Policies and procedures are essential tools for any organization. By clearly articulating the requirements established by external oversight bodies and internal standards, they are an effective control to support consistency, accountability, and compliance. To be effective, policies and procedures should be: Designed as tools that help employees make decisions related to their assigned tasks/responsibilities; Clear,…

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It’s no secret that Star Ratings can have a significant impact on a health plan’s membership and bottom line. As competition increases, it’s essential to have strategies in place to elevate or maintain a 4+ star rating. The Centers for Medicare and Medicaid Services (CMS) recently released Highlights of Contract Performance in 2021 Star Ratings.…

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In today’s rapidly changing environment, health plans operating in silos or with dated legacy systems are struggling to keep up. As competition increases and technology evolves, companies are searching for answers—should they purchase software applications individually or buy a suite or bundle? IT purchasing managers face difficult challenges as business needs grow, software solutions change,…

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Artificial Intelligence (AI) will become a larger factor in all facets of life soon… …in everything from self-driving cars to industrial manufacturing to the way we entertain ourselves. These changes will impact every part of healthcare also, from diagnosis through treatment and even into administrative and operational functions. CMS has started two initiatives directly related…

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Health plans are wondering “where are my updated Medicare Communications and Marketing Guidelines (MCMG)?” For the second consecutive year, the Centers for Medicare & Medicaid Services (CMS) stated that there will be no updated MCMG for CY2021. Instead, plans are instructed to use the existing MCMG and related memos from CY2020. How will changes be…

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Many health plans are currently considering how to manage creation and distribution of marketing materials due to members September 30. The reality is, health plans have two options: Develop materials in-house, and outsource printing and fulfillment to a vendor; or Outsource the entire materials production process – materials creation, and print and fulfillment – to…

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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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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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Health plans today are feeling more pressure than ever before to do more with less. This is especially true now that health plans have to operate within the federal minimum medical-loss ratio (MLR) requirement. The minimum MLR requirements leaves health plans with only 15 percent of their Medical revenue to spend on administration, marketing, and,…

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Good news for Medicare agents and brokers: The Centers for Medicare and Medicaid Services (CMS) recently reported that of the 1,320 marketing events secretly shopped during the 2014 contract year Annual Enrollment Period (AEP), 85.5% were fully compliant. This is a huge improvement from previous years, when CMS found more than half of secretly shopped…

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