22 12, 2015

3 Ways to Help your Star Ratings Shine in 2016

In October, the Centers for Medicare and Medicaid Services (CMS) released its 2016 Star Ratings for Medicare Advantage (MA) plans. The good news is the Star Ratings for plans with prescription drug coverage (MA-PDs) climbed from an average of 3.92 out of 5 stars last year to 4.03 this year with approximately 49 percent of MA-PDs earning four stars or [...]

15 12, 2015

How Did 2015 Impact Your Revenue Cycle Management?

Just when you thought you had a firm grasp on the revenue cycle operations at your provider organization, 2015 comes along and changes everything. ICD-10, Affordable Care Act (ACA) plans and, perhaps, a merger or acquisition at your organization presented major challenges to managing revenue cycle performance. In greater detail, the following are just a few of the major trends [...]

8 12, 2015

Accurately Identifying Risk Requires Better Data and Smarter Math

Despite the vast amount of electronic data available to health plans and providers to determine member or patient risk levels, accurate and timely stratification is actually becoming more complex. That’s because more data doesn’t necessarily mean that the information is reliable, normalized or useful for stratifying risk. Data integrity has become increasingly emphasized at provider and payer organizations. Although, as [...]

24 11, 2015

5 Tips to Beat Next Year’s CMS Encounter Data Submission

Next year, the Centers for Medicare and Medicaid Services (CMS) will begin transitioning how it adjusts risk scores for beneficiaries of Medicare, Medicare Advantage, Medicaid and other plans. CMS will base 90 percent of the score on data delivered to the older Risk Adjustment Processing System (RAPS) with the remaining 10 percent based on the new Encounter Data Processing System [...]

19 11, 2015

Despite ACA-RADV IVA Delay, a Mock Audit is a Smart Move

The U.S. Department of Health and Human Services (HHS) was supposed to send the first Affordable Care Act (ACA) risk adjustment data validation (RADV) audit sample to issuers this summer, but, as often happens in government, there was a delay. Despite the delay, HHS announced it intended to move forward with the “test” ACA RADV Initial Validation Audits (IVA) in [...]

16 11, 2015

Three Essential Elements of Provider-Chart Retrieval and Coding Reviews

Provider-chart retrieval and risk-adjustment coding reviews used to be time-consuming, occasionally antagonistic, projects. Providers were suspicious of payer representatives in their practice or department digging through charts and analyzing documentation, while payers struggled to find the charts they needed to accurately calculate risk scores. Two major trends in the healthcare industry are changing this process from adversarial to – almost [...]

12 11, 2015

Altegra Health (Virtual) Employee Spotlight: MaryBeth

As accountable care and other value-based payment programs expand across the nation, the demand for care managers has never been greater for both provider and payer organizations. Both types of organizations share similar care management and monitoring goals: to help patients/members manage their chronic conditions, prevent frequent hospital readmissions and avoid unnecessary emergency room visits. Building a care management staff [...]

28 10, 2015

Transition to ICD-10 Smooth So Far. What Will an Audit Reveal?

Perhaps due to the multiple delays over the years, the healthcare industry’s switch to the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) on October 1 has been surprisingly smooth, according to recent press coverage. This article from Health Data Management, for example, which features comments from payer and provider group representatives attending the Medical Group [...]

22 10, 2015

New MA Risk Score Calculation Requires Powerful Tools

As promised, the Centers for Medicare and Medicaid Services (CMS) announced earlier this year that it is changing the way it calculates risk scores for Medicaid Advantage (MA) plans in the 2016 payment year. In April CMS reported 90 percent of a MA plan’s risk score will be based on encounter data submitted to the older Risk Adjustment Processing System [...]

15 10, 2015

Data, Data, Everywhere and Not a Metric that Informs

“Water, water everywhere/Nor any drop to drink” is a famous verse from Samuel Coleridge’s epic poem, The Rime of the Ancient Mariner. Coleridge was writing about the sea, but healthcare provider organizations could write a similar verse about the data they’re drowning in from their electronic health record (EHR) systems and health information exchanges. Information technology has the ability to [...]