Reprinted with AIS Health permission from the January 6, 2022, issue of RADAR on Medicare Advantage For the Medicare Advantage industry, change wasn’t a major outcome of the Biden administration’s first year in office. But for 2022, MA organizations face…

Health plans are undergoing a transformation as they evolve their capabilities and business models to not only use data in new and innovative ways, but also cope with the increasing volume, variety and velocity of data. Given the impact COVID-19…

YOUR PROVIDER DATA QUALITY PROBLEM MAY BE BIGGER THAN YOU THINK… AND IT COULD BE GETTING WORSE Under normal circumstances, inaccurate provider data presents significant operational and financial challenges for health plans. In 2020, these problems have been exacerbated across…

On June 30th, CMS announced it was enhancing its Program Integrity efforts that focus on addressing improper Medicaid payments and CMS oversight of state Medicaid programs. The announcement introduced 8 initiatives, including stronger audit functions, enhanced oversight of state contracts…

Traditional revenue cycle management arrangements that focus solely on billing and collections are no longer reliable in the world of delegated risk models, especially for Medicare Advantage (MA) populations. That’s why Pareto recommends an innovative approach to managing value-based payments,…

WHO IS AT RISK The federal government has indicated that it is still investigating, and could ultimately join a false claims whistleblower qui tam action against Aetna, Inc., Humana, Inc., Cigna, Inc. (through its Bravo Health unit) and Health Net,…

In a court decision last year in Swoben v. United Healthcare, the United States Court of Appeals for the Ninth Circuit held that an allegation—that a Medicare Advantage Plan performed a “biased” HCC-RAF retrospective medical review designed only to identify…

Health plan revenue is increasingly tied to the concept of risk adjustment. In practice, risk adjustment aligns payments received by health plans with the risk of the populations they manage. Although each market has its own unique version of risk…