RISE

RISE reviews the latest DOJ fraud cases: • Texas doc sentenced in $54M Medicare scam scheme • Detroit pharmacy owner to serve two years in prison for role in $7M fraud case • Arizona doctor sentenced to prison for health care fraud • Tennessee business owner convicted of $35M fraud

CMS reports the net savings in 2023 is the largest savings in the Medicare Shared Savings Program’s history. In addition to saving Medicare more than $2.1 billion in 2023, CMS said that accountable care organizations in the program earned shared savings payments of $3.1 billion, the highest since the program’s inception more than 10 years ago. Read More: https://lnkd.in/gV9dCXx5 #Medicare #MedicareAdvantage #accountablecare

NEW! Join us on January 23, 2025 for Think Differently: Innovative Paths to Success in Today’s MA Market, a RISE webinar in partnership with Vatica Health. Matthew Neis and Eric Wallace, who have more than 35 years of combined experience in the industry, will discuss how payers can restructure, identify additional data sources for clinical validation, and work with key departments to succeed in this dynamic environment. Register here: https://lnkd.in/gPwA3rvp #MedicareAdvantage #riskadjustment #valuebasedcare #Starratings

Save the date for a brand-new event – The RISE Audit Readiness Master Class – taking place January 12-14, 2025 in Phoenix. This exclusive conference goes beyond surface-level discussions, providing attendees with an unparalleled deep dive into the full spectrum of CMS and OIG audits. Learn more: https://lnkd.in/ghDSAEhr #RISEAuditMC25 #riskadjustment #RADV

The 2024 Nowhere to Go: Maternity Care Deserts in the US Report found that more than 35 percent of U.S. counties are maternity care deserts, meaning they are an area without a single birthing facility or obstetrician clinician. These 1,104 counties are home to more than 2.3 million women of reproductive age and more than 150,000 babies were birthed by women living in a maternity care desert. The report underscores the urgent need for action to address the ongoing maternal health care crisis in the U.S. to ensure all mothers and babies have access to quality care.

NEW! Join us for this upcoming webinar, Medication Therapy Management: An Opportunity to Improve Health Outcomes, Star Ratings, and Medicare Advantage Performance, December 17 in partnership with Signify Health. With a new approach to your Medication Therapy Management program and MA member service strategy, your health plan can mitigate health risks and associated costs while driving a valued experience with members and positively impacting your Star and quality measures. Register Here: https://buff.ly/3UpG6k9

RISE reviews the latest headlines in #SDoH: • Healthgrades report ranks hospitals for specialty care • CDC data shows drop in youth tobacco use yet persistent disparities • Better Medicare Alliance launches supplemental benefits database

If your Medicare Advantage plan is finding it more difficult to maintain or raise your current Star rating, you don’t want to miss The RISE Star Ratings Master Class to learn from the best in the industry. Rex Wallace, Ana Handshuh, CHC, and Melissa Newton Smith provided some insight into why this year it is so important to attend and learn how to adapt to the regulatory changes, review the current legal landscape, and innovate to boost your plan's ratings. “Across the board, almost 70 percent of cut points got higher, so many plans were surprised to find themselves earning lower ratings on the same or higher scores because so many cut points went up. Plans should note that continuous improvement is an imperative now. What got them to a higher rating in the past was not enough to keep them there.” Read More: https://lnkd.in/e_PWCN-C #RISEStars24 #StarRatings #MedicareAdvantage

The new report reveals CMS paid $7.5 billion in Medicare risk-adjustment payments in 2023 for diagnoses that only appeared in Medicare Advantage members’ health risk assessments and no other records. The analysis follows a July investigation by the Wall Street Journal that found Medicare Advantage insurers were paid $50 billion from 2018 to 2021 for thousands of questionable diagnoses. Physicians or other health care professionals conduct health risk assessments to gain information about patients’ health status, health risks, and daily activities. But the OIG set out to determine whether the assessments lead to follow-up care. #Medicare #MedicareAdvantage #riskadjustment

Save the new dates! The Medicare Advantage Member Accounting and Reconciliation Summit will now be taking place virtually on June 17-18, 2025. Offering both high-level strategy and critical operational training, this is the only conference of its kind presenting a deep and evaluative look into membership and revenue reconciliation. Learn More: https://lnkd.in/gEnSxXSm #MARecon25 #MedicareAdvantage