Medicare
2024 Oversight Activities – Utilization Management Changes
CMS notified Medicare Advantage Organizations (MAOs) on October 24, 2023, that it will be conducting strategic conversations on the new Utilization Management (UM) requirements effective January 1, 2024. Following these conversations, CMS will start conducting routine and focused audits of the new prior authorization and related rules published in April of this year in the…
Read MoreThe Bridge — Volume 12
Madena™ and CODY® Merge to Expand Technology and Consulting Capabilities CODY® Acquires Madena Madena has been acquired by CODY®, leading healthcare technology and consulting firm. The combined offerings and decades of industry expertise provide Medicare, Medicaid, and Commercial health plans an ‘end-to-end integrated solution’ previously unavailable in the marketplace. CODY® works with over 60 government-funded,…
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 MoreThe Bridge – Volume 10
We Wish You a Successful and Compliant AEP Season! While we are all in the throes of Annual Enrollment Period (AEP), Madena is looking to support you by dedicating a newsletter to upcoming critical activities that can easily be overlooked during this busy time. CMS Low Income Subsidy Processing Have you reached out to your…
Read MoreMedicare 2021 Timeliness Monitoring Project
In October CMS issued a memo regarding the 2020 Timeliness Monitoring Project (TMP). As in previous years, CMS will once again be conducting an industry-wide monitoring project in 2021. What’s changed? Beginning with the 2021 TMP, CMS will no longer collect the Part D Coverage Determination Appeals and Grievances universes used to evaluate these measures.…
Read MoreCMS Program Audits – Preparation Is Critical
Comprehensive preparation is critical to producing accurate universes and achieving a successful CMS Program Audit. Madena’s experts have dozens of years of experience and can help Part C and D plans with all aspects of the Audit process. How Madena Can Help With Your CMS Program Audit Development and implementation support of universe design – we…
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 MoreIndependent Validation Audits
What’s Possible After a Program Audit? by Sue Dahlkamp, Interim Compliance Officer & Senior Consultant CMS requires that sponsoring organizations undergo an Independent Validation Audit (IVA) if they receive a number of ICARs or CARs on their Program Audit to demonstrate correction of all reported audit conditions. CMS then determines when the audit can be…
Read MoreThe Bridge – Volume 9
[vc_row][vc_column][vc_column_text] October/November CMS Software Release: Impacts to Plans The October CMS Software HPMS memo dated 9/1/2020 has some interesting changes, and the implementation time frames are compressed. Health plans must implement the additional data elements for Preferred Language and Accessible Format by 10/15/2020. Any new 2021 enrollment (TC61) will need to include these data…
Read MoreThe Bridge – Volume 8
Highlights of Medicare Advantage Chapter 2 (Enroll & Disenroll) Updates Updates for Chapter 2 of the Medicare Managed Care Manual have been posted to the CMS website–and be aware that the amount of changes are more than we typically see. Plans must be responsive and alert to these updates to ensure enrollment and operations processes…
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