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


Strengthening Cyber Resilience: Inovaare’s HITRUST r2 Certification Fortifies Healthcare Data Security

The recent cyberattack on a major healthcare IT vendor, as outlined in the letter from the U.S. Department of Health and Human Services, serves as a sobering reminder of the vulnerabilities facing the healthcare industry. With patient data and provider … Read More


Changes for Prescription Drug Encounter Data in 2024

The Centers for Medicare & Medicaid Services (CMS) has been processing Part D drug claim data via the Drug Data Processing System (DDPS) since inception of Part D in 2006. PDE provide the foundation for revenue reconciliation with drug plan … Read More

Pard B and Part D drugs payment

Proper Payments for Part B and Part D Drugs

Until the enactment of the Medicare Modernization Act (MMA) in 2006[1], the Centers for Medicare & Medicaid Services does not cover most outpatient prescription drugs under Part B (“Part B drugs”). However, some drugs self-administered by Medicare beneficiaries at home … Read More


Medicare Part D Risk Adjustments and Bidding Instructions for 2025

The Centers for Medicare & Medicaid Services (CMS) uses the Hierarchical Condition Category (CMS-HCC) medicare risk adjustment model to determine monthly capitation fees for Medicare Advantage (MA) plans. For the prescription drug program or Part D, the prescription drug hierarchical … Read More