This year’s RISE National was jam-packed with information about Medicare Advantage, managed care, compliance, risk adjustment, quality, member engagement, technology, and data analytics that health care professionals can bring back to their organizations. Here are eight memorable quotes from just a few of the 45 sessions we attended, as well as those heard in hallway chats, during our three days in Nashville.
Christi A. Grimm, the sixth inspector general of the U.S. Department of Health and Human Services, opened RISE National 2024 with a presentation on how to cultivate trust through a culture of compliance. Here are key takeaways from her speech at last week’s conference.
The founder of Collaborative Healthcare Strategies and a nationally recognized thought leader in the field of reducing readmissions and improving care for high-risk patients received the annual Dr. Martin L. Block Award for Innovation & Excellence on Tuesday, March 19 at RISE National 2024 in Nashville, Tenn.
It’s been an incredible two days at RISE National with 45 sessions, 150 speakers, three amazing keynotes, and an exhibit hall featuring 175 sponsors. Here are the highlights from this morning’s sessions
Two thousand RISE National attendees took over the Music City Center in Nashville on Monday morning, the first day of the main conference, to hear back-to-back presentations from the Office of Inspector General (OIG), Department of Justice (DOJ), and Centers for Medicare & Medicaid Services (CMS).
Get your bags packed and be sure to bring a comfortable pair of shoes! RISE National 2024 will take over the Music City Center, Nashville’s convention center, March 17-19. Read on to find out just a few of the things we’ve planned. And don’t worry if you haven’t registered yet. There is still time!
In this interview with RISE, Jeremy Poincenot talks about the trauma of suddenly losing his vision as a college sophomore and how the support of family and friends helped him become a world champion blind golfer and live an extraordinary life beyond any he ever imagined.
Ian Khan, Jeremy Poincenot, and Dr. Aditi Nerurkar will take the main stage at RISE National, March 17-19 in downtown Nashville.
The Harvard physician will present a keynote address on Monday, March 18, the first day of the main conference, on how to rewire your brain for less stress and more resilience. In this interview, she shares her personal experience that led to her interest in stress management.
Proposed payments to Medicare Advantage plans are expected to increase on average by 3.70 percent, or more than $16 billion, from 2024 to 2025.
Accountable care organizations (ACOs) now serve nearly half of the people with traditional Medicare, a three percent increase since 2023.
The RFI seeks data-related input from the public related to all aspects of the Medicare Advantage program, including data collection and release methods, access to care, prior authorization, provider directories, and networks, supplemental benefits, marketing, care quality and outcomes, value-based care arrangements and equity, and healthy competition in the market, including the effects of vertical integration and how that affects payment.
Marketplace enrollment is nearly five million higher than last year.
The new policies aim to shorten wait times and reduce burden on patients, providers, and payers.
More health care organizations plan to send teams to RISE National 2024 to ensure they get the most out of the must-attend Medicare Advantage conference of the year. We spoke to a few individuals who are traveling with their colleagues to downtown Nashville March 17-19 to find out why and what they hope to accomplish.
There is still so much to digest from our three days of learning at RISE National 2023 in Colorado Springs. But here are five quotes that we’ll remember throughout the year.
The learning continued during the final day of our mega Medicare Advantage conference with two keynotes, specialized sessions in five concurrent tracks, interactive roundtables, and a look at health care trends in 2023.
The director of risk adjustment and stars for government programs at Blue Cross and Blue Shield of Kansas City, received the annual Dr. Martin L. Block Award for Innovation & Excellence on Wednesday, March 8 at RISE National 2023 in Colorado Springs.
Christi A. Grimm, the sixth inspector general of the U.S. Department of Health and Human Services (HHS), told RISE National attendees on Tuesday that the risk of health care fraud is real and Medicare Advantage plans must make compliance a top priority.
This year’s conference drew a record-breaking number of 1,800 attendees, 130 speakers, and 175 sponsors who took over The Broadmoor Resort in Colorado Springs. The day was jampacked with special presentations, interactive roundtables, and concurrent specialized sessions in five different tracks, ending with our networking cocktail reception.
This year’s RISE National will be our biggest ever with 1,800 attendees! We’ve gathered the highlights to ensure the best conference experience March 6-8 when we take over the Broadmoor Resort in Colorado Springs.
The Department of Health and Human Services (HHS) last week issued a rebuttal against industry concerns that the proposed payment rule will result in payment reductions to Medicare Advantage (MA) plans and possible increases to premiums and/or fewer benefits to seniors.
Reductions in funding to Medicare Advantage (MA) could mean increased premiums and/or reduced benefits for millions of seniors and individuals with disabilities.
Read on for a sneak peek at what we’ve planned for RISE National 2023 on the second day of the main conference, Wednesday, March 8. You won’t want to miss one moment!
In addition to a special presentation by Inspector General Christi A. Grimm, RISE National attendees will hear from Office of Inspector General (OIG) representatives about their current priorities in the managed care space.
Back by popular demand! Digital health expert Wendy Sue Swanson, M.D., a keynote speaker at RISE National 2021, has been added as the third keynote for this year’s annual conference.
Medicare Advantage (MA) plans have a unique opportunity to improve health outcomes, quality metrics, and financial performance by adopting a member-centered approach focused on understanding and addressing the unique needs of each individual. Member-centricity requires that you recognize that what is good for the member is good for business.
The Centers for Medicare & Medicaid Services (CMS) proposes updates to Medicare Advantage (MA) payment growth rates, changes to the MA and Part D Prescription Drug Programs, and technical updates to the MA risk adjustment model.
The Centers for Medicare & Medicaid Services (CMS) finalized controversial policies to extrapolate data generated from 2018 Risk Adjustment Data Validation (RADV) audits without the use of a the Fee-For-Service (FFS) adjuster to offset the error rate.
RISE will offer two full-day and three new half-day workshops on Monday, March 6 prior to the kickoff of RISE National 2023. The preconference workshops will address risk adjustment, HCC audits, payer-provider connections, and member-centered health plans.
The Inspector General, and a team of brother triathletes and cognitive neuroscientists from UC Berkeley's Haas School of Business have been confirmed as speakers at RISE National, March 6-8, at The Broadmoor Resort in Colorado Springs.
The Centers for Medicare & Medicaid Services (CMS) issued a notice Friday that it couldn’t meet the timeline to finalize the proposed rule originally issued on November 1, 2018.
Nominations for both the 2023 Martin L. Block Award for Innovation & Excellence and the Health Care Hero Award are due by December 31.
The Justice Department has filed a civil health care fraud lawsuit against Cigna, claiming that the insurer hired vendors to conduct in-home assessments of its Medicare Advantage (MA) members and falsely document medical conditions.
Roughly 51 percent of Medicare Advantage (MA) plans that offer prescription drug coverage will have an overall rating of four stars or higher in 2023.
RISE summarizes recent Medicare Advantage news, including Office of Inspector General (OIG) audits that show two MA plans owe the federal government millions in overpayments and a ruling that will allow a Department of Justice (DOJ) fraud case against Anthem to move forward.
RaeAnn Grossman, EVP, Cotiviti, who co-chaired RISE National 2022 with Kevin Healy, CEO, Allymar Health Solutions, reflects on her experience at this year’s conference, which returned to Nashville as a live, in-person event for the first time since March 2019.
The associate chief medical officer of HonorHealth Medical Group in Arizona received the Dr. Martin L. Block Award for Innovation & Excellence on Wednesday, March 9 at RISE National 2022 in Nashville.
What an incredible two days we’ve had at RISE National 2022!
More than 1,600 participants (a RISE National record) representing 562 organizations across 46 states gathered at the Gaylord Opryland Resort & Convention Center to learn the latest on Medicare Advantage, regulatory and compliance updates, risk adjustment, quality, HEDIS®, Star ratings, member experience, social determinants of health (SDoH), the latest technology advancements, and payer/provider collaboration.
It’s been a long three years and we are counting down the days until we are all back together again in Nashville, Tenn. for RISE National 2022. You’ve heard about the incredible content and speakers we’ve lined up, but you may be unaware of all the fun and activities we’ve planned. Here’s a helpful guide so you can make the most out of the three-day event, March 7-9.
Future forecaster and game designer Jane McGonigal, Ph.D., specializes in creating simulations that help people imagine the biggest global challenges they might face in the future. In 2008, one of those simulations was a global outbreak of a fictional respiratory virus originating in China set 11 years in the future, in the fall of 2019. Sound familiar?
The Centers for Medicare & Medicaid Services (CMS) on Wednesday released proposed payment policy changes for Medicare Advantage (MA) and Part D drug programs in 2023. Here’s a summary of the proposed changes to risk adjustment, Star Ratings, and the agency’s plans to advance health equity.
The proposed rule would revise Medicare Advantage (MA) and Medicare Part D regulations related to marketing and communications, Star ratings, the criteria used to review applications for new or expanded plans, provider network adequacy requirements, medical loss ratio reporting, special requirements during disasters or public emergencies, and the use of pharmacy price concessions to reduce the out-of-pocket costs for prescription drugs under Part D.
Jane McGonigal, Ph.D., a world-renowned designer of alternate reality games—games that are designed to improve real lives and solve real problems—will speak on the second day of the main conference about how we can apply gaming to the health care industry.
Here are our predictions for the health care industry in 2022 based on interviews with industry experts in 2021, presentations at RISE conferences, and observations from our editorial team.
Dr. Nancy Messonnier, former director of the National Center for Immunization and Respiratory Diseases at the Centers for Disease Control and Prevention, answers questions about the pandemic. The Q&A was originally published by Participant.
Ryan Avery, a world record holder, two-time best-selling author, Emmy award winning journalist, and world champion, joins us for the latest episode of RISE Radio, our podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.
RISE National 2022—the #1 trusted source for all things Medicare Advantage—returns to Nashville, Tenn. on March 7-9 as a live, in-person event and will feature two blockbuster keynotes.
RISE rounds up the latest regulatory headlines that impact Medicare, Medicare Advantage, and Medicaid.
The Centers for Medicare & Medicaid Services (CMS) on Friday released Star ratings ahead of Medicare open enrollment. Seventy-four Medicare Advantage plans received the highest rating of 5 stars.
Nominations are now open for RISE’s annual Martin L. Block Award for Innovation & Excellence. RISE’s highest honor recognizes excellence and clinical leaders’ passion to improve patient care.
The Centers for Medicare & Medicaid Services (CMS) announced Wednesday that the average premium for Medicare Advantage (MA) plans will be $19 per month in 2022. The agency also projects enrollment in MA plans to spike to 29.5 million people in the upcoming year.
A new Office of Inspector General (OIG) report found that 20 of 162 Medicare Advantage (MA) companies studied drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and health risk assessments (HRA) and on no other service records.
In an August 5 memo to all Medicare Advantage (MA) plans, the agency announced that the COVID-19 public health emergency significantly impacted the validity of measures related to physical and mental health currently used in the Star Ratings.
The government has intervened in False Claims Act lawsuits against Kaiser Permanente affiliates for submitting inaccurate diagnosis codes for risk-adjusted payments to the Medicare Advantage (MA) program. Mary A. Inman, a partner in the whistleblower practice group at Constantine Cannon, which is representing one of the whistleblowers, will take a deeper look at the case as part of a RISE West session on lessons learned from whistleblower-litigated False Claims Act cases.
Check out the recap of the final day of RISE National 2021.
Heather O’Toole, M.D., chief medical officer at Innovation Care Partners, a clinically integrated network and an accountable care organization in Arizona, received RISE’s highest quality award at this year’s RISE National.
RISE National was in full swing today, filled with timely updates for 2021 and 2022, an insightful keynote address, collaborative panel discussions, and so much more.
RISE National 2021 is finally here! Our 2021 virtual summit kicked off Friday with pre-conference workshops, an inspiring family-friendly keynote, and virtual networking. If you missed it, we've got you covered.
RISE National is right around the corner. Check out the interactive virtual sessions and activities planned for our live-streamed event, which will take place March 26, 29, and 30.
Luciana Borio, M.D., who warned the public in an opinion piece published in the Wall Street Journal in late January 2020 about the pending COVID-19 pandemic, will be a keynote speaker at RISE National, a virtual live-streaming event, later this month. In this interview, Dr. Borio talks to RISE about COVID, what’s on the horizon, and what health plans can do to support their members.
Four representatives from the Centers for Medicare & Medicaid Services (CMS) will kick off the RISE National main conference with a policy update on Monday, March 29. The virtual live-streamed event will include preconference workshops on Friday, March 26 and the main conference March 29-30.
Health care policy expert Ezekiel J. Emanuel, M.D., will present a keynote on the future direction of the American health care system on Monday, March 29, the first day of RISE National. Dr. Emanuel, former advisor to President Joe Biden’s transition team on COVID-19, talked to RISE ahead of the virtual conference about the current health care landscape and potential changes that could improve it.
Wendy Sue Swanson, M.D., a pediatrician, author of Mama Doc Medicine, and a pioneer in the use of the digital space to provide humanistic doctor-patient information, will be one of five keynote speakers at RISE National, a virtual live-streamed event March 26, 29, and 30. In this interview, Dr. Swanson previews her talk and offers insight into the current landscape as well as the potential for even more innovation to transform the health care system into one that is both patient-centered and provider-centered.
Representatives from the U.S. Department of Health & Human Services’ Office of Inspector General (OIG) will join our roster of more than 50 speakers at RISE National, which will be live-streamed March 26, 29, and 30.
Join us for the second episode of RISE Radio, our new podcast series that focuses on issues that impact our three communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health.
Tara Lipinski, internationally acclaimed figure skater and Olympic gold medalist, will share her inspirational life lessons about how she overcame adversity to achieve her storied career in figure skating, at 4 p.m. EST Friday, March 26 during a presentation to kick off RISE National, a live-streaming virtual event.
RISE is pleased to introduce the launch of RISE Radio, a series of podcast episodes that will focus on issues that impact our three RISE communities: Quality & Revenue; Member Acquisition & Experience; and Social Determinants of Health. Joining us for our inaugural episode of RISE Radio are the members of the RISE Risk Adjustment Policy Committee.
RISE summarizes recent research of interest to our RISE Quality & Revenue community.
RISE reviews the latest headlines that impact Medicare, Medicare Advantage, and the Affordable Care Act marketplace.
The Better Medicare Alliance’s Center for Innovation in Medicare Advantage today released new research that examines the current limitations of measuring patient experience in the Medicare Advantage and Prescription Drug (MA-PD) Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. Based on those findings, the advocacy group proposes changes to modernize the measurement tool.
The Centers for Medicare & Medicaid Services late Friday announced it released Medicare Advantage (MA) and Part D payment information due to COVID-19. The Rate Announcement includes final policies on risk adjustment for 2022.
The Centers for Medicare & Medicaid Services (CMS) Friday issued a final rule that aims to advance the agency’s efforts to strengthen and modernize the Medicare Advantage and Part D prescription drug programs. Most of the changes are effective for the 2022 plan year and could lower enrollee cost sharing on some of the most expensive prescription drugs.
Dr. Emanuel, a member of President-elect Joe Biden’s transition COVID-19 advisory board, will kick off the first day of RISE National on Monday, March 29, with a keynote address on the future direction of the American health care system. Also slated to speak at the virtual conference: Tara Lipinski, internationally acclaimed figure skater and Olympic gold medalist; infection disease expert Dr. Luciana Borio, who warned the public in January 2020 about the pending COVID-19 pandemic; Dr. Wendy Sue Swanson, M.D., a leading innovator in digital health, innovation and prevention; and health care futurist Ian Morrison.
What’s in store for the RISE Association communities in 2021? We asked experts in Medicare Advantage, quality and revenue, consumer engagement, and social determinants of health for their predictions on trends that will impact the industry in the upcoming year. Spoiler alert: COVID-19 will continue to play a big role.
The Centers for Medicare & Medicaid Services (CMS) on Wednesday released its proposed annual Notice of Benefit and Payment Parameters for the 2022 benefit year. The proposal, more commonly known as the proposed 2022 Payment Notice, provides a blueprint for the changes CMS plans to make to the risk adjustment program and risk adjustment data validation (RADV) in the Affordable Care Act marketplace.
Morrison will address the future of the health care marketplace, trends, and implications during RISE National 2021, which will take place March 28-30, 2021. RISE is pleased to announce that Ian Morrison, internationally known author, consultant, and health care futurist, will present a keynote address on March 30, 2021, the final day of the RISE National Summit.
A new analysis by the health care consulting firm uses Medicare Advantage (MA) claims data through June 2020 to estimate the impact of the reduction in claims on risk scores and payments for 2021. The Centers for Medicare & Medicaid Services (CMS) uses diagnosis data from claims to calculate MA risk scores that are then used to adjust MA plan payments. But because diagnosis from the 2020 claims will be used to determine 2021 risk scores, the report notes that fewer claims in 2020 may mean lower risk scores, even though the health status of MA members have not changed. “Consequently, risk scores may not fully reflect the cost of care,” the analysts noted.
The Centers for Medicare & Medicaid Services (CMS) released the second part of its 2022 Medicare Advantage advance notice three months earlier than usual to help Medicare Advantage (MA) plans prepare their bids for 2022. CMS on Friday issued Part 2 of the 2022 Medicare Advantage and Part D Advance Notice to provide MA plans and prescription drug plans with earlier notification of proposed payment changes so they have more time to better address 2022 plan costs in light of COVID-19.
The Risk Adjustment Policy Committee offers policy guidelines for risk adjustment involving telehealth services. The RISE Risk Adjustment Policy Committee addresses the public policies involving risk adjustment and quality payments for value-based programs, most particularly Medicare Advantage (MA) and the Affordable Care Act (ACA) marketplace.
RISE is now accepting nominations for its annual Martin L. Block Award that recognizes excellence and clinical leaders’ passion to improve patient care. For 2021, RISE has broadened the criteria beyond risk adjustment and Stars to ensure the spirit of excellence and innovation lives on.
The RISE Risk Adjustment Policy Committee looks at the implications of the Centers for Medicare & Medicaid Services’ (CMS) plans to fully phase in the CMS-HCC model in 2022. As RISE reported on September 15, CMS intends to fully phase in the CMS-HCC model in 2022: This is a change from the mix for 2021 of 75 percent of the risk score calculated using the 2020 CMS-HCC model and 25 percent of the risk score calculated using the 2017 CMS-HCC model.
The Centers for Medicare & Medicaid Services (CMS) issued a notice Friday that it couldn’t meet the timeline to finalize the proposed rule originally issued on November 1, 2018.
Mark your calendars! We are excited to return to Nashville, Tenn. in March for RISE National 2021. Get a first look at the new tracks we’ve already planned for you. Join us March 28-30, 2021 for the RISE National Summit in Nashville, Tenn., the annual Medicare Advantage mega conference where you’ll learn the latest news and best practices for risk adjustment, quality, Stars, health care reform, and technology. Check out the planned tracks and sessions you definitely don’t want to miss:
The Centers for Medicare & Medicaid Services (CMS) on Monday released Part 1 of its 2022 Advance Notice, which outlines changes to Part C CMS-Hierarchical Condition Categories (HCC) risk adjustment model and the use of encounter data for 2022. CMS intends to finalize the payment policies by April 5, 2021. CMS said in a fact sheet that it issued Part 1 of the 2022 Advance Notice earlier than usual so Medicare Advantage (MA) organizations and Part D sponsors have more time to factor in the changes as they prepare their bids for 2022. What you need to know Here are the key changes outlined in the proposal: CMS intends to fully phase in the CMS-HCC model in 2022: This is a change from the mix for 2021 of 75 percent of the risk score calculated using the 2020 CMS-HCC model and 25 percent of the risk score calculated using the 2017 CMS-HCC model. Under the proposal for 2022, CMS will calculate 100 percent of the risk score using the 2020 CMS-HCC model.
Did you miss last month’s RISE National 2020 virtual conference? Here’s a summary of a few of the sessions. OIG's work on vulnerabilities with Medicare Advantage. Megan Tinker, senior advisor for legal affairs, and San Le and Jacqualine Reid, both social science research analysts at the Office of Inspector General, gave an excellent presentation, providing attendees with the findings of recent evaluations and investigations aimed to ensure that beneficiaries of the Medicare Advantage (MA) program get the services they need and funds aren’t being diverted through fraud, waste, and abuse.
Phenomenal keynote speakers took the virtual stage over two days at the annual event, RISE National 2020, and offered stories of hope and perseverance during the darkest of times. In a world of ethical dilemmas, John Quiñones lights the way to the moral high ground. Weeks after speaking at RISE’s National Summit on Social Determinants of Health, Emmy Award winning journalist John Quiñones returned as the keynote speaker for RISE National 2020 but with a different message for the audience. As the creator and host of the long-running, hidden camera show, What Would You Do?, Quiñones has become the face of doing the right thing when confronted with moral and ethical dilemmas.
Leading experts in the Medicare Advantage and Affordable Care Act market continue to call for collaboration between providers and payers. Take an inside-look at their tips to bridge the gap. Provider/payer collaboration was a consistent theme throughout last month’s virtual conference, RISE National 2020. During the two-day mega-conference, industry leaders shared insights and best practices for providers and payers to remove existing barriers, improve risk and quality, and work together in a virtual world. Here are three of the biggest takeaways.
The annual event, formerly known as RISE Nashville, will now stream live on June 29-30 with pre-conference workshops on Friday, June 26. Designed to be highly interactive and hosted on a state-of-the art digital platform, RISE National 2020 will deliver the same high-quality content and engagement opportunities that attendees have come to expect from RISE live events. Here’s a look at what you can expect at this year’s mega-conference for professionals of all levels in the Medicare Advantage and Affordable Care Act market.
Now in its 14th year, RISE Nashville has become the must-attend event for the latest information and strategies for risk adjustment, quality, Star ratings, CMS and OIG RADV audits, predictive analytics, payer-provider collaboration, social determinants of health, value-based care, member engagement, and physician engagement. In 2019, more than 1,400 attendees from 587 organizations joined RISE in Nashville for unmatched learning and networking opportunities. Here’s what you can expect at next year’s event...
RISE Nashville 2020 attendees will hear the latest policy updates from representatives of CMS when the annual conference convenes March 15-17, 2020 at Music City Center.
Erin Sutton, deputy director for the Payment Policy and Financial Management Group, and Kelly Drury, director, division of risk adjustment operations, for CMS, will join a roster of more than 100 speakers at the annual Medicare Advantage mega conference. Representatives from the U.S. Department of Health and Human Services’ Office of Inspector General will also be on hand to offer an overview of the OIG’s work to combat fraud, waste, and abuse in Medicare Advantage.
The Supreme Court has no plans to take up a pivotal case involving the Affordable Care Act (ACA) before the presidential election in November but also didn’t rule out a full review in the future. The Supreme Court on Tuesday denied a motion to rush a case that challenges the constitutionality of the Affordable Care Act (ACA). The one-sentence decision means the earliest the high court would hear the case is during their next term, which begins October 1. However, the Supreme Court could still deny the petition to review the case, which would send the case back to U.S. District Judge Reed O’Connor, who ruled in December 2018 that the ACA became unconstitutional when Congress enacted President Donald Trump’s tax overhaul. The tax plan eliminated the financial penalty of the law’s individual mandate, which required most United States citizens and legal residents to obtain health insurance or pay a penalty.
The United States Court of Appeals for the Tenth Circuit has reversed a district court decision that found flaws in the Department of Health & Human Services’ (HHS) risk adjustment formula. The decision is a blow to small insurers, particularly the New Mexico co-op that argued in a lawsuit that the way the federal government implemented the Affordable Care Act risk adjustment program “brutally penalizes new innovative, low-cost insurance companies and flouts Congress’ intent in enacting the ACA.”
The court decision, first reported by Katie Keith in the Health Affairs Blog, was passed down on Dec. 31, 2019. The three-judge panel disagreed with a previous ruling by the district court in New Mexico that struck down the use of the statewide average premium in the payment transfer formula for the 2014-2018 benefit years. The latest ruling reinstates HHS’ risk adjustment methodology for 2014 through 2016. The panel determined that the challenges over the rules for 2017 and 2018 methodologies are moot because HHS issued new rules for those benefit years.
The Centers for Medicare & Medicaid Services (CMS) Friday issued a final rule that aims to advance the agency’s efforts to strengthen and modernize the Medicare Advantage and Part D prescription drug programs. Most of the changes are effective for the 2022 plan year and could lower enrollee cost sharing on some of the most expensive prescription drugs.
RISE looks at three health care headlines in 2019 that will have implications for health plans in 2020.
The uncertain future of the Affordable Care Act
The fate of the Affordable Care Act (ACA) was uncertain as we headed into 2019 and will end the year in the same way.
Last year U.S. District Judge Reed O’Connor of the Northern District of Texas declared the entire health care reform law as invalid but allowed the law to remain in effect while the case was appealed. He sided with Republicans, who argued that the ACA became unconstitutional when Congress enacted President Donald Trump’s tax overhaul and eliminated the provision as part of the law’s individual mandate that required most Americans to purchase health insurance or pay a penalty.
Increased focus on social determinants of health
Another top story from 2018 continued to make headlines in 2019 and will likely do so in the upcoming year: the industry’s focus on the conditions in the places that people live, learn, work, and play that affect health risks and outcomes.
Unexpected findings in Medicare shopping and switching behavior
Approximately 10 percent of Medicare members switched plans or insurers during the 2019 Annual Election Period (AEP), according to Deft Research’s 2019 Medicare Shopping and Switching Study. Half of the switchers were happy with their 2018 coverage but shopped around for better coverage in 2019 anyway. The findings mean MA plans need to add or increase benefits to keep existing members and attract new ones.
A new report from the U.S. Department of Health and Human Services’ Office of Inspector General (OIG) raises concerns that Medicare Advantage (MA) plans may use chart reviews to inflate risk-adjustment payments from the Centers for Medicare & Medicaid Services (CMS). But the OIG’s methodology and findings don’t add up, according to Sean Creighton, managing director, Avalere, and chair of the RISE Risk Adjustment Policy Advisory Committee.
The OIG conducted the investigation over concerns that MA organizations may use chart reviews to increase risk adjustment payments inappropriately.
The agency reviewed 2016 MA encounter data for diagnoses only reported on chart reviews and found that in 99 percent of the cases, MA plans used chart reviews as a tool to add, rather than to delete diagnoses such as cancer, diabetes, and heart disease.
Eliminating the Fee-for-Service Adjuster from the Risk Adjustment Data Validation methodology would likely have significant implications for plan payment and could change plan incentives and behavior, including plans’ willingness to assume the risk of participating in the program, writes Sean Creighton, managing director of Avalere, who also serves as a RISE board member and the chair of the RISE Risk Adjustment Policy Advisory Committee.