Erik Swanson’s Post

Under the CY 2025 Medicare Physician Fee Schedule (PFS) proposed rule, CMS proposes several modifications to the Medicare Shared Savings Program (MSSP) that would become effective in performance year 2025. CMS also proposed finalizing certain amendments to the existing regulations for Medicare Parts A, B, C, and D regarding the standard for reporting and returning identified overpayments under the 60-day rule. This article summarizes key proposed changes to the MSSP and the 60-day rule and discuss their potential implications. Comments on the Proposed Rule are due on September 9, 2024. Read more: https://lnkd.in/e_ribceU

In this MedPage Today article “Prior Authorizations on the Rise in Medicare Advantage, Report Finds,” there has been a significant increase in prior authorization requests from Medicare Advantage plans. One quote caught our attention… “Of the requests (in 2022) submitted, 90.4% were approved in full, while 7.4% were denied -- an increase from 5.7% in 2019…” The quote continues, “We know that if 90% of prior authorization requests are approved, then these programs are not targeted efforts to ensure appropriate utilization," Furr continued. "Instead, they are arbitrary, unnecessary paperwork burdens that, at best, slow down access to care and increase burnout, and at worst completely deny access to care.” If you are struggling with prior authorization resources or technology, Abax Health’s industry leading prior authorization technology enabled services can help. Drop us an email at info@abaxhealth.com https://lnkd.in/enFY69Yi

Prior authorization continues to be a point of contention in the healthcare industry, especially within Medicare Advantage plans. Recent terminations between healthcare systems and MA plans highlight deeper challenges around #PriorAuth processes, contributing to payer-provider friction. Both payers and providers face financial pressures, and misunderstandings about utilization management add to the strain. While 90% of prior authorization requests are ultimately approved, the drawn-out process, largely due to insufficient documentation, causes frustration. Automated prior auth systems and clearer documentation practices could ease tensions. Read the full article here: https://hubs.la/Q02WdFt30

Strategic negotiations with Medicare Advantage plans are more critical than ever. MA plans continue to grow in influence, making it essential for healthcare providers to stay ahead by understanding the nuances of contract terms, reimbursement rates, and performance metrics. It’s not just about reaching an agreement, it’s about leveraging these negotiations to drive sustainable growth and improve patient outcomes. #HealthcareFinance #MedicareAdvantage #PayerNegotiations #ValueBasedCare #HealthcareLeadership

Medicare Advantage continues to grow, yet profitability for health plans has become more elusive. More effective and efficient execution is essential to remain competitive in the new environment. See more detail in the attached perspective. https://lnkd.in/gTeqdU3H

Small Medicare Advantage plans face unique hurdles in maintaining competitive Star Ratings. Writing for Healthcare Business Today, Cotiviti's Marge Ciancetta offers strategies such as: 🔹 Use data to determine where to focus limited resources 🔹 Track members with social risk factors (SRF) 🔹 Keep an eye on future measures of significance 🔹 Don't view measures in a vacuum 🔹 Provide excellent care, customer service, and support https://bit.ly/4dmTDkn' Healthcare Business Today #HealthPlans #healthcare #payments

Accountable care organizations (ACOs) can apply to the Medicare Shared Savings Program (MSSP) with no downside risk for seven years. Learn important application deadlines and details of the MSSP to help earn shared savings payments and reduce health care costs in this article by Georgia Green, MS, CHFP and Rachael Peterson, MPH with Moss Adams.

Emphasizing clinical & health equity measures while maintaining a strong member experience is crucial for securing 4+ stars in Medicare Advantage. With regulatory challenges ahead, investing in Star Ratings can stabilize business & enhance care quality. #MedicareAdvantage #HealthcareQuality

🌟 Exciting Changes Ahead for Medicare Part D! 🌟 The healthcare landscape is perpetually evolving, and the upcoming changes to Medicare Part D are no exception. Whether you’re a beneficiary or a healthcare professional, these changes are set to bring about significant impacts that are worth embracing and understanding. Let's dive into the key changes and what they mean for you: 🩺 **Lower Out-of-Pocket Costs:** - Beneficiaries can anticipate reduced prescription drug costs. The implementation of the Inflation Reduction Act ensures caps on yearly out-of-pocket expenditures. - This shift is designed to alleviate the financial burden for seniors, making necessary medications more accessible. 👩⚕️ **Expanded Coverage:** - Coverage is extending to include more life-saving medications, bringing peace of mind to those previously constrained by limited options. - Enhanced negotiation power for Medicare with pharmaceutical companies promises wider access to medications without compromising quality. 📊 **Improved Transparency:** - The roadmap to transparency is underway. Beneficiaries can expect clearer communication regarding plan options and costs. - This clarity empowers individuals to make informed decisions, tailoring their healthcare to best fit their needs. 🔍 **More Plan Choices:** - An increase in available plans will offer a tailored experience to meet diverse health needs. - With new preventive care benefits and flexibility, beneficiaries can select plans that align perfectly with their health priorities. 🚀 These changes are not merely policy shifts; they represent a profound commitment to improve the quality of life for millions. It’s an enthusiastic step forward in addressing long-standing issues within our healthcare system. To make the most out of these changes: 👉 Ensure your plan aligns with your personal health requirements; review it annually. 👉 Stay informed by connecting with Medicare representatives for personalized advice. 👉 Engage and participate in open enrollment periods to explore the new horizons offered. The journey forward with Medicare Part D is a transformative one—a move towards enhanced affordability, transparency, and choice in healthcare. As we witness these changes come to life, the focus remains steadfast: prioritizing health, wellbeing, and empowerment. Let’s make every moment count. Are you ready to embrace the future of Medicare Part D? Share your thoughts and experiences in the comments below. Let's discuss how these changes are impacting you or your loved ones. 👇 #MedicarePartD #HealthcareRevolution #PatientEmpowerment #FutureOfHealthcare

🌟 Exciting Insights from the Latest Harvard-Inovalon Medicare Study! 🌟 As professionals in the Medicare Advantage space, we’re always on the lookout for data that underscores the efficacy and efficiency of MA plans. A recent study by Harvard and Inovalon has brought some compelling findings to light, showing that Medicare Advantage not only reduces healthcare expenditures but also maintains high levels of care compared to traditional Medicare Fee-for-Service. Here are some key takeaways: - MA enrollees experience over 50% fewer inpatient stays and 22% fewer emergency visits compared to FFS, with no significant reduction in primary care or prescription drug services. - Overall, MA shows a 12% reduction in health expenditures, highlighting its efficiency in managing healthcare resources. At Sonder Health Plans, we're proud to say that we're already implementing many of the strategies that make Medicare Advantage so beneficial. Our focus on care coordination and preventive care isn’t just about keeping costs down—it's about providing a foundation for healthier, happier lives for all our members. This study reinforces the value of the Medicare Advantage program and the potential for more innovative, cost-effective care models. Let’s continue to push forward, driving improvements that matter. #MedicareAdvantage #HealthcareInnovation #SonderHealthPlans