Executive Briefing | November 13, 2018

Navigating CMS’ Enhanced Program Integrity—Preparing for the Spotlight

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On June 30th, CMS announced it was enhancing its Program Integrity efforts that focus on addressing improper Medicaid payments and CMS oversight of state Medicaid programs. The announcement introduced 8 initiatives, including stronger audit functions, enhanced oversight of state contracts…

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hfm Magazine | September 6, 2018

Integrated Revenue Cycle: Coordination Between Insurers and Providers to Ensure Revenue Accuracy

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Traditional revenue cycle management arrangements that focus solely on billing and collections are no longer reliable in the world of delegated risk models, especially for Medicare Advantage (MA) populations. That’s why Pareto recommends an innovative approach to managing value-based payments,…

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Executive Briefing | March 1, 2017

The Siege Continues: Justice Department Investigating Four Additional Medicare Advantage Plans

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WHO IS AT RISK The federal government has indicated that it is still investigating, and could ultimately join a false claims whistleblower qui tam action against Aetna, Inc., Humana, Inc., Cigna, Inc. (through its Bravo Health unit) and Health Net,…

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Executive Briefing | February 20, 2017

Medicare Advantage Plans Under Siege: Another Whistleblower Lawsuit

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In a court decision last year in Swoben v. United Healthcare, the United States Court of Appeals for the Ninth Circuit held that an allegation—that a Medicare Advantage Plan performed a “biased” HCC-RAF retrospective medical review designed only to identify…

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hfm Magazine | November 15, 2016

Translating Risk into Revenue

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Health plan revenue is increasingly tied to the concept of risk adjustment. In practice, risk adjustment aligns payments received by health plans with the risk of the populations they manage. Although each market has its own unique version of risk…

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