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Strategic Insights Blog

Chronic Care Special Needs Plan Changes Coming

We have spent a great deal of time telling you about the Centers for Medicare and Medicaid Services (CMS) refined…

CMS Issues CARA Drug Management Program Guide

In an earlier blog found here, we told you about the tremendous opportunity provided by the Comprehensive Addiction and Recovery…

Medicare Advantage Plans’ Supplemental Benefits Could Forge Huge Impact on Long-Term Care Costs

This year the Centers for Medicare and Medicaid Services (CMS) announced that plans now can offer certain non-traditional benefits as…

Democrats Promise Focus on Healthcare

Nancy Pelosi’s fate as Speaker of the House is not yet known, but Democrats have already come forward with a…

Medicaid Mega Rule Tweaks Proposed

While the Medicaid Mega Rule instituted by the former Obama administration will remain substantially intact, earlier this month the Centers…

CMS Medicare Preclusion List Requirements Go Into Effect in 2019

In April of this year, the Centers for Medicare and Medicaid Services (CMS) rescinded the requirement that providers serving Medicare…

Midterm Results Likely Mean Gridlock but Certain Healthcare Issues Could Get Traction

President Donald Trump surprised everyone by galvanizing the Republican base in a number of states to stop what was once…

Population Health Comes to the Fore

While it has been a focus of health plans for years, Population Health is taking on renewed significance with the…

Trump Lays Out Ambitious Medicare Drug Price Control Proposal

On the campaign trail in 2016, Donald Trump promised action on drug prices. Since his election as President, his proposals…

PPO Products Proving Growth Engine for Medicare Advantage

The healthcare industry is abuzz about the potential of Medicare Advantage (MA). With Exchange and Medicaid lines having limited margins…

CMS Clarifies Treatment of AOR Requests

Some time ago the Centers for Medicare and Medicaid (CMS) clarified to MedHOK and some health plans that Appointment of…

Big Changes Coming for Special Needs Plans

The Bipartisan Budget Act of 2018 created some major changes for Medicare Advantage Special Needs Plans (MA and SNP). While…

Medicare Star Announcement Shows Continued High Performance Overall, But Churn Among Plans

As we have seen over the past few years, the 2019 Star announcement shows that the Centers for Medicare and…

CMS Administrator Verma Champions MA at AHIP Conference

Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma spoke to attendees at the AHIP Medicare, Medicaid & Duals…

CMS Seeking Comments on Combining Medicare Advantage and Part D Chapters 13 and 18

The Centers for Medicare and Medicaid Services (CMS) recently announced that it is seeking comment on merging Chapters 13 (Part…

CMS Releases 2019 Plan Year Checklist

The Centers for Medicare and Medicaid Services (CMS) recently released its 2019 Plan Year Checklist. The checklist is not a…

Medicare Plans Could Face Additional Appeal Scrutiny

A recently released Health and Human Services (HHS) Office of Inspector General (OIG) report could mean Medicare Advantage (MA) and…

ACO Changes Draw Unfair Fire

The Trump administration announced recently that it plans on curtailing one payment model in the Accountable Care Organization (ACO) pilot…

CMS Administrator Verma: Medicaid Audits Coming

Boom! A huge bomb went off last week when Centers for Medicare and Medicaid Services Administrator (CMS) Seema Verma announced…

CMS Reinforces Ability to Go Digital

While the move has not gained great publicity since its announcement in the Medicare Communications and Marketing Guidelines (MCMG) on…

Notification Relief For Plans on Part C External Reviews

A little bit of the burden on external reviews has been lifted from Medicare Advantage (MA) plans by the Centers…

Enrollment Changes Hitting Medicare Advantage

With welcome season in October upon us, Medicare Advantage (MA) health plans are preparing for two major enrollment-related changes. One…

Medicare Advantage Medicaid Status Report Best Way to Track True Medicaid Status

In response to our blog last week on Medicaid dual status identification, we had a number of people inquire as…

FAQ Memo Helps Plans Train Providers on Cost-Sharing Hold Harmless Obligations

A great Centers for Medicare and Medicaid Services (CMS) memo issued in July 2018 (link here) as well as other…

CMS Begins to Move Again on Encounter Data Transition

There has been notable flux in the Centers for Medicare and Medicaid Services’ (CMS) effort to retire the old Risk…

Strategic Insights September 2, 2014 – CBO Projecting Lower Medicare and Medicaid Costs

The Congressional Budget Office (CBO) said Wednesday that the budget deficit this federal fiscal year will be $506 billion, or…

Recent Audits Point to a Few Key Audit Policy Changes

As informal information trickles in on 2018 audits, we wanted to share with you two trends that we are hearing…

Accountable Care Organization Rules Come Out – Part II

Yesterday, we analyzed the cost-effectiveness and shared savings of ACOs as defined by CMS’ proposed rules governing their establishment. Today,…

Yodelayheehoo… Obamacare Repeal and Replace Taking Shape

About one month into President Trump’s administration, the strategy to repeal and replace Obamacare is beginning to take shape. This…

CARA Act Implementation Gives Medicare Plans Additional Opportunities to Impact Drug Abuse

In early March, the Centers for Medicare and Medicaid Services (CMS) announced its final rule related to policy changes for…

Amazon Makes Its Mark in Healthcare

The long-rumored entry of Amazon into the drug world became reality when the online retail behemothbought PillPack for about $1 billion…

You’ve Got Mail: CMS Boldly Goes Digital

Just out -- the Centers for Medicare and Medicaid Services (CMS) has endorsed a digital strategy for Medicare Advantage and…

Thoughts on Universal Coverage from Across the Pond

I am still vacationing in the United Kingdom for my daughter’s college graduation and coincidentally have been here during the…

What Scottish History and Obamacare Have In Common

Some of you may be thinking, ‘This man’s gone crazy. What can Scottish history have in common with Obamacare?’ It’s…

Plans Need Efficiencies To Maintain Margin

With the advent of much stricter bidding rules in almost all lines of business, as well as the introduction of…

Insights from the MedHOK 2018 User Conference

MedHOK held its 2018 User Conference earlier this month in St. Petersburg, Florida. The four-day affair featured a series of…

2017 Program Audit Results Show Continued CMS Enforcement Regime and Rigor

A few blogs ago we told you about major Centers for Medicare and Medicaid Services (CMS) Civil Monetary Penalty (CMP)…

Medicare Drug Changes in Store

The Secretary of Health and Human Services (HHS), Alex Azar, indicated recently that major changes in how drugs are administered…

2019 CMS Call Letter Is Treasure Trove of New Policies

Due to recent mandate by Congress, the Centers for Medicare and Medicaid Services (CMS) is releasing the Advance Notice of…

The Case For Universal Health Coverage

In the past, this blog has made the case that universal health coverage means not only a healthier nation but…

Major Reporting and Universe Changes Again From CMS

Our blog has been ripe with information lately regarding Centers for Medicare and Medicaid Services (CMS) Civil Monetary Penalties (CMPs),…

IRE Auto-Forward Sanctions Robust Over Past Several Years

As a follow-up to our recent blog on 2017 Civil Monetary Penalties (CMPs), we thought it would be important to…

2017 CMPs Issued by CMS

The Centers for Medicare and Medicaid Services (CMS) recently posted Civil Monetary Penalties (CMPs) for 2017 and the trend toward…

A Few Changes Between the Final Call Letter and the January Proposal

The release of the final Centers for Medicare and Medicaid Services (CMS) 2019 Call Letter for Medicare Advantage and Part…

CMS Throws Last-Minute Curve Ball on MBI Migration

Health plans have been busy changing internal systems to plan for the arrival of the first Medicare Beneficiary Identifier (MBI)…

Get Ready For Medicaid Compliance Regime

Long frustrated with the lack of quality in the Medicaid program and poor compliance records of states and plans alike,…

HHS Secretary Endorses Value-Based Healthcare Transformation

When Donald Trump took office as President in January 2017, many (including this blogger nonetheless) predicted the end of (at…

Two Changes Will Have a Major Impact on Medicare Advantage and Part D

Reforms on the horizon mean big changes to financing and service delivery. If adopted, Medicare Advantage and Part D plans…

The Three Wise Men (Warren, Jeff and Jamie) To The Rescue?

Large healthcare plans and other health-related stocks took a tumble last week on word that three very powerful men may…

Provider Network Review: The Next Great Compliance Bogey

Another compliance headache hits plans! The Centers for Medicare and Medicaid Services (CMS) completed its second round of Medicare Advantage…

Work Requirements and Waivers Could Lead To Medicaid Reform Compromise

The Trump administration’s announcement that it will entertain work requirements for eligibility for Medicaid is just one small example of…

Provider Network Review: The Next Great Compliance Bogey

Another compliance headache hits plans! The Centers for Medicare and Medicaid Services (CMS) completed its second round of Medicare Advantage…

Did You Get Your Timeliness Monitoring Notice Yet?

Back in mid-December, we told you to get ready for the return of Timeliness Monitoring in the Medicare Advantage and…

Timeliness Monitoring is Back, Putting a Cramp in Holiday Plans

As everyone suspected but perhaps hoped wouldn’t happen, the Centers for Medicare and Medicaid Services (CMS) announced in a recent…

Risk Adjustment Changes Outlined In Additional 2019 Advanced Call Letter

While the Medicare Advantage and Part D Advance Notice Call Letter is usually done early each calendar year, plan actuaries…

Risk Adjustment Changes Outlined In Additional 2019 Advanced Call Letter

While the Medicare Advantage and Part D Advance Notice Call Letter is usually done early each calendar year, plan actuaries…

Look For Both Vertical and Horizontal Healthcare Integration in 2018

In this first week of this new year, I share a few insights regarding acquisitions and consolidations in healthcare. The…

What a Healthcare Year It Has Been!

The year is just about over and activity was robust for healthcare in 2017. Here is a quick recap about…

Healthcare Round Up 2017

Healthcare Trends Slowed But Still Marching On costs_final.jpgRecently, the Centers for Medicare and Medicaid Services (CMS) Actuary announced 2016 healthcare…

The Healthcare Consolidation Craze and Tax Reform

There was blockbuster news this weekend when it was confirmed that CVS Health will buy Aetna in the largest ever…

Keep Puerto Rico in Your Thoughts This Thanksgiving Holiday, and the Mandate Repeal in Your Sights

As you sit down with family and friends this Thanksgiving and as we get into the Christmas Holiday season, keep…

Can Trump Undertake Medicaid Overhaul Without Changing the Law?

With healthcare reform changes dead on Capitol Hill for now, many are asking: Can the President essentially do Medicaid reform…

Plans Must Get Ready For Comprehensive Management Measures

The recent 2018 Star score announcement shows that Medicare Advantage (MA) plans continue to struggle with the high-performing system that…

Health Plans And Their Members Win in Medicare Advantage and Part D

With uncertainty over the state of Medicaid in the long term and the looming collapse of the Exchanges, health plans…

Cost-Sharing Subsidies Gone For Now; Exchange Premiums Explode

In our last blog, we told you that we expected a federal judge to strike down an emergency request made…

Trump Throws Exchanges into Even Greater Chaos

With Donald Trump’s executive order last week to allow the creation of association health plans (AHP’s) to sell across state…

Mixed Star News for Medicare Advantage and Standalone Part D Plans

With its announcement of Star ratings for the 2018 enrollment season this week, the Centers for Medicare and Medicaid Services…

Healthcare Roundup

This week, MedHOK gives some brief updates on a myriad of issues in the healthcare arena. CMS Issues Civil Monetary…

With Price Out, What To Expect Next In Healthcare

The meteoric rise and swift fall of Health and Human Services (HHS) Secretary Tom Price shocked many in the healthcare…

Why Medicaid is Good – Part 2

Medicaid has become a polarizing subject in Washington over the years. Many Democrats view Medicaid as their Holy Grail (and…

Our Hearts Go Out To The People of Puerto Rico

For many in the United States, Puerto Rico is a sunny destination point to fly in and out of on…

Health Reform Update: Rule Requiring Reviews of Unreasonable Rate Increases Finalized

Last week, CMS released the final rule implementing a requirement in health reform that directs the Secretary of HHS to…

Rotting Corpse of Obamacare Repeal Haunting Congressional Hallways. Chance of Zombie Attack Rising

An idea that looked like a potentially good Obamacare stabilization stop-gap months ago appears to be another tired GOP Affordable…

September 2017 Compliance Insights

IMPORTANT REMINDERS September 7, 2017 2017 MA & PDP Fall Conference & Webcast Event Materials can be found on the…

Cheers and Jeers in Health Care

Cheers to a number of health insurance commissioners and health plans who were able to get health plans to cover…

Look to Europe to Overcome the Stigma of Universal Coverage

Those who have read the British news magazine The Economist (affectionately called “This Newspaper” by the editors), know that it…

CMS Will Look Closely at Member Materials

The past several years, the Centers for Medicare and Medicaid Services (CMS) has levied substantial findings and penalties related to…

Price (Tom, That Is) Kills Medicare Experiments

When then Rep. Tom Price of Georgia was named HHS Secretary, we had predicted that he would end certain experiments…

TrumpCare Dead? What’s Next?

With the announcement that two more GOP senators are opposed to the latest draft of the Obamacare repeal and replace…

Best Practice Memo on Encounter Data Submission is Telling Sign That CMS Has Not Given Up On Risk Adjustment and Payment Accuracy Changes

On June 22, 2017, the Centers for Medicare and Medicaid Services (CMS) issued a best practice memo related to encounter…

Trumps and Turns of Healthcare

Republicans abandon Trump on master repeal While Republican leadership in the Senate has left the door slightly ajar, by and…

Superhero John McCain Strikes Again

Our Superhero John McCain was spotted at the Capitol again last night hard at work. In the wee hours of…

Superhero McCain Shows Us What Grit and Responsible Stewardship Is All About

With all the Obamacare repeal and replace rhetoric flying around Washington, D.C., lately, we were beginning to lose faith in…

Why Medicaid is Good – Part 1

Over the past many weeks and months, we have written about the Obamacare repeal and replace saga that is gripping…

ACA vs AHCA vs BCRA: More Healthcare Ructions and Ruminations

Senate Obamacare Repeal Vote to Happen Soon; Senate Replacement Bill Unveiled We had predicted action in the Senate would not…

Audit Scrutiny At All Time High for Medicare Plans

2017 is off to a quick and challenging start when it comes to compliance in the Medicare Advantage (MA) world.…

Healthcare Challenges Not Limited to Obamacare

While the administration and Congress continue to focus on the future of Obamacare, executive and legislative branch officials are also…

The Age of Wisdom and the Age of Foolishness: A Tale of Two Healthcare Visions

We were witness to the starkest of contrasts recently when financier Warren Buffet delivered a strong admonition about the perils…

Obamacare Repeal and Replace: From the Knee-Jerk House to the Sensible Senate?

President Donald Trump and House Speaker Paul Ryan finally twisted enough arms and convinced just enough Republicans to get on…

Keep Quality in the American Healthcare System Front and Center

Notwithstanding the failure of the recent American Health Care Act (AHCA) in the House, with Republicans in firm control of…

Never a Dull Moment in Healthcare!

Those of us in healthcare know that there is never a dull moment in our world. Below are some short…

Final Medicare Advantage and Part D Call Letter Brings Few Surprises

On April 3, 2017, the Centers for Medicare and Medicaid Services (CMS) released the Announcement of Calendar Year (CY) 2018…

Will the Real Donald Trump Please Stand Up?

In our last blog, we referenced the 1950s comedy I Love Lucy to describe the fiasco in the House surrounding…

Time Out! Don’t Make Healthcare A Political Football

In his impassioned push to get conservative Republicans in line to vote for the House’s bill to repeal and replace…

AHCA DEBACLE: Healthcare Repeal and Replace Train Derails

For old-time comedy TV aficionados, after the House leadership’s repeal and replace debacle this week, it was hard not to…

Civil Monetary Penalties Continue at CMS for Medicare Advantage Plans

On March 1, 2017, the Centers for Medicare and Medicaid Services (CMS) released their list of plan audit results for…

CMS Audit Season Is Upon Us

Now that the holidays are over and the calendar flipped to 2017, many health executives are waiting nervously to hear…

Will Common Sense Prevail In Repeal and Replace?

Last week, we told you about the emerging House GOP plan to repeal and replace Obamacare. True to the fast-paced…

Yodelayheehoo … Obamacare Repeal and Replace Taking Shape

About one month into President Trump’s administration, the strategy to repeal and replace Obamacare is beginning to take shape. This…

2018 Call Letter Rather Humdrum; But No Signals Away From Value-Based Purchasing

Perhaps due to the new administration taking office just a few days earlier and the uncertainty surrounding health policy, the…

Healthcare Ructions Abound

The New Administration Takes Shape As promised, President Trump has come out swinging in the first week of his presidency.…

Will The U.S. Healthcare System Finally Make Care Management Its Main Focus?

Since the introduction of modern insurance back in the days of the Blue Cross and Blue Shield Associations, managing utilization…

Does PhRMA Have More to Fear Under Trump Than Clinton?

Former President George W. Bush was famous for measuring every word he said in public for fear of spooking corporations,…

CMS Alphabet Soup – Medicare HICN to Become MBI

After we just got over the implementation of ICD-10, health plans and providers are being asked to go through another…

Of Healthcare Punditry and Crystal Balls: Anniversary Edition – Part 2

Last week, we bragged about our incredible success at predicting what would happen in the 2016 healthcare arena. We admitted…

Of Healthcare Punditry and Crystal Balls: First Anniversary Edition – Part 1

With this first edition review of our annual prognostications, we boldly say that our best guesses about what would happen…

Where, Oh Where, Will Our Healthcare System Go?

With President-elect Donald Trump's inauguration now about a month away, we can expect a flurry of activity surrounding Obamacare and…

CMS Timeliness Monitoring To Challenge Plans

If plans that just went through a Medicare program audit thought they could breathe a quick sigh of relief, they…

What Will Trump Healthcare Policy Look Like?

President-elect Donald J. Trump has named many key Cabinet positions over the last few weeks. Two words can describe many…

Medicare Doctor Pay Reformed At Last

The decade-long political saga of Medicare physician pay increases is finally over! For those familiar with the Sustainable Growth Rate…

A Slight Softening on Obamacare

Two weeks after Election Day, President Elect Donald J. Trump has already signaled that he will likely be far more…

Will Shocking Election Result Put Affordable Care Act on Chopping Block

Donald Trump proved almost every political pundit wrong Tuesday night by pulling off one of the greatest upsets in presidential…

CMS Medicare Plan Outreach Requirements in the Spotlight

As anyone involved in a Medicare Advantage Part D (MA-PD) or standalone Part D (PDP) plan knows, the Centers for…

Obamacare Fact Check

With the election just around the corner and Obamacare dominating the political news, Strategic Insights is attempting to demystify some…

Provider Network Travails Become New CMS Compliance Focus

The Centers for Medicare and Medicaid Services (CMS) has found a new compliance focus that promises to challenge health plans…

Overall Medicare Star Improvement Levels Off; Gains on Part D Side

The Centers for Medicare and Medicaid Services (CMS) can continue to be happy about the progress it has made over…

Healthcare Roundup

This week,Strategic Insights is updating you on issues covered in past blogs. Risk Corridor Controversy Continues Last week we told…

Obamacare Lifeline May Be Too Little and Too Late

Strategic Insights has written often about the looming erosion of Obamacare plan participation due to numerous factors. One of the…

2016 Program Audit and Enforcement Report Shows Continued Drive Toward Rigorous Compliance Regime

On September 6, 2016, the Centers for Medicare and Medicaid Services (CMS) released their annual Part C and Part D…

Compliance Insights Newsletter – Sept 2016

IMPORTANT REMINDERS Medicare Parts C & D Fraud, Waste and Abuse (FWA) Training hosted by CMS Center for Program Integrity…

Medicare Advantage Risk Adjustment Data Validation Will Be Keen Focus of Feds

Just as Medicare Advantage (MA) plans have begun adjusting to the rigorous audit and compliance environment and value-based reimbursement of…

CMS Medicare Advantage Value-Based Insurance Design Initiative to Expand

In our May 23, 2016 blog and June 23, 2016 podcast, we discussed the Centers for Medicare and Medicaid Services…

ObamaCare Storm Set for Next President

News about Obamacare continues to dominate the healthcare headlines this summer. The administration continues to defend its program, even as…

Long-Term Care Costs: Ticking Time Bomb for American Healthcare and Our Economic Future

This week, Kaiser Health News shined a light on a rarely talked about issue that literally threatens the future of…

Retiring President Calls for Obamacare 2.0

With the remaining days of his presidency ticking away, President Barack Obama is focusing on his national healthcare achievement and…

CMS Channeling Teddy Roosevelt on 1115 Waiver Renewals and Medicaid Expansions

Teddy Roosevelt was famous for saying, "Speak softly and carry a big stick; you will go far.” Well, the Centers…

Compliance Insights Newsletter – June 2016

IMPORTANT REMINDERS On Monday, June 13, 2016, the OMB posted the 2017 draft Program Audit Protocols for public comment in…

Podcast: The Emerging National Model of Care

In this Podcast, Mar6.pngc Ryan, Chief Strategy and Compliance Officer for MedHOK Inc., discusses the plans that the Centers for…

HCC Risk Adjustment Refinement Coming for 2017

As we have written about several times over the past year, Special Needs Plans (SNPs) and other plans with heavy…

MMP Star Program Coming to Fruition

The Centers for Medicare and Medicaid Services (CMS) continues its push to bring STAR quality performance programs to all lines…

CMS Pushing Plans on Compliance While Lending a Helping Hand

Strategic Insights has written often about the ever-increasing regulatory focus practiced by the Centers for Medicare and Medicaid Services (CMS)…

Will Obamacare Survive? Has Aetna’s CEO Defined a Possible Path Forward?

A striking duality in large-scale health insurers’ approach to participation in Obamacare has emerged. It gives hope that some large…

CMS’ Bundled Payment Craze Hits Traditional Medicare

Strategic Insights writes often about the far-reaching quality and cost reforms in the Medicare managed care arena, as well as…

Medicaid Uber Rule Becomes Official, and It’s ‘Huuuuuge’!

Almost a year after it was initially announced in draft form by the Centers for Medicare and Medicaid Services (CMS),…

Compliance Insights Newsletter – April/May 2016

IMPORTANT REMINDERS The CY 2017 MTM program submission deadline was May 2, 2016 for all Part D sponsors (includes renewing…

United Drops the Other Shoe on Obamacare; Will Other Plans Follow?

Having warned that it was extremely troubled by the financing and risk in the Exchange Marketplace, United Healthcare announced what…

CMS Demonstration Projects Continue To Expand

The Centers for Medicare and Medicaid Services (CMS) is actively continuing its push beyond the Medicare Advantage (MA) Star program…

Few Changes in Final 2017 Call Letter

The Centers for Medicare and Medicaid Services (CMS) issued the Final 2017 Call Letter this week with few changes from…

Podcast: Emerging Value-Based Healthcare Environment

In this podcast, Marc Ryan, Chief Strategy and Compliance Officer for MedHOK Inc., discusses the steps being taken to evolve…

Compliance and Quality Take Center Stage in Medicare

We write often about how compliance and quality are taking center stage throughout our healthcare system now that the Centers…

CMS Backtracks on Star Penalty for Plans under Intermediate Sanctions

Fresh off issuing its 2017 Call Letter where it stayed the course (and even ramped up) on strong compliance and…

Medicare Advantage and Part D Draft Call Letter: Good News Mixed with Warnings of Increased Compliance and Complexity

The 2017 Draft Call Letter has relatively good news for Medicare Advantage-Part D (MA-PDs) and standalone Part D plans (PDPs)…

HS Test 2

Pharmacy Outcomes Will Make or Break Health Plans In Future

While about 50% of Medicare Advantage-Part D (MA-PD) plans (covering about 70% of enrollees) are 4-Star or greater, many plans…

Obamacare on the Precipice

Try as it may with its positive press releases on enrollment statistics and healthcare inflation numbers, the Obama administration has…

Compliance and Quality Focus Increases As CMS Embraces SNP Potential

Not too long ago, Special Needs Plans (SNPs) seemed destined for the dust heap. SNPs were literally on life support…

CMS Pushing Hard To Launch Medicare-Medicaid Plan Star Program

With its success with the Medicare Advantage Star program and its role as national healthcare shutterstock_206718085_stars_man_thinking.jpgpolicy-maker and czar, the Centers…

Compliance Insights Newsletter – January 2016

IMPORTANT REMINDERS On December 30, 2015, CMS provided an update to the Standard Operating Procedures (SOP) for theshutterstock_134715920_important-Note.jpg handling of…

Medicare Plans Need to Embrace Conversion to Encounter-Based Risk Adjustment

The New Year is more than just a fresh slate for health plans – it’s also the year that we…

Expect Rigorous CMS Audit Season

With the new year now in full swing, Medicare Advantage and Part D plans should begin readying for shutterstock_163640981_audit_image.jpganother rigorous…

Medicaid Expansion Fight Among Republicans Shows Need for Compromise

The New York Times’ Robert Pear had a fantastic article on December 27, 2015 describing the great shutterstock_344371520-compromise.jpgphilosophical divide emerging…

Of Healthcare Punditry and Crystal Balls, Part 2

We, here at Strategic Insights, don’t see ourselves as ever rivaling Nostradamus’ prophecies, but in the shutterstock_201766217_Nostradamus.jpgspirit of the season,…

Compliance Insights Newsletter – December 2015

IMPORTANT REMINDERS January 1, 2016: Plan Benefit Period Begins COMPLIANCE NEWS ICE Conference This past November, the Industry Collaboration Effort,…

Of Healthcare Punditry And Crystal Balls: Part 1

It is that time of year when pundits of all sorts reflect on the past and prognosticate the future. In…

Overall Increases in Health Costs Slowing

The Office of the Actuary for the Centers for Medicare and Medicaid Services (CMS) reported this monthshutterstock_310816169-coins-graph-72dpi.jpg that overall healthcare…

Compliance Insights: November 2015

IMPORTANT REMINDERS Mid December 2015 Display measures data on cms.gov updated January 1, 2016 Plan Benefit Period Begins COMPLIANCE NEWS…

Bad News Trickling In on Exchanges

In a recent blog post, we told you that although the first two years of the Exchange seemed to be…

Risk Adjustment and Encounter Data Changes – Webinar on demand

Since risk adjustment’s introduction in the Medicare Advantage (MA) program, the Centers forshutterstock_169176878-webinar-button.jpg Medicare and Medicaid Services (CMS) has calculated…

CMS Set To Further Reform Approach To Dual Eligibles in Medicare Advantage

As mentioned in previous blogs, after turning a cold shoulder to Medicare Advantage Special Needs Plans (SNPs) just a decade…

Podcast: Medicare Advantage Star Program Update

CMS continues to have unprecedented success with its Star ratings program. In this podcast, Marc Ryan of MedHOK Inc. discusses…

Dual Demonstrations: Challenges and Promise

The Centers for Medicare and Medicaid Services (CMS) is banking a lot on the Medicare-Medicaid Plan pilots, also known as…

MedHOK Compliance Insights Newsletter: October 2015

IMPORTANT REMINDERS October 15, 2015 2016 Annual Election Period Begins Early November, 2015 First display of Plan Finder data in…

Health Care Exchange Announcements Show Some Mixed Results

The Healthcare Exchanges will enter their third year soon and news of late shows that the grand national experiment in…

Proposed Medicaid Rules will Create Medicare-like Compliance Regime

We have long discussed the impending emergence of a national healthcare accountability model. With the Centers for Medicare and Medicaid…

2016 Star Announcement Shows CMS’ Continued and Remarkable Progress With Quality Performance

In past blogs, we noted the phenomenal progress the Centers for Medicare and Medicaid Services (CMS) has been making in…

Compliance Insights January 2014

Summary: In this issue of Compliance Insights, MedHOK covers the revised Notice of Denial of Medicare Prescription Drug Coverage (CMS-10146),…

Preliminary Results for Primary Care Transformations

On February 23, 2015, the Centers for Medicare & Medicaid Services (CMS) announced the promising findings from two large-scale tests…

What Will Come of Medicaid Expansion Under PPACA?

The Patient Protection and Affordable Care Act (PPACA) relied on the twin pillars of Medicaid expansion and the introduction of…

CMS Finalizes Changes for Medicare Advantage and Part D Programs for CY2016

On February 6, 2015, the Centers for Medicare & Medicaid Services (CMS) released a final rule revising certain requirements for…

Shifting Medicare Payment from Quantity to Quality

In a historic announcement issued by the Department of Health and Human Services (HHS) on January 26, 2015, the agency…

MedHOK Podcast – CMS: Shooting for the Stars

Marc Ryan of MedHOK, Inc. presents what plans will face in 2016 and beyond for Star ratings. Marc explains the…

Podcast – Medicare Advantage’s Future

Marc Ryan of MedHOK, Inc. presents an overview of the future of Medicare Advantage Plans. Currently, Medicare Advantage Plans are…

Traditional Medicare Beneficiaries Switching to Medicare Advantage

A study published in Health Affairs journal found that a majority of beneficiaries who enrolled in private Medicare Advantage plans…

CMS Adding New ACO Participants

On December 22, 2014, The Centers for Medicare and Medicaid Services was excited to announce that 89 new Accountable Care…

Medicare Part D Study Results on Access to Preferred Cost Sharing Pharmacies

The Centers for Medicare & Medicaid Services (CMS) announced in the CY2015 Call Letter various concerns surrounding beneficiary access to…

Reminders, Part D Reporting Requirements, and CMS Audit Findings Reminder

Important Reminders Save the date - this year's Medicare Advantage & Prescription Drug Plan Spring Conference & Webcast will be…

New CMS Rules to Enhance Provider Oversight

On December 3, 2014, The Centers for Medicare & Medicaid Services (CMS) announced new rules that strengthen oversight of Medicare…

MedHOK Compliance Insights December 2014 – Important Reminders, Reporting of Emergency Part C&D Issues, and Physician Medicare Enrollment File

IMPORTANT REMINDERS 2015 Medicare CAHPS® Survey - Sponsors with 600 or more enrollees as of July 1, 2014 are required…

SNPs May Yet Get the Star Relief They Want

Special Needs Plans (SNPs) have long argued that the current Star program discriminates against standalone SNP plans, plans with a…

The Latest on 2016 Program Audits from CMS’ Fall Conference Yesterday

Yesterday, the Centers for Medicare & Medicaid Services (CMS) held its annual Medicare Advantage and Prescription Drug Plan Fall Conference…

Pioneer ACO Model Saves Millions

The Medicare Shared Savings Program provides incentives for Accountable Care Organizations (ACOs) that meet standards for quality performance and reduce…

Strategic Vision for Physician Quality Reporting Programs

In March, 2015, the Centers for Medicare and Medicaid Services (CMS) released its strategic vision for physician quality reporting programs,…

CMS 2016 Proposed Draft Call Letter – Stars are Changing

On February 20, 2015, the Centers for Medicare and Medicaid Services (CMS) released proposed changes for the coming year for…

Commercial Plans Face Shock As Stringent Exchange Regulations Roll Out

In the wake of reforms under the Affordable Care Act (ACA), all lines of business - including Exchange plans -…

CMS Proposed Rule To Update Medicaid and CHIP

On May 26, 2015, the Centers for Medicare & Medicaid Services (CMS) proposed a rule to modernize Medicaid and Children's…

CMS Pushes Medicaid Expansion

In a new report, the White House Council of Economic Advisers, Department of Health and Human Services (HHS) and the…

CY 2016 Medicare Advantage and Part D Final Call Letter

On April 6, 2015, CMS released the Calendar Year (CY) 2016 Medicare Advantage Capitation Rates and Medicare Advantage and Part…

ICD-10 Transition Updates

The Centers for Medicare & Medicaid Services (CMS) announced on July 6, 2015, that it would work with the American…

CMS Audit Season in Full Swing

The Centers for Medicare and Medicaid Services (CMS) audit season is in full swing with numerous Medicare Advantage and standalone…

Affordable Care Act Here to Stay

As you may have read, the second major decision on the Affordable Care Act's (ACA) survival occurred late last week.…

Medicare Raising Bar for “Big-Ticket” Items Coverage

Medicare coverage for "big-ticket" and sometimes controversial drugs, imaging, surgeries, procedures, and devices were more likely to be approved without…

Bundled Payments for Care Improvement Initiative Pilot Project Grows

The Centers for Medicare & Medicaid Service (CMS) has announced that thousands of providers have moved forward with the Bundled…

Major Risk Adjustment Changes Will Require Plans to Develop New Strategies to Improve Revenue

One of the fast-emerging parts of the value-based purchasing realm is government regulators’ move toward apportioning revenue in our health…

Prescription Drug Premiums Projected to Stabilize

Prescription drug spending increased nearly 13 percent in 2014, the highest since 2002, according to the Centers for Medicare and…

Medicare Advantage Pay Rates to Increase, Not Decrease, in 2016

The Centers for Medicare and Medicaid Services (CMS) announced on April 6, 2015, that payments to Medicare Advantage plans will…

Medicare Access and CHIP Reauthorization Act of 2015

A bill passed by the House on March 26, by a surprising bipartisan majority of 392-37, H.R. 2, the Medicare…

Exchange Plans and the Coming Rigorous Compliance Environment

Marc Ryan of MedHOK, Inc. presents an overview of the compliance regulations affecting the Exchange Plans created as a result…

MedHOK Podcast – Providers and the New Healthcare Accountability Model

Marc Ryan of MedHOK, Inc. presents an overview of the emerging accountability model for providers. This model is the result…

MedHOK Podcast – CDAG Audit Overview

Over the past several years, the Centers for Medicare & Medicaid Services (CMS) has been ramping up audit requirements and…

MedHOK Compliance Insights March 2015 – Important Reminders and 2015 Program Audit Protocols and Process Updates

 Important Reminders Registration is now open for this year's Medicare Advantage & Prescription Drug Plan Spring Conference & Webcast which…

No Summer Doldrums for Healthcare News

There are no summer doldrums when it comes to healthcare news. Here are a few of the events that have…

MedHOK Compliance Insights – July 2015 – Important Reminders and Information

Compliance Insights Important Reminders Mid July, 2015 - Release of CY 2016 Update in advance of the Limited Formulary Update…

Star Program Driving Quality in Medicare Advantage

Success in the future of healthcare means paying significant attention to quality measures today. The Centers for Medicare and Medicaid…

Value-Based Purchasing Comes to the Fore

While many see the major expansion of Medicaid and the creation of the federal and state Exchanges as the biggest…

MedHOK Compliance Insights: September 2015

Important Reminders Early September 2015 CMS begins accepting plan correction requests upon contract approval. September 8-11, 2015 Second CY 2016…

Testing the Waters for Medicare Advantage Value-Based Insurance Design Model

On September 1, 2015, the Centers for Medicare & Medicaid Services (CMS) announced the opportunity for plan sponsors to test…

PPACA Supreme Court Review – The Last Day

The Supreme Court arguments on the Patient Protection and Affordable Care Act (PPACA) concluded Wednesday. With the first two days…

PPACA Supreme Court Review – The First Day

On the first day (Monday, March 26) of the Supreme Court review of the Patient Protection and Accountable Care Act…

PPACA Supreme Court Review – Day Two

The Second Day of Supreme Court review of the Patient Protection and Affordable Care Act (PPACA) lived up to the…

PPACA: Supreme Court Review And A Flurry Of Regulations

The Supreme Court is set to begin hearing arguments next week on whether the Patient Protection and Affordable Care Act…

PPACA: Reflecting on Two Years

The Patient Protection and Accountable Care Act (PPACA or health reform) turns two today and we couldn’t help but reflect…

PPACA Rebates would Have Been Sizable in 2010

The Commonwealth Fund released a study recently that determines that consumers would have received rebates of nearly $2 billion if…

PPACA, Medicaid and Medicare Updates

Governors question PPACA progress Governors are increasingly expressing frustration with the lack of clarity related to setting up the state…

PPACA Essential Benefits Outlined

The Department of Health and Human Services (HHS) essentially gave in a little on crafting rigorous essential benefits under the…

PPACA and Medicare Updates Part 2

Medicare FFS Hospital Readmissions Aren’t Dropping Despite an intense effort to reduce readmissions at hospitals, new data from the Centers…

PPACA and Medicare Updates

Medicaid Expansions And Exchanges In Limbo As we told you last week, in light of the Supreme Court’s declaration that…

Pioneers! Oh Pioneers! ACO Demonstrations: Pioneer and Advance Payment Models

Last week CMS announced a new ACO demonstration to be run through the Center for Medicare and Medicaid Innovation (Innovation…

Strategic Insights November 20, 2014 – 2015 Readiness Checklist for Medicare-Medicaid Plans

On November 19 2014, the Centers for Medicare & Medicaid Services (CMS) sent a reminder for Medicare-Medicaid Plans (MMP) of…

On a Roll – Rules to Implement Health Reform Issued Fast and Furiously

The health reform mandates keep rolling along. On September 23, 2011, many plans are required to implement a second increase…

No Quick Fix for Doctors’ Incessant Headache – Decrease in Medicare Physician Reimbursement Looming

It’s about that time of year again when Congress starts talking about allocating billions of dollars toward fixing the Medicare…

Multi-Tasking Metrics

Our latest article, Multi-Tasking Metrics, is now available on HISTalk.

Compliance Insights February 2014

This issue of Compliance Insights focuses on the proposed CY 2015 Policy and Technical Changes to the Medicare Advantage and…

Compliance Insights December 2013

In this issue of Compliance Insights, we bring you important regulatory information from recent HPMS memos and other sources including:…

Compliance Insights – August 2014

In this issue of Compliance Insights you can read about QIO Change, New MTM Form, HOS and OMS Updates. To…

Compliance Insights April 2014

This issue of Compliance Insights reminds plans of upcoming deadlines to issue Part C EOBs (5/31/2014) and the submission of…

Compliance Insights 2013 3rd Quarter

In this issue of Compliance Insights, MedHOK reminds plans the new version of the Medicare Denial Notice is required on…

Medicare Restructuring

While major changes to Medicare are unlikely to occur this election year, more and more proposals are coming out that…

Medicare Quality Big Focus for CMS

In lieu of its usual analysis, MedHOK is updating you on developments from past Strategic Insights. Quality Focus in Medicare…

Medicare Bonus Program Under Fire

Two major developments on the Medicare Advantage (MA) finance front over the past week or so. On one hand, the…

Medicare Audit Environment Podcast

Marc Ryan of MedHOK gives an overview of the Medicare Audit Environment.

CMS Unveils Comprehensive Primary Care Initiative

While the Patient Protection and Affordable Care Act (PPACA) is best known for the health mandate, the coming exchange marketplaces,…

Medicare Advantage Update

RADV update In a previous issue we told you about increased scrutiny around risk score (HCC) reporting by Medicare Advantage…

Medicare Advantage Making Headlines – But is it Too Much Attention?

Medicare Advantage (MA) plans are enjoying continued success despite some major changes in recent years. That could portend further reforms…

CMS Pushing ACO Pilots in Numerous Ways

While the Supreme Court could strike down the entirety of the Patient Protection and Affordable Care Act (PPACA) this month,…

Medicaid Quality Measures Announcement Mirrors Efforts in Other Programs

While some states initiated strong quality enhancement programs (complete with quality bonuses and extra member assignments) years back in their…

Medicaid Becomes Political Football

Last week, we discussed the budding debate over the Medicaid Maintenance of Effort (MOE) and whether the mandate remains in…

MedHOK Ushers Out 2014 Ranked by Inc. as Nation’s 25th Fastest Growing Company

Inc. ranking as sixth fast-growing healthcare company is MedHOK’s third performance-oriented recognition in 2014 TAMPA, Fla. - Dec. 16, 2014…

Two Birds, One Stone – Reducing Hospital Readmission Rates

Two of the main goals of the health reform legislation are to improve the quality of care delivered to Americans…

The Role of Information Technology in Overcoming Challenges to MA, PBM Appeals and Grievances

In this article, recently published by the Health IT Law & Industry Report, Anil Kottoor, CEO of MedHOK Healthcare Solutions,…

Health Care Reform Updates

This week we update you on a few topics we have written about before. PPACA Supreme Court Ruling Healthcare stakeholders…

Is President Obama Banking On a Health Reform Shot In The Re-Election Arm?

Judicial review of national health reform’s individual mandate is thus far mixed, with some court rulings in favor and others…

MedHOK Strategic Insights: CMS Audits & More

Strategic Insights March 2013 CMS increases focus on Appeals and Grievances, Coverage Determinations A review of 2012 CMS Medicare Advantage…

IOM Throws Curve Ball at Essential Benefits: Next up HHS

A number of external organizations have been tasked with advising the Department of Health and Human Services (HHS) on critical…

MedHOK’s Technology Platform Positions CMS Comprehensive Primary Care Initiative Participants to Improve Care Coordination, Share in Savings

TAMPA, Fla. – Oct. 3, 2012 – MedHOK, one of the healthcare industry’s fastest growing software companies, announced today that…

Individual Mandate Remains Elephant in the Room – Obama Reaches Out to GOP on State Flexibility

The individual mandate as contained in the health reform law will continue to be the subject of controversy until the…

I Catch Your Shift – Raising the Medicare Eligibility Age to Contain Federal Spending

While a debt deal has been signed, it is clear that much more work needs to be done to get…

How Do I Rate? – Medicaid Rate Cuts Take Center Stage in Case Before Supreme Court

Providers and advocates know that Medicaid rate setting is recognized for being more art than science. Certain states have made…

How Does Your Provider Measure Up? “Report Cards” Ranking Provider and Supplier Performance Coming Soon

Earlier this week, the Centers for Medicare and Medicaid Services released a proposed rule that would make Medicare information regarding…

Hospital Value Based Purchasing & Dual-Eligibles Demonstrations

Last week, CMS released the final rule implementing a requirement in health reform that directs the Secretary of HHS to…

“Insuring” Health Reform’s Solvency – Are There Alternatives to the Individual Mandate?

The Supreme Court is primed to consider whether it will expedite its review of the many lawsuits challenging constitutionality of…

Health Reform Update

A number of developments occurred on health reform and other issues this past week, including the release of the final…

The One That Got Away – Glitch in Reform Law Will Allow Middle Class to Join Medicaid

While speaking at a professional society meeting recently, Richard Foster, Medicare’s chief actuary, revealed that early retirees would have access…

The Future of the Medicaid Expansion under PPACA

Headlines regarding the pending Supreme Court case on the Patient Protection and Affordable Care Act (PPACA) tend to focus on…

The Emerging Health Care Landscape Podcast

Millions of Americans are covered in private health plans through various channels and levels such as the Exchange, Medicaid and…

Supreme Court PPACA Fallout

The 10 days since the Supreme Court upheld the Patient Protection and Affordable Care Act (PPACA) have been a combination…

Supreme Court Fallout

President Obama’s comments that the Supreme Court would not overturn PPACA drew harsh rebukes from many and forced the White…

Healthcare Reform Updates

MA Star bonuses We recently told you that CMS was administratively overriding the healthcare reform act by making quality bonuses…

Strategic Insights September 29, 2014 – In Exchanges: Rate Death Spiral May Not Come True But Greater Scrutiny Will

For those predicting a so-called death spiral occurring in the Obamacare Exchange Marketplace, preliminary evidence suggests that naysayers could be…

Strategic Insights September 25, 2014 – CMS Announces New Goal to Improve Dementia Care in Long-Term Care

Long-term care providers are being asked to reduce the use of antipsychotic drugs among residents by 25 percent by the…

Strategic Insights September 15, 2014 – Provider Enrollment 2015

On May 19, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will revise the…

Strategic Insights September 8, 2014 – Interdisciplinary Care Team

As mentioned in the August 20th blog, one of the critical elements of the Model of Care (MOC) is the…

Accountable Care Organization Rules Come Out – Part I

Over the past several months, we have felt a little like the kids in the back seat of the car…

Strategic Insights October 24, 2014 – Basic Health Program – Proposed Funding Methodology

On October 21 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed notice establishing the methodology on…

Strategic Insights October 17, 2014 – Part C and Part D Program Annual Audit and Enforcement Report

In the July 7, 2014 Strategic Insights, we recommended reviewing the June 24, 2014 CMS Oversight and Enforcement Conference presentation…

Accountable Care Organization Rules Come Out – Part I

Over the past several months, we have felt a little like the kids in the back seat of the car…

Strategic Insights October 17, 2014 – Part C and Part D Program Annual Audit and Enforcement Report

In the July 7, 2014 Strategic Insights, we recommended reviewing the June 24, 2014 CMS Oversight and Enforcement Conference presentation…

Strategic Insights October 8, 2014 – CMS Open Payments Database

On September 30 2014, as part of the Centers for Medicare & Medicaid Services (CMS) ongoing effort to increase transparency…

Strategic Insights November 25, 2014 – Proposed Enhancements to the Star Ratings for 2016 and Beyond

On November 21 2014, the Centers for Medicare & Medicaid Services (CMS) sent out proposed methodology enhancements and changes for…

Strategic Insights November 12, 2014 – Contract Year 2015 Readiness Checklist for Medicare Advantage Organizations

On October 31 2014, the Centers for Medicare & Medicaid Services (CMS) sent out their annual reminder of the 2015…

Strategic Insights November 3, 2014 – Medicare Advantage’s Bright Future

It was not long ago that some were predicting the demise of the Medicare Advantage (MA) program due to the…

Strategic Insights June 30, 2014 – Medicare Advantage Bill Introduced

As discussed in our March 31, 2013 Strategic Insights blog, the Centers for Medicare & Medicaid Services (CMS) proposed new…

Strategic Insights June 24, 2014 – CMS “From Coverage to Care”

Nearly 13 million Americans gained coverage through the Marketplace, Medicaid and Children's Health Insurance Program (CHIP). More than 500,000 uninsured…

Strategic Insights July 28, 2014 – What’s Next for Exchanges and Medicaid

Kaiser Health News reported last week on a just published study in the New England Journal of Medicine by the…

Strategic Insights July 24, 2014 – CMS Delays MTMP Enhancement

Medicare plans and PBMs breathed a sigh of relief recently when CMS backed off significant expansion and enhancement of the…

Strategic Insights July 14, 2014 – Plans Reducing Administrative Costs Using Auto-Authorization

With scarcer governmental resources and tighter financial bids, health plans and other payers are looking for ways to reduce administrative…

Strategic Insights July 7, 2014 – CMS STRENGTHENING MEDICARE PLAN OVERSIGHT; AUDIT PENALTIES

If any health plan or payer executive missed the June 24, 2014 CMS Oversight and Enforcement Conference, we highly recommend…

Strategic Insights August 25, 2014 – Medicare FFS System Pursuing Chronic Care Management

Strategic Insights has told you recently about the major focus the Centers for Medicare & Medicaid Services (CMS) is putting…

Strategic Insights August 20, 2014 – Special Needs Model of Care – Additional Audit Details

n its July 7 blog, Strategic Insights discussed the emerging strict enforcement policies of the Centers for Medicare and Medicaid…

Strategic Insights August 11, 2014 – Public Use File Now Available

On July 31, the Centers for Medicare & Medicaid Services (CMS) released the first public use file (PUF) containing CY2012…

Strategic Insights August 4, 2014 – Updated Hospice Drug Rule

Great news for plans - Medicare has modified the original Hospice prescription drug rules. In May 2014, the Centers for…

MedHOK Compliance Insights: CMS Requirements Updates & More

In this issue of Compliance Insights, MedHOK covers updates to CMS Part C and D Reporting Requirements and the Complaints…

States Making Changes to Medicaid: User Fees and Expansion Among Proposals

Earlier this month, the Florida Legislature passed legislation overhauling the Medicaid program. In addition to increasing oversight of managed care…

ACO Final Rules Issued: CMS Bows To Provider Pressure, But Will It Be Enough?

The Centers for Medicare and Medicaid (CMS) released its final Accountable Care Organizations (ACOs) rules this past week and made…

State Exchange Marketplace Taking Shape – HHS Releases Two Proposed Rules

HHS published two Notices of Proposed Rulemaking (NPRM) a few weeks ago relating to developing a framework for Insurance Exchanges.…

From Passage to Implementation: Health Reform, A Year in Review

Since its passage one year ago today, the Patient Protection and Affordable Care Act (PPACA) has been the center of…

Final Rules Don’t Give Relief on Minimum MLR: Mixed Signals from HHS On States’ PPACA MLR Waivers

When the national health reform bill passed, many insurers and state insurance regulators reacted with chagrin to the 85 percent…

Final Exchange Rules Out/Medicaid Proposals Gain Attention

Final Exchange Rules Out The final rules for the state exchanges under the Patient Protection and Affordable Care Act (PPACA…

Final 2012 MA Rates

CMS’ final Call Letter for 2013 plan coverage calls for average increases of 3.07 percent for Part C and Part…

Winners and Losers in MedPAC Proposal to Fix SGR – Specialists would see Pay Cut

Last week the Medicare Payment Commission (MedPAC) unveiled recommendations that would change the way physicians in the Medicare fee-for-service program…

Few Swimmers Take Plunge Into High-Risk Pool – Feds Throw Life Preserver

The Pre-Existing Condition Insurance Program (PCIP), which passed as part of the Patient Protection and Affordable Care Act (PPACA), is…

Feds May Be Pushing Minimum MMR Consistency Across All Lines of Business

A federal response to the Florida Medicaid agency's new 1115 waiver request shows that the Centers for Medicare and Medicaid…

Feds May Be Pushing Minimum Medical Loss Ratio Consistency across All Lines of Business

A federal response to the Florida Medicaid agency's new 1115 waiver request shows that the Centers for Medicare and Medicaid…

Exchange Regulations Released – Essential Providers Play Leading Role

Last week, the Department of Health and Human Services (HHS) released regulations governing the establishment of Exchanges, set to begin…

Major Clinic Takes Wait and See Approach to ACOs: Industry Abuzz with Meaning of Decision

Since 2005, CMS has been running a Physician Group Practice Demonstration (PGP) that operates similar to an Accountable Care Organization…

Dual Integration Continues

Since our last discussion on the dual eligible demonstration projects, a great deal has occurred. Here are the highlights. The…

Research Aims to Reduce Over-Practicing Among PCPs

Best practices have always been emphasized by the various medical societies and academies. But under health reform, payers and providers…

Debt Crisis Could Lead To Major Medicaid Managed Care Expansion

With the debt crisis consuming national attention, entitlement reform is inevitable and Medicaid spending will almost certainly be on the…

Deadline Looms As The Super Committee Tries To Prepare Thanksgiving Deal

All attention in Washington is focused on whether the Super Committee created under the recent deficit and debt reduction act…

Lack of Standardization Surrounding Innovation: Regulations for Innovation Waivers Lack Specificity

Last week, HHS released rules that establish an application process for states to request a waiver of innovation requirements that…

Keeping Current – MedHOK Strategic Insights

On February 15, 2013 CMS issued The 2014 Advance Notice and Call. February's Strategic Insights covers the highlights of this…

Compliance Insights November 2014 – Important Reminders, 2015 Readiness Checklists, and Chapter 4 Update

Request for Comments: Enhancements to the Star Ratings for 2016 and Beyond - On 11/21/14 CMS released the proposed methodology…

What is in the Stars: Medicare Advantage Star Ratings Take Leading Role, Part 2

As we discussed yesterday, passage of the health reform bill created a quality bonus system using the CMS ratings. In…

What is in the Stars: Medicare Advantage Star Ratings Take Leading Role, Part 1

Congress and CMS have taken steps recently to reward high-quality Medicare Advantage Plans. CMS utilizes a five-star rating system to…

Wading Into the Deep End – Is Current High-Risk Pool Enrollment Indicative of Future?

Last week, we told you about the Pre-Existing Condition Insurance Program (PCIP), a program designed to provide insurance to high-risk…

Feds May Be Pushing Minimum Medical Loss Ratio Consistency Across All Lines of Business

A federal response to the Florida Medicaid agency's new 1115 waiver request shows that the Centers for Medicare and Medicaid…

All Aboard–The Health Care Savings Train is Leaving the Station

Finally, policy-makers seem to be getting serious about the size of government and America’s ever-growing debt. A main focus is…

All Aboard—The Health Care Savings Train is Leaving the Station

Finally, policy-makers seem to be getting serious about the size of government and America’s ever-growing debt. A main focus is…

A Few Thanksgiving Healthcare Morsels

Given the short week, MedHOK’s Strategic Insights will offer up some Thanksgiving-themed morsels on recent healthcare happenings. Happy Thanksgiving! Super…

Compliance Insights March 2014

This issue of Compliance Insights covers important regulatory information from recent HPMS memos and other sources, and reminds plans of…

Compliance Insights July 2014

This issue of Compliance Insights reviews the June 24, 2014 CMS Oversight and Enforcement Audit Conference and reminds plans of…

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