Are Your Systems Ready to Properly Process the CMS Annual Coordination of Benefits-Other Health Insurance (COB-OHI) Files?

The CMS Annual COB-OHI process is quickly approaching, and health plans must be prepared to complete mandatory processes to remain compliant. The Centers for Medicare and Medicaid Services (CMS) play a crucial role in ensuring efficient coordination of benefits for individuals with Medicare coverage. The CMS COB-OHI File is an essential resource that facilitates seamless…

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CMS 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…

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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…

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A True End-to-End (E2E) Communications Suite is Essential for Health Plans—Here’s Why…

As Health Plans know well—planning, building, maintaining, and fulfilling accurate mandated member and provider materials requires alignment of all departments and months of coordinating and managing internal and external dependencies and deliverables to meet AEP timelines. Dates like September 30th and October 15th are ingrained in memory, and summers become a head-down race to deliver…

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Provider Directory Accuracy—Why is it Important?

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to post an online provider directory that is up-to-date and accurate. Beneficiaries must be able to use the online provider directory to find contracted providers they can see to receive covered services. Inaccurate provider directories pose risks to beneficiaries. Because members rely on…

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Why Consolidating COB & MSP Data Collections Are Crucial for Health Plan Revenue Recovery & Compliance

The Centers for Medicare and Medicaid Services (CMS) requires MA and PDP health plans to update systems timely and accurately. Consolidating and analyzing COB & MSP data collections while maximizing recovery options and complying with CMS regulations is a challenging task. Incorrect data sets can easily contribute to non-compliance and lead to inaccurate claims payments,…

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AEP Enrollment Processing Tips—Do’s & Don’ts from End-to-End (E2E)

How well your organization handles a new enrollment during the Annual Enrollment Period (AEP) generally sets the tone for the upcoming contract year for you and your new member. Beginning with Sales and flowing to Enrollment Operations—it’s critical to understand specific actions that trigger reconciliation challenges and member abrasion. With CMS shifting the weight of…

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How to Build an Effective Compliance Monitoring Program & Support Ongoing Risk

A monitoring program is an important part of a health plan’s compliance program and provides valuable information to the Compliance Department to ensure the plan is meeting requirements. Effective monitoring requires coordination with operational areas and supports ongoing risk assessment. Monitoring not only provides a mechanism to detect compliance issues throughout the organization but also…

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