Category Archives: Health Plans

Medicare Advantage risk adjustment: How deep is the well?

Health plans realize the value of comprehensive risk and quality programs to meet the needs of providers and members. These programs are also critical to addressing increasing regulations and the focus on quality. For Medicare Advantage in particular, it’s important to address quality as defined by the Star Rating system and the bonuses that are […]
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Boost Star ratings with a focus on CAHPS®

In a value-based model world, there are fewer points of differentiation for health plans seeking to show increasingly engaged consumers that quality comes first. Plans are beginning to realize that establishing a year-round focus on the annual Consumer Assessment of Healthcare Providers & Systems (CAHPS®) survey is essential to reaching that level of separation. CAHPS […]
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Best practices for analyzing the Medicare Advantage revenue cycle

The Medicare Advantage market is in the midst of change. Contractions in capitation rates continue to pressure health plans to improve operations and tighten their financial management. For payers offering Medicare Advantage products, Part C and Part D, the risk-adjustment cycle represents a significant challenge to achieve both transparency in operational processes and forward visibility […]
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Aligning risk adjustment and quality management

Many health plans maintain separate risk adjustment and quality management programs, with purposefully siloed objectives and metrics. But aligning the two enables true transparency from data to analytics, and provides numerous benefits: Revenue growth Improved outcomes Reduced medical spend Managing at-risk populations requires health plans to have the appropriate controls and processes in place that […]
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Maximize savings with an enterprise payment integrity strategy

Health plans transforming their business models to accommodate new markets and new lines of business may also experience a strain on their payment integrity programs. This strain can create membership fluctuations, business complexities and regulatory mandates across all areas of claims processing. Without a vigorous payment integrity strategy, these pressures can create competing or misaligned […]
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Modernizing Medicaid: Mega-Reg implications health plans should know

Payers manage a multitude of responsibilities as it relates to their Medicaid membership. From regulatory adherence, and payment integrity optimization to enrollment management, the current, and sometimes, complex canvas of Medicaid oversight is now growing.   The Department of Health and Human Services (HHS) issued a new ruling earlier this year with the intention to […]
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Three factors to consider when implementing a VBR strategy

Health plans are facing significant, systemic changes as they move away from strictly fee-for-service payment arrangements and toward quality-focused, risk-based payment models. While health plans recognize that their existing financial and operational models must look different to accommodate these changes, they may be struggling with how to design and implement a risk-based reimbursement strategy. In […]
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Keys to managing the top 10 HEDIS challenges

A health plan’s Star Ratings and bottom-line performance depend heavily on improvements made to quality measures and Healthcare Effectiveness Data and Information Set (HEDIS®) scores. The key to boosting HEDIS scores and gaining competitive advantage is to be proactive and meet its challenges head on. But what exactly does that mean? We’ve identified the top […]
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Improving Consumer Assessment of Healthcare Providers and Systems scores

With the continued transition to value-based care, the points of differentiation for health plans are narrowing. However, those plans that prove capable of moving the needle on traditionally difficult measures will have the opportunity to become four- and five-Star plans. One group of those measures — the Consumer Assessment of Healthcare Providers & Systems (CAHPS®) […]
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Optimizing population health management strategies using data and analytics

With the emergence of value-based care and increasing focus from buyers on outcomes, health plans are feeling the pressure to prove that their population health programs are delivering on the promise to achieve the Triple Aim. Increasingly, reimbursement is tied to quality, utilization, and financial outcomes and health plans need to act now to develop […]
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