Verisk Health
Verisk Health
Blog Post
  • Remember the infomercial tagline, “Set it and forget it!”? That might be what you would look for in a rotisserie grill, but if it describes what you’re doing with claim editing, then you’re leaving a lot of savings on the table.

Verisk Health
Verisk Health
Blog Post
  • The Centers for Medicare & Medicaid Services (CMS) has released its advance notice of proposed changes to the Medicare Advantage (MA) risk adjustment model for the 2019 calendar year (CY 2019). These changes are in line with the agency’s continued commitment to ensure MA payments accurately reflect the relative health risk and actual expected healthcare costs of plan beneficiaries. In addition,...

Verisk Health
Verisk Health
Blog Post
  • When Santa made his list this past Christmas, the vast majority of healthcare providers were nice, but a small handful of them were … fraudy. Okay, that was a pretty bad joke, but not nearly as bad as the alleged healthcare fraud schemes that the National Health Care Anti-Fraud Association compiled from October through December 2017. Here’s our round-up of the top five busts made by the feds in...

Verisk Health
Verisk Health
Blog Post
  • You can’t have a conversation about healthcare quality without talking about HEDIS®, which has played a pivotal role in the industry for more than 25 years. Once thought to be nearly impossible, quality measurement is now a critical component of the industry’s transformation to value-based care delivery and payment systems.  Inside health plan board rooms, however, there’s a growing realizati...

Verisk Health
Verisk Health
Blog Post
  • Last week, the National Committee for Quality Assurance (NCQA) informed health plans, vendors, and auditors that it has decided to suspend the requirements for the Patient Level Detail (PLD) files for Medicaid, Marketplace, and commercial populations for HEDIS® 2018. The organization noted that the decision was a direct response to “comments about the number of measures and the burden ...

Verisk Health
Verisk Health
Blog Post
  • In the 2017 payment year, the 25 percent Encounter Data System (EDS) contribution and its impact on risk scores and associated revenue have challenged Medicare Advantage (MA) plans, which have much more experience submitting Risk Adjustment Processing System (RAPS) data. The difficulty of submitting data via EDS and getting the Centers for Medicare & Medicaid Services (CMS) to accept h...

Verisk Health
Verisk Health
Blog Post
  • Sophisticated data analytics can process billions of claim code line edits through the course of the day, helping payers identify hundreds of providers with aberrant billing patterns with each pass of the data. However, this is just the first step in a resource-intensive process to determine whether fraud, waste, and abuse (FWA) have actually occurred—and then, what to do about it. The...

Verisk Health
Verisk Health
Blog Post
Verisk Health
Verisk Health
Blog Post
  • Visiting a corn maze on Halloween can be fun, but trying to navigate the transition from RAPS to EDS has been more like a house of horrors for Medicare Advantage plans. Revenue loss has been a major concern for health plans due to the difficulty of submitting data via EDS and getting the Centers for Medicare & Medicaid Services (CMS) to accept it. This challenge, coupled with the recon...

Verisk Health
Verisk Health
Blog Post
  • The National Committee for Quality Assurance (NCQA) has released its HEDIS® 2018 Technical Specifications Update, closely tracked by health plans, auditors, and quality reporting and analytics vendors. Jenna Fitcher, product director for Verscend’s Quality Improvement solutions, breaks down the key takeaways.

Verisk Health
Verisk Health
Blog Post
  • From California to New York, fraud and abuse took no vacation over late spring and summer this year. The National Health Care Anti-Fraud Association has collected some of the top healthcare fraud busts from May to September 2017, representing schemes in home healthcare, pill mills, sober homes, and many more. Here’s our round-up of the top 10.

Verisk Health
Verisk Health
Blog Post
  • Remember Aesop’s Fables? They may be thousands of years old, but the moral of each tale is just as relevant today. One of the most famous fables, “The Ant and the Grasshopper,” tells of a careful ant that stored up food for the winter. The grasshopper put this task off until the last minute and would have starved during the winter if not for the ant’s help. The moral to the story: “It’...

Verisk Health
Verisk Health
Blog Post
  • Medical record retrieval is labor intensive, consumes time and resources, and requires great patience and persistence—but it’s a crucial component of any risk adjustment or HEDIS® project. Is there a way for health plans to increase their retrieval success rate without simply throwing more money at the problem? How can they ensure they’re getting the best return on investment (ROI) in ...

Verisk Health
Verisk Health
Blog Post
  • As we’ve explored in earlier blog posts, the provider decision quadrant uses two dimensions—fraud likelihood score and 12 months of paid claim exposure—to classify providers into four groups based on whether they are high or low risk and high or low cost. This framework allows health plans to better understand often subtle differences in provider risk profiles and tailor their fraud, w...

Verisk Health
Verisk Health
Blog Post
  • How is your health plan setting its target return on investment (ROI) per chart for your 2018 retrospective risk adjustment program? We’ve found that many payers simply base their estimates on the previous year’s financial results with perhaps a few minor tweaks—but there are myriad program changes and other factors that should be considered holistically.

Verisk Health
Verisk Health
Blog Post
  • So far in our blog series on the provider decision quadrant, we’ve explained how this tool helps health plans fine-tune how they identify and prioritize potential fraud, waste, and abuse (FWA) in their provider networks, and also performed a close examination of providers who reside in the low-risk quadrants. In this blog post, we’ll zero in on the high-risk quadrants, where payers alr...

Verisk Health
Verisk Health
Blog Post
  • The transition from fee-for-service to value-based healthcare, where payers compensate providers based on the patient’s quality outcomes, is still moving slowly. What are the major obstacles standing in the way of providers taking on more risk?

Verisk Health
Verisk Health
Blog Post
  • Recently on the Verscend blog, we introduced the concept of a provider decision quadrant to help health plans fine-tune the prioritization process when it comes to addressing potential fraud, waste, and abuse (FWA) in their provider networks. Replacing the more traditional approach of simply examining the fraud likelihood score, Verscend has found that by plotting providers in a quadra...

Verisk Health
Verisk Health
Blog Post
  • Sophisticated data analytics can process billions of claim code line edits at a rapid pace, helping payers identify hundreds of providers with aberrant billing patterns with each pass of the data. However, this is just the first step in a resource-intensive process to determine whether fraud, waste, and abuse (FWA) have actually occurred—and then, what to do about it. The next step is ...

Verisk Health
Verisk Health
Blog Post
  • This week the U.S. Justice Department announced one of the biggest multi-agency healthcare fraud busts in history involving a total of 412 people, including almost 115 doctors, nurses, and other medical professionals. The alleged fraudsters were charged with defrauding Medicare, Medicaid, and TRICARE programs of $1.3 billion, billing for unneeded drugs and treatments that were often ne...

Verisk Health
Verisk Health
Blog Post
  • Quality reporting is closely aligned with financial success for health plans across the country, amplifying the importance of keeping an eye on HEDIS metrics year-round. Although HEDIS measurement and reporting requirements and timelines are always subject to annual changes from NCQA, effective pre-submission planning streamlines the process and helps plans more easily achieve successf...

Verisk Health
Verisk Health
Blog Post
  • While the House and Senate attempt to re-write healthcare policy, the pressing problems that the Affordable Care Act (ACA) aimed to address are still at play and being managed by healthcare providers and payers alike, with a continued focus on how to manage the individual and small-group markets. The Senate delayed the vote on the latest bill, the Better Care Reconciliation Act of 2017...

Verisk Health
Verisk Health
Blog Post
  • Ah, summer. Time to relax, pat yourself on the back for a job well done for HEDIS® 2017, and think about something else for a change. Or is it?   Summer’s not exactly cancelled, but you’d be wise to devote some time to a few key initiatives that will help you get a jump on HEDIS 2018.  

Verisk Health
Verisk Health
Blog Post
  • The Office of Inspector General (OIG) sets the bar for coding accuracy at 95 percent, but you can’t achieve that goal without a comprehensive approach that gets it right from the beginning. Are you following best practices to ensure accurate code capture, or is there room for improvement? Here are some concrete steps you can start implementing today to step up your risk adjustment game...

Verisk Health
Verisk Health
Blog Post
  • As the transition from fee-for-service to value-based care continues to disrupt the healthcare industry, payers and providers must share data with each other—and increase transparency—to drive costs down. That was among the messages Verscend president and CEO Dr. Emad Rizk recently shared with the Red Hot Healthcare podcast, which features in-depth interviews with top leaders in the he...

Verisk Health
Verisk Health
Blog Post
  • Under HIPAA, healthcare fraud is defined as “knowingly, and willfully executing or attempting to execute a scheme … to defraud any healthcare benefit program.” Unlike waste and even abuse, which are characterized by an unintentional practice that directly or indirectly results in an overpayment, fraudsters are distinguished by their intention to obtain monies that they are not otherwis...

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