In healthcare, data is the primary keeper of information. Data in healthcare has high sensitivity and large volume, so cybercriminals and insiders might be interested in hacking the organization. The factors of confidentiality, integrity, and availability of data are paramount … Read More
Real-Time Compliance Central
Explore health-plan Appeals & Grievances, Regulatory Compliance and Audit & Monitoring developments
Streamlining Medicare Advantage Organizations Member Communication: A Guide to CMS’s Model Materials for CY 2025
Every year, Medicare Advantage Organizations (MAO)1 must update their member communication materials, such as the Annual Notice of Change (ANOC), Evidence of Coverage (EOC), Provider Directory, Excluded Provider Model, Formulary (Comprehensive and Abridged), Low-Income Subsidy (LIS) Rider, Notice of Formulary … Read More
Medicare Prescription Payment Plan (M3P) Implementation: Key Considerations for Part D Plan Sponsors and PBMs
The upcoming Medicare Prescription Payment Plan (M3P), set to launch in January 2025, marks a significant shift in Medicare’s approach to prescription drug coverage. This initiative, introduced under the Inflation Reduction Act of 2022, aims to smooth out-of-pocket costs for … Read More
Ensuring Accurate Drug Claims: Insights from CMS Audits and Best Practices
The Centers for Medicare & Medicaid Services (CMS) has added another category of drugs—immunosuppressants—to their national audits in collaboration with the Integrity Medicare Drug Integrity Contractor (PPI MEDIC). CMS began covering end-stage renal disease (ESRD) in 1973, which includes kidney … Read More
Capitation Rates Announcement for Medicare Advantage Plans for CY 2025
The Centers for Medicare & Medicaid Services (CMS) officially announced capitation rates for Medicare Advantage (MA) plans for CY 2025 – average increase of 3.7% or $16 billion in 2025 over 2024 in expected MA payments. CMS explains, in details, … Read More
Navigating the Intersection of Payment Integrity and Provider Relations in Healthcare
Payment integrity and provider relations are two critical pillars of a well-functioning healthcare system. When effectively managed, they can lead to reduced costs, improved efficiency, and better patient outcomes. However, achieving the right balance between stringent payment controls and positive … Read More