HCCA’s Managed Care conference this year was a great opportunity to listen to and learn from health plan and government agency leaders. We love the collaboration that this conference encourages and the emphasis on making healthcare smarter and safer. Here are some of the topics and takeaways that stuck out to our ProviderTrust team. 

CMS Update by Kim Brandt, Administrator for Operations and Policy, CMS

Kim Brandt’s quick-moving presentation is always a delight. She spoke at length about CMS’s Patients Over Paperwork initiative “to remove regulatory obstacles and allow providers to focus on improving their patients’ health.” By simplifying documentation requirements, CMS is making 40 changes to CoPs and CFCs for Medicare providers and suppliers as part of the Omnibus Reduction Rule. Analysts estimate these changes will save $5.7 billion and 40 million hours between 2018-2021. 

Another important takeaway is the development of MyHealthEdata, which is aimed at giving patients electronic access to all their health records and allows that data to follow them throughout their healthcare journey. Patients are more empowered and better able to advocate for themselves and their families when they have easy access to their records. 

Brandt shared that with Blue Button 2.0, more than 2,400 developers are building user-friendly apps to help beneficiaries understand and access their data.   

The part of the session that really caught the attention of the ProviderTrust team was the section on Program Integrity and the trend to focus more on provider enrollment in CMS. As the gateway to the Medicare and Medicaid programs and providers’ first interaction with CMS, provider enrollment is an important stop-gap for fighting fraud, waste, and abuse.

This focus follows the trend of agencies becoming more proactive and fighting to end the “pay and chase” model. Empowered by the first-of-its-kind final rule on September 10, 2019, CMS has been applying proactive methods to “keep unscrupulous providers and suppliers out of Medicare and Medicaid from the outset.”  

“This rule brings a new era of smart, effective, proactive and risk‐based tools designed to protect the integrity of these vitally important federal healthcare programs we rely on every day to care for millions of Americans.”

– Kimberly Brandt, CMSAdministrator for Operations and Policy

View the full presentation handout here – CMS Update by Kim Brandt


Managed Care: Government Oversight and Enforcement Trends by Megan Tinker, Senior Advisor, Office of Counsel to the Inspector General

The expansive presentation from Megan Tinker of the OIG highlighted the agency’s commitment to elevating the quality of care, protecting the integrity of federal funds, and ensuring the security and compliance of data. 

On the quality front, Tinker shed light on how the enforcement agency is getting smarter about fighting fraud, waste, and abuse, and recommending MCOs and MAOs partner with CMS to identify and stop bad actors. This is exactly what we mean when we talk about making healthcare safer through enhanced data and smarter monitoring

Tinker also highlighted the OIG report Medicare Advantage Appeal Outcomes Raise Concerns about Service Denials. Although MAOs overturned 75% of their own denials between 2014-2016, OIG recommends CMS “enhance oversight of MAO contracts, address inappropriate denials, provide beneficiaries with clear information about serious violations by MAOs.”

In her section about protecting federal funds, Tinker identified these risk areas: 

  • MA Risk Adjustment Data
  • Medicaid payments for deceased or incarcerated beneficiaries
  • Medicaid payments to ineligible providers
  • Part D Sponsor compliance with remuneration reporting requirements

The OIG has been focused on diagnoses that resulted from chart reviews, which are from MAOs’ retrospective reviews of medical records. By analyzing payment adjustments based on chart reviews, OIG found that chart reviews were adding, but not deleting diagnoses, and $2.6 of $6.7 billion in chart review payments did not link to any specific service. 

Payments to ineligible providers continue to be a risk area within managed care. We believe this cannot be solved without smarter ongoing monitoring of provider networks. By plugging into your existing processes, we can deliver exact-matches for provider eligibility issues in our Dash product or your existing system via API.  

Tinker’s final section focused on data quality, use, and security. She emphasized that data can be used to identify critical incidents and better protect patients. Tinker promoted the OIG’s Resource Guide for Using Diagnosis Codes in Health Insurance Claims to Identify Unreported Abuse or Neglect

The guide recommends health plans develop unique processes for analyzing claims data to identify: 

  1. Unreported instances of abuse or neglect 
  2. Beneficiaries that require immediate intervention 
  3. Providers exhibiting patterns of abuse or neglect 
  4. Instances providers did not comply with mandatory reporting requirements

View the full presentation here – Managed Care: Government Oversight and Enforcement Trends by Megan Tinker, Senior Advisor, Office of Counsel to the Inspector General 


Exclusions vs. Preclusions: Insights, Analytics, and Monitoring Best Practices After One Year of Releases

Presenters: Michael Rosen, Co-Founder of ProviderTrust, Annie Hsu Shieh Senior Compliance Counsel, Central Health Plan of California, and Liza Filtz-Freimark Provider Operations Manager, DentaQuest

Our very own Michael Rosen co-led a breakout session with Liza Filtz-Freimark and Annie Hsu Shieh, two friends of ProviderTrust. The group dug into what we’ve learned about the CMS Preclusion List in its first year and how that insight helps health plans to determine provider eligibility. Here are a few high-level takeaways from evaluating CMS Preclusion List data: 

  • Only 48% of all excluded providers also appear on any state or federal exclusions source, so checking the Preclusion list in addition to all exclusion sources is imperative for determining provider eligibility. 
  • On average, 38 providers are added to the Preclusion List every month. 18 of those are also excluded.
  • 100% of Preclusion List records contain an NPI Number. 
  • Best Practice is to check the Preclusion list (and all exclusion sources) at provider enrollment and on an ongoing basis to confirm eligibility and reduce recoupment.

View the presentation here – Exclusions vs. Preclusions: Insights, Analytics, and Monitoring Best Practices After One Year of Releases 


HCCA Managed Care Conference Resources

We had a blast getting to hear from so many valuable speakers, and receiving presentation handouts to further review. For a full list of all of the presenters and to download presentation handouts from this year’s conference visit the HCCA Managed Care site.  


ProviderTrust Prepares for 2020 Healthcare Conference Season

We’re gearing up for the 2020 HCCA Compliance Institute in our hometown of Nashville, TN. Our team is hard at work planning some fun and unique experiences for our customers and friends. If you’re coming to town for the conference and would like to spend some time getting to know more about us, Contact Us today! See you in Nashville. 


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