Compliance

Sharing Protected Health Information (PHI)

Dude, where’s my flying car Electronic Medical Record/Electronic Health Record (EMR/EHR)? The year is 1989, and the panel discussion focuses on electronic medical records. One panelist expresses concern about the vulnerability of such a system: imagine if someone walked by with a high-powered magnet. A more forward-thinking panelist remarks that the same thing would happen…

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Tips for CPE Audit Tracer Evaluations

CPE Audit Tracer Presentations continue to be a hot button for plan sponsors.  CMS auditors frequently find compliance and operational deficiencies through the tracer process. Since the Compliance Officer is responsible for the management of tracer presentations, it is crucial that the Compliance Program employs strict protocols for the development of the tracer presentations and…

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An Advance Look at Medicare Advantage Benefits Changes for CY2020

Every year, the Centers for Medicare and Medicaid Services (CMS) updates its Plan Benefit Package (PBP) Software that Medicare Advantage (MA) and Part D plans use as part of their bid submissions. The PBP Beta Software is released in late January to allow plans to test and provide feedback before the full version is available…

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4 ways to reduce – or eliminate – errors in your ANOCs and EOCs

The accuracy of Annual Notice of Changes (ANOC) and Evidence of Coverage (EOC) documents is an important requirement for all health plans. The Centers for Medicare and Medicaid Services (CMS) takes errors in these documents very seriously and penalties are given to health plans that distribute documents with errors. CMS recently announced changes to the…

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3 Keys to a Successful Compliance Program

Complying with state and federal rules and regulations is a challenging endeavor. It requires health plans to manage a slew of different processes and resources.  Missteps pose risks that could result in compliance violations, fines and a drop on CMS’s Five Star Quality Ratings. Some of the most difficult areas to manage, from a compliance…

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How to Avoid FDR Oversight Issues in a CMS CPE Audit

First Tier, Downstream or Related Entity (FDR) Oversight continues to be a hot topic for the Centers for Medicare and Medicaid Services (CMS) and plan sponsors. CMS auditors annually find deficiencies in FDR oversight and monitoring activities in program audits, with poor oversight of FDRs trending as a common condition in yearly audits. Many plan…

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6 Traits of a Great Consulting Partner

In the world of Medicare and Medicaid, choosing a consulting partner to help streamline your health plan’s operations can be tricky. While a company or individual may be well-versed in best practices for project management or operational efficiency, they may not understand the unique requirements of the payer market – making them less than effective…

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3 Ways your Health Plan is Overspending – And How to Stop

Health plans today are feeling more pressure than ever before to do more with less. With increased scrutiny from The Centers for Medicare and Medicaid Services (CMS) and decreased budgets, leadership is constantly looking for ways to save money. Doing so might be easier than you think. Below are three ways that health plans are…

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Errors in ANOCs and EOCs could cost up to $55 per affected enrollee

Over the last several years, The Centers for Medicare and Medicaid Services (CMS) has taken an increasingly tough stance on health plans that distribute Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) documents with unclear and/or inaccurate benefit information. CMS is no longer sending health plans warnings for these errors; they are imposing…

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