
- [Glass Half Full on Medicare Reform Prospects](https://ghgadvisors.com/glass-half-full-on-medicare-reform-prospects/) - Former CMS Administrator and friend of the firm Gail Wilensky, MD is out with a great op-ed piece in the New England Journal of Medicine today on directions for bipartisan Medicare reform. She echoes many of our recent thoughts on the improving prospects for Medicare reform, not in this hotly-contested election year, but as part
- [Solving your claims-based HCC conundrum](https://ghgadvisors.com/solving-your-claims-based-hcc-conundrum/) - Everybody knows that 37% of claims-based HCCs fail in a RADV audit, but no one ever talks about how to fix the problem. How to fix the high failure rate of claims based HCCs? 1. Filter your claims and tier into confidence levels (high, moderate and low). (We call our filtration, tiering, and resolution tracking solution
- [It's Super Tuesday and Romney Still Gets No Respect](https://ghgadvisors.com/its-super-tuesday-and-romney-still-gets-no-respect/) - Today is Super Tuesday, the biggest event thus far in the Presidential race, with more delegates at stake for the GOP candidates than any other primary or caucus to date. Mitt Romney was supposed to have the nomination locked up by now; instead, as today's Wall Street Journal points out, he's more like the Rodney
- [Preaching to the Converted on Medicare Reform](https://ghgadvisors.com/preaching-to-the-converted-on-medicare-reform/) - Politico is out with a great op-ed today from centrist thought leader Will Marshall on why the Ryan/Wyden Medicare reform plan deserves a fair hearing -- especially among Democrats. He's preaching to the converted here at GHG -- the Wall Street Journal noted our support for the plan last week in Fred Barnes' column. I
- [Integration around chronic conditions, such as chronic kidney disease](https://ghgadvisors.com/integration-around-chronic-conditions-such-as-chronic-kidney-disease/) - Many of our clients have requested customized mapping and integration which electronically links the findings from the Advanced Evaluation into their medical management system. Health plans and medical groups both appreciate the in-depth reporting, plus electronic connection that triggers or flags particular members for placement into unique case management programs, whether it is a COPD,
- [When Worlds Collide: ACOs and Risk Adjustment](https://ghgadvisors.com/when-worlds-collide-acos-and-risk-adjustment/) - By John Nimsky & RaeAnn Grossman As we enter the era of ACOs, we have to be aware of all the clinical and operational essentials that are needed to make the ACO a viable health care solution for members, plus the elements needed to support the ACO as an engaged and intelligent communicator with CMS. If you
- [RADV Rules Show a New Era Dawning at CMS](https://ghgadvisors.com/radv-rules-show-a-new-era-dawning-at-cms/) - After the market close last Friday CMS released its long-awaited methodology for conducting Risk Adjustment Data Validation (RADV) audits. It's a critically important document as for years President Obama has threatened in his budgets to recover billions in payments from Medicare Advantage plans. What it shows is that a new era is dawning at CMS,
- [Medicare Advantage Hospital Readmission Rates Substantially Lower than FFS](https://ghgadvisors.com/medicare-advantage-hospital-readmission-rates-substantially-lower-than-ffs/) - An article in the American Journal for Managed Care found that Medicare Advantage (MA) patients experienced a much lower 30 day hospital readmission rate than FFS patients. The study found the MA readmission rate was 14.5 percent during 2006-2008, which was 22 percent lower than the FFS readmission rate. After adjusting for risk and excluding disabled
- [How Doctors Die](https://ghgadvisors.com/how-doctors-die/) - Today's Wall Street Journal opinion page included a terrific op-ed on how physicians approach their own end of life care planning differently than most of their patients do, primarily because they actually understand the limitations of American medicine in prolonging life, and because they actually plan for the end. The author, Dr. Ken Murray, a
- [Physician Engagement... What can you really do?](https://ghgadvisors.com/physician-engagement-what-can-you-really-do/) - Health plans have tried a hundred ways to engage providers — incentive stipends, P4P, P4Q, capitation, clinical initiatives, episode of care payment, onsite coders, in office case management liaisons. But what works? Open communication, reasonable expectations, and simplicity. Before CenseoHealth launches a patient evaluation program we meet with the community physicians to discuss: 1. Program Overview 2. Program
- [Let's Get the Ryan/Wyden Party Started!](https://ghgadvisors.com/lets-get-the-ryanwyden-party-started/) - This morning I was quoted in conservative standard-bearer Fred Barne's lead opinion piece in the Wall Street Journal on the Ryan/Wyden Medicare reform plan. Fred makes the point that Ryan is beginning to convince Democrats that his approach is reasonable. I don't know if Ron Wyden, Jim Capretta and I make Ryan's new proposal "bipartisan", but the
- [Garbage In. Clarity Out](https://ghgadvisors.com/garbage-in-clarity-out/) - So you may have bad, ugly, horrible, scary data and internally you don't have a means to lump it all together to give you a clear picture of what happened in 2010, 2011, and the challenges you are facing in 2012 with your members, your network physicians or your risk adjustment program. You have twelve
- [Memo on CMS Advance Notice and Draft Call Letter for 2013](https://ghgadvisors.com/advance-notice-and-draft-call-letter-for-2013/) - CMS continues to refine operational policy for Medicare Advantage and Part D plans. View our summary of the 45-Day Advance Notice and Draft Call Letter for 2013 by clicking here. I was disappointed CMS did not finalize their proposed regulations prior to issuing this document. As a result some of the more significant policy changes will
- [Why Medicare Advantage is Here to Stay](https://ghgadvisors.com/why-medicare-advantage-is-here-to-stay/) - If you want to understand why Medicare Advantage is now part of the firmament of the US healthcare economy, and will now weather almost anything Congress and the Administration can throw at it, you need only comprehend what Medicare contributes to the big players' bottom lines. Since the exodus from the program that followed the
- [The Goat Rodeo](https://ghgadvisors.com/the-goat-rodeo/) - You hear a lot of interesting comments when you are meeting with health plans and large medical groups. One of my favorite phrases is "last year was a goat rodeo." The visual makes me laugh every time — goats, kids, and general goat chaos. However, in risk adjustment, you cannot afford an internal or vendor
- [My Crystal Ball](https://ghgadvisors.com/my-crystal-ball/) - IF the Supreme Court (SCOTUS) find the mandate unconstitutional, THEN the Exchanges begin to unravel. And IF that happens, THEN the Dems will have an extraordinary issue to run on in 2012, which is as meaningful to Congressional races (remember: Congress holds the money) as it is to the Presidency. But IF it doesn't, the
- [More Good News for Medicare Advantage in 2013 Rate Announcement](https://ghgadvisors.com/more-good-news-for-medicare-advantage-in-2013-rate-announcement/) - CMS released the 45-Day Notice of CY 2013 Medicare Advantage (MA) rates after the market close on Friday, and while it's the usual hot mess of green-eyeshade factors that comprise payment, it brought unexpectedly positive news for the industry. If it holds up in the final rate announcement on April 2, it will represent the
- [End of an Era -- and a New Beginning -- at XLHealth](https://ghgadvisors.com/end-of-an-era-and-a-new-beginning-at-xlhealth/) - United Health Group closed the acquisition of XLHealth this week, two months ahead of schedule. XLHealth has been one of our biggest clients for the last 8 years, and I had the distinct honor of serving on their board of directors the last 4 years. It was a brilliant "get" for United -- both in
- [Medicare Advantage and Diagnostic Accuracy](https://ghgadvisors.com/medicare-advantage-and-diagnostic-accuracy/) - There have been recent suggestions that Medicare Advantage plans are receiving excessive reimbursement from CMS as a result of "up coding" in the risk adjustment system. There are a number of reasons why these suggestions are inaccurate and counterproductive. First, one must understand where the codes submitted for risk adjustment originate. The majority of diagnostic
- [At Supremes' Mid-Session Recess, Hints on the Individual Mandate](https://ghgadvisors.com/at-supremes-mid-session-recess-hints-on-the-individual-mandate/) - I've long thought this November's Presidential and Congressional elections are far more relevant to the future of the Accountable Care Act than the US Supreme Court's consideration of the Constitutionality of the individual mandate. On that point, this morning's WaPo had a new poll showing President Obama with his first clear lead in a hypothetical matchup against
- [Ryan Redux: Another Medicare Cage Match Smackdown is Coming](https://ghgadvisors.com/ryan-redux-another-medicare-cage-match-smackdown-is-coming/) - The FY 2013 budget battle lines are being drawn up now here in DC and Democrats are licking their chops over the idea of another GOP budget that attempts to dramatically reform the Medicare program. House Budget Committee Chairman Paul Ryan (R-WI) said this week that his budget will address Medicare and could include the revised
- [The State of the Union in Medicare Advantage Has Never Been Stronger](https://ghgadvisors.com/the-state-of-the-union-in-medicare-advantage-has-never-been-stronger/) - At long last the January 1 enrollment numbers are in from CMS and the State of the Union in Medicare Advantage has never been stronger. Our favorite program hit almost 13 million enrollees last month. Premiums are down 7% on average for 2012 and enrollment has grown by about 10% year-over-year from last January. Hate
- [MA Enrollment - Good News](https://ghgadvisors.com/ma-enrollment-good-news/) - Today Secretary Sebelius announced the results of the annual election period showing that Medicare Advantage (MA) enrollment increased by 10 percent compared to this time last year. She declared that Medicare Advantage is "stronger than ever". This is consistent with my prediction in a December 2, 2011 blog based on reports we were seeing on
- [Don't Throw Away Your Insurance Card Just Yet](https://ghgadvisors.com/dont-throw-away-your-insurance-card-just-yet/) - I just can't resist commenting on the January 30th commentary in The New York Times by Ezekiel Emanuel and Jeffrey Liebman on the demise of the Insurance industry by 2020 at the hands of an explosion of Accountable Care Organizations. To test that premise, let's go back to the role that insurance companies play in
- [The End of Health Insurance?](https://ghgadvisors.com/the-end-of-health-insurance/) - Writing in the January 30 New York Times, Zeke Emanuel and Jeffrey Lieberman predict that accountable care organizations will totally replace health insurance within the next eight years. They credit the health care reform act with establishing this revolutionary new form of care, in which claim processing is unnecessary, and ACOs will perform the risk-pooling
- [WSJ asks, "Can ACOs Improve Health Care While reducing Costs?"](https://ghgadvisors.com/canacosimprovehealthcare/) - Specifically the question that the WSJ posed in its article on January 23 to three health industry experts, (Don Berwick, former CMS Administrator, Jeff Goldsmith, President of Health Futures and Tom Scully, CMS Administrator from 2001-2004) was whether ACOs are the answer to what ails the health care system. As expected, the response from each
- [Tea Party Losing Stranglehold on GOP is Good News for Medicare](https://ghgadvisors.com/tea-party-losing-stranglehold-on-gop-is-good-news-for-medicare/) - As Washington, DC's sports team suck so badly, this time of year politics is our smashmouth football, and I am loving this GOP primary season! It's had everything so far: a thorough vetting of the candidates (hasta la vista, Govs. Perry, Huntsman and Pawlenty), high drama (Palin and Christie indecision; the Iowa caucuses squeaker), sex (awesome
- [Health Care Innovation Challenge](https://ghgadvisors.com/health-care-innovation-challenge/) - Today applications for the Center for Medicare and Medicaid Innovation (CMMI) Health Care Innovation Challenge grants are due. There is a lot of money on the table --- $1 billion. And many health care organizations are in the final stages of writing detailed proposals that describe innovative programs that will add new jobs and improve
- [The Cost of Care: "How high can premiums go?"](https://ghgadvisors.com/the-cost-of-care-how-high-can-premiums-go/) - One of the less publicized requirements of the Accountable Care Act is the requirement of health plans to spend at least 80-85% of the premium dollar on medical services. Aside from the expected discussion of what qualifies as a medical expense, under the previously mentioned medical expense target, health plans that submit "excessive" rate increases will be
- [Election vs. Supreme Court on Health Reform](https://ghgadvisors.com/election-vs-supreme-court-on-health-reform/) - In my travels many I've spoken with about health reform's future seem to have the impression that the Supreme Court's consideration of the individual mandate is where the law will live or die. Think again -- the American electorate will have far more sway over the future of the ACA than the 9 Supremes ever
- [Welcome to Another Year of Gridlock in DC](https://ghgadvisors.com/welcome-to-another-year-of-gridlock-in-dc/) - Welcome to the second session of the 112th Congress, when the most unpopular group of politicians in history (13% job approval rating last week) is poised to shirk their responsibilities to govern, and turn the House and Senate into campaign stumps. In an election year characterized by the most polarized electorate in recent memory, don't expect much
- [Your Risk Adjustment Road Map](https://ghgadvisors.com/your-risk-adjustment-road-map/) - Where are you going? And how quickly are you getting there? The risk adjustment model is evolving rapidly because of RADV, EDPS, and your health plan competitors. Health plans and medical groups are moving from a chart review model to the premier member knowledge & engagement model. Your transformation should look like this if you
- [Berwick Redux? Recess Appointments Could Derail Tavenner Nomination at CMS](https://ghgadvisors.com/berwick-redux-recess-appointments-could-derail-tavenner-nomination-at-cms/) - President Obama's recess appointment of Richard Cordray to run the Consumer Financial Protection Bureau could derail the nomination of acting CMS Administrator Marilyn Tavenner to run the agency in an escalating spat over appointments. Republicans have been blocking Cordray's confirmation process for a year because of concerns with the consumer watchdog's powers, and the recess appointment was like
- [A Risk Adjustment Road Map](https://ghgadvisors.com/a-risk-adjustment-road-map/) - Where are you going? And how quickly are you getting there? The risk adjustment model is evolving rapidly because of RADV, EDPS, and your health plan competitors. Health plans and medical groups are moving from a chart review model to the premier member knowledge & engagement model. Your transformation should look like this if you
- [2012 has a lot in store](https://ghgadvisors.com/2012-has-a-lot-in-store/) - 2012 will be a busy year for GHG and our clients. The first Legislative agenda item will be the Medicare physician Sustainable Growth Rate (SGR) fix. The 27 percent physician fee schedule cut has only been postponed for the first 2 months in 2012. The big question is how the Congress will choose to pay
- [Capitation in Accountable Care Organizations](https://ghgadvisors.com/1463-2/) - If you don't already subscribe, we suggest you check out Accountable Care News, an online publication focused specifically on Accountable Care Organizations. I published an article in the December 2011 Issue that covers capitation in accountable care organizations. A sample issue of the publication is here. For a full copy of the article, click here.
- [New CMS HSD Guidance Issued - What's New?](https://ghgadvisors.com/new-cms-hsd-guidance-issued-whats-new/) - In case you haven't studied the recent CMS HSD Guidance memo, let me save you some time (and pain). This is the first of my blogs on the new CMS changes that will impact all MA Plans filing this year for a 2013 product launch. Here's what caught my attention: • County Designations Changed - This
- [Enjoy Some LOLZ with Jon Stewart's "Intervention 2012"](https://ghgadvisors.com/enjoy-some-lolz-with-jon-stewarts-intervention-2012/) - I love me some Daily Show and this week Jon Stewart offered up one of their best commentaries on the state of the Republican Presidential nomination. Having had the office next door to former House Speaker Newt Gingrich's when I worked for US Rep. John Conyers, I can heartily agree with the assessments of Senator Tom Coburn (R-OK), John
- [If I want a Risk Adjustment Super Hero ....](https://ghgadvisors.com/if-i-want-a-risk-adjustment-super-hero/) - Ask yourself: What would my 2012 member assessment strategy & timing look like if I want a Risk Adjustment Super Hero? Step 1: Compile data in February Step 2: Launch member evaluations in March Step 3: Complete 50% of your member evaluations by June 30th Step 4: Reduce dependence on chart review to .30 charts
- [ACO: Change agent or fad?](https://ghgadvisors.com/aco-change-agent-or-fad/) - Aetna recently published results of two studies suggesting that ACOs can indeed cut Medicare enrollee costs. The results came from two medical groups - one in Ohio and one in Florida. The Florida group reduced inpatient hospital days by 37% and hospital readmissions by 27%. The Ohio group reduced inpatient days by 30% and hospital readmissions
- [It's the Providers' Turn to Make the Transformation](https://ghgadvisors.com/its-the-providers-turn-to-make-the-transformation/) - I just read Dr. Don Berwick's speech at the IHI National Forum and I am awed with his insight and inspiration. It reminds me of the speech that I heard Dr. Ken Kaiser give at a Veterans Administration conference that led to the transformation of the VA health system from "worst to first" in the
- [Berwick, Unshackled, Blasts "Death Panels"](https://ghgadvisors.com/berwick-unshackled-blasts-death-panels/) - Freed from the shackles of his Washington job, last week former CMS Administrator Don Berwick described for an audience of health policy wonks Washington's cynicism, epitomized by the "hogwash" claim that health reform included "death panels." "The outrageous rhetoric about death panels — the claim, nonsense, fabricated out of nothing but fear and lies, that some
- [CMS to Part D Plans: "Curb Use of Antipsychotics in Nursing Home Patients"](https://ghgadvisors.com/cms-to-part-d-plans-curb-use-of-antipsychotics-in-nursing-home-patients/) - Medicare Sponsors' are failing to monitor the safe utilization of antipsychotic drugs among the elderly. CMS is stepping up its warnings to Medicare Plans to implement more effective management of these drugs. Plans can expect increased scrutiny. Will your plan meet the standard? Patrick Conway, Chief Medical Officer and Director for the CMS Office of
- [Some Daylight in the Medicare Reform Debate](https://ghgadvisors.com/some-daylight-in-the-medicare-reform-debate/) - This morning's New York Times featured a terrific editorial that provided some daylight for the left in the ongoing Medicare reform debate. Essentially the Times rejects House Budget Committee Paul Ryan's (R-WI) draconian approach but opens the door to examining "premium support" as thought of by Alice Rivlin, former President Clinton's budget director, which is
- [Risk Adjustment: Are you driving a Pacer or an Audi R8?](https://ghgadvisors.com/risk-adjustment-are-you-driving-a-pacer-or-an-audi-r8/) - How can you tell if your risk adjustment program is a high performance machine? Here is the quick test: 1. Did you hit your volume target for member evaluations for 2011? 2. Did you hit your revenue target for chart review and member evaluations for 2011? 3. Are you planning for a 2012 Quarter 1 launch for member evaluations?
- [The Doc Fix Returns](https://ghgadvisors.com/the-doc-fix-returns/) - The collapse of the Congressional Deficit "Not-So-Super-Committee" ushered in the return of the "doc fix". With only days left in the Congressional session, lawmakers will be scurrying to address several key healthcare issues, including the imminent 27% physician cut to Medicare FFS rates to physicians, and also the 2013 sequestration across the board cuts to Medicare of 2%.
- [Medicare Advantage - the Value Plan](https://ghgadvisors.com/medicare-advantage-the-value-plan/) - GAO just came out with a report announcing that Medicare Advantage enrollment increased 6 percent between April 2010 and April 2011 - to 8.4 million beneficiaries - and that the average premium decreased 14 percent between 2010 and 2011. The White House blog and key Senators are citing the GAO report's findings and touting the success
- [Berwick Departs, Tavenner Ascends at CMS](https://ghgadvisors.com/berwick-departs-tavenner-ascends-at-cms/) - Friday is Dr. Don Berwick's last day as Administrator of CMS, the victim of a recess appointment in 2010 and Congressional Republicans' obsession with keeping him from confirmation. It's a tragic result, as Berwick is a rare visionary talent for our favorite agency. His #2, Marilyn Tavenner, is preparing to take the reins of CMS at
- [Corporate Greed Puts Profits over Safety: Pfizer Inc. is Moving into Retail](https://ghgadvisors.com/corporate-greed-puts-profits-over-safety-pfizer-inc-is-moving-into-retail/) - In an effort to hold onto sales of cholesterol fighter Lipitor after the drug loses patent protection at the end of this month, Pfizer is planning to sell the pills at generic prices directly to patients, breaking a longstanding triad between the patient, prescriber, and pharmacist, which provides a system of checks and balances for
- [The Impact of the Sequester on Private Plans](https://ghgadvisors.com/the-impact-of-the-sequester-on-private-plans/) - Medicare Advantage (MA) plans and Part D plans are slated for a 2 percent cut beginning in FY 2013 now that the Super Committee has failed to recommend any changes that cut the deficit. This is probably a better deal than private plans would have faced if $1.2 trillion in cuts were recommended and adopted.
- [Why it's gonna get worse](https://ghgadvisors.com/why-its-gonna-get-worse/) - Not since the Edsel has anything been so perfectly designed to fail as the Supercommittee. So now what? The doc fix, for one, is in big trouble. In Washington accounting, it will cost an arm and a leg to do a permanent doc fix, since the savings it is supposed to generate go on forever,
- [Deficit Supercommittee: Epic FAIL.  Brief Relief for Medicare/caid.](https://ghgadvisors.com/deficit-supercommittee-epic-fail-brief-relief-for-medicarecaid/) - It appeared at the market open Monday that after much hand-wringing this weekend there is no clear path to a compromise for the Congressional Deficit Supercommittee in time for its Thanksgiving deadline. Epic FAIL. The markets responded, down 300 points as of this post. As an American, I'm pissed: now here comes again the credit
- [Member Retention has an Exponential Effect on Revenue](https://ghgadvisors.com/member-retention-has-an-exponential-effect-on-revenue/) - The typical MA health plan, on average, loses eight percent of its members annually through voluntary disenrollment, and another four percent involuntarily. Let's assume that same health plan has a membership of 50,000 lives, and from a revenue perspective, typically realizes $1000 per member per month in premiums and Medicare payments to the health plan.
- [The Secret Sauce of Risk Adjustment: Implementation, Implementation, Implementation](https://ghgadvisors.com/the-secret-sauce-of-risk-adjustment-implementation-implementation-implementation/) - As we are coming close to year end, we have all learned a great deal. The number one thing we hear from health plans: "I thought they could implement." Risk adjustment is successful only if you couple speed with quality. The three most constant stumbling points for member evaluations programs are 1) compilation of data
- [CMS Insights](https://ghgadvisors.com/cms-insights/) - At a November 16 forum on Clinician Leadership sponsored by Brookings, Dr. Richard Baron, Group Director of Seamless Care Models at the CMS Innovation Center provided several insights into CMS thinking. Most notably, Dr. Baron said that CMS is running as fast as possible away from the FFS payment system, which is not considered a
- [The Air of Inevitability Around Romney](https://ghgadvisors.com/the-air-of-inevitability-around-romney/) - I can't remember the last time I had more fun watching electoral politics. Obama suffers an open-mic gaffe and is losing White House staff like he's losing his hair. Herman Cain's sexual harassment fiasco deepened in its second week. Rick Perry suffered an excruciating 45-second brain-fart in a GOP debate where he couldn't remember one of 3
- [The Impact of Health Reform](https://ghgadvisors.com/the-impact-of-health-reform/) - Estimates and projections of the costs of a new health program are often way off the mark. Two major expansions of Medicare had opposite impacts. The ESRD benefit which was added to Medicare in 1972 has resulted in significantly higher costs than originally estimated while the Medicare Part D program ended up costing about 40
- [Get Ready for Network Shock](https://ghgadvisors.com/get-ready-for-network-shock/) - Have you submitted an application to CMS to expand your provider network lately? If not, you may be in for a big surprise. Inadequate provider networks have always been the number one reason CMS rejects Medicare Advantage (MA) applications. But in recent years CMS has raised the bar even higher. So what's so new at
- [Super-Committee: On An Elevator to Hell, Going Down!](https://ghgadvisors.com/super-committee-on-an-elevator-to-hell-going-down/) - It's crunch time for the Congressional "Super-Committee" on the deficit, and predictably, it ain't going well. The Super-Committee has until Thanksgiving to come up with its proposal to cut at least $1.5 Trillion from the national debt, and the battle lines are so immovable at this point that Congressional leaders went behind closed doors this
- [ACOs Are Here to Stay. They will vary in form, but not function](https://ghgadvisors.com/acos-are-here-to-stay-they-will-vary-in-form-but-not-function/) - I just returned from the Second National Accountable Care Organization Congress. It was a three day conference focused on discussing the role that ACOs, public and private, will play in the movement to reengineer how healthcare services are delivered, evaluated, priced and paid f or. The speaker panels consited predominately of public and private policy
- [Forbes Gets it Wrong on Medicare Advantage](https://ghgadvisors.com/forbes-gets-it-wrong-on-medicare-advantage/) - Forbes recently published a blog post ("Seniors: No, You Cannot Keep Your Plan Even if You Like It") that was wildly off the mark on the future of Medicare Advantage. I commented directly there (my handle on the Forbes blog is MedicareNinja), but had to call it out here. I agree, the President overpromised to seniors
- [ACO Workload](https://ghgadvisors.com/aco-workload/) - The final Shared Savings ACO regulation was published November 2, 2011 in the Federal Register. As I was reading through these regulations, I kept thinking about Bob Berenson's remark at a recent Health Affairs meeting where he said that CMS has fewer staff today than they did in the 1980s. How have they managed all
- [Final ACO Regulations and Guidance](https://ghgadvisors.com/final-aco-regulations-and-guidance/) - I have finally finished reading the Shared Savings ACO regulations and companion guidance. No wonder it took so long. There are so many changes ranging from major policy changes to smaller changes intended to reduce burden. In my career with CMS, I do not remember any final regulation where the policy moved so far from
- [Creativity Shapes the Complexity of Part D Benefit Design](https://ghgadvisors.com/creativity-shapes-the-complexity-of-part-d-benefit-design/) - The question was recently posed on a social website as to "why some PDPs have no incentives for mail order and why some PDPs have bizarre generic tiers?" Although the question was specific to Oregon Medicare Prescription Drug Plans (PDP), it can be extrapolated nationwide. There are a variety of dynamics in play in the
- [Surgery in the last year of life](https://ghgadvisors.com/surgery-in-the-last-year-of-life/) - Lancet recently published a fascinating study of surgery in the last year of life in Medicare members. During 2008, 1,802,029 Medicare beneficiaries over 65 years of age died; one of every three of those had a surgical procedure during his or her last year of life. The study did not sort out the reasons the
- [A Big Deal in Medicaid Following One in Medicare](https://ghgadvisors.com/a-big-deal-in-medicaid-following-one-in-medicare/) - Right on the heels of the CIGNA/HealthSpring deal, AmeriGroup announced it's acquiring Health Plus, a large Medicaid plan in New York City with around 320,000 members owned by safety net hospital sponsor Lutheran Healthcare in Brooklyn, for $85 million. The price reflects just 0.09x of Health Plus' $1 billion in revenue, a big discount to public
- [New ACO Reg has some zingers](https://ghgadvisors.com/new-aco-reg-has-some-zingers/) - The newly minted ACO regulation from Medicare has some zingers hidden in its 696 pages. Okay, to be fair, the actual regulation is only 70 pages long, double spaced. The rest is all preamble, where CMS describes the 1200 comments on the proposed rule, and how they have responded (or not) in the final rule.
- [Cigna Acquisition of HealthSpring Continues Deal Drumbeat in Senior Markets](https://ghgadvisors.com/cigna-acquisition-of-healthspring-continues-deal-drumbeat-in-senior-markets/) - This morning CIGNA announced it was acquiring HealthSpring for $3.8 billion, continuing the drumbeat of M&A deals in the Senior market. HealthSpring Chairman and Chief Executive Officer Herb Fritch will lead Cigna's expansion in the Medicare segment. It's definitive proof that even bit players in government programs like CIGNA are investing heavily in the space as the commercial
- [Medicare ACO Regs Out While Private Sector Surges](https://ghgadvisors.com/medicare-aco-regs-out-while-private-sector-surges/) - CMS released the final Medicare ACO Shared Savings Program regulations yesterday after taking a beating in over 1,200 industry comments on the draft. Let's hope they made some big changes, as Medicare is in danger of being left in the dust as ACOs surge forward in the commercial sector. Population-wide accountable care partnerships (ACPs) are moving
- [PBM Compliance-Oversight: What you Don't Know Can Cost You](https://ghgadvisors.com/pbm-compliance-oversight-what-you-dont-know-can-cost-you/) - Whether plans stick their heads in the sand or not, it doesn't change the fact that delegating services to a contracted entity is emerging as one of the fastest growing areas of audit risk. CMS defines Compliance-Oversight Activities to include developing effective metrics and controls, monitoring and reporting, and risk assessment with corrective action for
- [To Save Medicare, Talk to Patients and Stop Spending on Things That Don't Work](https://ghgadvisors.com/to-save-medicare-talk-to-patients-and-stop-spending-on-things-that-dont-work/) - Just about every discussion on the Hill about "saving Medicare" these days is talk about decreasing reimbursements to providers and health plans. There's also a lot of talk about preventive care -- and yes, I'll say it -- prevention has little potential of saving money in Medicare. You can't prevent away heart disease or diabetes in
- [Prescription Drug Abuse: A Growing Compliance Risk for Medicare Advantage Plans](https://ghgadvisors.com/prescription-drug-abuse-a-growing-compliance-risk-for-medicare-advantage-plans/) - The GAO recently released a report on fraud and prescription drug abuse in Medicare Part D. Prescription drug abuse is a serious and growing public health problem. According to the CDC, drug overdoses, including those from prescription drugs, are the second leading cause of deaths from unintentional injuries in the United States, exceeded only by motor
- [Regulations, Duals and Stars](https://ghgadvisors.com/regulations-duals-and-stars/) - GHG recently posted our summary of the October 3 proposed rule on changes to the MA and Part D programs for FY 2013. Most of the provisions in this rule are codifying current policies or implementing ACA provisions without interpretation. However there are two provisions of special interest. The first is a proposal to allow
- [Shared Savings in ACOs is not a fair game](https://ghgadvisors.com/shared-savings-in-acos-is-not-a-fair-game/) - In the proposed rules for ACOs, and in the rules for Pioneer ACOs, CMS has established a clear preference for ACOs to take down-side risk. CMS wants to be repaid if an ACO records costs that are higher than expected. This is proposed as a reasonable counter-balance to the proposed payments that CMS will make to
- [Costs Too High?](https://ghgadvisors.com/costs-too-high/) - Well, more news and comments out lately about the cost of health insurance, or actually the premium trend being too high. Additionally, articles on the cost of healthcare and it being too high. So, let's give this some quick thought: What's the difference between "price" and how "cost" is often referred to? To me, the price of a
- [The Difficulty in Making A Thousand Flowers Bloom](https://ghgadvisors.com/the-difficulty-in-making-a-thousand-flowers-bloom/) - Politico included a recent article on "Why Moving on Delivery Reform is so Difficult" that described the dilemma facing Henry Ford Health System, which resulted in a decision to withdraw their application for the Medicare ACO program. They would rather focus on participating in private sector initiatives, which offer more predictability and flexibility than demonstrations designed
- [Stars don't matter to real people](https://ghgadvisors.com/stars-dont-matter-to-real-people/) - Kaiser Permanente published a study on Monday that found only about 6% of Medicare beneficiaries used the CMS star quality ratings to select a Medicare Advantage plan. And only 2% know what their plan's currnet rating is. What is important to customers regarding their insurance companies? Pay my claims. Fix problems quickly. Don't let problems happen. Don't raise my
- [OnStar for Risk Adjustment: Are you Okay?](https://ghgadvisors.com/onstar-for-risk-adjustment-are-you-okay/) - Did you just hit something — a bump in the road or another car? Is there a calm voice coming from your car, asking if you are okay? If only there were OnStar for risk adjustment. It is almost year end and if there were an OnStar for risk adjustment this is what she would be asking you today:
- [The Continuing State vs. Federal Struggle to Manage Dual Eligibiles](https://ghgadvisors.com/the-continuing-state-vs-federal-struggle-to-manage-dual-eligibiles/) - I was just beginning to believe that the states, CMS and the health policy community were finally recognizing a larger scale opportunity for managed care to integrate Medicare and Medicaid funding and care for the most expensive and vulnerable beneficiaries, thus reducing costs and improving quality. After decades of demonstration projects and waivers, a discussion at
- ["Lean and Clean" is Key to Survival for Medicare Plans -- Join the exclusive GHG Compliance Forum November 2-4 in Las Vegas](https://ghgadvisors.com/lean-and-clean-is-key-to-survival-for-medicare-plans-join-the-exclusive-ghg-compliance-forum-november-2-4-in-las-vegas/) - New regs every other week. 500 HPMS notices a year. RADV audits and Star Ratings surveys. Intermediate sanctions and the threat of termination for poor Stars performance. And now a new, uncoordinated CMS Central Office/Regional Office audit approach that could result in multiple government reviews in a calendar year. "Lean and clean" must define a cultural and
- [GHG Revenue Management Forum in Vegas Coming October 6-7](https://ghgadvisors.com/ghg-revenue-management-forum-in-vegas-coming-october-6-7/) - We've been saying since passage of the ACA that the next 3 years' survival in Medicare Advantage is all about revenue management. The rules have changed and MA plans need new processes and new solutions to avoid serious financial troubles these next several years. Clinical initiatives often take years to bear fruit. As rates come
- [Part B versus Part D Drug Benefit Reform is Long Overdue](https://ghgadvisors.com/part-b-versus-part-d-drug-benefit-reform-is-long-overdue/) - Injectable drug therapy administration is generally covered as a medical expense under Medicare Advantage Plans. The member typically goes to an outpatient facility or hospital to receive the drug treatment and pays the associated medical visit copayment or deductible as required by the member's plan, until he or she reaches the policy's out-of-pocket maximum. Once
- [Should Medicare premium information be shared with PPO providers?](https://ghgadvisors.com/should-medicare-premium-information-be-shared-with-ppo-providers/) - CMS and the Center for Medicare and Medicaid Innovation (CMMI), in an effort to provide a more coordinated and satisfactory patient experience when it comes to the delivery of healthcare services, has placed much focus on improving Medicare program transparency around access to services, provider quality measures, clinical outcomes and fair pricing. It is fair to ask whether or not
- [Pioneers Move Forward, But Medicare May Still Be Left Behind on ACOs](https://ghgadvisors.com/pioneers-move-forward-but-medicare-may-still-be-left-behind-on-acos/) - A CMS official announced Tuesday that final regulations for the Medicare Accountable Care Organization (ACO) Shared Savings Program are now expected mid-October. It looks like ACA's requirement that the SSP launch January 1 is now out of reach, and there's scuttlebutt here in DC that the launch date will be pushed to June or July
- [It's Official: the Supremes Will Decide on the Mandate.  Smack in the Middle of the Presidential Election.](https://ghgadvisors.com/its-official-the-supremes-will-decide-on-the-mandate-smack-in-the-middle-of-the-presidential-election/) - On Monday the Department of Justice confirmed that it did not request a review of an appeals court's decision to overturn the ACA's individual mandate. The decision ensures the Supreme Court will rule on the mandate sometime in June of 2012: just months before the Presidential election. My thinking up until today was that health reform wouldn't play
- [CMS Pioneer ACO Demonstration Program: Update](https://ghgadvisors.com/cms-pioneer-aco-demonstration-program-update/) - The CMS Pioneer Demonstration program is in stage two of the application process -- meaning that certain applicants have been invited by CMS to proceed to the next level, which is to defend/expand their submitted application in front of a CMS interview panel. Those interviews are currently in process and it is satisfying to know that all
- [Repairing Medicare](https://ghgadvisors.com/repairing-medicare/) - Last week the President outlined his proposal for salvaging Medicare. He suggested cutting $248 billion in expenditures over the next ten years. Significantly, that is only 4% of the $6.3 trillion estimated to be spent on the program in that decade. The money is to come from two places: The majority (90%) is from decreased reimbursement
- [Insourcing: So you are thinking about internalizing risk adjustment . . .](https://ghgadvisors.com/insourcing-so-you-are-thinking-about-internalizing-risk-adjustment/) - We talk to health plans everyday that want to internalize risk adjustment. Bottom line: It is a good idea. Taking control and building an expert, internal risk adjustment team is one of the best tactics a health plan can take. Here, we share an initial checklist of those areas needed for "in-sourcing":  Claims based HCC filtering  RAPS filtering and
- [Become a Star: What MA-PD Plans can learn from Mickey Mouse](https://ghgadvisors.com/become-a-star-what-ma-pd-plans-can-learn-from-mickey-mouse/) - The Five Star Quality Rating System for Medicare Advantage Plans is run by CMS, and was put in place as part of an effort to help educate consumers on quality, and to make quality data more transparent. Universal assets of a successful business are the links in Disney's "Chain of Excellence": Leadership excellence, people management,
- [Obama Kicks the Hornet's Nest on Medicare](https://ghgadvisors.com/obama-kicks-the-hornets-nest-on-medicare/) - The President laid out his recommendations on Medicare and Medicaid to the Congressional Super-Committee on Tuesday: about $320 Billion's worth, mostly retreads of long-standing recommendations from other budget-cutting panels like Bowles-Simpson. Kaiser Health News has the details in their Wednesday story. The White House fact sheet on the President's proposal can be found here. Obama really
- [Marketplace snapshot: Integrating quality and risk adjustment](https://ghgadvisors.com/marketplace-snapshot-integrating-quality-and-risk-adjustment/) - Just a short note about a Webinar we did last week, hosted by MCOL, and focused on the integration of quality and risk adjustment. While discussing the relationship between risk adjustment and quality for health plans, we asked three questions during that drew some interesting answers: First, we asked about the Star ratings of the
- [Last week at AHIP: How are you sleeping lately?](https://ghgadvisors.com/last-week-at-ahip-how-are-you-sleeping-lately/) - We heard a lot about STARS and compliance, about integration and collaboration. But what should be keeping you up at night? EDPS and RADV extrapolation. Sean Creighton said that EDPS compliance and accuracy may affect your STARS rating and Jonathan Blum shared that the RADV extrapolation equation is under review but will be released soon.
- [Medicare Advantage Premiums Down, Enrollment Way Up in 2012](https://ghgadvisors.com/medicare-advantage-premiums-down-enrollment-way-up-in-2012/) - We've long said on these pages that all the predictions of the demise of Medicare Advantage following passage of the ACA and its steep cuts to the program were premature. Finally, confirmation from CMS: MA premiums will fall another 4% in 2012, and enrollment will grow by a brisk 10%. The news was delivered Friday by Jonathan
- [Obama Submits (Medicare) Proposal to Super-Committee Today](https://ghgadvisors.com/obama-submits-medicare-proposal-to-super-committee-today/) - The Congressional deficit "Super-Committee" formally began its work last week, and President Obama is expected to release his deficit reduction proposal today at 10am EDT. The President's plan is expected to seek as much as $3 Trillion in savings -- including, most notably, the new "Buffett Rule" establishing a new tax bracket for millionaires. The
- [My Talk at AHIP's Medicare Conference](https://ghgadvisors.com/my-talk-at-ahips-medicare-conference/) - I had the pleasure of addressing a standing-room-only crowd at the AHIP Medicare conference yesterday, sponsored by our friends at TMG Health, our 4th year together there. That speech always keeps me on my toes, especially this year -- a tough, smart audience that demands a tough, smart message on how to survive in the new
- [Get your money's worth](https://ghgadvisors.com/get-your-moneys-worth/) - When I was a kid, we would jump on those tiny merry-go-arounds outside of stores or those little goofy race cars in Toys R Us and my dad would shake them. Yes, it is true. He refused to put the 25 cents in to move them mechanically. He would just shake them and after a
- [GHG hosting Revenue Forum Oct 6-7 in Las Vegas](https://ghgadvisors.com/ghg-hosting-revenue-forum-oct-6-7-in-las-vegas/) - Your payment is coming down. Your blood pressure is going up. • How are you planning to mitigate the coming payment reductions? • Can we make the difference up through efficiencies alone or do we need to look to top-line solutions, too? • What strategy have you developed to integrate revenue management into operations? • When will we know
- [Using What You Know to Improve Care for Your Members](https://ghgadvisors.com/using-what-you-know-to-improve-care-for-your-members/) - In the current issue of the New England Journal of Medicine , a group of physicians from Harvard Medical School describe an unfortunate and instructive case.[1] One of the system's patients had her spleen removed after an automobile accident. I would venture to guess that just about every sophomore medical student knows that people without
- [Law of Averages: How does it add up to a complete health picture of your members?](https://ghgadvisors.com/law-of-averages-how-does-it-add-up-to-a-complete-health-picture-of-your-members/) - I attend a number of industry conferences, and at a recent event hosted by Opal in San Diego, I heard the following: The average 75 year old has three chronic conditions and takes five medications The average 75 year old Medicare Advantage (MA) member spends 12 hours a year in doctor visits The average amount
- [Do Stars Matter?](https://ghgadvisors.com/do-stars-matter/) - I have occasionally made the point that MA can have a positive impact on members' lives in a way that fee for service Medicare can never replicate. Over the weekend, I was catching up on old journals and ran across a nice case in point. If you are like me, you have wondered from time
- [Alternatives to the Individual Mandate](https://ghgadvisors.com/alternatives-to-the-individual-mandate/) - Kaiser Health News is doing some tremendous reporting these days. Today they offered some perspectives from a number of experts on alternatives to the individual mandate, recognizing the unlikely chance the US Supreme Court will strike it down when it considers the issue next year. We think the mandate will be upheld given other precedents that allow
- [Medicaid Managed Care = Risky (BIG) Business](https://ghgadvisors.com/medicaid-managed-care-risky-big-business/) - The Washington Post printed a recent expose on the coming explosion in Medicaid managed care opportunities, coupled with the tremendous challenges of caring for lower-income, vulnerable beneficiaries, especially dual eligibles. Texas is moving some 425,000 beneficiaries into health plans this year. California began moving 380,000 older and disabled patients into private plans in June. Louisiana debuted managed-care
- [America's Hospital Patient Safety Problem in 1 Awesome Graphic](https://ghgadvisors.com/americas-hospital-patient-safety-problem-in-1-awesome-graphic/) - The graphics geniuses at MedicalBillingandCodingCertification.net have come out with another of their charticles examining the American health-care system. The quick takeaway? "The United States ranks dead last out of 19 developed nations in preventable deaths at hospitals." The problem is preventable and the solutions pretty straightforward. The charticle is fascinating and scary. Enjoy.
- [And the Survey Says... Claims based submissions are scary](https://ghgadvisors.com/and-the-survey-says-claims-based-submissions-are-scary/) - During our September 1st webinar, Risk Adjustment: Vulnerabilities in Claim Based HCC Codes, we asked our health plan attendees a few questions about claims-based HCC codes. Here are the answers. What percentage of your HCC submissions comes from claims? 25% of the health plans answered 45-60% 21% of the health plans answered 61-80% 44% of the health plans answered 81-100% Studies
- [Debt Crisis Hangover: 'Scary Erosion in Confidence'](https://ghgadvisors.com/debt-crisis-hangover-scary-erosion-in-confidence/) - Politico had a terrific story last week on the lingering hangover from the debt crisis. New data from The Conference Board suggest that the bitter debt ceiling debate in DC not only drove the US to the edge of default and cost the nation its triple-A credit rating, but crushed American confidence like few recent events and may
- [Consolidation in Medicare Advantage and Prospects for Regional/Local Plans](https://ghgadvisors.com/consolidation-in-medicare-advantage-and-prospects-for-regionallocal-plans/) - In the past 12 months three health insurers have each acquired a Medicare Advantage HMO: HealthSpring (Bravo), WellPoint (CareMore), and Humana (Arcadian). Large plans are finding that acquisitions make more sense than investments in organic growth in certain markets, and that enrollment will be driven by millions of plan-friendly Baby Boomers and employers seeking to transfer
- [United Acquisition of Monarch Healthcare (CA): Marx Meets Managed Care, Again](https://ghgadvisors.com/united-acquisition-of-monarch-healthcare-ca-marx-meets-managed-care-again/) - The Wall Street Journal reported this morning that United Healthcare is acquiring our longtime client, Monarch Healthcare in Irvine, CA. The transaction is further evidence that Marx (Karl, not Groucho) has met managed care: a payer controlling the means of production in an intensely competitive market. There have been several other payer/provider deals in the last few
- [CMS Innovations: Bundled Payments for Care Improvement Program](https://ghgadvisors.com/cms-innovations-bundled-payments-for-care-improvement-program/) - CMS Innovations: Bundled Payments for Care Improvement Program On August 23, 2011 CMC/CMMI unveiled its most recent tool in its arsenal to reduce cost and impact quality and access to healthcare services for Medicare beneficiaries. Referred to as the Bundled Payments for Care Improvement Initiative, it is a variation on the theme first employed in
- [Prices in Healthcare](https://ghgadvisors.com/prices-in-healthcare/) - For months now the national and local news has focused on the price of gas. $3.79 per gallon this week in my part of the San Francisco Bay area. At Costco it is $3.59 per gallon, if you are willing to wait in line. Of course there is a website that will tell you gas prices and map
- [Medicare Advantage Plans as Laboratory for Best Practices](https://ghgadvisors.com/medicare-advantage-plans-as-laboratory-for-best-practices/) - In announcing the 2012 Chronic Care Improvement Program and Quality Improvement Projects for Medicare Advantage plans, CMS is going back to the future. When these quality improvement programs were begun over a decade ago, CMS established national projects on priority areas for all MA plans. CMS is returning to a national project for 2012 and
- [PBM merging pharmacy and medical claims: The time is right](https://ghgadvisors.com/pbm-merging-pharmacy-and-medical-claims-the-time-is-right/) - Pharmacy claims exist in a health plan in two distinct silos. Medical pharmacy claims are billed to the medical benefit using a professional claim format such as a CMS 1500. Claims are coded with HCPCs rather than NDCs and are generally much higher cost pharmaceuticals than their retail counterparts. Medical claims are generated by physician
- [Medicare's Looming Risk Transfer](https://ghgadvisors.com/medicares-looming-risk-transfer/) - Please read Dr. Jaan Sidorov's Health Affairs blog on "Medicare's Looming Risk Transfer" where he describes how the ACA and Democrat and Republican proposals to reform Medicare "transfer substantial portions of Medicare's monetized risk from the government to one or more third parties."
- [The Water Hazard of Risk Adjustment: HCCs from Claims](https://ghgadvisors.com/the-water-hazard-of-risk-adjustment-hccs-from-claims/) - I love the saying "Golf isn't a sport - It is old man walking around in ugly pants." Ugly pants aside, golf definitely has its challenges: water hazards, sand pits ... other golfers, trees, birds... finding your inner athlete .... and so does risk adjustment. In the last six years we have gone from focusing on chart
- [Too Much of a Good Thing](https://ghgadvisors.com/too-much-of-a-good-thing/) - Ever find yourself in the cereal aisle, staring blankly at the mosaic of options, your enthusiasm for the task waning with each passing second? Everyone has heard (and experienced) the phenomenon of being overwhelmed by choice. Now, a new study, published in Health Affairs and conducted by Harvard Medical School appears to show that as
- [The Medicare Pioneer ACO Program: What's Next?](https://ghgadvisors.com/the-medicare-pioneer-aco-program-whats-next/) - For those of us even vaguely involved in Medicare, the reference to the Pioneer ACO Demonstration program elicits feelings of optimism and relief—optimism because it is an approach to reengineering healthcare and relief because the application submission deadline has come and passed. Most of you will recall that the Pioneer ACO Demonstration program is a
- [Remember, Mom: Digital is Forever.](https://ghgadvisors.com/remember-mom-digital-is-forever/) - Humana has launched a social network for its Medicare Advantage and Part D members called "Humanaville." No word yet if members have started posting embarrassing pictures of shenanigans in the skilled nursing facility... Actually, it's not exactly a social network like Facebook. Rather, the design and functionality more closely resembles Second Life, in which users
- [11th Circuit Court Strikes Down Mandate](https://ghgadvisors.com/11th-circuit-court-strikes-down-mandate/) - Much of the news related to healthcare last week focused on those headlines. Those who have consistently argued that the Health Care Reform act is bad policy hailed the circuit court's decision as a victory. Those who believe in the mandate that every American have access to and be motivated to buy health insurance, decried the decision as
- [Data Security & Compliance: The Dwayne Johnson of Risk Adjustment](https://ghgadvisors.com/data-security-compliance-the-dwayne-johnson-of-risk-adjustment/) - These days, Risk adjustment is a lot like WrestleMania these. I am not sure if that makes CMS John Cena…but I am certain health plans should be prepared for that folding chair to the head move. Health plans need a new training regime and a new foundation. Security and compliance is the cornerstone on which a health plan's
- [How's their security and compliance? Your vendor oversight checklist](https://ghgadvisors.com/hows-their-security-and-compliance-your-vendor-oversight-checklist/) - Yesterday Gorman Health Group Executive VP Steve Balcerzak and CenseoHealth's Director of Techology Archie Block joined me for one of our Flash Webinars, which covered the security and compliance points every health plan should review with their vendors. We'll follow up later today with a recap of the event's live polls and surveys, as well
- [Obama and Boehner Have Forever Changed the Medicare Debate](https://ghgadvisors.com/obama-and-boehner-have-forever-changed-the-medicare-debate/) - President Obama and House Speaker Boehner may have failed to strike a "grand bargain" on the nation's deficit, but they have accomplished one thing in our world: they have forever changed the terms of the Medicare debate. There is an air of inevitability about some of the proposals they have put forth brewing here in DC. Obama has
- [Medicare Advantage and PDP Plans Continue Robust Growth](https://ghgadvisors.com/medicare-advantage-and-pdp-plans-continue-robust-growth/) - The August enrollment numbers are in from CMS. 61,000 new MA members in August and 544,000 year-to-date. MA and PDP plans continued their robust growth on pace to exceed 2010's enrollment gains. Year to date it appears Boomer "age-ins" are continuing to choose MA at a higher rate than their forebears -- more than 40% for
- [What If the Individual Mandate is Overturned?](https://ghgadvisors.com/what-if-the-individual-mandate-is-overturned/) - If the individual mandate is overturned, what will happen next will largely depend on the outcome of the 2012 elections. At the moment, it is hard to imagine that the Congress could compromise on any legislation related to health care reform. But that could change. The biggest problem will be the issue of adverse selection
- [President Ryan?](https://ghgadvisors.com/president-ryan/) - Washington is abuzz this week that Paul Ryan is considering a run for President. Remember him? He reportedly is in Colorado with his family at this time discussing their position on turning their life into a 24/7 freakshow. Say what you will about the Roadmap--- a Ryan candidacy would put Medicare solvency and Government-sponsored health
- [Timing is Everything](https://ghgadvisors.com/timing-is-everything/) - We chatted with several health plans during the GHG August 11, 2011 webinar. The purpose was to highlight that the earlier you begin your risk adjustment the better because you have more chances to: • Get the data • Interact with the member • Impact the member's satisfaction • Link the findings to care • Impact the premium sooner We
- [The Medicare "Doc Fix" Will Get Pegged to Quality Measures](https://ghgadvisors.com/the-medicare-doc-fix-will-get-pegged-to-quality-measures/) - We're hearing from friends on the Hill that Republican staff on the Energy and Commerce Committee are thinking about attaching a pay-for-performance system to any fix of the Medicare Sustainable Growth Rate. The new approach would cost less than a straight fix of the SGR, which will slash Medicare payments to doctors by 29 percent
- [The Individual Mandate Will Get Settled by the Supremes](https://ghgadvisors.com/the-individual-mandate-will-get-settled-by-the-supremes/) - On Friday the 11th Circuit Court of Appeals in Atlanta found the ACA's individual mandate unconstitutional, ensuring the matter will be decided by the US Supreme Court in 2012. The only question among the DC chattering class is if the ruling will come in time to have an impact on the election, not whether the
- [Exchange Eligibility Regs: Massive and Visionary](https://ghgadvisors.com/exchange-eligibility-regs-massive-and-visionary/) - Just as we were speculating Friday on timing for the Exchange eligibility and enrollment regs, out it came. The NPRM is a massive and visionary document that starts a discussion about how to revolutionize the way Americans select, enroll and pay for insurance. States and the Federal government face a daunting task of preparing for a flood
- [Exchange Operations Regs Due Next](https://ghgadvisors.com/exchange-operations-regs-due-next/) - Recently at a Bipartisan Policy Center forum, CMS said the health insurance exchange regulations from HHS will cover enrollment and eligibility requirements. As we saw firsthand with the messy launch of Medicare Part D in 2006 -- one plagued by enrollment and eligibility SNAFUs for the first 6 months of the program, which kept thousands
- [Help take the "salesguy" out of your sales force](https://ghgadvisors.com/sales-agent-oversight-made-simple/) - With CMS sure to maintain their focus on agent conduct, plans must demonstrate adequate oversight of their ever-changing sales force. The Gorman Health Group Sales Sentinel organizes oversight data from multiple sources into one easy-to-use dashboard. Identify risks sooner and make decisions more quickly and decisively. From tracking compliants to gathering enrollment data, this is
- [Why should physicians do prospective evaluations?](https://ghgadvisors.com/why-should-physicians-do-prospective-evaluations/) - Most plans that have done prospective evaluations have taken one of two approaches: Using their existing physician network, or using mid-level practitioners who live in the same general area as the members to be evaluated. Although they have been significantly more effective than network physicians in these programs, there is a better way. It
- [Obama is the Best Conservative President since Bill Clinton](https://ghgadvisors.com/obama-is-the-best-conservative-president-since-bill-clinton/) - An interesting article by noted wild-eyed liberal* Bruce Bartlett. *Bartlett served on the staffs of Congressmen Ron Paul and Jack Kemp and Senator Roger Jepsen; as staff director of the Joint Economic Committee of Congress; senior policy analyst in the Reagan White House; and deputy assistant secretary for economic policy at the Treasury Department during the George
- [In Tough Times, the Elderly Make Easy Prey](https://ghgadvisors.com/in-tough-times-the-elderly-make-easy-prey/) - Financial abuse of the elderly is up -- way up. It's a tragic sign of the times that seniors are being targeted for theft and abuse at record levels as the economy continues to sputter.
- [Further Evidence that Part D is Working](https://ghgadvisors.com/further-evidence-that-part-d-is-working/) - New data shows that seniors enrolled in Medicare Part D will pay about $30 in monthly premiums in 2012, 76 cents less than they do now and about 44 percent lower than originally projected in 2003. Indeed, since 2007, premium costs in Medicare's Part D program have increased by about $8, according to CMS. The program
- [What Happened to the Crack-berry?](https://ghgadvisors.com/what-happened-to-the-crack-berry/) - This amazing letter was written to RIM leadership by a ranking exec about the woes of their flagship product line, which you know and love as BlackBerry. It's not often that a company* can appropriate a 1000-year-old word and completely change its meaning in the culture. It's a testament to the way RIM changed--one could say created--the
- [A Way Out of the Healthcare Cost Explosion?  Look North](https://ghgadvisors.com/a-way-out-of-the-healthcare-cost-explosion-look-north/) - According to a study by the University of Toronto in Health Affairs, US health care spending could be cut by billions a year if doctors spent the same amount of time and money dealing with insurance plans as their Canadian counterparts. Because Canada has a single-payer system -- essentially Medicare for all -- and because of
- [Hey Star Czars: Look Here](https://ghgadvisors.com/hey-star-czars-look-here/) - McKnight's Long Term Care News is reporting that results released from two separate studies show that seniors who receive transitional care following a hospital discharge are far less likely to return to the inpatient setting. With hostpital re-admits a huge driver of medical utilization and under consideration for a new star rating measure, plans are
- [Medicaid Came This Close to Deep Cuts in the Debt Battle](https://ghgadvisors.com/medicaid-came-this-close-to-deep-cuts-in-the-debt-battle/) - Keeping Medicaid from automatic cuts was a priority of the Obama administration in the final, ugly days of the debt ceiling fight. It was the one major concession the President and the Democrats won in the whole nasty sausage-making exercise. Politico did a great job telling how the deal was done, and the tense moment when
- [Debt "Deal": Not As Bad for Medicare as Expected, Medicaid Spared](https://ghgadvisors.com/debt-deal-not-as-bad-for-medicare-as-expected-medicaid-spared/) - So we have a deal on the debt ceiling. The President is now authorized to raise the debt ceiling by at least $2.1 Trillion. The roughly $2.5 Trillion in cuts over 10 years represents 5% of expected Federal spending over that time period. $917 Billion in cuts are made up-front. A joint bipartisan committee will then decide on
- [Poll: Cut the Deficit, but Not Medicare](https://ghgadvisors.com/poll-cut-the-deficit-but-not-medicare/) - Half of all Americans say the deficit should be reduced by cutting spending on government programs and services, but there is strong opposition to cutting entitlements, according to a poll released Thursday by the Kaiser Family Foundation. Kaiser's July Health Tracking Poll found that 62 percent of people don't want Social Security cut, 59 percent
- [What Happens to Medicare and Medicaid If We Default, continued](https://ghgadvisors.com/what-happens-to-medicare-and-medicaid-if-we-default-continued/) - The Bipartisan Policy Center tried this week to break down the daily cash flow in the days following the Aug. 2 deadline to give an idea of what could get paid. On Aug. 3, a day when there will be a $20 billion shortfall, $2.2 billion in Medicare and Medicaid bills will vie with $23
- [Blowing up the "Health Insurance" Service Model](https://ghgadvisors.com/blowing-up-the-health-insurance-service-model/) - In the 15 months since ACA passed, MA plans have scrambled to improve their Star Rating. Nothing motivates like the promise of a 5% premium bump in an era otherwise marked by dramatic payment decline. Also motivating: CMS appears to be making initial steps towards delivering on intimations that low-rated plans will have their contracts terminated. Early
- [Blame it on the Heat](https://ghgadvisors.com/blame-it-on-the-heat/) - Things are getting goofy in DC. Anne Lowrey of Slate explains the latest idea to plunge the clogged toilet that is Congress: "One option is coin seigniorage—aka, the "really-huge-coin workaround." The United States has a statutory limit on the amount of paper money in circulation, but no such limit on coins. The Treasury secretary has
- [Your weekend mental health break](https://ghgadvisors.com/your-weekend-mental-health-break-3/) - Over here at the GHG HQ we're a big fan of Jessica Hagy. We hope you enjoy her insightful venn diagrams and especially hope you incorporate them into your next corporate powerpoint presentation.
- [Medicare Part D Works](https://ghgadvisors.com/medicare-part-d-works/) - According to a recently released study Medicare Part D is successful in assisting seniors in affording maintenance and other drugs that keep them out of hospitals and emergency rooms. This results in an estimated $12 billion in savings per year or about $1200 per senior that was inadequately covered before the program came into effect
- [Sebelius Weighs in on the Debt Debate](https://ghgadvisors.com/sebelius-weighs-in-on-the-debt-debate/) - Politico Pro got the "get" with HHS Secretary Kathleen Sebelius yesterday, who said the debt ceiling negotiation is casting a shadow over HHS's day-to-day operations. "I would think it would make people a little leery about contracting with us, not knowing if we're going to pay our bills. That's a pretty precarious place to be,"
- [Collaboration and Partnership with CMS](https://ghgadvisors.com/collaboration-and-partnership-with-cms/) - Having spent my government career at CMS, it was interesting for me to listen to current CMS officials Steve Larsen (CCIIO) and Cindy Mann (Medicaid) describe the many opportunities for states and other stakeholders to participate in the development of federal policy for Health Exchanges that were authorized by the Affordable Care Act. The discussion
- [What are the amendments anyway?](https://ghgadvisors.com/what-are-the-amendments-anyway/) - As I watched the increasing drama of the debt ceiling unfold over the weekend, several commentators discussed the possibility of Obama being able to raise the limit regardless of congress due to the 14th amendment. Interesting article on this yesterday in the NY times. We hear commentators and politicians quoting the constitution and amendments constantly
- [CenseoHealth & GHG Poll on Prospective Evaluations](https://ghgadvisors.com/censeohealth-ghg-poll-on-prospective-evaluations/) - Question: What percentage of your membership are you targeting for prospective evaluations? Answers: Prof. McCallum Report Card: 9% of webinar attendees said 80 - 100% of members A+ 7% of webinar attendees said 65 - 79% of members A- 21% of webinar attendees said 50 - 64% of members B+ 19% of webinar attendees said 35
- [CenseoHealth & GHG: Retrospective Review Poll Results](https://ghgadvisors.com/censeohealth-ghg-retrospective-review-poll-results/) - Drum roll please… Question: What percentage of your membership are you targeting for retrospective evaluations? Answers: Prof. McCallum Report Card: 32% of webinar attendees said 80-100% of members B- Far too large a net is being cast and possibly too much money spent on charts that are not yielding much clinical or financial impact. Let's focus
- [Economic Calamity Update: Scoring Deficit Reduction](https://ghgadvisors.com/economic-calamity-update-scoring-deficit-reduction/) - Senator Harry Reid's plan reduces the deficit more that Rep. John Boehner's plan, says the CBO.
- [GHG Announcement!](https://ghgadvisors.com/ghg-announcement/) - We're thrilled to announce the launch of CenseoHealth, a new kind of HCC Management company. Stand by for more discussion on these pages with my colleagues Jack McCallum, M.D. and RaeAnn Grossman. If you have any questions or feedback I welcome it at ngoldstein (at) gormanhealthgroup.com--- or just leave a comment here.
- [Joe Scarborough's Vision of the Day After Will Haunt My Dreams](https://ghgadvisors.com/joe-scarboroughs-vision-of-the-day-after-will-haunt-my-dreams/) - The President and the Speaker have made their case to the American people...and still couldn't seem farther apart. They're both now dug in and appealing to different constituencies. Obama was all Kool and the Gang, quoting Reagan and Jefferson to the beat of "Too Hot" and trying out the 2012 "I'm the only grownup here" stump speech
- [Givin' Props to End of Life Care](https://ghgadvisors.com/givin-props-to-end-of-life-care/) - What do you get when you combine Health Policy with Bracketology? Modern Healthcare recently held a public tournament in celebration of its 35th birthday in order to determine what "one person, event, organization or innovation had the biggest impact on the health care delivery system in the past 35 years." The tournament began on April
- [Being Tim Geitner](https://ghgadvisors.com/being-tim-geitner/) - Try your hand at prioritizing US outlays post-default!
- [The Republicans Have Won. Will They Get Out of Their Own Way?](https://ghgadvisors.com/the-republicans-have-won-will-they-get-out-of-their-own-way/) - The GOP came to the debt ceiling fight with goals of avoiding a deal where they have to vote for tax increases and preventing President Obama from getting a political victory. Given what US House Speaker Boehner and Senate Majority Leader Reid are working on today -- new debt-reduction proposals without tax increases -- the
- [Unintended Consequences](https://ghgadvisors.com/unintended-consequences/) - Yes, another post on default. But a short one. The irony of the discussion regarding payment prioritization in the event of a default on 8/2 is that if we indeed honor our obligations to pay interest on the debt (as is universally acknowledged we would do) first as part of a prioritization scheme.... the effect
- [What is the "advantage" in Medicare Advantage?](https://ghgadvisors.com/what-is-the-advantage-in-medicare-advantage/) - All the clamor over cuts in MA reimbursement and audits of MA payments has caused us to lose track of what this program can do that traditional Medicare cannot. Risk adjustment has made direct, careful clinical assessment of MA members a financial imperative. The Stars program has made measuring quality of care for those members
- [Debt Negotiations Collapse.  What Does it Mean for Medicare?](https://ghgadvisors.com/debt-negotiations-collapse-jhc-wtf-does-it-mean-for-medicare/) - Another week, another impasse in debt ceiling negotiations with 9 days to go before default. My favorite wonk, WaPo's Ezra Klein, does a CSI-style autopsy of how we got here and a primer on the issue. We just proved to the world that Washington has become California: ungovernable. Credit agencies aren't grading our ability to raise the
- [Options on the Table for Debt Reduction at the 11th Hour](https://ghgadvisors.com/options-on-the-table-for-debt-reduction-at-the-11th-hour/) - This morning WaPo offered great coverage on the state of play on the debt negotiations and included this terrific visual on the options on the table. Yesterday my colleague Nathan Goldstein wrote about recent polling showing the public's preferences, and it appears class warfare is alive and well in the US. Nathan's right: Democrats are winning
- [Rep. Conyers -- My Old Boss -- Faces the Redistricting Music](https://ghgadvisors.com/rep-conyers-my-old-boss-faces-the-redistricting-music/) - The man with whom my Washington career began 21 years ago, US Rep. John Conyers from my hometown of Detroit, is in real danger of losing his seat to redistricting, Politico reports this morning. It would be an unfortunate end to a storied and at times controversial career. Conyers is a prince of a man
- [Amen to that (the US Chamber of Commerce??)!](https://ghgadvisors.com/amen-to-that-the-us-chamber-of-commerce/) - I'm not usually one to agree with right-wing leaning pro-business groups, but this debt ceiling fight makes strange bedfellows. Republican business allies are growing more restless as the crisis persists, Politico reports. "Jeopardizing our country's credit rating and fiscal security by refusing to compromise isn't the answer," R. Bruce Josten, U.S. Chamber of Commerce executive
- [House GOP Warned on Fiscal Irresponsibility](https://ghgadvisors.com/house-gop-warned-on-fiscal-irresponsibility/) - From Politico: "House Republicans were cautioned Thursday in a closed door meeting with credit rating agency officials that a "death spiral" in the bond market was one of the possible outcomes in the event of default. One official warned of a worst-case scenario in which a default on the nation's credit could result in a
- ["For Medicare and Medicaid, Drama"](https://ghgadvisors.com/for-medicare-and-medicaid-drama/) - We're definitely in uncharted waters should the US be allowed to default on its debts August 2. Politico explores what might happen to Medicare and Medicaid should the unthinkable happen. Consider this: Medicare Advantage monthly capitation payments don't get made in September. Despite it being over 100 in DC today, that cold chill down my
- [Cut, Cap and Balance Crashes and Burns in the Senate](https://ghgadvisors.com/cut-cap-and-balance-crashes-and-burns-in-the-senate/) - The Senate just rejected the idiotic House GOP bill to "Cut, Cap and Balance" the Federal budget. "It's one of the stupidest constitutional amendments I have ever seen," said Senate Budget Committee Chairman Kent Conrad (D-N.D.), a member of the "Gang of Six" that unveiled a bipartisan deficit-reduction framework this week. "It looks like it
- [Carmegeddon and the Drive Towards More Access](https://ghgadvisors.com/carmegeddon-and-the-drive-towards-more-access/) - As many of you have heard, "Carmegeddon" took place over the weekend. A ten mile stretch of Los Angeles' 405 Freeway was closed for a full 48 hours. Why? To make it bigger of course! After all, pushing the same amount of traffic through greater lane capacity should reduce congestion in the country's busiest road….
- [Dems Are Winning the Argument, Losing the War](https://ghgadvisors.com/dems-are-winning-the-argument-losing-the-war/) - Today's ABC News poll shows that: 62 percent of those surveyed believe we need a mixture of tax hikes and spending cuts to deal with the debt, compared with only 32 percent wanting spending cuts alone. By far the most popular specific measure for tackling the debt is ending the Bush tax cuts for those earning
- [GHG Overview and Analysis: NPRM on Exchanges](https://ghgadvisors.com/ghg-overview-and-analysis-nprm-on-exchanges/) - On July 11, 2011, the Center for Medicare and Medicaid Services (CMS) released two proposed rules to implement provisions of the Affordable Care Act (ACA) which authorize competitive marketplaces known as Affordable Insurance Exchanges, or "Exchanges," where individuals and small employer groups can compare private health insurance options on the basis of price and quality,
- [The Boomers' Expanding Waistlines Bodes Dangerously for Medicare](https://ghgadvisors.com/the-boomers-expanding-waistlines-bodes-dangerously-for-medicare/) - The Associated Press reported yesterday that Baby Boomers are more obese than other generations, setting them up for unhealthy senior years: "For all the talk of '60 is the new 50' and active aging, even those who aren't obese need to do more to stay fit." It's a scary portent of things to come, warning
- [The Plot Thickens on Florida Medicaid Reform](https://ghgadvisors.com/the-plot-thickens-on-florida-medicaid-reform/) - Government health programs geeks like me are closely watching developments in Florida as Governor Rick Scott attempts a drastic overhaul of his state's Medicaid program. The state intends to seek a broad waiver of Medicaid requirements from CMS on August 1 to force almost all beneficiaries in the state into health plans, including the Aged,
- [The "Potomac Two-Step" at its Worst](https://ghgadvisors.com/the-potomac-two-step-at-its-worst/) - Last night the Cut, Cap and Balance Act of 2011 (H.R. 2560) was passed in the House by a vote of 234-190. The bill would cut and cap federal spending and would also require a balanced budget amendment to be passed by Congress prior to increasing the federal debt limit. The bill is more fiddling
- [Surprises in the Proposed Exchange Regulation](https://ghgadvisors.com/surprises-in-the-proposed-exchange-regulation/) - On July 11 HHS released the proposed Exchange regulation that will govern the new health care marketplace beginning in 2014. One of the issues that surprised me was the lack of detail on consumer protection. While there are many and perhaps even competing provisions impacting consumer information e.g. from the Exchanges, call centers, new Navigator
- [Just Desserts for the Queen of "Death Panels"](https://ghgadvisors.com/just-desserts-for-the-queen-of-death-panels/) - Sarah Palin's vanity "documentary" flick "The Undefeated" tanked at the box office over the weekend . Forgive my snickering. It's just desserts for the woman who brought us the biggest distortion of the 2010 Presidential campaign: "death panels". Regardless of your politics, as healthcare professionals, we should be able to agree that those two words
- [Rushing Toward Another Financial Cliff with 6th Graders Screaming in the Backseat](https://ghgadvisors.com/rushing-toward-another-financial-cliff-with-6th-graders-screaming-in-the-backseat/) - I'll admit I'm a geek about economics, so I'm fascinated and appalled as another weekend went by as Congressional "leaders" continue to flirt with disaster on the debt ceiling. We're rushing toward another financial cliff when we default on August 2, and politicians are acting like 6th graders screaming in the backseat. So I went
- [Going to the Mat for Capitated Pioneer ACOs](https://ghgadvisors.com/going-to-the-mat-for-capitated-pioneer-acos/) - GHG is leading an effort with several of our clients to bring real-world capitation to the Pioneer ACO Demonstration. We've had several meetings with CMS to advance the idea, which AIS details in their story in Health Reform Week out last week. Featured Health Business Daily Story, July 13, 2011 Potential ACO Sponsors Warn CMS
- [HHS Secretary Sebelius and Rep. Paul Ryan are Both Right on IPAB](https://ghgadvisors.com/hhs-secretary-sebelius-and-rep-paul-ryan-are-both-right-on-ipab/) - It's "IPAB Beat-Down Week" in DC with no fewer than 4 Congressional hearings scheduled on the Independent Payment Advisory Board (IPAB), the controversial Medicare cost-cutting group established in health reform. IPAB was established as an expert "backstop" in case Congress couldn't agree on methods to contain Medicare costs in the future. The 15-member board will
- [Are We Fixing or Destroying Health Care in America?](https://ghgadvisors.com/are-we-fixing-or-destroying-health-care-in-america/) - The short answer….."who knows yet"? I don't. Having led provider groups, health plans, and hospitals over nearly 30 years in healthcare management, I would have hoped that I could have answered that question definitively by now. Apparently, to add to my education, about 6 months ago I encountered the system as a patient for a very
- [Cuts Would Only Shift Healthcare Costs](https://ghgadvisors.com/cuts-would-only-shift-healthcare-costs/) - I was quoted in Tom Burton's nice piece in today's Wall Street Journal along with friends of the firm Gail Wilensky, Bob Laszewski, and Sara Rosenbaum. The story focuses on how Medicare cuts proposed by House Majority Leader Eric Cantor (R-VA) could impact Medicare beneficiaries and others without addressing long-term costs. At all. It's the
- [The Debt Ceiling Impasse Explained in One Chart](https://ghgadvisors.com/the-debt-ceiling-impasse-explained-in-one-chart/) - Negotiations on the Debt Ceiling ground to a halt after weekend negotiations. President Obama laid out a $4 trillion package his own party is getting upset about, especially his latest proposal to raise Medicare eligibility to 67. Congressional Republicans are calling for a debt reduction plan half that size, but have a drawn a line
- [High-Wire Act on Entitlements as Debt Negotiations Stretch into the Weekend](https://ghgadvisors.com/high-wire-act-on-entitlements-as-debt-negotiations-stretch-into-the-weekend/) - President Obama and Congressional Democratic leaders are walking a high-wire going into weekend negotiations on the debt ceiling with their Republican counterparts. Discussions center around Medicare, Medicaid and Social Security, and the concern is that the President could cut a deal that his Democratic colleagues may not support. The Wall Street Journal has a nice
- [Exchange Regs Released!](https://ghgadvisors.com/exchange-regs-released/) - Is that steamy summer novel not quite holding your interest? Luckily, CMS has stepped in with its latest publication, "Patient Protection and Affordable Care Act; Establishment of Exchanges and Qualified Health Plans." While this work may not make the New York Times best seller list, this initial attempt at defining the exchanges at a Federal
- [CMS Oversight Goes into Hyperdrive](https://ghgadvisors.com/cms-oversight-goes-into-hyperdrive/) - In recent weeks, CMS has sent word to plans of two extraordinary changes in their audit practices. The first is a notice to certain low-rated (plans with contracts
- [‘Dual-Eligibles' Require New Ideas, Not Cuts](https://ghgadvisors.com/dual-eligibles-require-new-ideas-not-cuts/) - Norm Ornstein from the American Enterprise Institute had a tremendous op-ed in Roll Call this week that deserves reprint here. I couldn't agree more, and find new ideas for dual eligibles -- managed long-term care through home and community-based services instead of institutions, aggressive coordinated care, and culturally-competent services -- among the most exciting work
- [CMS Administrator Berwick's "Race Against Time"](https://ghgadvisors.com/cms-administrator-berwicks-race-against-time/) - WaPo had a great piece yesterday on the clock ticking down on CMS Administrator Berwick's time remaining before his recess appointment runs out. It's clear that Congressional Republicans are not going to allow Berwick to be confirmed, and that partisan politics are driving this eminently qualified leader from office at the end of this year. It's
- [The State of Play on Medicare ACOs](https://ghgadvisors.com/the-state-of-play-on-medicare-acos-2/) - GHG and our longtime client North Texas Specialty Physicians were featured in a terrific piece by Harris Myer in this month's Health Affairs. We're continuing to work closely with the CMS Innovation Center to bring some real-world sensibility to capitated Pioneer ACOs. The biggest hurdle so far: bureaucratic inertia around claims payment by ACOs. CMS
- [ACOs Won't Work? What Really Matters When Discussing the Next Steps in Health Reform](https://ghgadvisors.com/acos-wont-work-what-really-matters-when-discussing-the-next-steps-in-health-reform/) - It is interesting that most conversations about healthcare reform either start out or turn very quickly to a discussion of the financial ramifications/barriers/challenges—place whatever moniker you will on it but the conversational road leads most often to the topic of how to best finance healthcare or how much to cut the cost of healthcare. Lost in
- [ACO Principles Worth Fighting For](https://ghgadvisors.com/aco-principles-worth-fighting-for/) - Much has been and continues to be said about the shortcomings of the CMS regulations/requirements associated with the CMS Accountable CARE Organization initiatives. The WSJ recently posted an article claiming that "the draft rule is so awful that even the models for it say they won't participate." It's true: many of the regulations proffered to date are cumbersome
- [This is what Dumb Looks Like](https://ghgadvisors.com/this-is-what-dumb-looks-like/) - The poster tells the story behind the photo: "This is a printout of a patient's medical record, sent from one office to another as the patient was changing primary care providers. An EHR was in place in both offices. Additionally, the EHR in both offices was created by the same vendor (a major vendor); each
- [Medical Mythbusters](https://ghgadvisors.com/medical-mythbusters/) - If John King wanted to confound the GOP candidates for President at last Monday's debate, he might have asked them to comment on this important post by one of our favorite bloggers, Aaron Carroll, over at The Incidental Economist. If one talks to physicians (and I do!) it's clear that that the spectre of malpractice
- [The New Political Calculus on Health Reform](https://ghgadvisors.com/the-new-political-calculus-on-health-reform-2/) - Fresh off the "shellacking" Republicans dealt to Congressional Democrats in the midterm elections, the GOP made "repeal and replace" of the Accountable Care Act their #1 priority. They had 4 major approaches to accomplishing their goal. None are working out particularly well. Repeal the ACA: for this to work it would require President Obama's signature,
- [Accountable Care Organizations (ACOs) for Duals](https://ghgadvisors.com/accountable-care-organizations-acos-for-duals/) - At the June 3 Alliance for Health Reform meeting on Dually Eligible Beneficiaries (i.e. beneficiaries who have Medicare and Medicaid benefits), the discussion focused on how to address the needs of the most complex, costly and frail beneficiaries. Currently only 100,000 of 9 million duals are in integrated systems. The incentives in Medicare and Medicaid
- [Medicare Advantage is Alive and Well](https://ghgadvisors.com/medicare-advantage-is-alive-and-well/) - It wasn't long ago that many in the industry thought Medicare Advantage (MA) was on life support, a casualty of health reform. Today it's viewed as a strategic imperative for publicly-traded companies, enrollment continues to exceed expectations, and we're seeing unprecedented valuations for Medicare plans. Last week WellPoint announced it was acquiring CareMore, a provider-owned
- [Member Evaluations Don't Replace the PCP](https://ghgadvisors.com/in-home-member-evaluations-dont-replace-the-pcp-and-for-good-reason/) - For obvious (and very good) reasons, Medicare Advantage plans want to maximize the unique opportunity afforded by in home evaluations of their members. There is no question that these evaluations can yield diagnostic information that is essential to risk adjustment revenue management. The opportunity to collect clinical information and merge it with data from claims
- [Exchange Will Do You Good](https://ghgadvisors.com/exchange-will-do-you-good/) - Two interesting items have been posted in recent weeks that perfectly capture the contrary motion of health reform implementation. The first, found in the Washington Post, addresses the laggard's pace many states are keeping in implementing provisions of health reform--- in particular the health insurance exchanges that subsidize the purchase of private insurance by low
- [Risk Adjustment: This isn't Dodgeball, People](https://ghgadvisors.com/risk-adjustment-this-isnt-dodgeball-people/) - Let's have a quick check in about risk adjustment and the multi-disciplinary team that should be pushing it to success. Remember the days of dodgeball? ...picking teams and getting smacked by the red rubber ball? In risk adjustment, you must ensure your team has the right members, or you're gonna be left with more than
- [June is GO Time for Risk Adjustment: Your Program Check List](https://ghgadvisors.com/june-is-go-time-for-risk-adjustment-your-program-check-list/) - It's June! And most people are thinking about summer vacation... unless, that is, you work in risk adjustment. This is Go Time. Those living in the risk adjustment world should have their programs designed and launched by now. Are you on target? Here's your checklist: Chart Review: List Developed, Outreach Done, Collection and Coding Started Goal:
- [The State of Play on Medicare ACOs](https://ghgadvisors.com/the-state-of-play-on-medicare-acos/) - The comment period for the Medicare Accountable Care Organization (ACO) Notice of Proposed Rulemaking closed yesterday, June 6. In the last two months CMS has taken a beating from virtually every corner on the draft regulation as being overly burdensome. Dozens of groups, including the American Hospital Association (AHA), American Medical Association (AMA) and America's
- [CMS Leadership and Implications for ACOs](https://ghgadvisors.com/cms-leadership-and-implications-for-acos/) - CMS Administrator Dr. Donald Berwick has been a strong proponent of Accountable Care Organizations as the ACO model embodies his triple aim of better care for individuals, better health for populations, and lower growth in expenditures. He has committed CMS to launching ACOs under the Shared Savings program and the Center for Innovation demonstration program

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- [Contact Us](https://ghgadvisors.com/contact/) - Contact Us Subscribe and stay up-to-date on the latest news and insights from GHG Advisors. Subscribe RELATED INSIGHTS GHG Healthcare Perspectives With Switching Down, MAOs Seek ‘Untapped’ Market Segments AIS Health recently spoke with GHG's Vice President, John Selby, about his analysis of the 2021 Medicare Annual Election Period. Read More 2021 Risk Adjustment Strategy
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- [About](https://ghgadvisors.com/about/) - GHG Advisors is the leading solutions and consulting firm for government-sponsored health programs.
- [Insights](https://ghgadvisors.com/insights/) - Insights by GHG Advisors February 23, 2021 With Switching Down, MAOs Seek ‘Untapped’ Market Segments AIS Health recently spoke with GHG's Vice President, John Selby, about his analysis of the 2021 Medicare Annual Election Period. Read More by Eric Shapiro December 3, 2020 2021 Risk Adjustment Strategy and Program Readiness The COVID-19 pandemic put a
- [Industry Alerts](https://ghgadvisors.com/industry-alerts/) - Industry Alerts by GHG Advisors September 16, 2020 2022 Advance Notice Part I Released, Heavy Focus on Risk Adjustment On September 14th, CMS published the 2022 Advance Notice Part I, with particular emphasis on Risk Adjustment. One key takeaway from this announcement is that CMS will push forward with their plan to… Read More by
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- [Drug pricing](https://ghgadvisors.com/tag/drug-pricing/)
- [Population health](https://ghgadvisors.com/tag/population-health/)
- [ACA](https://ghgadvisors.com/tag/aca/)
- [Affordable Care Act](https://ghgadvisors.com/tag/affordable-care-act/)
- [Supplemental Benefits](https://ghgadvisors.com/tag/supplemental-benefits/)
- [Telehealth](https://ghgadvisors.com/tag/telehealth/)
- [SDOH](https://ghgadvisors.com/tag/sdoh/)
- [AEP](https://ghgadvisors.com/tag/aep/)
- [Clinical](https://ghgadvisors.com/tag/clinical/)
- [Enrollment](https://ghgadvisors.com/tag/enrollment/)
- [covid-19](https://ghgadvisors.com/tag/covid-19/)
- [Medicare Advantage](https://ghgadvisors.com/tag/medicare-advantage/)
- [SDOH Strategy](https://ghgadvisors.com/tag/sdoh-strategy/)
- [coronavirus](https://ghgadvisors.com/tag/coronavirus/)
- [COVID](https://ghgadvisors.com/tag/covid/)
- [COVID-19 Pandemic](https://ghgadvisors.com/tag/covid-19-pandemic/)
- [Fee-for-Service (FFS)](https://ghgadvisors.com/tag/fee-for-service-ffs/)
- [Primary Care Providers](https://ghgadvisors.com/tag/primary-care-providers/)
- [Value-Based Care](https://ghgadvisors.com/tag/value-based-care/)
- [Emergency Departments](https://ghgadvisors.com/tag/emergency-departments/)
- [ACO](https://ghgadvisors.com/tag/aco/)
- [CMS administrator](https://ghgadvisors.com/tag/cms-administrator/)
- [Pioneer ACO Demonstration](https://ghgadvisors.com/tag/pioneer-aco-demonstration/)
- [dual eligibles and ACOs](https://ghgadvisors.com/tag/dual-eligibles-and-acos/)
- [Pioneer ACO Model](https://ghgadvisors.com/tag/pioneer-aco-model/)
- [Accountable Care Organization](https://ghgadvisors.com/tag/accountable-care-organization/)
- [Health Reform](https://ghgadvisors.com/tag/hcr/)
- [Bundled Payments](https://ghgadvisors.com/tag/bundled-payments/)
- [Medicare ACO](https://ghgadvisors.com/tag/medicare-aco/)
- [medicare spending](https://ghgadvisors.com/tag/medicare-spending/)
- [Compliance and HCC Management](https://ghgadvisors.com/tag/compliance-and-hcc-management/)
- [Dual-Eligible](https://ghgadvisors.com/tag/dual-eligible/)
- [Super committee](https://ghgadvisors.com/tag/super-committee/)
- [CMS innovation center](https://ghgadvisors.com/tag/cms-innovation-center/)
- [healthcare reform](https://ghgadvisors.com/tag/healthcare-reform/)
- [GHG ACO](https://ghgadvisors.com/tag/ghg-aco/)
- [Gorman Health Group ACO](https://ghgadvisors.com/tag/gorman-health-group-aco/)
- [Shared Savings ACO regulations](https://ghgadvisors.com/tag/shared-savings-aco-regulations/)
- [Gorman Health Group ACOs](https://ghgadvisors.com/tag/gorman-health-group-acos/)
- [Shared Savings ACO regulation](https://ghgadvisors.com/tag/shared-savings-aco-regulation/)
- [gorman health group](https://ghgadvisors.com/tag/gorman-health-group/)
- [MLR](https://ghgadvisors.com/tag/mlr/)
- [health insurance](https://ghgadvisors.com/tag/health-insurance/)
- [HCC Management](https://ghgadvisors.com/tag/hcc-management/)
- [Member stratification](https://ghgadvisors.com/tag/member-stratification/)
- [Individual Mandate](https://ghgadvisors.com/tag/individual-mandate/)
- [Fiscal cliff](https://ghgadvisors.com/tag/fiscal-cliff/)
- [healthcare delivery](https://ghgadvisors.com/tag/healthcare-delivery/)
- [Smart Networks](https://ghgadvisors.com/tag/smart-networks/)
- [dual eligibles](https://ghgadvisors.com/tag/dual-eligibles/)
- [medicare fee for service](https://ghgadvisors.com/tag/medicare-fee-for-service/)
- [network development](https://ghgadvisors.com/tag/network-development/)
- [Fee For Service](https://ghgadvisors.com/tag/fee-for-service/)
- [FFS payments](https://ghgadvisors.com/tag/ffs-payments/)
- [payment models](https://ghgadvisors.com/tag/payment-models/)
- [NextGen ACO](https://ghgadvisors.com/tag/nextgen-aco/)
- [CMS Accountable Health Communities Model](https://ghgadvisors.com/tag/cms-accountable-health-communities-model/)
- [Managed Long Term Services and Supports (MLTSS)](https://ghgadvisors.com/tag/managed-long-term-services-and-supports-mltss/)
- [service area expansion (SAE)](https://ghgadvisors.com/tag/service-area-expansion-sae/)
- [integrated delivery systems](https://ghgadvisors.com/tag/integrated-delivery-systems/)
- [provider incentive program](https://ghgadvisors.com/tag/provider-incentive-program/)
- [risk adjustment program](https://ghgadvisors.com/tag/risk-adjustment-program/)
- [Trump administration](https://ghgadvisors.com/tag/trump-administration/)
- [Provider Network Adequacy](https://ghgadvisors.com/tag/provider-network-adequacy/)
- [Provider Networks](https://ghgadvisors.com/tag/provider-networks/)
- [provider relations](https://ghgadvisors.com/tag/provider-relations/)
- [Value-Based Arrangements](https://ghgadvisors.com/tag/value-based-arrangements/)
- [Value-Based Contracting](https://ghgadvisors.com/tag/value-based-contracting/)
- [face to face member evaluations](https://ghgadvisors.com/tag/face-to-face-member-evaluations/)
- [Medicare Advantage compliance](https://ghgadvisors.com/tag/medicare-advantage-compliance/)
- [prospective evaluations](https://ghgadvisors.com/tag/prospective-evaluations-2/)
- [vendor oversight](https://ghgadvisors.com/tag/vendor-oversight/)
- [CMS Call Letter](https://ghgadvisors.com/tag/cms-call-letter/)
- [risk adjustment vendor security](https://ghgadvisors.com/tag/risk-adjustment-vendor-security/)
- [Claims based HCC submissions](https://ghgadvisors.com/tag/claims-based-hcc-submissions/)
- [RADV risk mitigation](https://ghgadvisors.com/tag/radv-risk-mitigation/)
- [CMS Star Ratings](https://ghgadvisors.com/tag/cms-star-ratings/)
- [compliance](https://ghgadvisors.com/tag/compliance-2/)
- [chief performance officer](https://ghgadvisors.com/tag/chief-performance-officer/)
- [delegated entity oversight](https://ghgadvisors.com/tag/delegated-entity-oversight/)
- [Appeals & Grievances](https://ghgadvisors.com/tag/appeals-grievances/)
- [CMS program audit](https://ghgadvisors.com/tag/cms-program-audit/)
- [CDAG](https://ghgadvisors.com/tag/cdag/)
- [CMS Program Audit Protocols](https://ghgadvisors.com/tag/cms-program-audit-protocols/)
- [Compliance Program](https://ghgadvisors.com/tag/compliance-program/)
- [Compliance Program Effectiveness](https://ghgadvisors.com/tag/compliance-program-effectiveness/)
- [mock audit](https://ghgadvisors.com/tag/mock-audit/)
- [Program Audit Cycle](https://ghgadvisors.com/tag/program-audit-cycle/)
- [ICARS](https://ghgadvisors.com/tag/icars/)
- [MA audit](https://ghgadvisors.com/tag/ma-audit/)
- [MA compliance](https://ghgadvisors.com/tag/ma-compliance/)
- [non-compliance](https://ghgadvisors.com/tag/non-compliance/)
- [Debate](https://ghgadvisors.com/tag/debate/)
- [Eligibility](https://ghgadvisors.com/tag/eligibility/)
- [health insurance exchanges](https://ghgadvisors.com/tag/health-insurance-exchanges-2/)
- [Federally Facilitated Exchanges](https://ghgadvisors.com/tag/federally-facilitated-exchanges/)
- [FFE](https://ghgadvisors.com/tag/ffe/)
- [policy](https://ghgadvisors.com/tag/policy-2/)
- [Claims Payment](https://ghgadvisors.com/tag/claims-payment/)
- [sequestration and medicare advantage](https://ghgadvisors.com/tag/sequestration-and-medicare-advantage/)
- [Call Center Management](https://ghgadvisors.com/tag/call-center-management/)
- [Health Insurance Broker Commissions](https://ghgadvisors.com/tag/health-insurance-broker-commissions/)
- [Health Insurance Broker Management](https://ghgadvisors.com/tag/health-insurance-broker-management/)
- [customer service](https://ghgadvisors.com/tag/customer-service/)
- [Medicare star ratings](https://ghgadvisors.com/tag/medicare-star-ratings/)
- [reconciliation](https://ghgadvisors.com/tag/reconciliation/)
- [consulting](https://ghgadvisors.com/tag/consulting/)
- [Health Insurance Exchange](https://ghgadvisors.com/tag/health-insurance-exchange/)
- [health insurance marketplaces](https://ghgadvisors.com/tag/health-insurance-marketplaces/)
- [GHG Forum](https://ghgadvisors.com/tag/ghg-forum/)
- [Part D](https://ghgadvisors.com/tag/part-d/)
- [HHS](https://ghgadvisors.com/tag/hhs/)
- [state-based exchanges](https://ghgadvisors.com/tag/state-based-exchanges/)
- [Program Audit](https://ghgadvisors.com/tag/program-audit/)
- [Corrective Action Plan](https://ghgadvisors.com/tag/corrective-action-plan/)
- [Exchange Marketplaces](https://ghgadvisors.com/tag/exchange-marketplaces/)
- [medicare advantage quality improvement programs](https://ghgadvisors.com/tag/medicare-advantage-quality-improvement-programs/)
- [HPMS memo](https://ghgadvisors.com/tag/hpms-memo/)
- [ICD-10](https://ghgadvisors.com/tag/icd-10/)
- [implementation](https://ghgadvisors.com/tag/implementation/)
- [2016 CMS Advance Notice](https://ghgadvisors.com/tag/2016-cms-advance-notice/)
- [Compliance program risk](https://ghgadvisors.com/tag/compliance-program-risk/)
- [FWA](https://ghgadvisors.com/tag/fwa/)
- [product development](https://ghgadvisors.com/tag/product-development/)
- [Civil Monetary Penalties](https://ghgadvisors.com/tag/civil-monetary-penalties/)
- [MA-PD](https://ghgadvisors.com/tag/ma-pd/)
- [Medical Loss Ratio](https://ghgadvisors.com/tag/medical-loss-ratio/)
- [Medicaid rule](https://ghgadvisors.com/tag/medicaid-rule/)
- [MOEG](https://ghgadvisors.com/tag/moeg/)
- [validation](https://ghgadvisors.com/tag/validation/)
- [interim staffing](https://ghgadvisors.com/tag/interim-staffing/)
- [Provider Directories](https://ghgadvisors.com/tag/provider-directories/)
- [Insurance marketplace](https://ghgadvisors.com/tag/insurance-marketplace/)
- [medicare advantage (MA)](https://ghgadvisors.com/tag/medicare-advantage-ma/)
- [provider payments](https://ghgadvisors.com/tag/provider-payments/)
- [value-based payment](https://ghgadvisors.com/tag/value-based-payment/)
- [HPMS](https://ghgadvisors.com/tag/hpms/)
- [PRA](https://ghgadvisors.com/tag/pra/)
- [reporting](https://ghgadvisors.com/tag/reporting/)
- [enforcement](https://ghgadvisors.com/tag/enforcement/)
- [Annual Election Period](https://ghgadvisors.com/tag/annual-election-period/)
- [Benefit Design](https://ghgadvisors.com/tag/benefit-design/)
- [Product Strategy](https://ghgadvisors.com/tag/product-strategy/)
- [CAHPS](https://ghgadvisors.com/tag/cahps/)
- [CAHPS Hospital Survey](https://ghgadvisors.com/tag/cahps-hospital-survey/)
- [HCAHPS](https://ghgadvisors.com/tag/hcahps/)
- [Hospital Consumer Assessment of Healthcare Providers and Systems](https://ghgadvisors.com/tag/hospital-consumer-assessment-of-healthcare-providers-and-systems/)
- [MA-VBID Model](https://ghgadvisors.com/tag/ma-vbid-model/)
- [provider network](https://ghgadvisors.com/tag/provider-network/)
- [FDR Oversight](https://ghgadvisors.com/tag/fdr-oversight/)
- [Program Audit Protocols](https://ghgadvisors.com/tag/program-audit-protocols/)
- [HCC Risk Adjustment Model](https://ghgadvisors.com/tag/hcc-risk-adjustment-model/)
- [CAP](https://ghgadvisors.com/tag/cap/)
- [Independent Auditor](https://ghgadvisors.com/tag/independent-auditor/)
- [2017 CMS Advance Notice](https://ghgadvisors.com/tag/2017-cms-advance-notice/)
- [ODAG](https://ghgadvisors.com/tag/odag/)
- [2017 CMS Draft Call Letter](https://ghgadvisors.com/tag/2017-cms-draft-call-letter/)
- [2017 Draft Call Letter](https://ghgadvisors.com/tag/2017-draft-call-letter/)
- [Provider Network Adequacy (PNA)](https://ghgadvisors.com/tag/provider-network-adequacy-pna/)
- [Enforcement Actions](https://ghgadvisors.com/tag/enforcement-actions/)
- [FFM Issuer](https://ghgadvisors.com/tag/ffm-issuer/)
- [Medicare Marketing](https://ghgadvisors.com/tag/medicare-marketing/)
- [CMS application](https://ghgadvisors.com/tag/cms-application/)
- [issuer compliance](https://ghgadvisors.com/tag/issuer-compliance/)
- [Risk Adjustment Data Validation (RADV)](https://ghgadvisors.com/tag/risk-adjustment-data-validation-radv/)
- [Health Plan Management System (HPMS)](https://ghgadvisors.com/tag/health-plan-management-system-hpms/)
- [marketing material review](https://ghgadvisors.com/tag/marketing-material-review/)
- [CMS Audit & Enforcement Conference](https://ghgadvisors.com/tag/cms-audit-enforcement-conference/)
- [compliance and program audits](https://ghgadvisors.com/tag/compliance-and-program-audits/)
- [member disenrollment](https://ghgadvisors.com/tag/member-disenrollment/)
- [member enrollment](https://ghgadvisors.com/tag/member-enrollment/)
- [fall conference](https://ghgadvisors.com/tag/fall-conference/)
- [Civil Money Penalties (CMPs)](https://ghgadvisors.com/tag/civil-money-penalties-cmps/)
- [Medicare Advantage Organizations (MAOs)](https://ghgadvisors.com/tag/medicare-advantage-organizations-maos/)
- [CMS Program Audits](https://ghgadvisors.com/tag/cms-program-audits/)
- [Health Services Management and Delivery (HSD)](https://ghgadvisors.com/tag/health-services-management-and-delivery-hsd/)
- [Part D application](https://ghgadvisors.com/tag/part-d-application/)
- [compliance risk](https://ghgadvisors.com/tag/compliance-risk/)
- [Medicare Parts C & D Oversight and Enforcement Group (MOEG)](https://ghgadvisors.com/tag/medicare-parts-c-d-oversight-and-enforcement-group-moeg/)
- [Network Accuracy](https://ghgadvisors.com/tag/network-accuracy/)
- [Bid Submissions](https://ghgadvisors.com/tag/bid-submissions/)
- [plan benefit package (PBP)](https://ghgadvisors.com/tag/plan-benefit-package-pbp/)
- [Compliance Officer](https://ghgadvisors.com/tag/compliance-officer/)
- [2018 Draft Medicare Marketing Guidelines](https://ghgadvisors.com/tag/2018-draft-medicare-marketing-guidelines/)
- [2018 Draft MMG](https://ghgadvisors.com/tag/2018-draft-mmg/)
- [internet shopping trend](https://ghgadvisors.com/tag/internet-shopping-trend/)
- [Medicare Advantage (MA) Website Strategy](https://ghgadvisors.com/tag/medicare-advantage-ma-website-strategy/)
- [sales and marketing strategies](https://ghgadvisors.com/tag/sales-and-marketing-strategies/)
- [CMS Spring Conference](https://ghgadvisors.com/tag/cms-spring-conference/)
- [culture of compliance](https://ghgadvisors.com/tag/culture-of-compliance/)
- [Website strategy](https://ghgadvisors.com/tag/website-strategy/)
- [Evidence of Coverage](https://ghgadvisors.com/tag/evidence-of-coverage/)
- [Formulary](https://ghgadvisors.com/tag/formulary/)
- [Medicare Marketing Guidelines](https://ghgadvisors.com/tag/medicare-marketing-guidelines/)
- [Sales & Marketing](https://ghgadvisors.com/tag/sales-marketing/)
- [scope of appointment](https://ghgadvisors.com/tag/scope-of-appointment/)
- [Summary of Benefits](https://ghgadvisors.com/tag/summary-of-benefits/)
- [NOIA](https://ghgadvisors.com/tag/noia/)
- [notice of intent to apply](https://ghgadvisors.com/tag/notice-of-intent-to-apply/)
- [MA Application](https://ghgadvisors.com/tag/ma-application/)
- [Medicare Medicaid Plan](https://ghgadvisors.com/tag/medicare-medicaid-plan/)
- [MMP](https://ghgadvisors.com/tag/mmp/)
- [timeliness monitoring](https://ghgadvisors.com/tag/timeliness-monitoring/)
- [Medicare Advantage implementation](https://ghgadvisors.com/tag/medicare-advantage-implementation/)
- [Compliant Independent Review Entity Data](https://ghgadvisors.com/tag/compliant-independent-review-entity-data/)
- [data integrity](https://ghgadvisors.com/tag/data-integrity/)
- [Universe Review](https://ghgadvisors.com/tag/universe-review/)
- [CMS Annual Audit Report](https://ghgadvisors.com/tag/cms-annual-audit-report/)
- [2019 CMS Model Marketing Materials](https://ghgadvisors.com/tag/2019-cms-model-marketing-materials/)
- [2019 CMS Part D Model Materials](https://ghgadvisors.com/tag/2019-cms-part-d-model-materials/)
- [CMS Enforcement](https://ghgadvisors.com/tag/cms-enforcement/)
- [CMS outlier](https://ghgadvisors.com/tag/cms-outlier/)
- [Formulary Administration](https://ghgadvisors.com/tag/formulary-administration/)
- [Medicare Plan Finder](https://ghgadvisors.com/tag/medicare-plan-finder/)
- [PACE](https://ghgadvisors.com/tag/pace/)
- [Program of All-incluside Care for the Elderly (PACE)](https://ghgadvisors.com/tag/program-of-all-incluside-care-for-the-elderly-pace/)
- [readiness checklist](https://ghgadvisors.com/tag/readiness-checklist/)
- [MA](https://ghgadvisors.com/tag/ma/)
- [MAO](https://ghgadvisors.com/tag/mao/)
- [PDP](https://ghgadvisors.com/tag/pdp/)
- [Readiness assessment](https://ghgadvisors.com/tag/readiness-assessment/)
- [Part C](https://ghgadvisors.com/tag/part-c/)
- [Appeals Guidance](https://ghgadvisors.com/tag/appeals-guidance/)
- [Coverage Determinations](https://ghgadvisors.com/tag/coverage-determinations/)
- [Part C & D](https://ghgadvisors.com/tag/part-c-d/)
- [Annual Enrollment Period (AEP)](https://ghgadvisors.com/tag/annual-enrollment-period-aep/)
- [D-SNP](https://ghgadvisors.com/tag/d-snp/)
- [Electronic Enrollment Mechanisms](https://ghgadvisors.com/tag/electronic-enrollment-mechanisms/)
- [consumer protection](https://ghgadvisors.com/tag/consumer-protection/)
- [proposed exchange regulations](https://ghgadvisors.com/tag/proposed-exchange-regulations/)
- [QHP marketing practices](https://ghgadvisors.com/tag/qhp-marketing-practices/)
- [debt ceiling](https://ghgadvisors.com/tag/debt-ceiling/)
- [Steve Larsen](https://ghgadvisors.com/tag/steve-larsen/)
- [health affairs](https://ghgadvisors.com/tag/health-affairs/)
- [IRS study of health reform](https://ghgadvisors.com/tag/irs-study-of-health-reform/)
- [Employers](https://ghgadvisors.com/tag/employers/)
- [Retiree Health](https://ghgadvisors.com/tag/retiree-health/)
- [SHOP Exchanges](https://ghgadvisors.com/tag/shop-exchanges/)
- [trends](https://ghgadvisors.com/tag/trends/)
- [Consumer Partnership Exchanges](https://ghgadvisors.com/tag/consumer-partnership-exchanges/)
- [FFM submission](https://ghgadvisors.com/tag/ffm-submission/)
- [QHP](https://ghgadvisors.com/tag/qhp/)
- [QHP Submission](https://ghgadvisors.com/tag/qhp-submission/)
- [CBO](https://ghgadvisors.com/tag/cbo/)
- [Congressional Budget Office](https://ghgadvisors.com/tag/congressional-budget-office/)
- [Medicare Modernization Act](https://ghgadvisors.com/tag/medicare-modernization-act/)
- [Prescription drug plan](https://ghgadvisors.com/tag/prescription-drug-plan/)
- [tax subsidies](https://ghgadvisors.com/tag/tax-subsidies/)
- [healthcare policy](https://ghgadvisors.com/tag/healthcare-policy/)
- [network](https://ghgadvisors.com/tag/network/)
- [Big Data](https://ghgadvisors.com/tag/big-data/)
- [data analytics](https://ghgadvisors.com/tag/data-analytics/)
- [Network Management Model (NMM)](https://ghgadvisors.com/tag/network-management-model-nmm/)
- [open enrollment period](https://ghgadvisors.com/tag/open-enrollment-period/)
- [Health Savings Account (HSA)](https://ghgadvisors.com/tag/health-savings-account-hsa/)
- [Medicare Medical Savings Account (MSA)](https://ghgadvisors.com/tag/medicare-medical-savings-account-msa/)
- [Special Needs Plan](https://ghgadvisors.com/tag/special-needs-plan/)
- [risk adjustment and stars](https://ghgadvisors.com/tag/risk-adjustment-and-stars/)
- [clinical innovations](https://ghgadvisors.com/tag/clinical-innovations/)
- [member management](https://ghgadvisors.com/tag/member-management/)
- [provider engagement](https://ghgadvisors.com/tag/provider-engagement/)
- [reimbursement models](https://ghgadvisors.com/tag/reimbursement-models/)
- [claims adjudication](https://ghgadvisors.com/tag/claims-adjudication/)
- [claims operations](https://ghgadvisors.com/tag/claims-operations/)
- [operational performance](https://ghgadvisors.com/tag/operational-performance/)
- [OIG](https://ghgadvisors.com/tag/oig/)
- [Electronic Health Record (EHR)](https://ghgadvisors.com/tag/electronic-health-record-ehr/)
- [Office of Management and Budget (OMB)](https://ghgadvisors.com/tag/office-of-management-and-budget-omb/)
- [Star rating](https://ghgadvisors.com/tag/star-rating/)
- [medicare advantage risk adjustment](https://ghgadvisors.com/tag/medicare-advantage-risk-adjustment/)
- [Medicare Essential](https://ghgadvisors.com/tag/medicare-essential/)
- [Star Measures](https://ghgadvisors.com/tag/star-measures/)
- [Quality Bonus Payments](https://ghgadvisors.com/tag/quality-bonus-payments/)
- [medicare secondary payer](https://ghgadvisors.com/tag/medicare-secondary-payer/)
- [MSP](https://ghgadvisors.com/tag/msp/)
- [COB Files](https://ghgadvisors.com/tag/cob-files/)
- [MAPD](https://ghgadvisors.com/tag/mapd/)
- [drug prices](https://ghgadvisors.com/tag/drug-prices/)
- [Medicare Advantage (MA) Value-Based Insurance Design (VBID)](https://ghgadvisors.com/tag/medicare-advantage-ma-value-based-insurance-design-vbid/)
- [Plan Benefit Packages (PBPs)](https://ghgadvisors.com/tag/plan-benefit-packages-pbps/)
- [operational assessment](https://ghgadvisors.com/tag/operational-assessment/)
- [grievances](https://ghgadvisors.com/tag/grievances/)
- [Prescription Drug Plan (PDP)](https://ghgadvisors.com/tag/prescription-drug-plan-pdp/)
- [Opioid](https://ghgadvisors.com/tag/opioid/)
- [Step Therapy](https://ghgadvisors.com/tag/step-therapy/)
- [Opioids](https://ghgadvisors.com/tag/opioids/)
- [2021 and 2022 MA & Part D Proposed Rule](https://ghgadvisors.com/tag/2021-and-2022-ma-part-d-proposed-rule/)
- [2021 CMS Advance Notice Part 1](https://ghgadvisors.com/tag/2021-cms-advance-notice-part-1/)
- [2021 CMS Advance Notice Part 2](https://ghgadvisors.com/tag/2021-cms-advance-notice-part-2/)
- [ESRD](https://ghgadvisors.com/tag/esrd/)
- [integrating risk adjustment and quality of care initiatives](https://ghgadvisors.com/tag/integrating-risk-adjustment-and-quality-of-care-initiatives/)
- [Medicare Advantage member evaluations](https://ghgadvisors.com/tag/medicare-advantage-member-evaluations/)
- [build a risk adjustment program](https://ghgadvisors.com/tag/build-a-risk-adjustment-program/)
- [face to face member evaluation](https://ghgadvisors.com/tag/face-to-face-member-evaluation/)
- [internal risk adjustment program](https://ghgadvisors.com/tag/internal-risk-adjustment-program/)
- [prospective evaluation](https://ghgadvisors.com/tag/prospective-evaluation/)
- [The Advanced Evaluation](https://ghgadvisors.com/tag/the-advanced-evaluation/)
- [Network Strategy](https://ghgadvisors.com/tag/network-strategy/)
- [Provider](https://ghgadvisors.com/tag/provider/)
- [medicare advantage provider networks](https://ghgadvisors.com/tag/medicare-advantage-provider-networks/)
- [network requirements](https://ghgadvisors.com/tag/network-requirements/)
- [home assessments](https://ghgadvisors.com/tag/home-assessments/)
- [member evaluations](https://ghgadvisors.com/tag/member-evaluations/)
- [risk adjustment check list](https://ghgadvisors.com/tag/risk-adjustment-check-list/)
- [risk adjustment timeline](https://ghgadvisors.com/tag/risk-adjustment-timeline/)
- [risk adjustment and EDPS](https://ghgadvisors.com/tag/risk-adjustment-and-edps/)
- [risk adjustment multi-disciplinary team](https://ghgadvisors.com/tag/risk-adjustment-multi-disciplinary-team/)
- [risk adjustment strategy](https://ghgadvisors.com/tag/risk-adjustment-strategy/)
- [jack mccallum](https://ghgadvisors.com/tag/jack-mccallum/)
- [raeann grossman](https://ghgadvisors.com/tag/raeann-grossman/)
- [retrospective review market trends](https://ghgadvisors.com/tag/retrospective-review-market-trends/)
- [prospective member evaluations market trends](https://ghgadvisors.com/tag/prospective-member-evaluations-market-trends/)
- [prospective member evaluations](https://ghgadvisors.com/tag/prospective-member-evaluations/)
- [prospective risk adjustment](https://ghgadvisors.com/tag/prospective-risk-adjustment/)
- [risk adustment](https://ghgadvisors.com/tag/risk-adustment/)
- [claims based HCC](https://ghgadvisors.com/tag/claims-based-hcc/)
- [Gorman Health Group and CenseoHealth partnership](https://ghgadvisors.com/tag/gorman-health-group-and-censeohealth-partnership/)
- [RADV](https://ghgadvisors.com/tag/radv/)
- [EDPS](https://ghgadvisors.com/tag/edps/)
- [RADV extrapolation](https://ghgadvisors.com/tag/radv-extrapolation/)
- [prospective review](https://ghgadvisors.com/tag/prospective-review/)
- [retrospective chart review](https://ghgadvisors.com/tag/retrospective-chart-review/)
- [risk adjustment vendor](https://ghgadvisors.com/tag/risk-adjustment-vendor/)
- [Gorman Health Group and CenseoHealth](https://ghgadvisors.com/tag/gorman-health-group-and-censeohealth/)
- [Medicare Advantage prospective member evaluations](https://ghgadvisors.com/tag/medicare-advantage-prospective-member-evaluations/)
- [prospective member assessments](https://ghgadvisors.com/tag/prospective-member-assessments/)
- [Encounter Data](https://ghgadvisors.com/tag/encounter-data/)
- [prospective programs](https://ghgadvisors.com/tag/prospective-programs/)
- [Medicare Advantage payment](https://ghgadvisors.com/tag/medicare-advantage-payment/)
- [risk adjustment reporting](https://ghgadvisors.com/tag/risk-adjustment-reporting/)
- [claims leakage](https://ghgadvisors.com/tag/claims-leakage/)
- [Encounter Data System](https://ghgadvisors.com/tag/encounter-data-system/)
- [Risk Adjustment Processing System](https://ghgadvisors.com/tag/risk-adjustment-processing-system/)
- [Medicare Shared Savings Program (MSSP)](https://ghgadvisors.com/tag/medicare-shared-savings-program-mssp/)
- [Sustainable Growth Rate (SGR)](https://ghgadvisors.com/tag/sustainable-growth-rate-sgr/)
- [Health Maintenance Organizations (HMOs)](https://ghgadvisors.com/tag/health-maintenance-organizations-hmos/)
- [Quality Bonus Program](https://ghgadvisors.com/tag/quality-bonus-program/)
- [RAPS](https://ghgadvisors.com/tag/raps/)
- [HCC](https://ghgadvisors.com/tag/hcc/)
- [EDS](https://ghgadvisors.com/tag/eds/)
- [360 Assessment](https://ghgadvisors.com/tag/360-assessment/)
- [2022 CMS Advance Notice Part 1](https://ghgadvisors.com/tag/2022-cms-advance-notice-part-1/)
- [On Demand Webinars](https://ghgadvisors.com/tag/on-demand-webinars/)
- [MPF](https://ghgadvisors.com/tag/mpf/)
- [ANOC](https://ghgadvisors.com/tag/anoc/)
- [EOC](https://ghgadvisors.com/tag/eoc/)
- [Sales and marketing](https://ghgadvisors.com/tag/sales-and-marketing/)
- [OEP](https://ghgadvisors.com/tag/oep/)
- [Coronavirus disease](https://ghgadvisors.com/tag/coronavirus-disease/)
- [marketing strategy](https://ghgadvisors.com/tag/marketing-strategy/)
- [Provider Communication Strategy](https://ghgadvisors.com/tag/provider-communication-strategy/)
- [Enrollment Growth Strategies](https://ghgadvisors.com/tag/enrollment-growth-strategies/)
- [OTC Benefit](https://ghgadvisors.com/tag/otc-benefit/)
- [Over-the-Counter Benefit](https://ghgadvisors.com/tag/over-the-counter-benefit/)
- [Pareto Intelligence](https://ghgadvisors.com/tag/pareto-intelligence/)
- [Deft Research](https://ghgadvisors.com/tag/deft-research/)
- [Advertising](https://ghgadvisors.com/tag/advertising/)
- [AEP Marketing](https://ghgadvisors.com/tag/aep-marketing/)
- [Presidential Election Year](https://ghgadvisors.com/tag/presidential-election-year/)
- [Special Enrollment Period (SEP)](https://ghgadvisors.com/tag/special-enrollment-period-sep/)
- [PY2021](https://ghgadvisors.com/tag/py2021/)
- [sales and marketing strategy](https://ghgadvisors.com/tag/sales-and-marketing-strategy/)
- [Open Enrollment Period (OEP)](https://ghgadvisors.com/tag/open-enrollment-period-oep/)
- [sales agents/brokers](https://ghgadvisors.com/tag/sales-agentsbrokers/)
- [Feasibility](https://ghgadvisors.com/tag/feasibility/)
- [Stars](https://ghgadvisors.com/tag/stars/)
- [CMS Advance Notice](https://ghgadvisors.com/tag/cms-advance-notice/)
- [Provider Organizations](https://ghgadvisors.com/tag/provider-organizations/)
- [Marilyn Tavenner](https://ghgadvisors.com/tag/marilyn-tavenner/)
- [CMS Final Notice CY 2013](https://ghgadvisors.com/tag/cms-final-notice-cy-2013/)
- [Gorman Health Group Summary](https://ghgadvisors.com/tag/gorman-health-group-summary/)
- [member retention](https://ghgadvisors.com/tag/member-retention/)
- [Market Analysis](https://ghgadvisors.com/tag/market-analysis/)
- [member onboarding](https://ghgadvisors.com/tag/member-onboarding/)
- [Medicare Marketing Guidelines (MMG)](https://ghgadvisors.com/tag/medicare-marketing-guidelines-mmg/)
- [summaries of benefits](https://ghgadvisors.com/tag/summaries-of-benefits/)
- [Annual Enrollment Period](https://ghgadvisors.com/tag/annual-enrollment-period/)
- [MA Enrollment](https://ghgadvisors.com/tag/ma-enrollment/)
- [Medicare beneficiaries](https://ghgadvisors.com/tag/medicare-beneficiaries/)
- [multi-channel strategy](https://ghgadvisors.com/tag/multi-channel-strategy/)
- [commission system](https://ghgadvisors.com/tag/commission-system/)
- [sales agents](https://ghgadvisors.com/tag/sales-agents/)
- [Sales Distribution Strategy](https://ghgadvisors.com/tag/sales-distribution-strategy/)
- [profitable growth](https://ghgadvisors.com/tag/profitable-growth/)
- [remote work](https://ghgadvisors.com/tag/remote-work/)
- [work from home](https://ghgadvisors.com/tag/work-from-home/)
- [Accountable Care Organization (ACO)](https://ghgadvisors.com/tag/accountable-care-organization-aco/)
- [Behavioral Health](https://ghgadvisors.com/tag/behavioral-health/)
- [NAACOS](https://ghgadvisors.com/tag/naacos/)
- [National Association of ACOs](https://ghgadvisors.com/tag/national-association-of-acos/)
- [Telemedicine](https://ghgadvisors.com/tag/telemedicine/)
- [FFS](https://ghgadvisors.com/tag/ffs/)
- [pharmacy networks](https://ghgadvisors.com/tag/pharmacy-networks/)
- [Niall Brennan](https://ghgadvisors.com/tag/niall-brennan/)
- [new year's resolution](https://ghgadvisors.com/tag/new-years-resolution/)
- [operational evaluation](https://ghgadvisors.com/tag/operational-evaluation/)
- [process review](https://ghgadvisors.com/tag/process-review/)
- [ECRS](https://ghgadvisors.com/tag/ecrs/)
- [Electronic Correspondence Referral System](https://ghgadvisors.com/tag/electronic-correspondence-referral-system/)
- [health information system](https://ghgadvisors.com/tag/health-information-system/)
- [Health Care Cost Institute (HCCI)](https://ghgadvisors.com/tag/health-care-cost-institute-hcci/)
- [field marketing organization](https://ghgadvisors.com/tag/field-marketing-organization/)
- [marketing lead and sales goals](https://ghgadvisors.com/tag/marketing-lead-and-sales-goals/)
- [remarketing](https://ghgadvisors.com/tag/remarketing/)
- [CMS Pilot Audit](https://ghgadvisors.com/tag/cms-pilot-audit/)
- [Government Accountability Office (GAO)](https://ghgadvisors.com/tag/government-accountability-office-gao/)
- [provider directory accuracy](https://ghgadvisors.com/tag/provider-directory-accuracy/)
- [Network Exceptions](https://ghgadvisors.com/tag/network-exceptions/)
- [expanding your provider network](https://ghgadvisors.com/tag/expanding-your-provider-network/)
- [CMS Announces Changes to the Network Review Process](https://ghgadvisors.com/tag/cms-announces-changes-to-the-network-review-process/)
- [deficit](https://ghgadvisors.com/tag/deficit/)
- [CMS national project](https://ghgadvisors.com/tag/cms-national-project/)
- [Fully Integrated SNPs](https://ghgadvisors.com/tag/fully-integrated-snps/)
- [Gorman Health Group Policy Summary](https://ghgadvisors.com/tag/gorman-health-group-policy-summary/)
- [Gorman Health Group Policy Analysis](https://ghgadvisors.com/tag/gorman-health-group-policy-analysis/)
- [Innovation Challenge opportunity](https://ghgadvisors.com/tag/innovation-challenge-opportunity/)
- [part d plans](https://ghgadvisors.com/tag/part-d-plans/)
- [super committee and medicare advantage](https://ghgadvisors.com/tag/super-committee-and-medicare-advantage/)
- [Medicare Advantage enrollment trends](https://ghgadvisors.com/tag/medicare-advantage-enrollment-trends/)
- [Medicare Advantage premium average drops](https://ghgadvisors.com/tag/medicare-advantage-premium-average-drops/)
- [Medicare Advantage vs Fee for Service](https://ghgadvisors.com/tag/medicare-advantage-vs-fee-for-service/)
- [readmission rates](https://ghgadvisors.com/tag/readmission-rates/)
- [Elections](https://ghgadvisors.com/tag/election/)
- [sequestration](https://ghgadvisors.com/tag/sequestration/)
- [MA Benefits Manual](https://ghgadvisors.com/tag/ma-benefits-manual/)
- [2021 Program Audit](https://ghgadvisors.com/tag/2021-program-audit/)
- [products](https://ghgadvisors.com/tag/products/)
- [Provider Network Adequacy Pilot](https://ghgadvisors.com/tag/provider-network-adequacy-pilot/)
- [webinars](https://ghgadvisors.com/tag/webinars/)