Health plan executives across the country have a lot of planning to do now that the 2018 Advance Payment Notice for Medicare Advantage (MA) and Part D plans has been released by the Centers for Medicare & Medicaid Services (CMS). The agency is now accepting public comments on the notice through March 3, 2017, before publishing the final version on April 3. We sat down with Verscend’s Sean Creighton, senior vice president of risk adjustment, to get a quick roundup of the key highlights.... Read More
There’s no question that automated claim editing is a crucial component of accurate and efficient claims payment. Using black-and-white sourced edits from the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association’s (AMA) CPT® book, as well as payer-sourced custom rules, these systems save plans a significant amount of money by keeping them from paying incorrect claims without human intervention.
But is having one automated claim editing system enough to ensure total claim accuracy, or are you leaving significant savings on the table without a secondary editor? And if you already have a secondary editor, is there a benefit to adding a tertiary editor? Here are three fast facts you should know about how far automated claims editors can go.... Read More
Verscend this week received the 2017 Best in KLAS award for payer quality analytics and reporting solutions. This first-of-its-kind award pitted top solutions against each other, using KLAS Research’s well-established methodologies and exhaustive customer research to evaluate vendor and solution performance across multiple categories. Verscend scored an 84.7 out of 100 in the ranking, published today in the report, “2017 Best in KLAS: Software & Services.”... Read More
You have many choices to make when it comes to how your health plan will conduct Medicare Risk Adjustment (MRA). Among the most critical choices is how you’ll retrieve your medical records for retrospective review and coding. How can you find the right partner to work with in order to ensure a successful MRA season? We recently sat down with our own medical record retrieval guru, Howard Gross, to help guide health plans in their decision-making process for pursuing medical record retrieval.... Read More
For most of the 2016 election cycle, the future of the Affordable Care Act (ACA) looked secure. But President-elect Donald Trump’s surprise victory, coupled with Republicans retaining their majority in both the House and Senate, has thrown the healthcare industry for a loop, with payers, providers, and participants alike all anxiously awaiting what may happen next. Could all the work that has happened to implement the ACA be reversed? One thing is for certain—everything is uncertain!... Read More
Healthcare technology is constantly evolving and improving. Although risk adjustment and predictive models have long been established in the industry, their power and accuracy cement their status as a cornerstone for healthcare strategy and operations. Risk adjustment and predictive models provide critical insight into risk, utilization, and cost, as well as ensure fair comparisons between populations. Developments in modeling advance these fundamentals and provide new insights into healthcare trends that propel value-based care strategies.... Read More
A core requirement for health plans across the country is measuring and reporting on quality metrics. However, directly influencing those metrics can often be a struggle. Improving quality metrics is directly correlated with identifying and addressing gaps in care. By deploying a proactive, year-round strategy that aligns data analytics with a focused approach for addressing gaps in care, your organization can turn routine quality measurement and reporting activities into a true strategic advantage by ensuring that quality measurably improves across key metrics.... Read More
In a recently released article from Kaiser Health News, Verscend senior vice president of risk adjustment Sean Creighton weighs in on industry concerns that under the Affordable Care Act (ACA), plans with greater administrative costs and higher premiums are succeeding disproportionally over lower-priced plans. Many exchange participants are calling for the Centers for Medicare & Medicaid Services (CMS) to take a closer look at how the risk adjustment formula is creating an environment in which “the rich get richer and the poor get poorer.” In the article, Creighton contends that “the industry complaints warrant a closer look,” adding that it might make sense to drop the average statewide premium from the formula and focus more directly on a health plan’s medical claims.... Read More
After years of focusing efforts on speeding up automated claim processing, most payers’ claim review systems have unintentionally let their guard down. As a result, improper outlier claims common to our industry continue to pass through automated systems right in plain view without getting flagged. For some payers, the impact can really sting, amounting to millions of dollars. Our latest infographic explores some of the most blatant examples of incorrect billing practices still going on today and what they may be costing you in inappropriate payments if not addressed.
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This week’s healthcare news takes a look at pushback against the Hospital Star Rating system released by the Centers for Medicare & Medicaid Services (CMS), a new guide designed to help providers find the right electronic health record system (EHR), a survey that shows how physicians’ outlooks are impacting their ability to adapt to healthcare reform, the latest on U.S. healthcare performance compared to other nations, and action from this week’s Verscend Health Conference (VHC16).... Read More