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RISE to the occasion: quality, risk adjustment, payers, and providers converge

Posted by Sean Creighton and David Bartley on 3/21/17 10:56 AM

Although its Nashville location remains the same, the Annual RISE Summit continues to grow in size and importance each year. RISE, or the Resource Initiative and Society for Education, has been bringing its membership together for 11 years to address fundamental issues in risk adjustment, performance measurement and improvement, and payment integrity. The American Health Care Act, the GOP alternative to the Affordable Care Act, was a focal point for this year’s meeting with its release on the eve of the conference. However, RISE is well known for its best-practice sessions, and while the future continues to be debated, there is clearly plenty of work still getting done to move the industry closer to value-based healthcare delivery and payment even in the midst of uncertainty.

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the art and science of handling Medicare risk adjustment coding “gray areas”

Posted by Deb Bradley on 3/9/17 8:30 AM

While the Centers for Medicare & Medicaid Services (CMS) has guidelines in place for Medicare risk adjustment coding, that doesn’t mean that every Medicare Advantage plan will code the same way. In fact, there is room for many different approaches—and it’s up to each plan to decide what will lead to the best outcome. We caught up with Deb Bradley, Verscend’s senior vice president of clinical coding services, to talk about how health plans can seek a better return on investment in their Medicare risk adjustment programs.

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10 steps to enhance your medicare risk adjustment success

Posted by Verscend on 7/20/16 9:45 AM

As its beneficiary population continues to expand, the Medicare program faces persistent pressure to do more with less. With The Centers for Medicare & Medicaid Services (CMS) facing continual legislative and regulatory payment policies, along with significant program cuts, budgets are sure to further tighten across the program, potentially impacting benefits for individuals enrolled in Medicare Advantage (MA) programs.

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RISE interviews Verscend experts on the impact of the EDS transition

Posted by Verscend on 6/20/16 2:11 PM

In its Summer 2016 newsletter, the Resource Initiative and Society for Education (RISE) features an interview with Verscend experts on the hot topic of the Centers for Medicare & Medicaid Services’ (CMS’) shift in how the risk adjustment factor scores for Medicare Advantage (MA) will be determined going forward. The interview sheds light on the implications of the transition from the Risk Adjustment Processing System (RAPS) to the Encounter Data System (EDS).

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prepping for what’s next in risk adjustment

Posted by Suzanna-Grace Sayre on 1/6/16 2:13 PM

2016 is expected to present new risk adjustment reporting challenges for Medicare Advantage plans. We recently visited with our internal analytics expert, Suzanna-Grace Sayre, to learn more about how CMS policy changes may affect plans going into the New Year and beyond. 

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what is value-based insurance design?

Posted by Sean Creighton on 11/4/15 8:20 AM

While the U.S. healthcare system is known for its rapid access to specialty providers and patient-centered care, the country continues to struggle with managing healthcare costs, expanding access, and improving efficiency. The United States is consistently ranked the most expensive healthcare system in the world, spending over 17 percent of its GPD on healthcare compared to an average of 10 percent among other developed countries. Healthcare expenditures are continuing their upward trend and the forecast looks bleak as the population ages into Medicare eligibility and premiums and cost-sharing continue to rise. As one method to bend the cost-curve and improve patient health the idea of value-based insurance design (VBID) is gaining traction.

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calculating risk scores for dual eligibles under the medicare risk adjustment model

Posted by Suzanna-Grace Sayre on 7/8/15 1:20 PM

While the Medicare Advantage risk adjustment model has been in place for several years now, health plans are just beginning to fully understand the model and its impact on payment for certain subsets of the Medicare population, especially those that are dually eligible for Medicare and Medicaid. Dual-eligible beneficiaries have many demographic and health-related characteristics that differentiate them from other populations, as well as influence how they are scored under the risk adjustment model.

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the features of best-in-class medicare risk adjustment reporting

Posted by Verscend on 6/3/15 12:00 PM

Health plans providing Medicare Part C (Medicare Advantage) coverage to beneficiaries are often under pressure to correctly identify, document, and report their members’ risk score to the Centers for Medicare & Medicaid Services (CMS) in a timely manner. Under its risk-adjusted payment model, CMS agrees to match member funding to the actual health profile of the member, which helps to ensure appropriate levels of care, but the challenge is that the burden of determining and proving that health risk profile falls on the health plan..

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bracing for big change in risk adjustment

Posted by Suzanna-Grace Sayre on 4/1/15 10:26 AM

It seems that just as Medicare Advantage plans understand a standard set of reporting rules, CMS makes large changes to the risk-adjusted payment model and its reporting methodology. The latest wave of rule changes significantly impacted the way that Medicare Advantage plans score risk, report conditions, and calculate bid rates in risk adjustment. The bullets below outline key changes in risk adjustment in 2015:

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the key elements of successful integrated care delivery

Posted by Sam Stearns on 2/4/15 6:00 AM

Integrated care delivery is an emerging trend in healthcare. Under this model, healthcare organizations and providers work together to coordinate care for a defined population. As the industry transitions from volume to value-based compensation, it is likely that integrated care delivery will gain popularity. In fact, the number of lives covered under value-based risk contracts is predicted to grow by 30 percent through 2020. Instead of being loosely tied through networks and payment models, integrated care delivery strengthens the relationship between health plans and providers, helping to rid organizations of disparate, wasteful, and costly care

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