Medicare Advantage Consulting
Enhancing Health Plan Compliance Through Comprehensive Risk Assessment and Management: Navigating New Guidelines and Expectations
While risk assessment has always been a core component of compliance programs, recently the Office of Inspector General (OIG), Centers for Medicare and Medicaid Services (CMS) and the compliance community have emphasized the importance of a formal risk assessment in prioritizing resources and developing work plans. The Office of Inspector General (OIG) released guidance at…
Read MoreCMS Program Audit Prep: Leveraging Your Appeals & Grievances Software
Happy New Year and ‘tis the season for CMS Program Audits! In the 2024 CMS Program Audit Updates memo released on December 19, 2023, CMS confirmed their plans to conduct both routine and focused audits of health plans in 2024. The new focused audits will assess compliance with the coverage and utilization management (UM) requirements finalized…
Read MoreRisk Management for Health Plans – Part 3
In Part 2 of our Risk Management for Health Plans series, we provided a high-level understanding of how to approach risk management from a tactical perspective. This week we will provide you with a strategic framework to apply to your program. The 5 Pillars of Risk Management Keep in mind, Risk Management is a continuous…
Read MoreRisk Management for Health Plans – Part 2
In Part 1 of our Risk Management for Health Plans series, we focused on risk culture. This week we will get more tactical and breakdown the operational approach to risk management. Organizational Approach to Identifying & Managing Risk The day-to-day operational approach to risk management requires people, processes, and systems for any organization to properly…
Read MoreRisk Management for Health Plans – Part 1
Recently, CODY® conducted, through our partnership with the Association for Community Affiliated Plans (ACAP), a webinar titled Identifying & Managing Risk. These are a few of the questions regarding risk management for health plans that we considered: How effective is your organization at identifying and managing risk within your health plan from an operational and…
Read MoreProposed Change to CMS CY2024 Part C Reporting Requirements – NEW Category Added
CMS Regulatory Change: CMS is proposing an additional Part C reporting requirement for supplement benefits. This is scheduled to be an annual reporting requirement, due the last Monday in February of the following calendar year. Published in the Federal Register Vol. 88, No. 184 on September 25, 2023 and also on the CMS web site,…
Read MoreThe Bridge – Volume 11
CMS Important News Releases With a general election, massive increases in COVID-19 cases across the country, and many organizations focusing on the Annual Election Period, you may have missed these important CMS news releases. Advance Notice of Methodological Change for 2022 CMS will calculate 100% of the risk score using the 2020 CMSHCC model (vs.…
Read MoreMedicare Part C and D Data Validation Audit
Medicare Part C and D Data Validation Audits (DVA) are required by the regulations (42 CFR 422,516, 422.514, CMS-4085-F) implemented by the Centers for Medicare and Medicare Services (CMS). In order to ensure the independence of the Data Validation Audit, organizations cannot use their own staff to conduct it. Instead, Medicare Advantage Organizations (MAO) and…
Read More