Managed Care
This archive displays posts tagged as relevant to managed care and fraud in managed care programs and services. You may also be interested in our pages:
The Calm Before the Storm: Enforcement Trends in Risk Adjustment: DOJ and the False Claims Act
Posted 11/17/15
Presentation by Mary Inman at SSN's Medicare Risk Adjustment & Revenue Management Conference in Miami. (November 17, 2015). Download presentation; Click here to view the agenda.
Medicare Advantage Plan Loses Members, Responds with Plans to Raise Risk Adjustment Scores
Posted 09/22/15
By Tim McCormack and Molly Knobler (published on The Compliance & Ethics Blog)
Modern Healthcare recently reported that although enrollment in the Medicare Managed Care Program (also known as Medicare Advantage or Medicare Part C) has grown by 8% on average since 2010, several top Medicare Advantage Plans are losing membership. Highmark, Blue Cross and Blue Shield of North Carolina, HealthNow New York, Wellcare...
Medicare Advantage Plan Loses Members, Responds with Plans to Raise Risk Adjustment Scores
Posted 09/21/15
The Compliance & Ethics Blog (September 21, 2015)
Click here to read the article.
Medicare Part C: Fighting Back Against Risk Adjustment Fraud
Posted 06/26/15
Health insurance companies that participate in the Medicare Managed Care program (also known as Medicare Advantage or Medicare “Part C”) routinely complain about cuts to their reimbursement rates – even in years, like this one, where the reimbursement rates are actually increased. At the same time, reports indicate that insurers are “leaning heavily on their Medicare business” and “signal[ing their]...
In Their Own Words -- Sparrow
Posted 04/23/15
-- "It shows the incentives provided for whistleblowers are working well, and all the other controls and detection systems are failing miserably."
Malcolm Sparrow, a health care fraud expert at Harvard's John F. Kennedy School of Government, on the increasing number of whistleblower actions challenging fraud in the Medicare Advantage healthcare program. Click here for more.The risks and rewards of medical loss ratio come to managed care
Posted 03/12/15
Managed Healthcare Executive (March 12, 2015). Click here to read the article.
GAO Report Finds Medicaid Managed Care Vulnerable To Fraud
Posted 06/26/14
By Marlene Koury
A new study conducted by the US Government Accountability Office ("GAO") shows that the Medicaid managed care program is vulnerable to serious health care fraud. The study found that the weakness is primarily due to the Centers for Medicare and Medicaid Services ("CMS") delegating managed care oversight to the states – but without providing them with clear guidance and resources to combat...
Medicare Risk Adjustment: Financial Incentives May Lead to Bad Practices
Posted 10/1/12
AAPC Coding Edge (October 2012), 30-32
Click here to read the article.
Beyond RADV: Does Your Plan's Risk Adjustment Strategy Run Afoul of the False Claims Act
Posted 02/13/12
Presented at the HCCA Managed Care Compliance Conference (February 13, 2012). Click here to view the presentation.