Category: Blog

As we approach the upcoming Affordable Care Act (ACA) Open Enrollment period starting November 1, it’s crucial for health plans to prepare for what could be another record-setting year. Last year’s open enrollment saw a historic 21.3 million people sign up for ACA Marketplace coverage—marking a 30% increase from the previous year and setting a… Continue reading ACA Risk Adjustment: 3 Keys to Open Enrollment Success

Today’s healthcare landscape is constantly evolving and with new regulations impacting risk adjustment, health plans are reevaluating their retrospective coding projects. With advances in analytics, technology, and Artificial Intelligence (AI), health plans have an opportunity to make their risk adjustment programs more efficient than ever before by implementing complete code capture. Complete code capture is… Continue reading 3 Reasons Why Your Health Plan Should Implement Complete Code Capture for Risk Adjustment

Health plans are facing a storm of changes with the arrival of the V28 risk adjustment model for Medicare Advantage, along with increased scrutiny from the OIG and CMS. With audits on the rise and regulations constantly shifting, plans need different strategies and approaches to ensure their risk adjustment and quality programs are compliant. We… Continue reading Navigating V28 and the Changing Regulatory Landscape: 3 Strategies for Health Plans

On April 1, The Centers for Medicare & Medicaid Services (CMS) released the Medicare Advantage (MA) PY2025 Final Notice. Here are some of the highlights for risk adjustment and quality programs: Risk Adjustment Model Updates Most commentators supported the continued rollout of the V28 risk model. The main improvements to the V28 risk model are the… Continue reading CMS PY2025 Final Notice: A Summary

On January 31, The Centers for Medicare & Medicaid Services (CMS) released the Medicare Advantage (MA) PY2025 Advanced Notice. Some of the highlights include:  Rollout of V28 Risk Adjustment Model  Based on analysis of the impacts of the risk adjustment model, CMS has concluded that it is necessary and appropriate to continue the phase-in of… Continue reading CMS PY2025 Advance Notice: A Clinical Perspective  

Medicare Advantage (MA) organizations are under extreme scrutiny to ensure proper coding to reduce overpayments for MA beneficiaries. The recent toolkit released by the Office of Inspector General (OIG) identifies the commonly miscoded diagnosis codes that result in inaccurate risk adjustment scores and lead to overpayments. OIG found that over 70% of the codes were… Continue reading Risk Adjustment Coding Challenges: Reducing MA Audit Risk

Effective member engagement allows a health plan to accurately assess the health status of its members. Engaged members are more likely to participate in their healthcare, seek information about providers, and adhere to treatment plans—all of which lead to better health outcomes and lower costs. Members who take an active role in their health and… Continue reading Three Strategies to Improve Member Engagement  

On March 31st, 2023, The Centers for Medicare & Medicaid Services (CMS) published the Final Rate Announcement for PY 2024. This is an update to the previously published CMS Advance Notice on February 1st, 2023. We’ve put together a recap of these proposed changes below: Risk Adjustment Changes The following provides a high-level overview of… Continue reading CMS Final Notice: A Clinical Perspective

The Centers for Medicare & Medicaid Services (CMS) has had a busy 2023 already with a flurry of regulatory activity. We saw the CMS RADV Final rule published on Jan 30, 2023 and the CMS Advance Notice for PY 2024 published on February 1st, 2023. Impact to risk adjustment and quality programs were minimal in… Continue reading CMS Advance Notice: A Clinical Perspective