Medicare Advantage For Health Plans

CMS has issued a major announcement that's reshaping how Medicare Advantage plans approach risk adjustment audits. A new era of oversight is here. Defined by tighter timelines, expanded audit scope, and heightened expectations around data accuracy. Along with the announcement, a detailed compliance memo introduces new submission deadlines that demand immediate attention from health plans. This shift has wide-reaching implications for compliance strategy, resource allocation, and revenue protection.In this bonus episode, we unpack what's changed, why it matters, and what plans need to consider next. Listen now.About Our Guest: Amanda Proctor is the Director of Coding Quality and Risk Mitigation and has over 14 years' experience in Risk adjustment and holds multiple certifications in Coding, Auditing, and Compliance and is an AAPC Approved Instructor. She specializes in Risk Mitigation, RADV Audits, Coding Compliance and Education.

In this episode, we explore how data consolidation is reshaping health plan operations and why it is becoming essential for the future of the industry. From breaking down data silos to enabling real-time, data-driven decisions, data hubs offer health plans a scalable solution to improve efficiency and streamline processes. Discover the challenges health plans face today and how a data-centric ecosystem can unlock powerful insights, enhance member engagement, and drive cost savings. Curious how a data hub can revolutionize your operations? Tune in to find out how this technology is transforming the payer industry and why it's not just a trend but a must-have for success in 2025 and beyond.About Our Guest: Adam Fenech is Vice President of Product. He has been in healthcare leadership for over 20 years, on both the payer and provider sides of the business. Adam has a degree in Computer Information Systems and has deep expertise in core administrative products and processes, as well as the emerging industry shift to a data-centric technology ecosystem model. 

Payers are seeking new ways to enhance member engagement and drive long-term retention. This podcast explores a powerful new-to-market strategy for transforming how health plans design member journeys to create a seamless experience in a combination of offline and online environments. Don't miss the insights in this episode that will redefine how your plan approaches member engagement.About Our Guest: Barb Ody is a payer consultant and expert in member experience solutions, technology and process implementations, clinical business informatics, data modeling and analysis.

Claims and enrollment management can feel like a juggling act, especially with rising volumes and the pressure to meet strict accuracy and timeliness standards. What if there were tools to simplify it all? In this episode, we dive into the game-changing power of modern workflow solutions. Discover how these tools eliminate inefficiencies, prevent cherry-picking by claims and enrollment processors, and streamline auditing, all while boosting internal team communication and productivity. Whether your health plan claims and enrollment teams are struggling with manual processes or looking to scale without adding staff, this discussion offers practical insights you can't afford to miss. Tune in to learn how to transform your claims and enrollment management strategy!About Our Guest: Alison South is the Vice President of revenue enablement and a subject matter expert in payer technology and operations. She brings 20+ years of experience in health plan operations, overseeing operational readiness, learning and development, and quality and audit operations. She has worked for large national payers running government programs, including Medicare and State Medicaid Demonstration programs and military healthcare operations. 

Health plans often underestimate the full financial burden of their core administration systems. This episode shines a light on the hidden costs buried and spread throughout the lifecycle of a typical core admin vendor contract. We will discuss what total total cost of ownership is, how to evaluate it, and what to do when costs are unexpectedly higher than you anticipated due to spread-out expenses, complex integrations, and recurring upgrades. Listeners will learn how to identify the operational “patchwork” that keeps plans tethered to legacy models and discover why taking a shorter, more honest view of long-term costs can reveal hidden savings. The conversation explores how integrated ecosystems provide stability, transparency, and scalability, positioning plans to invest in growth rather than wasting unoptimized resources.

Clinical documentation improvement (CDI) is essential for accurate patient care, compliance, and effective risk adjustment. Health plans and providers must work together to address common challenges like incomplete records, workflow disruptions, and slow technology adoption. By integrating solutions that fit seamlessly into provider workflows—whether through EMR-compatible platforms or flexible engagement models—health plans can reduce administrative burdens while ensuring compliance with CMS guidelines and HIPAA requirements.This episode explores best practices for health plans to support providers with clinical documentation and how proactive risk adjustment strategies improve efficiency by addressing documentation gaps upfront, reducing costly retrospective corrections.Listen to this episode to learn how to build a stronger partnership between health plans and providers, improve compliance, and enhance operational efficiency.About Our Guest:Keicia Hutchinson has been in the healthcare industry for over 18 years specializing in medical billing, Medicaid and Medicare auditing, and clinical documentation improvement. She is a member of AAPC and holds credentials in COC, CPC, CPC-P, CDEO, CPMA, and CRC.

In this episode, we discuss the history of tech ecosystems for health plans, the most common operating model today, the multiple-vendor model, and an innovative new operating model that relies on an end-to-end ecosystem from a single, accountable vendor partner. We discuss the pros and cons of the different models, as well as provide recommendations for future-forward plans that are ready to improve the delivery of healthcare and reduce the inefficiencies native to the industry. About Our Guest: Kevin Adams is the co-founder and CEO of UST HealthProof. Under his leadership, strategic vision, and commitment to innovation, UST HealthProof has grown into a global organization with over 4,000 employees. Kevin served as the healthcare Chief Technology Officer for UST Global and has held roles with Cigna and Accenture. He also led the digital transformation effort at Edifecs. 

Accurate coding in healthcare is critical, especially with the recent changes brought about by the RADV extrapolation rule. This regulation allows the Office of the Inspector General (OIG) to apply audit findings from a sample across an entire Medicare Advantage plan, significantly increasing the financial risks associated with coding errors. For example, a $500,000 penalty for mistakes in coding can now balloon to millions, making it essential for health plans to prioritize coding accuracy and compliance.To navigate these challenges, the OIG has developed helpful resources that guide health plans in identifying high-risk diagnosis codes and highlighting common mistakes to avoid. Organizations can leverage this information to enhance their coding practices and protect themselves against potential audits. Tune in to learn more about effective strategies and resources to improve coding accuracy and compliance in your organization. About Our GuestKristi Reyes is the Director of Risk Adjustment Coding Operations. She leads a team of medical coders from various aspects of risk adjustment—including retrospective, prospective, CDI, QA, risk mitigation, and RADV. Kristi holds certifications in Certified Professional and Outpatient Coding, Risk Adjustment Coding, and Auditing.Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

This episode explores the challenges and opportunities plans face during the digital transition. The most common challenges are outdated systems, fragmented data sources, and managing data integration effectively. We discuss innovative strategies to reshape HEDIS reporting and analytics—from integrating diverse digital data into a unified platform to accelerating processing speeds for real-time insights. Plans can leverage these powerful analytical tools, flexible reporting, and actionable data to proactively identify care gaps, deploy intervention campaigns, streamline workflows, and ensure regulatory compliance. This episode equips health plan leaders with the strategies they need to stay competitive and fully embrace the latest industry strategies for HEDIS success. About Our GuestSharon Kurht is the Director of Quality. She has 14 years of experience in HEDIS, Medicare Stars, and Medicaid. Sharon is an RN who holds a doctorate in nursing from Northeastern University, where she is also a health informatics professor at the graduate level. Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

The 2025 Medicare Advantage and Part D Star Ratings were released on October 10, 2024. This year brought significant shifts that will impact health plans across the industry. With new challenges in place and more stringent performance measures, it's essential for health plans to understand how these changes have affected Star Ratings. The introduction of updated methodologies, such as the use of Electronic Clinical Data Systems (ECDS) for certain measures, and increased weight on critical performance areas, are just a few of the factors reshaping the ratings landscape.Looking ahead, plans need to stay ahead of the curve as Star Year 2026 and beyond bring even more changes. New measures, adjusted weights, and upcoming initiatives like the Health Equity Index will play a major role in future performance. Discover key strategies to prepare your plan for these changes and ensure your Stars strategy is built for success. For a deeper look at what's ahead and expert insights on how to stay competitive, listen to the Bonus Podcast Episode: Star Ratings 2025 Industry Report.Thank you to our sponsor, usthealthproof.com—unburdening the healthcare experience. 

Preparation and a vigilant organizational mindset are critical to reducing the financial and reputational risk of cybersecurity incidents.  Join CISO, Hans Guilbeaux for an in-depth discussion on ways health plans can ensure their vendors have implemented industry best practices and are prepared for incident response with detailed disaster recovery and business continuity processes.About Our Guest:Hans Guilbeaux is the UST HealthProof CISO and has over 25 years of experience in network and infrastructure engineering, security systems administration, network penetration, vulnerability assessment, IT auditing, incident response, and forensics investigation. Hans is a Certified Information Systems Security Professional (CISSP), and a Certified CSF Professional (CCSFP). 

Previously, Medicare Advantage For Health Plans podcast,  we're changing names in Season 3 to Current Trends For Payers podcast. In response to the growing needs of our audience, we're expanding our topic coverage to include commercial, ACA, government-sponsored health plans, and more. You'll be hearing from experts across all aspects of the business and learning about cutting-edge strategies and tactics used by some of the nation's most successful health plans. Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

Retrospective risk adjustment involves several administratively heavy processes, from chart retrieval to coding to supplemental data and submissions. The ever-changing regulatory environment requires continual updates in processes and technology.Join expert Greg Pastor to discover ways to streamline retrospective risk adjustment processes and develop a strategic, multi-faceted approach to addressing industry changes.About Our Guest: Greg is the Managing Director of Risk Adjustment Operations, leading a team of over 350 risk adjustment professionals to drive client execution, customer value, and plan revenue optimization.

While prior authorization serves as vital checks and balances, ensuring clinical quality and preventing fraud, the administrative burden it imposes on providers and payers alike has led to an industry-wide reevaluation of certain codes and an increased push towards technology for auto-approvals and Gold Carding. Now, it's up to payers to encourage provider adoption of the technology by offering platforms with user-friendly interfaces, intuitive design, and seamless workflows. Streamlining prior authorization improves the overall experience for payers, providers, and members to ensure timely care and a more efficient healthcare system. Tune in to discover: Current shifts in the industry to reduce administrative burden while maintaining clinical quality and medical necessity How plans are leveraging technology to gain insights and refine prior authorization processesWhat CMS is doing to ensure guidance and appropriate timeframes serve members' best interestsAbout Our Guest:Chris Hugenberger has been in healthcare software for nearly 20 years, working on operations, implementations, and product development for both the provider and payer sides. He has niche expertise in utilization management and prior authorization software. 

As payers adopt artificial intelligence (AI) technologies in different aspects of healthcare operations, there is a need for AI governance and the careful vetting of vendor AI practices to safeguard patient welfare. AI solutions can offer valuable decision support to create efficiencies at scale, timeliness, and accuracy. However, AI solutions should not run autonomously, nor should the final result go unquestioned. It is essential that all stakeholders understand how AI solutions draw their conclusions, what data sources inform the models, and the potential sources of biases that can occur. This level of critical thinking via human oversight is the crux of responsible AI principles: transparency, accountability, and safety.Tune in to this episode to hear the latest on: Current challenges using AI for decision supportResponsible AI principles The vital information needed for all stakeholdersWays to implement best practice processes for AI oversight The AI algorithm lawsuit that's shaking up the payer space About Our Guest:Sam Keith is an expert in data science, marketing, and analytics. He has over 18 years of experience working in the technology product space, leading product development teams and initiatives to support consumer engagement, user experience, digital experience, and operations. Sam has worked in healthcare, higher education, pharmaceutical, and network security industries and is particularly interested in digital accessibility practices. 

As more and more provider organizations enter into risk-sharing agreements, provider engagement programs are experiencing a surge in participation. Provider engagement programs improve the collaborative relationship between plans and providers to keep documentation up-to-date for CMS submission. It's essential for plans to offer a variety of delivery methods to suit the provider's practice. Some practices enjoy an in-person, on-site method to receive personalized guidance for education and to maximize documentation opportunities, while other practices enjoy an EMR-integrated solution for a highly efficient digital workflow. Providers with an already established process for responding to queries may prefer a remote option via fax. The important aspect of a healthy provider engagement program is not necessarily the delivery method but rather the timely and continuous communication between plans and providers to close gaps on addressable conditions. Tune in to discover the best practices for running a successful provider engagement program. About Our Guest:Michelle Calagaz is an expert in prospective risk adjustment programs specializing in provider engagement tactics. She has over 30 years of experience working in healthcare with a focus on Medicare Advantage initiatives and has an array of experience across risk adjustment, business operations, program implementation, product development, and client relations. 

NLP is an AI technology that is being used in healthcare IT for clinical documentation and medical coding. For medical coding, the program identifies diagnoses codes for HCC risk adjustable categories and flags it for a medical coder to review. In robust medical charts that span up to thousands of pages in length, this enables coders with an automated way to identify diagnoses codes for review, hence increases speed, efficiency, and output. Academic research has found NLP increases medical coding productivity by 15-20%. After the medical chart is reviewed by a medical coder, the chart goes through a pre-submission QA process for accuracy and compliance review. In some cases the chart will go through the NLP program for a second pass to identify additional insights and potential missed opportunities. Tune in to this episode to learn: Additional opportunities and limitations of NLP Why medical coders are needed now more than everHow organizational goals influence the way plans customize their NLP engine

The intention for developing RADV audits was to develop a checks and balances to ensure reimbursement payment accuracy for Medicare Advantage Organizations (MAOs). There's a history of CMS addressing payment accuracy in the Medicare space that dates back to the 80's with the prospective payment system, PPS, and in the late 90's with the Balanced Budget Act. The first RADV audit for MAOs wasn't performed until 2007. The initial audits determined that MAOs were being significantly overpaid which justified the 2011 proposed rule that suggested overpayments should be extrapolated, in other words, overpayments should be returned to the Centers for Medicare and Medicaid Services (CMS). Over the years, CMS has explored different ways to determine the error rate of MAO overpayment. In the most recent 2023 Final Rule, CMS has released their go-forward plan to extrapolate beginning in payment year 2018, however, no specific methodology for error rate determination has been defined, nor has a commencement date been announced. Plans can expect to be notified prior to extrapolation so they can forecast. Health plans need to implement a strong risk mitigation program to ensure reimbursement accuracy. Tune in to this episode to discover: The impact to smaller plansIndustry-wide changes in response to the Final RuleHow plans will deal with the potential reimbursement lossWays to improve reimbursement accuracyAbout Our GuestAmanda Proctor has over 13 years in risk adjustment coding and specializes in risk mitigation, coding quality and education. She holds multiple certifications in coding and is an AAPC approved instructor.

There is a distinct advantage to enrollment technologies that are built specifically for CMS's enrollment and dis-enrollment regulations for Medicare Advantage and Part D.  One such specification includes the Application Programming Interface (API) integration of the CMS MARX database for the validation of eligibility for Medicare Part A, B and D. This is a unique function that allows for real-time eligibility validation within the enrollment technology and avoids the less timely alternative of using batch processes for file submission to CMS. Additionally, special election periods are factored in to the technology logic and consists of low income subsidies from CMS, moving service areas, Chronic Condition Special Needs Plans (CSNPs), and members losing employer-sponsored group coverage. Another CMS rule set defines whether an enrollment is complete or incomplete. Certain elements must be present such as: member's signature, responses to questions about other sources of coverage, ensuring the member's permanent address is within the service area. Incomplete enrollments are funneled through automated workflows to obtain missing information, for example, a request for information letter may be triggered. Once the membership is complete, changes in membership status or updates to information are initiated through the enrollment technology and flows to impacted systems. Because enrollment is the member's first touchpoint with the health plan, enrollment technologies should also enable other downstream activities like claims processing, vendor integration, and member correspondence so each aspect of the member experience feels seamless and promotes a cohesive brand identity for the health plan. About Our Guest:Dave Laity is the Product Director for Advantasure's Enrollment and Billing products. Dave has nearly 20 years of healthcare experience that include the development of enrollment solutions that focus on Medicare Advantage and Part D. 

In this bonus episode, we welcome Stars expert, Megan Piotrowski, for an in-depth review of the recent Star Ratings release. On October 13, 2023, the 2024 Medicare Advantage and Part D Star Ratings were published on Medicare Plan Finder, largely representing Measurement Year 2022 data submitted to CMS. We discuss the variables that influenced performance and why it's the second year in a row, the average Star Ratings have declined and some plans might be seeing less than ideal performance. More than a third of plans saw a Star Ratings decline this cycle. Tune in to learn about the changes that will impact 2024 performance including the Tukey Outlier Deletion Method, the transition of several HEDIS measures to Electronic Clinical Data Systems (ECDS),  measure weight changes, and more.About The ExpertMegan Piotrowski is a Star Ratings and quality strategy manager evaluating market trends and competitive landscape to develop initiative offerings and long-term strategies for the continued maintenance of 4-Star Ratings. Megan has held a variety of regulatory, quality leadership and consultant roles across the continuum of healthcare. She's led the quality improvement initiatives on behalf of health plans across all lines of business, as well as for health systems, providers, and community and government-based organizations. She holds a Master of Science in Health Informatics from Northwestern University. 

In this episode, we discuss the significant changes in the weight of Star measures, with the reversal of the 2022 Final Rule—many measures are returning to their previous weights. In response to the 2022 Final Rule, plans made significant investments to enhance the member experience in areas like customer service and developing digital platforms. The 2023 Final Rule has recently announced the removal of the Reward Factor and is replacing it with the Health Equity Index, which aims to incentivize plans to focus on serving members with higher social risk factors. “Members are getting a better experience because plans reacted to the measure weight increases. Even though the measure weights may be redacted, the investments are already there and members are going to continue to feel the benefits of these enhancements.” - Michelle SimonAlthough the removal of the Reward Factor may temporarily affect Star Ratings, plans that perform well for their underserved members will receive a bonus tied to their performance. The point system and measure weights play a crucial role in plan performance for Star Ratings. The difference between a 4-Star and a 5-Star plan is often a very tight threshold. It's critical for plans to adopt a dynamic approach that constantly evaluates the data and how it relates to the weight of the measures. Stars is a math game that requires constant analysis and iteration to strategically direct efforts and resources towards the highest impact. While the upcoming changes are generating a mix of excitement and apprehension among plans, the focus remains on advocating for the members and achieving better outcomes. Tune into this episode to hear valuable insights into the challenges and opportunities in the Stars program, and learn strategies in navigating the changes and improving performance. About Our GuestMichelle Simon has over 15 years of experience in quality programs. She began her career on the commercial side with the quality rating system and transitioned into the Stars space where she has spent the majority of her career. Simon has a Masters degree in Organizational Leadership and a Post-Graduate Certificate in Healthcare Informatics and Data Analytics.

As stewards of healthcare, health plans are responsible for managing the care of its members. This includes working with providers to capture member conditions accurately and comprehensively via medical charts and coding. This improves member outcomes and optimizes the plan's risk adjustment revenue which ultimately reduces member costs. The scope of a prospective risk adjustment program is to account for historical member conditions, and identify and close gaps on suspected member conditions.  Many plans attempt to close as many prospective gaps in a year as they can and whatever they cannot close in that year is sent to retrospective programs. This is an unsophisticated, costly approach that tends to over-suspect and send providers weak evidence which diminishes provider trust and engagement.Based on CMS guidelines, the prospective format has very specific language requirements for how providers document member conditions.  Plans cannot go back in time and change how its providers code and document a condition, thereby making retrospective programs administratively heavy.AI machine learning models offer a higher level of sophistication by scanning the clinical evidence and assigning a probability score to each piece of evidence in support of a suspected member condition. This saves administrative time and offers providers a high level of trust that the data sent via CDI alerts is compelling and indicative of a condition. When providers have confidence in the data, it increases their participation in prospective programs and leads to more gaps closed.Tune in to this episode to learn more about AI suspecting program logic and prospective programs. About Our Guest:Elizabeth Burreson is an expert in risk adjustment analytics technology and has 20 years of IT data management experience, managing product portfolios and backlogs.

Best practices for Medicare and Medicare Advantage marketing and ads continue to evolve as greater numbers of seniors integrate digital activity, such as online news and Facebook, into their daily routines. While the goal of any campaign is to stop-the-scroll and convert, there are marked differences for achieving this across generational cohorts. Current research on Medicare markets tend to be very broad, lumping all senior age brackets into one cohort—meaning someone who's 60 is not differentiated from someone who's 70, 80, or 90+.  This practice would be akin to studying the digital activity patterns of a 15 year old and a 45 year old in the same cohort. Medicare Ad expert, Holly Wolniakowski, recognizes the research gap and uses independently curated data to develop, test, and retest ads. "It's a dynamic and iterative process," reports Wolniakowski. In the past, Medicare markets have been most responsive to text-based ads paired with stock image graphics. However, internal tests at Advantasure have identified an increase in ad performance when a greater emphasis is placed on graphic selection. Currently, stock images that look highly posed do not perform as well as authentic, natural images, and the depiction of active seniors outperforms the ads of seniors in sedentary poses. Additionally, Baby Boomers through age 75 have developed a growing preference for video content, typically viewed on silent with close captioning. It's important to remember that insights gleaned from ad performance tests are ever-evolving, so what seems to be true today could change tomorrow. The best strategy includes an AI model where target segments are constantly evolving with updates from multiple input streams such as demographic information, claims data, and digital interaction data, followed by analysis from a behavioral scientist to ensure the message is relevant, timely, and maximizes engagement.About Our Guest: Holly Wolniakowski has over 20 years of experience in content development and analysis, PR and media relations. She has unique expertise in the development and management of ad campaigns for government-sponsored health plans. Wolniakowski holds a Masters degree in advertising and a Bachelors in journalism from Michigan State University. 

Join us for insider insights and perspectives for healthcare executives of government-sponsored health plans. We're talking to the experts about the unique operating infrastructure necessary for profitability and providing a best-in-class member experience. Topics include technology, data security, operations, health management, member engagement, risk adjustment, quality measures, start-up and growth tactics, legal and regulatory. 

CMS Interoperability and Patient Access Final Rule was developed to connect healthcare technology systems  so members can access their own data. All CMS-backed plans—Medicare Advantage plans, Medicare plans and ACA plans will be required to provide a patient access API, a provider API, and a payer-to-payer data exchange system. An API is an application program interface. An API is like an electrical outlet—there's a standard shape and size for the outlet and all electrical devices in the U.S. are designed to connect to it. The API is designed to provide the technical ability to access and exchange data in a standardized way. For the patient access API, this provides the member with a way to access all of their health information from the health plan including clinical data, claims data, enrollment data, etc. The provider directory API provides members with a way to find providers within their health plan and it allows providers with an expedited way to obtain prior authorization. CMS's goal is to incentivize innovation and enhance the member experience. Once the APIs are developed, the industry will have the foundation for continual improvement. The final API is the payer-to-payer data exchange, which provides a connection between health plans so if a member switches plans, their historical data follows them. This will encourage better quality and continuity of care by empowering providers with a full health history, the member retains all of their data, and the plans can identify gaps in care immediately rather than waiting to develop their own historical data. The entire healthcare ecosystem benefits from a collaborative data exchange.Health plans are facing some challenges with the implementation of interoperability standards. Most health plans are insurance companies and do not have a technology arm. In order to meet the compliance standards, plans must form vendor partnerships that are specialized in technical solutions for government-sponsored health plans. The goal of a 3rd party vendor in interoperability is to: create an environment where PHI is both protected and available, craft a strong authentication layer, shield proprietary information from competing health plans in the payer-to-payer data exchange, and provide an operational ecosystem where data is maximized across different aspects of the business. About our Guest: Brian Edwardson is the Director of HEDIS Operations for Advantasure. Edwardson has a longstanding career in healthcare technology and quality data. At Advantasure, he joined the product team to build and launch the quality, provider engagement, and interoperability products. He is a Certified Product Owner/Product Manager (POPM) delivering products in the Scaled Agile Framework and he holds the third level of certification, PMC-III, from the Pragmatic Institute Product Management. Currently, Edwardson leads a quality performance team that supports multiple health plans.

Technology is essential for today's care management operations, yet it's important to recognize that technology can either help or hinder the business. At its best, technology offers a reduction in the basic cost of doing business through streamlined workflows, automation and digital processing of administrative functions. But, at its worst, improperly designed technology can cause wasted man hours, rework, increase the likelihood of human error, and create job dissatisfaction—all of which creates staffing issues and distracts clinicians from the primary mission of caring for members. About Our Guest: Laura Franklin has over 15 years of clinical nursing experience and 8 years with healthcare technology platforms guiding clinical informatics. Franklin is an Advanced Practice Nurse, MSN from UCSF.Listen in to learn more about how innovations in workflows for case management and utilization management are solving common healthcare and business problems for health plans. 

Social determinants of health (SDoH) is an important variable to consider when interacting with Medicare Advantage populations and as the healthcare system increases its use of digital technologies, such as telehealth visits, online prescriptions and digital communications, digital inequality is becoming a forefront issue within SDoH.Digital inequality examines populations to determine internet accessibility, internet literacy, and how are people of different sub-populations are using the internet. All of these factors influence how plans should develop messaging and outreach programs. In order to collect this information and develop solutions to reach this population, health plan data scientists have to be conscientious of SDoH when building algorithms to avoid biases. For example, a new strategy for closing gaps is to offer telehealth services.  To test the efficacy of this strategy, a health plan may build a model to predict a member's likelihood of using telehealth services using cohorts of urban versus rural member data. If they don't include data related to digital inequality, they may come to a faulty conclusion that telehealth is a good solution for its rural members. By not accounting for digital inequality,  the telehealth program may result in poor engagement. By including SDoH data, health plans can identify micro-segments of the population and innovate solutions to address each cohort. In this case, the health plan might plan to partner with an internet service provider and pay for a portion of the internet fees to enable their offline member's access to telehealth visits. The takeaway is the data used to feed algorithms must be consistent with the population the logic is applied to. One way to ensure that models are built accurately is to ensure data science teams are well rounded and include not just highly technical data scientists but also social scientists to account for the specific needs and challenges of any given population.About Our Guest: Brandon Brooks is the Data Scientist for Advantasure's Member Acquisition & Engagement technology, a machine learning solution for Medicare Advantage plans. With over ten years of experience in computational social science research, he is an expert in human communications and engagement in digital ecosystems using data and behavioral sciences. He's worked in several industries including healthcare, energy, environmental, education and information technology. With an appreciation for details and analytics, Brandon is highly skilled at telling stories with data and enjoys working on complex problems without a clear solution.

“The goal is to support consumers in making informed decisions about which plan to choose”HEDIS hones in on 5 domains of care and measures whether the healthcare services rendered are actually improving conditions. The domains include effectiveness of care, access or availability of care, experience of care, utilization and resource use, and information about the health plan.In the domain of access or availability of care, advancing health equity and improving quality of care for underserved populations is an up and coming topic that the NCQA is focusing on. There will be a requirement, tentatively set for 2024, for health plans to have race and ethnicity data on 80% of a health plan's population. Health plans should be auditing their member information now to identify incomplete information sets and develop a plan for incorporating the right data into race and ethnicity stratifications. This data can be sourced directly or indirectly. Direct data comes directly from the member. For example, from a survey, enrollment information, or even requested from provider's EMRs. Indirect data is the practice of using data for a purpose other than the reason it was originally collected, such as census data.Another change we can expect from the NCQA is the shift to acquire more electronic sources for data collection. They've started to develop specific measures, Electronic Clinical Data System sets, ECDS. It's not required today for the Medicare Advantage population, but this should be on every health plan's radar because it will be a NCQA requirement in the future.HEDIS data is valuable beyond HEDIS. Forward-thinking plans can leverage the output of HEDIS data to support CAHPS and HOS. The data can be pushed downstream to other areas of the business to provide member-level insights like member compliance for care management teams or member communications. This is where risk adjustment—closing gaps, health management, communications, and member experience intersect. This should be each health plan's future goal—to have a holistic model where all business units are on the same page, fueled by the same data and working together towards the same goal. About Our GuestAlyse Schwartz is the Director of HEDIS Analytics for Advantasure. Alyse holds a Master of Science degree in public health with a focus on epidemiology. She's an experienced researcher and has been in the quality improvement space for over 10 years. 

It's hard to imagine a time when claims were submitted on paper. In 2003, Medicare required electronic submission of all claims via an electronic data interchange (EDI) for auto-adjudication. This means claims are processed, paid, and have a status update without human contact. Plans should aim for an auto-adjudication rate in the high 90's, but some systems still struggle with this benchmark.There are a number of system errors that can impact auto-adjudication rates including faulty matching logic, incorrect claims information, and missing provider contracts to name a few. Information maintenance is critical to a successful auto-adjudication process, otherwise it front-end rejects or receives a pending status. In these cases, a manual correction is required and not preferable, as human resources are costly. In order to stay competitive, plans have to invest in a strong adjudication engine that can handle high volume.Another area of investment that behooves plans to prioritize is the configurability of their claims processing technology. A high level of configurability allows for faster response to change such as: CMS regulatory updates, changes to the health plan's plan types, benefit plans, contracts, provider contracts, capitation-related contracts, payor information, bank information, group information, member configuration, authorizations. There are a number of variables that must be accounted for and having a system that is highly configurable takes the edge off of changing with the times.About Our GuestKirsten Lynch is a product manager and claims technology expert who has been in the healthcare industry for over 20 years. 

"The operating infrastructure of health plans rely on technology to expedite processes, scale, react quickly to regulatory changes and changes in the market."Technology debt is the cost of maintaining legacy software systems over time, often built in hard code. Updates and workarounds are expensive and the process for implementation is slow, but there's also the opportunity cost, business goals and timelines to consider. In order to adapt to the fast-paced landscape of today's health plan operations, plans need to be nimble and adaptable to change to stay competitive. There are tool sets in the cloud that allow for innovation of processes, software products, and the ability to scale which wasn't previously available. There are many different ways to leverage the cloud and a spectrum of what it means to be cloud-native.  Infrastructure as a Service (IaaS) takes all the same servers, infrastructure, and architecture that's in place today, keeps it in-tact and runs it virtually in the cloud. For many this has a lot of benefits, scales, and can be optimized. The next step in the evolution on the spectrum is Platform as a Service (PaaS). This gets rid of the limitation of having the infrastructure and architecture lifted into the cloud and it builds an infrastructure through code by leveraging the cloud-native storage, tools, and technology as the platform itself for software services, products and applications—allowing for greater innovation capacity. PaaS allows for quick scaling, up or down,  enhanced automation and connectivity between development pipelines, heightened security, API management, governance and toolsets. Beyond the cloud's abundant flexibility, speed and configurability, it's a more cost-effective environment.About Our GuestLarry Moncol leads Advantasure's product software and technology platforms. 

The concept of marketing segmentation isn't new, but what may be new, is the idea of generational segments within the Medicare market. Until recently, messaging to the senior market has involved painting  a picture of a peaceful and relaxing retirement. The Silent Generation, born between 1925-1945, responded very favorably to this messaging. And many of the older Baby Boomers, born between 1946-1954, also respond well to this promise of peace, although not all.  The younger Baby Boomers have absolutely challenged the norm and the expectation of what it means to age, and they're not resonating with this ideal of retirement. They feel they're just getting started and respond best to the promise of adventure and exploration.  A 2018 Columbia University study found "considerable evidence for age-group dissociation" meaning today's older adults don't see themselves as old.  And it's not just messaging that's changed with the younger Boomers. The tactics and channels have changed too. Whereas older Boomers still prefer word-of-mouth, traditional marketing, and in-person opportunities, like agents; younger Boomers prefer a transactional relationship that maximizes value and efficiency. Another concept not widely considered in the Medicare market but certainly avant-garde, is messaging aimed towards Generation X and the Millennials. As the insurance space becomes increasingly more digital, it may be perceived as confusing or intimidating to aging-in seniors. In many cases, seniors are looking to their children and even their children's children to help them navigate online platforms and even the growing complexities of health insurance. Generation X is not the first generation to help their parents through the aging process, but they are the first generation to understand things that their parents may not. They're essentially taking the place of agents in some cases. This aspect of Medicare marketing is an under explored area of opportunity. There are some data points that can indicate whether you're interacting with a proxy, although this concept is in its infancy. Perhaps the greatest benefit of interacting with future generations as proxies is the opportunity to build  rapport and members for life.About Our GuestMarcie Robinson-Caughey has been studying senior programming for 20 years. She began her career in operations and marketing for senior community recreation programs. Today, Marcie is the Operations Manager for Advantasure's Digital Outreach platform. ReferencesWeiss, D. & Kornadt, A. E. (2018, October 19). Age-Stereotype Internalization and Dissociation: Contradictory Processes or Two Sides of the Same Coin? Current Directions in Psychological Science, Vol 27(Issue 6), page(s) 477-483, 2018.

“One area of opportunity that a lot of health plans overlook, is taking a step back and looking at data that's right in front of them with a new perspective..”The weight of the CAHPS survey has steadily increased over the years from 8% in 2014 to 32% of the overall Star Rating in 2021. Scoring is complex and there's no one size fits all strategy. Two health plans the same size can do the same thing and get different results. The reason for this is attributed to the unique nature of every member experience in different member populations. There are a number of variables that contribute to positive CAHPS performance. Although CAHPS performance can't be pinned to one effort, the health plans that are most successful have a wholistic strategy that involves multiple departments and synergies between their member communications and outreach. Every single thing that's printed on paper, published on websites, sent via email, or communicated verbally—matters. Carefully crafting and optimizing a targeted member journey is essential to successful CAHPS. It's often forgotten that health plans are surveyed not just on their own interactions with members, but also their agents and provider networks. Education and onboarding partners to deliver a member experience is just as important as training customer service representatives. All member touch points are a reflection of the health plan.In order to improve the member journey, plans must evaluate their available data from multiple perspectives. For example, it's no longer sufficient to evaluate appeals and grievances through the narrow lens of whether it was an appropriate denial or not. Today, plans need to also analyze complaint data from a quality vantage point and determine it its more expensive to have an abrasive member experience. About Our GuestAmy Weiser is an accomplished healthcare executive with 20+ years of experience in health plans and facility and practice management. Weiser has experience with Medicare Advantage, Dual Special Needs Plans, MMP, and Medicaid lines of business. She has had responsibilities that have included Star and Hedis oversight, operations, member and provider materials and engagement, medical management leadership over care management and utilization departments, as well as experience starting a new quality and patient experience department for a large physician network.

“It's essential to accelerate the speed and time for gaps to identify them faster and proactively.”In the context of risk adjustment gaps, there are two overarching goals—to identify and accurately predict member conditions. To do this, health plans are reliant on the amount and quality of the data they have—primarily sourced from clinical and claims data. Plans need this data to produce intelligence and directives to providers on how best to proceed on a proactive care path. Due to COVID, plans experienced a decrease in access to data and that resulted in unique challenges for risk adjustment and their ability to supply predictive analytic recommendations to providers. As we return to normalcy, plans can expect a huge influx of data in 2022 and 2023 as members return to their normal care and procedures. This is going to be great for generating greater intelligence and actionable insights, but it's also going to present some unique challenges and strain on some plan's operational systems, especially if they're manual. For plans who have the technology and capacity to process large amounts of data, these coming years may be very fruitful for risk adjustment. The large data sets will provide a lot of intelligence for predicting member gaps and creating strong member segmentation models. About Our Guest: Abe Chaaya is the Managing Director of Product Management for Analytics Products within Advantasure. Abe has over twenty years of experience as a global IT leader in QA, DevOps, and product management spanning several industries including manufacturing, payment systems, and healthcare IT. He holds a bachelor's degree in mechanical engineering from Rensselaer and an MBA in operations and technology from Bentley. 

“There's a whole new range of possibilities for interacting with members through digital medium.”Marketing and communications in the Medicare Advantage space have evolved significantly in the past five years. Leaving behind a one-size-fits-all outreach approach, today's best practice is messaging for a journey of one—targeting unique individuals or groups of individuals with similar needs. For example, health plans would want to communicate differently with members who have chronic conditions versus healthy members. Deploying specific-to-the-member messaging engages the member, grabs their attention, serves them up with relevant information, and guides them through a progression of messaging including calls to action. Messages are deployed via a number of digital channels such as email campaigns, social media, and newsfeed ads. Make note, that the depth of modern-era outreach is expanding rapidly to include cutting-edge technologies such as artificial intelligence voice technology bots and care robots. It's important to remember that all of these digital tactics are not just forms of communication flowing back and forth. It's a form of optimizing and understanding the communications. Most digital interactions leave a trail of data that can be analyzed with machine learning and artificial intelligence tools. What that means ultimately, the member journey with the plan and with their own health no longer needs to be an isolated journey. The member's health trajectory with the plan can be smooth, seamless, and guided by the hand of these digital tactics and insights.  About Our Guest: Andrea Wallace (Dre) has a background in product development and is an innovator in solutions for healthcare organizations. Wallace has served in a variety of roles across the technology industry as an innovator, investor, and strategist. She is the recipient of the 2019 Nolan Groce Business Leadership Award for her work in the startup and entrepreneurial ecosystems. Resources: Tech Adoption Climbs Among Older Adults. Monica Anderson, Andrew Perrin. May 17, 2017. https://www.pewresearch.org/internet/2017/05/17/technology-use-among-seniors/

"The only way to proactively identify and manage members with rising risk is by connecting care teams with real time data, analytics, and predictive models."In this episode, we explore the origins of care management, reactive versus proactive models of care, ways to coordinate care with real time data, practical uses for data and analytics for diagnosis and treatment, as well as the ideal care management dashboards for frontline healthcare workers, managers and directors of care management programs. Guest : Dr. Chris Johnson is the Symphony Product Lead at Advantasure, designing and implementing health management solutions for government-sponsored health plans. Building upon academic training in medicine, public health, and medical informatics, Dr. Johnson, pioneered new work- flow methods at companies such as Dignity Health, Zynx Health, and Adventist Health. He co- founded Performance Clinical Systems (PCS) to develop the Symphony workflow concept. With Symphony's acquisition by Advantasure in 2019, Dr. Johnson now leads a growing team to create effective solutions for health payers and provider networks. Resources:Baclic, O., Tunis, M., Young, K., Doan, C, Swerdfeger, H., Schonfeld, J. (2020). Challenges and opportunities for public health made possible by advances in natural language processing. Cana- da Communicable Disease Report, 46(6): 161-168. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC7343054/ 

Season 1 is coming soon! Join us for insider insights and perspectives for healthcare executives of government-sponsored health plans. We're talking to the experts about the unique operating infrastructure necessary for profitability and providing a best-in-class member experience. Topics include technology, data security, operations, health management, member engagement, risk adjustment, quality measures, start-up and growth tactics, legal and regulatory. 

“Maintain the spirit of continual improvement across the organization. Even though there is uncertainty, CMS rewards heavily for improvement year over year.” 2021 was the first year that CMS shifted away from clinical metrics and skewed the weight towards member experience. Health plans will need to address matters such as how well members understand their benefits, the ease of the experience surrounding the use of benefits, and resolution of issues with paying for services—to name a few examples. Member experience is the summation of the entire scope of interactions for a member with their health plan and providers. We're talking with Erica Krieger about what plans can do in 2022 to boost Star Ratings.Guest: Erica Krieger is the Vice President of Quality for Advantasure, a front runner in the Medicare Advantage plan operation space. Krieger has more than 20 years of experience—spanning strategic informatics, management of Star program reporting, HEDIS operations, forecasting models for HEDIS improvement initiatives and scoring methodologies. ResourcesAge of MA plans plays role in success:  (2021). Fact Sheet - 2021 Part C and D Star Ratings. https://www.cms.gov/files/document/ 2021starratingsfactsheet-10-08-2020.pdf By 2030, the entire baby boomer generation will be older than 65:  (2018, March 13. Revised 2019, Oct 8). Older people projected to outnumber children for first time in U.S. history. https://www.census.gov/newsroom/press-releases/2018/cb18-41- population-projections.html