Value-Based Payment Initiatives Really Do Require Paradigm Shifts (No Joke!)

  With so many different interest groups touting value-based payments (VBP) as the key to reform of our fragmented and expensive health care system, too little attention is being devoted to the paradigm shift that value-based payments require. In a traditional volume-based fee-for-service contract between an insurance company and a provider organization, the “levers” that each party gets to move are straightforward.  Insurance companies have... Read More

There Was Significant Movement Past the 4-Star Threshold in 2018 MA Star-Ratings

A little noticed fact emanating from the release of detailed Medicare-Advantage Star-ratings on October 11, 2017 was the number of contracts that either gained 4-star status in 2018 or lost their 4-star status that they had earned in 2017. Focusing on just the 55 contracts (about 15% of all contracts rated for both 2017 and 2018) that crossed the 4-star threshold (either up or down),... Read More

Medicare Advantage star-rating policy shift

Modern Healthcare reported that CMS shocked the industry by scrapping plans to lower star ratings for Medicare Advantage plans facing sanctions for poor compliance. The change will protect up to $350 Milion for Cigna Corp which received sanctions in January. Previously policy stated that any Medicare Advantage plan that faced “intermediate sanctions” would have its quality rating dropped to 2.5 stars or, if their rating... Read More

Medicare Advantage Part D Fines Less in 2015

Modern Healthcare recently reported that civil monetary penalties issued to insurers offering private Medicare were down over 4% in 2015 compared with the prior year. These fines, issued for noncompliance with Medicare’s coverage rules, totaled $4.72M last year, and while the jury is still out, most experts believe that the decline is primarily due to plans getting better at interpreting the rules. “Richard Lieberman, chief... Read More

Top Quality Improvement Trends for 2016

Quality Management Trends | Mile High Healthcare Analytics

In recent years both providers and plans have placed increasing emphasis on quality improvement. CMS Star ratings can have a major impact on financial performance with significant incentives delivered to programs receiving 4-stars or more. The “rules of the game” for quality ratings continue to shift as CMS gains more insight on which measures drive the most positive consequences. As we kick-off 2016, we thought... Read More

Root Cause Data Integrity Issues Impact Quality

Data Integrity | Mile High Healthcare Analytics

Mile High Healthcare Analytics understands that data integrity is critical to risk adjustment and quality improvement success. In fact, data quality management is the starting point for nearly every client engagement. When it comes to quality improvement initiatives, data governance needs to be done at the individual member level and organizations must address the most common root causes of data inaccuracy. In large organizations where... Read More

Risk Adjustment in Medicaid

Medicaid Risk Adjustment | Mile High Healthcare Analytics

Many people believe that risk adjustment started with Medicare Advantage in 2004, but actually Medicaid risk adjustment led the way, starting in Maryland and Minnesota in the late 1990’s and Colorado in 2000. Current State of Medicaid Risk Adjustment Today 36 states currently have risk-bearing contracts with managed care organizations (MCOs). At least 23 states use a risk adjustment model to adjust payments to these... Read More

CMS Announces Plans to Expand RACs to Medicare Advantage and Part D Plans

A tremor was felt across the healthcare industry as CMS released a request for information (RFI) that outlined the planned expansion of Medicare’s Recovery Audit Program. Under this program the government pays private recovery audit contractors (RACs) to assess medical records at hospitals and doctor offices to find instances of overpayment. The first set of audits, based on payment data for 2007, yielded $13.7M in... Read More

Free Webinar: “2016 Quality Improvement Trends”

2016 Quality Management Trends | Mile High Healthcare Analytics

The 2016 Mile High Healthcare Analytics Free Webinar Series kicks off on January 7th with Richard Lieberman previewing upcoming trends in Quality Measurement. Don’t miss this session as we outline important learning from 2015 and tips for QI program success in 2016 including how to prepare for, 1) new quality ratings in Medicaid and on the Exchanges, and 2) changes to Medicare-Advantage Stars for 2016.... Read More

ICD-10 Transition Update

ICD 10 | Mile High Healthcare Analytics

Despite much nail biting and teeth gnashing in anticipation of the cutover to ICD-10, the apocalypse appears to have been avoided. To many in the industry, the October 1 transition to ICD-10 created a Y2K-like frenzy, and, like Y2K, it appears to be mostly a non-event. ICD-10 Code Quantity Explosion That is not to downplay the significance of this transition. The new ICD-10-CM diagnosis coding... Read More