Tag Archives: medicare advantage plans

Lessons from the Cigna/DOJ Lawsuit: Health Risk Appraisals (Part 2)

Last week’s first installment of this blog started our review of HRAs in the MRA environment. Let’s continue searching for lessons to apply in your practice. A third issue with Cigna’s HRAs was the supposed expectation to capture all the … Read Full Post

Tagged Cigna, cms, coding compliance, DOJ, HCC, health risk appraisal, HRA, medical coding, medical documentation, medicare advantage plans, medicare risk adjustment, mra, risk adjusted reimbursement |

Lessons from the Cigna/DOJ Lawsuit: Health Risk Appraisals (Part 1)

This blog is the first in a series of lessons, or reminders, gleaned from the Department of Justice’s (DOJ) lawsuit against health insurer Cigna. The suit alleges that Cigna essentially committed fraud by reporting false information to CMS in a … Read Full Post

The DOJ Targets MA Plans

The Office of the Inspector General (OIG) of the Department of Health and Human Services (HHS) reported that a study conducted in 2019 revealed, “Unsupported risk adjusted payments are a major driver of improper payments in the Medicare Advantage (MA) … Read Full Post

Tagged Anthem, Cigna, DOJ, fraud, HCC, medical coding, medicare advantage plans, mra, risk adjusted reimbursement |

2014 Holds Big Changes for the CMS-HCC Model

The purpose of the CMS-HCC model is to improve the accuracy in predicting the costliness of Medicare Advantage (MA) enrollees’ healthcare costs and to properly fund MA plans for those expenses. It isn’t a perfect model but it surpasses the … Read Full Post

Tagged annual wellness visits, center for medicare and medicaid services, chronic kidney disease, cms-hcc model, ffs medicare, government accountability office, health risk appraisals, hierarchical condition categories, medicare advantage enrolles risk scores, medicare advantage plans, medicare payment advisory commission, medicare risk adjustment, mra, national institutes of health, national kidney foundation, risk adjustment in medicare advantage, risk scores, the patient protection and affordable care act |

What We’re Reading – GAO recommends ending CMS bonus payment demonstration

From the GAO.gov website and different healthcare news websites. The Government Accountability Office (GAO), a nonpartisan investigative arm of Congress, recommends that CMS should discontinue its quality bonus program demonstration. The reasons are the budgetary impact, lack of data to … Read Full Post

Tagged center for medicare and medicaid services, cms, government accountability office, hedis program, medicaid cahps, medicare advantage bonus payment system, medicare advantage plans, mra, risk adjustment, the patient protection and affordable care act |

What We’re Reading – CMS overpaid Medicare Advantage (MA) by as much as $5.1 billion, according to the Government Accountability Office (GAO)

A report issued by GAO the week of March 7, indicates that CMS overpaid the MA program run by private companies by between $3.2 and $5.1 billion for the years 2010-2012. The overpayments were the results of CMS inadequately adjusting … Read Full Post

Tagged america's health insurance plans, center for medicare and medicaid services, cms, diagnostic coding, fee-for-service, gao, government accountability office, medicare advantage plans, overpayments, risk scores |

Medicare ACOs: Risk Adjusted Reimbursement’s Mathematical Impossibility (Part 5)

So far in this five-part series on Medicare ACOs, we’ve explored the basics of the concept, the patients’ participation, the fundamentals of reimbursement as well as the provider’s role and incentives. Recall that we explained in an earlier section that … Read Full Post

Tagged aco physicians, center for medicare and medicaid services, managed care plans, medicare acos, medicare advantage plans, medicare fee-for-service, risk adjusted reimbursement |

Medicare ACOs: Medicare beneficiaries and the ACO (Part 2)

Last time, we reviewed some of the background information concerning ACOs and the objective of this care delivery model. In this installment of the five-part series, we will begin where health care truly starts: the patient. Medicare beneficiaries will be … Read Full Post

Tagged accountable care organizations, medicare acos, medicare advantage plans, medicare beneficiaries and the aco, medicare beneficiary, primary care physicians, primary care services |

HEDIS: Is Yours a Five-Star Health Plan?

To most patients, quality is amorphous; we know it when we see it. To a healthcare administrator, however, quality has a whole other meaning. It’s measurable, measured and a measure of the congruence of several factors. In managed care, quality … Read Full Post

Tagged center for medicare and medicaid services, colorectal cancer screening, health plans, hedis, henry j kaiser family foundation, medical providers, medicare advantage plans, mra, risk adjustment |

CMS Risk Adjustment Data Submission Deadlines and Payment Schedule

The nature of capitation and the risk adjustment payment method requires specific deadlines for data submission that correlate to dates of service and affect capitation payments. The Centers for Medicare and Medicaid Services (CMS) observes the following three deadlines each … Read Full Post

Tagged cms, cms risk adjustment, hierarchical condition categories, icd-9-cm, medicare advantage plans, medicare risk adjustment, mra, risk adjustment processing system |