While prior authorization serves as vital checks and balances, ensuring clinical quality and preventing fraud, the administrative burden it imposes on providers and payers alike has led to an industry-wide reevaluation of certain codes and an increased push towards technology for auto-approvals and Gold Carding. Now, it's up to payers to encourage provider adoption of the technology by offering platforms with user-friendly interfaces, intuitive design, and seamless workflows. Streamlining prior authorization improves the overall experience for payers, providers, and members to ensure timely ..read more

As payers adopt artificial intelligence (AI) technologies in different aspects of healthcare operations, there is a need for AI governance and the careful vetting of vendor AI practices to safeguard patient welfare.  AI solutions can offer valuable decision support to create efficiencies at scale, timeliness, and accuracy. However, AI solutions should not run autonomously, nor should the final result go unquestioned. It is essential that all stakeholders understand how AI solutions draw their conclusions, what data sources inform the models, and the potential sources of biases that can o ..read more

As more and more provider organizations enter into risk-sharing agreements, provider engagement programs are experiencing a surge in participation. Provider engagement programs improve the collaborative relationship between plans and providers to keep documentation up-to-date for CMS submission. It's essential for plans to offer a variety of delivery methods to suit the provider's practice. Some practices enjoy an in-person, on-site method to receive personalized guidance for education and to maximize documentation opportunities, while other practices enjoy an EMR-integrated solution for a hig ..read more

NLP is an AI technology that is being used in healthcare IT for clinical documentation and medical coding. For medical coding, the program identifies diagnoses codes for HCC risk adjustable categories and flags it for a medical coder to review.  In robust medical charts that span up to thousands of pages in length, this enables coders with an automated way to identify diagnoses codes for review, hence increases speed, efficiency, and output. Academic research has found NLP increases medical coding productivity by 15-20%.  After the medical chart is reviewed by a medical coder, the ..read more

The intention for developing RADV audits was to develop a checks and balances to ensure reimbursement payment accuracy for Medicare Advantage Organizations (MAOs). There’s a history of CMS addressing payment accuracy in the Medicare space that dates back to the 80’s with the prospective payment system, PPS, and in the late 90’s with the Balanced Budget Act. The first RADV audit for MAOs wasn't performed until 2007. The initial audits determined that MAOs were being significantly overpaid which justified the 2011 proposed rule that suggested overpayments should be extrapolated, in other words ..read more

There is a distinct advantage to enrollment technologies that are built specifically for CMS's enrollment and dis-enrollment regulations for Medicare Advantage and Part D.  One such specification includes the Application Programming Interface (API) integration of the CMS MARX database for the validation of eligibility for Medicare Part A, B and D. This is a unique function that allows for real-time eligibility validation within the enrollment technology and avoids the less timely alternative of using batch processes for file submission to CMS. Additionally, special election periods are fa ..read more

In this bonus episode, we welcome Stars expert, Megan Piotrowski, for an in-depth review of the recent Star Ratings release. On October 13, 2023, the 2024 Medicare Advantage and Part D Star Ratings were published on Medicare Plan Finder, largely representing Measurement Year 2022 data submitted to CMS.  We discuss the variables that influenced performance and why it's the second year in a row, the average Star Ratings have declined and some plans might be seeing less than ideal performance. More than a third of plans saw a Star Ratings decline this cycle.  Tune in to learn about th ..read more

In this episode, we discuss the significant changes in the weight of Star measures, with the reversal of the 2022 Final Rule—many measures are returning to their previous weights. In response to the 2022 Final Rule, plans made significant investments to enhance the member experience in areas like customer service and developing digital platforms. The 2023 Final Rule has recently announced the removal of the Reward Factor and is replacing it with the Health Equity Index, which aims to incentivize plans to focus on serving members with higher social risk factors. “Members are getting a better e ..read more

Best practices for Medicare and Medicare Advantage marketing and ads continue to evolve as greater numbers of seniors integrate digital activity, such as online news and Facebook, into their daily routines. While the goal of any campaign is to stop-the-scroll and convert, there are marked differences for achieving this across generational cohorts. Current research on Medicare markets tend to be very broad, lumping all senior age brackets into one cohort—meaning someone who's 60 is not differentiated from someone who's 70, 80, or 90+.  This practice would be akin to studying the digital ac ..read more

Join us for insider insights and perspectives for healthcare executives of government-sponsored health plans. We’re talking to the experts about the unique operating infrastructure necessary for profitability and providing a best-in-class member experience. Topics include technology, data security, operations, health management, member engagement, risk adjustment, quality measures, start-up and growth tactics, legal and regulatory.  ..read more