Medicare Advantage and Part D

From Medicare Advantage News - Pharmacies participating in the first phase of a joint SCAN Health Plan-Express Scripts Holding Co. incentive-based program to improve outcomes for SCAN’s Medicare Advantage beneficiaries had dramatically higher performance scores in several measures than did a national sample of retail pharmacies, the two organizations said last month. The differences in performance related to some measures that also are examined in CMS star quality ratings, the two organizations said, include 60% higher scores for reducing use of high-risk medications among SCAN members and 23% higher scores for improving compliance with diabetes treatment guidelines. The scores also were 34% higher on high-risk… Read more

From Medicare Advantage News - The issue of whether Medicare Advantage plans are being overpaid because of inflated risk-adjustment scores is starting to play out in the courts as well as via regulatory scrutiny. At least “a half dozen whistleblower lawsuits” alleging such overcharges have been filed since 2010, the Center for Public Integrity (CPI) news organization reported last month, and one of those pending cases shows the kinds of allegations MA organizations increasingly may… Read more

Medicare Advantage & Part D Blog

By James Gutman - June 24, 2015
Massachusetts had probably the toughest assignment in making a CMS-backed demonstration for Medicare-Medicaid dual eligibles work — and it’s about to get even harder. Fallon Total Care, one of three chosen plans that actually started the demo (three others dropped out before the demo started in...
By James Gutman - June 8, 2015
Now that the Medicare Advantage plan industry has somewhat dodged one bullet for the next year in the form of payment rates, it will need to dodge another one: increasing probes and calls for probes of alleged MA upcoding of member risk scores. And since this situation more resembles multiple...
By James Gutman - May 27, 2015
If there is one time of year when Medicare Advantage (MA) and Part D executives are sure to be burning the midnight oil, it is now: a few days before the deadline for submission to CMS of their bids for the following year. But while the pre-bid period this time around still is hectic, the...

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