Podcasts about medicare advantage ma

Lynn Nonnemaker joins Julia Grabo to discuss what Medicare Advantage (MA) and Part D proposals have been finalized, and, more importantly, which ones have not yet been addressed.

The Medicare Advantage (MA) landscape is shifting dramatically. With over half of all Medicare beneficiaries now enrolled in MA plans, the program faces unprecedented scrutiny from lawmakers, regulators, and beneficiaries themselves. During this 40-minute podcast, MA policy experts Carrie Graham and Neil Patil dissect the changing political and regulatory climate surrounding MA and offer crucial insights for health plans navigating these turbulent waters. They explore how the Trump administration is approaching MA reform through payment adjustments, increased oversight, and technological innovation.Graham and Patil delve into hot-button issues driving the reform conversation: prior authorization practices that frustrate both providers and patients, marketing tactics that have drawn Department of Justice attention, and the accuracy of provider directories that directly impact beneficiary access to care. They discuss key bipartisan legislative proposals gaining traction, including the No UPCODE Act and the Improving Seniors' Timely Access to Care Act.Want to learn more? Graham and Patil will speak at RISE West 2025, the Medicare Advantage senior leadership event of the year, August 25-27, at Paris Las Vegas. Also check out additional information from the Medicare Policy Initiative blog posts, publications, tools, and resources, including a compendium of Medicare Advantage policies and a comparison tool of legislation that's been rumored to be included in a potential end-of-the-year legislative package (the Improving Seniors Access to Timely Care Act) and CMS regulations.Carrie Graham, Ph.D., is a research professor and the director of the Medicare Policy Initiative at Georgetown University's Center on Health Insurance Reform (CHIR), where she oversees a portfolio of policy analysis, research, and technical assistance for policymakers on Medicare Advantage and original Medicare. Previously she was the director of aging and disability policy at the Center for Health Care Strategies. She also holds an adjunct professor appointment at the University of California, San Francisco, Institute for Health and Aging.Neil Patil, MPP, is a senior fellow and the policy director at the Medicare Policy Initiative at CHIR, where he conducts policy analysis and provides technical assistance to policymakers on Medicare Advantage issues. Prior to joining CHIR, he was a senior analyst at the Centers for Medicare & Medicaid Services Office of Legislation, where he provided technical assistance to Congress on issues related to Medicare Advantage and the Medicare Drug Price Negotiation Program. In this role, he served as the lead analyst on Medicare Advantage issues. 

On this Ropes & Gray podcast, health care partner Michael Lampert and counsel Sam Perrone are joined by litigation & enforcement partner Andrew O'Connor for a two-part discussion, with this first episode focused on recent enforcement activity and broker arrangements in the Medicare Advantage (“MA”) space. They delve into the Oak Street settlement, the Office of Inspector General's (“OIG”) Special Fraud Alert, and a recent Department of Justice (“DOJ”) False Claims Act (“FCA”) suit against major Medicare Advantage plans and brokers. The conversation covers the complex regulatory framework governing broker arrangements, the implications of recent enforcement actions, and practical takeaways for providers. Listen in for an insightful analysis of these critical issues affecting the health care industry, and stay tuned for part two, where the focus will shift to enforcement in the patient assistance program space.

Web: www.JonesHealthLaw.comPhone: (305)877-5054Instagram: @JonesHealthLawFacebook: @JonesHealthLawYouTube: @JonesHealthLawThe Centers for Medicare & Medicaid Services (CMS) established the Preclusion List under its authority to administer Medicare Advantage (MA) and Part D programs. The list features healthcare providers and prescribers who are precluded from receiving payment for items or services furnished to Medicare beneficiaries enrolled in MA plans or for prescriptions covered under Part D.The U.S. Department of Health and Human Services, Office of Inspector General (OIG) maintains the List of Excluded Individuals and Entities (LEIE) under the authority of the Social Security Act §§ 1128 and 1156. Exclusions are imposed on individuals or entities found to have engaged in certain misconduct, such as fraud or patient abuse.

Medicare Advantage (MA) is one of the most popular insurance programs for the Medicare-eligible population, however it faces significant headwinds from both payer and provider organizations. Alan Lassiter, Principal, ECG Management Consultants, speaks with Christine Worthen, Member, Epstein Becker & Green PC, and Joe Mangrum, Partner, ECG Management Consultants, about the current state of MA, the complex issues confronting both payers and providers, and strategies for successfully navigating these uncertain times. They discuss issues related to provider-sponsored plans, structuring value-based arrangements with MA plans, how MA plans can maintain margin, CMS' recent final rule, sustainable MA plan reimbursement, network design and supplemental benefits, and the value drivers of data. From AHLA's Payers, Plans, and Managed Care Practice Group.AHLA's Health Law Daily Podcast Is Here! AHLA's popular Health Law Daily email newsletter is now a daily podcast, exclusively for AHLA Premium members. Get all your health law news from the major media outlets on this new podcast! To subscribe and add this private podcast feed to your podcast app, go to americanhealthlaw.org/dailypodcast.

(This episode originally aired on October 22, 2024.) For years, the best word to describe Medicare Advantage (MA) was “untouchable.” Hugely popular among seniors, profitable for health plans—the hybrid public-private payment model grew to the point that it now covers more seniors than traditional Medicare. But in the past few years, the tide has started to change. And if you've been paying attention in recent months, you'll have seen headlines announcing that payers that are scaling back their MA offerings and providers are exiting MA contracts. The MA market has gone from “untouchable” to “volatile.” The question is: why is this happening, and what does it mean for payers, providers, and seniors moving forward? In this episode, hosts Rachel (Rae) Woods and Abby Burns invite health plan experts Max Hakanson and Chelsea Needham to dissect what is going on in MA and how plans and providers are—or should be—navigating the changing tide. Links: Ep. 203: Value series: Is the future of VBC in specialty care? Zing Health & Strive Health say yes. Ep. 149: Senior Care (Part 1): Specialized primary care for an aging population Ep. 150: Senior Care (Part 2): The rapid growth of Medicare Advantage 3 traits health plans want in a provider partner 4 traits providers want in a health plan partner Around the nation: CMS releases Medicare Advantage Star Ratings Q&A: Cardiologist Navin Kapur discusses the future of complex PCI

(This episode originally aired on October 22, 2024.) For years, the best word to describe Medicare Advantage (MA) was “untouchable.” Hugely popular among seniors, profitable for health plans—the hybrid public-private payment model grew to the point that it now covers more seniors than traditional Medicare. But in the past few years, the tide has started to change. And if you've been paying attention in recent months, you'll have seen headlines announcing that payers that are scaling back their MA offerings and providers are exiting MA contracts. The MA market has gone from “untouchable” to “volatile.” The question is: why is this happening, and what does it mean for payers, providers, and seniors moving forward? In this episode, hosts Rachel (Rae) Woods and Abby Burns invite health plan experts Max Hakanson and Chelsea Needham to dissect what is going on in MA and how plans and providers are—or should be—navigating the changing tide. Links: Ep. 203: Value series: Is the future of VBC in specialty care? Zing Health & Strive Health say yes. Ep. 149: Senior Care (Part 1): Specialized primary care for an aging population Ep. 150: Senior Care (Part 2): The rapid growth of Medicare Advantage 3 traits health plans want in a provider partner 4 traits providers want in a health plan partner Around the nation: CMS releases Medicare Advantage Star Ratings Q&A: Cardiologist Navin Kapur discusses the future of complex PCI

Lynn Nonnemaker and Amy Kelbick join Julia Grabo to discuss the two Medicare Advantage (MA) final rules released in the past week and how they fit into the Administration's other initiatives and larger priorities.

A live and interactive discussion with one of the leading voices in elder care policy that will provide insights into the complex world of aging services during this period of policy uncertainty. Howard Gleckman, a senior fellow at the Urban Institute and author of Caring for Our Parents will provide a comprehensive analysis drawing on his expertise in tax policy, elder care, and healthcare.https://howardgleckman.com/Caring for Our Parents: Inspiring Stories of Families Seeking New Solutions to America's Most Urgent Health Crisis Hardcover – May 26, 2009 by Howard Gleckman (Author)Summary Generated by https://notebooklm.google.com/ Gleckman began by addressing **Social Security**, highlighting President Trump's promise not to cut benefits directly. However, he cautioned that the administration's actions, such as limiting access through closed offices and phone line difficulties, are already impacting beneficiaries and applicants, particularly those seeking disability benefits, where waiting times are expected to exceed a year. More critically, Gleckman stressed the looming **insolvency of the Social Security trust fund within the next nine years**, which could lead to an automatic 23% cut in benefits if no action is taken. He criticized the political stalemate on this issue, noting that inaction is akin to "taking Social Security off a cliff".Turning to **Medicare**, Gleckman noted Trump's similar pledge not to cut benefits directly. However, he anticipated potential cuts to providers, which could further strain access to care. A significant focus was placed on **Medicare Advantage (MA)**, with the administration recently announcing a substantial 5.3% increase in payments to MA plans. Gleckman pointed out the inconsistency with the stated goal of cutting government spending. He discussed the possibility of MA becoming the default Medicare option, as suggested by Project 2025. While acknowledging potential benefits of coordinated care in theory, Gleckman raised concerns about network limitations, complexity, and prior authorizations in current MA plans. He also touched upon the negotiation of drug prices initiated by the Biden administration and the uncertainty of Trump's future stance on this, while noting the current administration's decision to not cover GLP-1 drugs for weight loss under Medicare and Medicaid.The **Older Americans Act (OAA)** and the **Administration for Community Living (ACL)** were also highlighted as being at risk. Gleckman predicted budget cuts for OAA programs like Meals on Wheels and adult day programs. More alarmingly, he discussed the announced plan to **abolish the ACL** and divide its functions among other HHS offices, along with the firing of half of its staff, including grant program administrators. This could severely disrupt the functioning of vital community-based services due to a lack of federal oversight and support. Gleckman also noted the potential impact of federal employee layoffs in the Washington D.C. area on the tax base and consequently on local senior service programs.Gleckman concluded by emphasizing the **unpredictability of the Trump administration** due to its impulsive and chaotic management style. He urged communities to proactively work together to support older adults and their caregivers during these uncertain times. He echoed the sentiment that individual storytelling and engagement with lawmakers are crucial for conveying the real-world impact of potential policy changes. The interactive nature of the discussion allowed participants to voice their concerns and ask questions, highlighting the community's eagerness to understand and navigate the evolving landscape of aging services.

During the next edition of Monitor Mondays, special guest Bill Dombi, senior counsel with Arnall, Golden, and Gregory, will offer an update on the hot-button issues affecting home healthcare, hospice, and long-term home care. These issues include the latest developments related to the Medicare Hospice Special Focus Program, the impact of the Medicare home health payment model, Medicare Advantage (MA) claim denials in post-acute care, and increasing threats to Medicaid support.The venerable weekly Internet broadcast will also include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the latest news concerning healthcare legislation.

Medicare Advantage (MA) plans are set to change with new Centers for Medicare and Medicaid Services (CMS) regulations and increased competition. This event explores the upcoming regulatory changes, including the annual review of Special Supplemental Benefits for the Chronically Ill (SSBCI), which will assess how these benefits impact member health. Starting in 2026, Medicare Advantage Organizations (MAOs) will also be required to notify members about unused supplemental benefits mid-year, improving health equity and ensuring enrollees are aware of available resources.Hear our conversation with Amy Schiffman, CEO of AgeTech DC and CMO of Heal Pros, and Doron Porat, co-founder and CEO of ActiveAging, about strategies for enhancing member outcomes and satisfaction, with a focus on addressing social determinants of health such as transportation, meals and housing support. Learn how MA plans can improve Star Ratings, boost retention and close care gaps by offering targeted, effective benefits. The event also showcases tools like ActiveAging's ActiveAgent platform, an AI-driven tool that ensures its members are fully utilizing supplemental benefits, driving engagement, satisfaction, retention and Star Ratings. Attendees gained key insights to remain competitive, meet CMS requirements and position their plans for long-term financial sustainability.This conversation was moderated by John Achoukian, executive in residence at MATTER.For more information, visit matter.health and follow us on social: LinkedIn @MATTERTwitter @MATTERhealthInstagram @matterhealth

Medicare Advantage (MA) plans (also known as "Part C") are rapidly increasing in use, and beneficiaries' co-pay and claims denials are becoming more frequent. In today's episode, host Dr. Andrew Pouw talks with Academy billing and advocacy experts Joy Woodke and Brandy Keys to learn more about MA plans and their impact on patients and how ophthalmologists deliver care. To review the requirements put forth by your Medicare Administrative Contractor, visit the Academy's page on local coverage determination policies. For all episodes or to claim CME credit for selected episodes, visit www.aao.org/podcasts.

* Oscar Fernandez, Host of Latino Media Collective, covers the Panama invasion's 35th Anniversary: On the 35th anniversary of the US invasion of Panama, Latino Media Collective Host Oscar Fernandez spends an hour with freelance producer Michael Fox and Politics Done Right host Egberto Willies to discuss the importance of the invasion today in Panama and US foreign policy. [More]* Senior Citizen caller refused to accept the Medicare Advantage SCAM from the insurance company: This senior did not fall for the Medicare Advantage (MA) scam. After they switched him to MA, he forced them to switch him back. [More] To hear more, visit egberto.substack.com

This senior did not fall for the Medicare Advantage (MA) scam. After they switched him to MA, he forced them to switch him back. Subscribe to our Newsletter: https://politicsdoneright.com/newsletter Purchase our Books: As I See It: https://amzn.to/3XpvW5o How To Make America Utopia: https://amzn.to/3VKVFnG It's Worth It: https://amzn.to/3VFByXP Lose Weight And Be Fit Now: https://amzn.to/3xiQK3K Tribulations of an Afro-Latino Caribbean man: https://amzn.to/4c09rbE

Denials in healthcare are a problem.Recently, though, the problem seems to be getting worse, especially with the misapplication of the Two-Midnight Rule by Medicare Advantage (MA) plans, according to Nick Hut, senior editor for Healthcare Financial Management Association (HFMA).Hut reports that MA plans are classifying hospital stays as outpatient observation visits at a significantly higher rate than traditional Medicare even though the rule is supposed to be applied the same way in both programs.And Hut believes the situation is likely to be getting worse because UnitedHealthcare is targeting provider coding while it seeks to bring down medical spending that has been higher than anticipated in recent fiscal quarters.Hut will be reporting this story during the next live edition of Monitor Mondays. He has more than 12 years reporting healthcare policy news and trends.Other segments during the weekly broadcast will include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Legislative Update: Adam Brenman, senior legislative affairs analyst for Zelis, will report on current healthcare legislation.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

For years, the best word to describe Medicare Advantage (MA) was “untouchable.” Hugely popular among seniors, profitable for health plans—the hybrid public-private payment model grew to the point that it now covers more seniors than traditional Medicare. But in the past few years, the tide has started to change. And if you've been paying attention in recent months, you'll have seen headlines announcing that payers that are scaling back their MA offerings and providers are exiting MA contracts. The MA market has gone from “untouchable” to “volatile.” The question is: why is this happening, and what does it mean for payers, providers, and seniors moving forward? In this episode, hosts Rachel (Rae) Woods and Abby Burns invite health plan experts Max Hakanson and Chelsea Needham to dissect what is going on in MA and how plans and providers are—or should be—navigating the changing tide. Links: Ep. 203: Value series: Is the future of VBC in specialty care? Zing Health & Strive Health say yes. Ep. 149: Senior Care (Part 1): Specialized primary care for an aging population Ep. 150: Senior Care (Part 2): The rapid growth of Medicare Advantage 3 traits health plans want in a provider partner 4 traits providers want in a health plan partner Around the nation: CMS releases Medicare Advantage Star Ratings [Webinar, 10/24] How the 2024 elections could impact the healthcare industry A transcript of this episode as well as more information and resources can be found on www.advisory.com/RadioAdvisory.

Hosts Kathe Kline and Joanna Wyckoff were joined by Jamieson Keller, Chief Commercial Officer at NCD, whose insights on dental insurance are invaluable for every Medicare agent. Cross-Selling Opportunities Jamieson emphasizes the importance of cross-selling dental insurance as a critical component of comprehensive client service. By integrating dental plans, agents can fill significant gaps in coverage that many clients overlook. This is not merely about augmenting sales; it's about addressing real healthcare needs. As Joanna Wyckoff noted, clients rely on their agents for full-spectrum coverage, making dental insurance an essential offer. Understanding the Value of Dental Plans Jamieson highlighted the need for agents to dive deep into dental insurance products to grasp their true value. Many plans offer significant in-network discounts, which can drastically reduce out-of-pocket expenses for clients. For example, the NCD by MetLife Dental Plans that Jamieson mentions provide phased benefits that improve over time, rewarding client loyalty and ensuring sustainable, long-term coverage. Mitigating Financial Pressures With recent changes in the Medicare Advantage (MA) and Prescription Drug Plan (PDP) spaces, where some carriers are cutting commissions, dental insurance stands as a viable alternative for agents to recoup lost income. Jamieson points out that level commissions from dental plans can offer financial stability for agents facing turbulent changes in the industry. Testimonial of Quality Care Jamieson's background adds credibility to his recommendations. With over 17 years in Medicare and three years focused on dental insurance, his experiences provide a robust framework for agents. His engaging discussion about network discounts underline the importance of personalized client education and well-researched plan selection. Call to Action Agents are encouraged to proactively ask clients about dental insurance. Jamieson suggests creative methods like using large tooth models to initiate conversations and attract attention at events. The simplicity of enrolling a client in an NCD dental plan, which takes only about 90 seconds, underscores its efficiency. Final Thoughts As the episode wraps up, the hosts reaffirm their commitment to utilizing Jamieson's insights. By attending webinars and leveraging the comprehensive resources available, agents can significantly enhance their service offerings and ensure their clients receive holistic care. The conversation reveals a compelling case for the strategic use of dental insurance within the realm of Medicare services, underscoring its critical role in client health and agent success.

Jackie Kimmel, your Health Systems CXO Podcast host for Strategy Executives,  discusses the challenges and trends in Medicare Advantage (MA) contract management. Jackie highlights the declining yield from MA contracts and the negative impact on health system financial sustainability. The increasing number of audits, denials, and prior authorizations from MA payers is also a major pain point for health systems. Contract terminations are becoming more common, with many health system executives considering terminating at least one major plan in the next year. The viability of provider-sponsored health plans in MA is also discussed, with some systems slowing down growth while others see it as a leverage point in negotiations.Welcome to the Health System CXO Podcast, sponsored by The Health Management Academy, featuring content designed for Health System Nurse Executives, Health Equity Officers and Strategy Executives provided by our company SME's - Anne Herleth, Jasmaine McClain, Ph.D. and Jackie Kimmell. Subscribe today and receive the latest insights from the country's leading Health System CXO experts regularly, helping you remain current and guide your health system strategy with thought leadership and success.The Health System CXO Podcast activates health system leaders towards outcomes and scalable solutions you can implement now.About The Health Management Academy:Since 1998, The Health Management Academy has cultivated the premier community of healthcare's most influential changemakers from the top U.S. health systems and innovative industry partners. We power more than 2,000 health system senior executives and 200 industry organizations through exceptional peer groups, original market insights, world-class leadership development programs and novel member alliances. Our industry-leading programs and solutions enable members to facilitate meaningful relationships, navigate strategic transformation and address critical industry issues. To learn more, visit hmacademy.com and follow The Health Management Academy on ...

You need to get paid properly for surgical procedures on the Centers for Medicare & Medicaid Services (CMS) Inpatient-Only (IPO) List, according to Mary Beth Pace, vice president of care management at Trinity Health, and also the special guest during the next live edition of Monitor Mondays.Pace, in making the statement, was referring to rules and regulations set forth in the Federal Register for Medicare in 2024. She also alleges that some Medicare Advantage (MA) plans are not abiding by some of those rules and regulations. Pace says all MA plans need to abide by the IPO and reimburse correctly.But does your facility have the processes in place to ensure that you are being paid correctly for surgical procedures on the IPO? Be sure to listen in order to find out.Other segments during the weekly Internet broadcast will include these instantly recognizable features:• Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on current healthcare legislation.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.

On this episode of The Health System CXO Podcast, Jackie Kimmell, Sr. Director - Member Insights at The Health Management Academy, discusses Medicare Advantage (MA) and its impact on health system executives. She also discusses the growth and significance of MA in the healthcare industry, the profitability for payers, the benefits and challenges for beneficiaries, and the struggles health systems face. She also highlights the regulatory changes and headwinds that have affected the profitability of MA plans, leading to decreased margins for payers and lower yields for health systems. Lastly - she shares the insights Strategy Executives need to know regarding the variations in MA penetration across different markets and the importance of understanding the MA landscape for healthcare executives.Key Takeaways-Medicare Advantage (MA) is a major topic of concern for health system executives due to its significant impact on the healthcare industry.-Payers have prioritized MA and have seen high profit margins, but regulatory changes and headwinds have affected their profitability.-MA offers benefits such as low premiums and supplemental benefits, but there may be hidden downsides and challenges for beneficiaries.-Health systems have contracted with MA plans to benefit from higher reimbursement rates, but they face challenges such as claims denials and lower yields.-Understanding the MA landscape is crucial for healthcare executives to navigate the changing market and ensure financial sustainability.Chapters00:00 Introduction and Podcast Evolution00:27 The Significance of Medicare Advantage for Health System Executives03:02 Medicare Advantage: Profitability and Challenges07:38 Regulatory Changes and Headwinds in Medicare Advantage09:31 Variations in Medicare Advantage Penetration Across Markets12:23 Challenges Faced by Health Systems in Medicare Advantage Contracts17:21 Navigating the Medicare Advantage Landscape as a Healthcare ExecutiveWelcome to the Health System CXO Podcast, sponsored by The Health Management Academy, featuring content designed for Health System Nurse Executives, Health Equity Officers and Strategy Executives provided by our company SME's - Anne Herleth, Jasmaine McClain, Ph.D. and Jackie Kimmell. Subscribe today and receive the latest insights from the country's leading Health System CXO experts regularly, helping you remain current and guide your health system strategy with thought leadership and success.The Health System CXO Podcast activates health system leaders towards outcomes and scalable solutions you can implement now.About The Health Management Academy:Since 1998, The Health Management Academy has cultivated the premier community of healthcare's most influential changemakers from the top U.S. health systems and innovative industry partners. We power more than 2,000 health system senior executives and 200 industry organizations through exceptional peer groups, original market insights, world-class leadership development programs and novel member alliances. Our industry-leading programs and solutions enable members to facilitate meaningful relationships, navigate strategic transformation and address critical industry issues. To learn more, visit hmacademy.com and follow The Health Management Academy on ...

Each year the Medicare Payment Advisory Commission, MedPAC, provides Congress a report on the Medicare fee-for-service (FFS) payment systems, the Medicare Advantage (MA) program, and the Medicare prescription drug program (Medicare Part D). Within the MedPAC report is also the often (until now) under-reported Chapter 12.During the next live edition of Talk Ten Tuesdays, Colleen Ejak, Solution Advisor for 3M/Solventum, will report on the particulars from Chapter 12 of this report, including the status of the MA program.Colleen will be sharing specifics from the report regarding MA enrollment trends and updates on risk adjustment reporting and risk-conscious coding practices.The live broadcast will also feature these other instantly recognizable segments:• Dateline Healthcare: Former Centers for Medicare & Medicaid Services (CMS) career professional Stanley Nachimson will report on the latest healthcare news.• Coding Report: Laurie Johnson, senior healthcare consultant with Revenue Cycle Solutions, LLC, will report on the latest coding news.• News Desk: Timothy Powell, ICD10monitor national correspondent and regulatory expert, will anchor the Talk Ten Tuesdays News Desk.• Point of View: Angela Comfort, guest cohost of the live broadcast, will report on a subject that has caught her attention.

With zero-dollar premiums, caps on out-of-pocket costs, and perks that range from meal delivery to gym memberships – even loaded debit cards – membership in Medicare Advantage (MA) plans is surging in enrollment and popularity among seniors.  In fact, earlier this year, enrollment in Medicare Advantage plans surpassed enrollment in traditional Medicare, with more than 50 percent of eligible seniors now choosing this privatized version of coverage.  However, aggressive marketing campaigns and a lack of transparency in coverage often hide the downsides of Medicare Advantage, which include limited networks and strict prior authorization policies that make it harder for millions of seniors to quickly get the care they need. As we explore in this episode, these downsides also impact care providers, like hospitals, as well as the taxpayers who are footing the bill.Our guest, Tricia Neuman, is the executive director of KFF's Program on Medicare Policy and has been with the organization for almost 30 years. She looks back on the creation of MA, discusses the program's unexpected rapid growth, examines its impact on the health care system, and shares what she thinks comes next for seniors' coverage.Topics discussed include:Evolution of Medicare Advantage – popularity and benefitsFlooding the airwaves – impact of overzealous marketingWhat's in it for insurers? – how insurers game the system Impact on patients– from narrow networks to excessive prior authorizations Problems for providers – limitations on care from denials and delays Taxpayers pay the price – MA now spends more per beneficiary than Traditional MedicareWhat's next – the future of Medicare Advantage More:KFF is an independent source for health policy research, polling, and journalism. Its stated mission is to serve as a nonpartisan source of information for policymakers, the media, the health policy community, and the public.KFF has four major program areas: KFF Policy; KFF Polling; KFF Health News (formerly known as Kaiser Health News, or KHN); and KFF Social Impact Media, which conducts specialized public health information campaigns.

On this episode of the podcast, Amanda Head is joined by former New York Congresswoman Ann Marie Buerkle to discuss the impact of the Biden Administration's recent slashing in funding that supports Medicare Advantage (MA), a program more than 33 million senior citizens rely on. Despite a 90% satisfaction among MA users, these cuts could hike out-of-pocket costs by at least $30 per month, adding financial strain on fixed income seniors amid rising inflation. This move aligns with previous increases in deductibles and premiums. Critics are questioning why the Biden Administration is undermining a program that has never been financially cut before. The former New York republican further suggests that seniors left unable to make a choice in their own healthcare plans is just one additional step toward the Democrats' highly favored end goal of “Medicare For All”. Additionally, this episode also features a segment with former New York Congressman George Santos' Communications Director. Naysa Woomer, resigned her post and has been publicly critical of Santos' lackluster communications plan while in Congress and after his expulsion. Woomer is a seasoned communications professional, having served stints as Communications Director for the Massachusetts State Republican Party and as a Spokeswoman for the Commonwealth's Department of Revenue before heading to the House of Representatives. But it's not just George Santos who has problems with publicity these days, newly indicted Congressman Henry Cuellar (D-TX) and former GOP vice presidential contender and current Governor of South Dakota Kristi Noem are both under public scrutiny. One thing that is certain is that neither career politician has prepared or executed adequate crises communications plans. Woomer joins Amanda to talk about these latest political scandals and offers her communications advice free of charge. Be sure to “follow” or “subscribe” to the podcast on your preferred podcast platform to ensure you don't miss future episodes. Furthermore, you can follow Amanda Head on all social media platforms by searching for @AmandaHead. This podcast also has an account exclusively on ‘X' using the handle of @FurthermorePod.See Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.

Host Gil Bashe and Gregg Masters welcome Sachin Jain, MD, MBA, FACP the CEO of SCAN Health Plan, a multistate operator in the Medicare Advantage (MA) space. They discuss the state of the health plan market, prospects for innovation and explore some of the traditional obstacles in the way of a move into value based care. SCAN (Senior Care Action Network) is an organization that serves more than 300,000 members and generates revenues exceeding $4.8 billion, and a participant in the original 'social' HMOs program. To stream our Station live 24/7 visit www.HealthcareNOWRadio.com or ask your Smart Device to “….Play Healthcare NOW Radio”. Find all of our network podcasts on your favorite podcast platforms and be sure to subscribe and like us. Learn more at www.healthcarenowradio.com/listen

In this third and final installment of Ropes & Gray's three-part podcast series exploring recent regulatory, compliance, and enforcement developments in the fraud, waste, and abuse space and the potential implications for health care and life science companies in 2024, health care partners Devin Cohen and Michael Lampert reunite with litigation & enforcement partner Andrew O'Connor for a conversation on key enforcement developments concerning the Medicare Advantage (“MA”) program, as well as the Department of Justice's (“DOJ's”) current enforcement trends regarding providers, labs, and electronic health record (“EHR”) companies. Additionally, their discussion covers two recent Supreme Court cases under the False Claims Act (“FCA”) and explores their potential impact on the health care industry moving forward. 

I don't know about you but I'm FASCINATED with Medicare Advantage (MA). Massive growth, fueled by its shrewd marketing of added benefits beyond traditional Medicare. But also chaotic, messy, a program in need of reining in.   It's a bit of the wild west.  I like some things about MA, including its emphasis on preventative care and aligning patients outcomes with rewards. But I'm also routinely disappointed by its excesses and denial of medically necessary care.   Some days MA seems poised to overtake and end traditional Medicare. But every time I think that, another shoe drops. Intensive audits from the OIG, and sharp criticism from the likes of former CMS administrator Don Berwick. Two weeks ago we saw the nation's largest ACO get hit with a whistleblower lawsuit for alleged upcoding abuses.  To get a big picture overview and figure out where we are with the program I invited 4Sight Health's David Burda to join me on the podcast. David is 4SightHealth's news editor and columnist and hosts a podcast, the 4sighthealth roundup, covering MA and other adjacent topics.  Listen in as we discuss:  David's journalism background and eventual path into covering healthcare  MAs rapid adoption: Will it continue until Medicare is phased out—or is a reckoning coming?   The problems with MA: Gaming of risk adjustment/upcoding to make patients appear sicker, denial of medically necessary care, prior authorization nightmares, and sky-high insurer profits  What MA is doing well, should be preserved, and what needs reform  Is healthcare compatible with a free-market economy and shareholder ROI?   How David stays on top of the torrent of healthcare news, and his cool addition to the #OTR Spotify playlist     Additional reading from 4sighthealth:   What Will Happen to Traditional Medicare? https://www.4sighthealth.com/ken-terry-what-will-happen-to-traditional-medicare/   Spy vs. Spy? More Like Medicare vs. Medicare Advantage https://www.4sighthealth.com/spy-vs-spy-more-like-medicare-vs-medicare-advantage/   

Joanna breaks down Veterans benefits and how that effects Medicare for our listeners. The Department of Veterans Affairs (VA) provides a range of healthcare services, but it's important to understand that the level of coverage varies based on priority levels. The highest priority is given to veterans who are 50% or more disabled, granting them free healthcare and prescriptions from the VA. Veterans at lower priority levels may have copayments for their care. Unfortunately, there are common misconceptions surrounding VA benefits. It is essential to debunk these myths to have a clear understanding of the available options. Contrary to popular belief, not all veterans receive free VA healthcare and prescriptions. Additionally, veterans are not limited to Medicare Advantage (MA) plans without drug coverage. Various options, such as MA, Medigap, and standalone drug plans, can all work in conjunction with VA benefits without any issues.

On part one of this two-part podcast installment, Ropes & Gray's health care partner Devin Cohen and litigation & enforcement partner Andrew O'Connor discuss the Strategic Plan for Oversight of Managed Care for Medicare and Medicaid issued in August by the Department of Health & Human Services (“HHS”) Office of Inspector General (“OIG”). Part one's discussion focuses on the first two phases of the managed care life cycle: plan establishment and enrollment and associated enforcement and regulatory actions, and OIG's compliance priorities for Medicare Advantage (“MA”) plans and how the Strategic Plan implicates regulatory and enforcement developments in the managed care space more broadly.

Good morning from Pharma and Biotech daily: the podcast that gives you only what's important to hear in Pharma and Biotech world.In today's episode, we have several news updates from the industry. Let's dive right in!First up, we have a webinar titled "Navigating Preclinical Drug Development Challenges with Lipid-Based Formulations." This webinar discusses how biopharma teams are utilizing lipid-based formulations (LBF) to improve the bioavailability of challenging molecules and reduce the transition time and cost requirements for clinical trials. The highlights of the webinar include strategies for dosing lipid formulations in preclinical models, key considerations for improving bioavailability through LBF, and the regulatory and technical nuances involved in transitioning preclinical LBF to viable clinical dosage forms.Next, we have a case study from Cambrex on their process to enable GMP production under tight time pressure for a first-in-human clinical trial. This case study highlights the importance of route development and designing synthesis for GMP production. Cambrex's experts successfully developed a robust and high-yield process to enable GMP production within a tight timeline for a first-in-human clinical trial.Moving on, Biogen and Sage have set the price of their postpartum depression pill at $15,900, which is significantly lower than initial predictions. This move aims to make the treatment more accessible to patients. Additionally, obesity drug biotech startup OrsoBio has raised $60 million in a series A funding round to develop new therapies for obesity and related metabolic disorders.In another news update, Anne Wojcicki, CEO of 23andMe, discusses the company's transition into a "full-fledged biotech" in an in-depth interview. Wojcicki explains how 23andMe is venturing into drug research and development, going beyond its initial focus on at-home genetics testing. Ventyx, a biotech company, has revised its plans for its tyk2 drug after lackluster study data, and Bristol Myers is paying $100 million for access to a blood and bone marrow cancer drug developed by Orum Therapeutics.Shifting gears, the Biden administration is proposing a rule to cap broker payment in Medicare Advantage (MA) plans in Massachusetts to prevent marketing misconduct. Kaiser Permanente reported a rebound in investment and operating income in Q3, Envision Healthcare has emerged from bankruptcy restructuring, and Surescripts has acquired drug alternatives company ActiveRadar.Hospitals are also facing challenges in preparing for extreme weather events caused by climate change. Financial and data challenges are making it difficult for hospitals to develop effective disaster planning strategies. In other news, Cigna is reportedly exploring the possibility of shedding its Medicare Advantage business, and there is an ongoing battle over drug prices between Secretaries Becerra and Azar. A new California law offers protection from steep ambulance bills.Moving on to the pharmaceutical industry, Novartis has signed a potential $1.3 billion deal with Chong Kun Dang Pharmaceutical for the global rights to develop an oral HDAC6 inhibitor. Ventyx Biosciences has decided to discontinue the development of its psoriasis candidate despite positive results in a phase II study. Vertex Pharmaceuticals reported third-quarter revenue of $2.48 billion, falling short of expectations. The Department of Health and Human Services is considering removing Johnson & Johnson's psoriasis treatment Stelara from Medicare drug price negotiations.Next, we have an article discussing Anne Wojcicki, CEO and founder of 23andMe, and her ambitions to disrupt the healthcare industry through genomics. Wojcicki's interest in healthcare began during her childhood, and she has positioned 23andMe as a leader in direct-to-consumer genetic testing and genetic data partnerships with pharmaceutical companies. The article highlights an in-depth interview with Wojcicki, wher

The Two-Midnight Rule was first announced 10 years ago, October 2013, by the Centers for Medicare & Medicaid Services (CMS). Even today, though, the Rule remains an ongoing source of confusion for physicians as well as revenue cycle and finance experts.However, it also will take on new importance, as CMS promises that Medicare Advantage (MA) plans will begin to follow the Rule in 2024.During the next live edition of the popular and long-running Internet broadcast Monitor Mondays, physician and attorney Dr. John K. Hall will summarize the current state of the Two-Midnight Rule and offer insights of its use into the next decade.Other broadcast segments will also include these instantly recognizable features:• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.• The Whistleblower Report: Famed whistleblower attorney Mary Inman, partner in the law offices of Constantine Cannon, will report on the latest news concerning whistleblowers.• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legislative Update: Matthew Albright, chief legislative affairs analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

Good morning from Pharma and Biotech daily: the podcast that gives you only what's important to hear in Pharma and Biotech world. In the fourth quarter of this year, the FDA is expected to make several important decisions. One of these decisions involves the potential approval of the first CRISPR medicine, which could have significant implications for gene therapy. Additionally, the FDA is considering clearances for companies such as Alnylam, Amgen, and Pfizer, which could lead to the approval of important new therapies.In a major acquisition move, Eli Lilly is set to enter the radiopharmaceutical drug field with a $1.4 billion acquisition of Point Biopharma. This deal will give Lilly access to a pipeline of experimental radioligand therapies and a valuable manufacturing plant. Speaking of leadership changes, Lilly has also announced that Mike Mason will be retiring as the head of its diabetes and obesity division, with Patrik Jonsson taking over.SAS, an analytics company, is encouraging the adoption of open-source technology in the life sciences industry. They emphasize the importance of maintaining security and compliance while utilizing open-source tools.AbbVie has acquired Mitokinin, a Parkinson's drug developer. This acquisition allows AbbVie to expand its portfolio in neurology.Moving on to other news, Amgen has completed its $28 billion acquisition of Horizon after facing challenges from the Federal Trade Commission. However, an FDA panel has found that the data for Amgen's lung cancer drug Lumakras is unreliable, which is a setback for the company. The National Institutes of Health (NIH) has funded research for three experimental drugs for amyotrophic lateral sclerosis (ALS) as part of the ACT for ALS program. Dana-Farber spinout Precede has emerged from stealth with $57 million in funding for its blood test technology.Aetna, the insurance company, may have received overpayments of $25.5 million in Medicare Advantage (MA) for 2015 and 2016. Novant Health has cut 160 jobs due to a challenging healthcare environment. A study published in JAMA Network Open found that physician burnout rates doubled between 2019 and 2021.GE Healthcare Imaging CEO, Jan Makela, discussed the collaboration between GE and Mayo Clinic to advance healthcare through technological innovation. The FDA has called for further tests on recalled devices from Philips due to inadequate testing. A retrospective study by Johnson & Johnson found that catheter ablation is more effective than antiarrhythmic drugs in reducing the risk of heart failure. Northwestern University researchers have found that generative AI models can match the accuracy and quality of radiologist reports.Amgen has successfully completed its acquisition of Horizon and plans to provide updated guidance during its third-quarter earnings call. Mirati Therapeutics is reportedly in acquisition discussions with Sanofi. The Oncologic Drugs Advisory Committee has voted against Amgen's request for full approval of its G12C KRAS inhibitor Lumakras. A study published in JAMA has found that GLP-1 agonists are associated with an increased risk of gastrointestinal adverse events when used for weight loss.In the gene therapy field, Kyowa Kirin is set to acquire Orchard, while uniQure has laid off staff and cut back on research to lower costs. Regeneron and Intellia have expanded their gene editing partnership to target neurological diseases. These developments highlight the ongoing advancements in biopharma and the potential for significant breakthroughs in medicine. Stay tuned for more updates on acquisitions, FDA decisions, cost-cutting measures, and partnerships in the gene therapy field.

The Centers for Medicare & Medicaid Services (CMS) is on record saying that Medicare Advantage (MA) payers must follow the Two-Midnight Rule as of Jan. 1, 2024. Yet, it has been reported by multiple hospitals that their MA plans have said their lawyers tell them that they do not have to follow the CMS directions on the Rule relative to inpatient status, claiming their contracts govern their relationships and coverage issues with hospitals.During the next live edition of Monitor Mondays, Dennis Jones, senior director of revenue cycle (a single business office) for Jefferson Health, will report on the arguments that seem to be iginiting a firestorm on the Internet.Broadcast segments will include these instantly recognizable features:• Monday Rounds: Dr. Ronald Hirsch, vice president of R1 RCM, will make his Monday Rounds.• The RAC Report: Healthcare attorney Knicole Emanuel will report the latest news about auditors.• Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Byron, will join the broadcast with his trademark segment.• Legislative Update: Cate Brantley, state legislative analyst for Zelis, will report on the latest legislative actions impacting the healthcare regulatory setting.

Good morning from Pharma and Biotech daily: the podcast that gives you only what's important to hear in Pharma e Biotech world. In recent biopharma news, Bavarian Nordic, a Dutch biotech company, has faced setbacks in its late-stage trials for respiratory syncytial virus (RSV) and COVID-19 vaccines. However, the company's CEO, Paul Chaplin, remains optimistic about the potential of the company in the travel vaccine market. Another development is that Eisai's Alzheimer's drug Leqembi has received approval in Japan and is still undergoing regulatory reviews in other countries. Intercept, a liver drug company, has agreed to a buyout by Alfasigma after failing to secure FDA approval for its research on nonalcoholic steatohepatitis (NASH). Bristol Myers' Opdivo has won a trial supporting its expanded use in lung cancer treatment, and new vaccines for respiratory syncytial virus (RSV) have the potential to be powerful tools, although their rollout poses challenges. In a merger deal worth $3 billion, HealthComp, a private equity-owned health benefits administrator, is set to merge with Virgin Pulse, a digital health and wellness company. The transaction aims to create an integrated platform for employer-sponsored health benefits, with investment firms joining forces for the merger. On the other hand, health insurer Centene is laying off 3% of its workforce due to challenges from Medicaid redeterminations and Medicare Advantage (MA) star ratings. Cano Health has sold its Texas and Nevada centers to a subsidiary of Humana for $67 million due to its worsening liquidity position. Lawmakers in Ohio have proposed minimum nurse-to-patient ratios to address nurse recruitment and retention and improve patient care. Nuance Communications has rolled out an automated clinical documentation tool called DAX Copilot, improving efficiency for healthcare providers.Roche has struck a deal to acquire preclinical RNA medicines from Ionis Pharmaceuticals, focusing on treatments for Alzheimer's and Huntington's diseases. Despite recent setbacks in phase 3 trials for respiratory syncytial virus (RSV) and COVID-19 vaccines, Bavarian Nordic CEO Paul Chaplin remains optimistic about the company's future in the travel vaccine market. ProQR's planned sale of eye drugs to Laboratoires Thea has fallen through due to certain ProQR personnel opting not to work for the French company. John Tsai has been appointed as CEO of UK heart drug startup Forcefield Therapeutics. The FDA staff have expressed "major concerns" with Brainstorm's ALS therapy. Obesity drugs like Ozempic and Wegovy could revolutionize the treatment of obesity and advance the understanding of the condition.Gilead Sciences has announced the discontinuation of a Phase III trial for its anti-CD47 antibody, magrolimab, in acute myeloid leukemia (AML). AbbVie has terminated its contract with Caribou Biosciences for the development of allogeneic CAR-T therapies. Astrazeneca and Bristol Myers Squibb have agreed to participate in the first round of price negotiations under the Medicare drug price negotiation program, despite filing lawsuits challenging the program. Italian pharma company Alfasigma has acquired Intercept Pharmaceuticals in an $800 million cash deal. Alto has reported positive Phase II data for post-traumatic stress disorder. Astellas has withdrawn its lawsuit challenging the inflation reduction act.BioNTech has announced plans to manufacture mRNA vaccines in Africa to address the vulnerability of relying on global supply chains for vaccine production. Proper chemical procurement is emphasized to avoid disruptions in the chemical supply chain for research and development (R&D) and drug manufacturing. AbbVie has terminated its contract with Caribou Biosciences as part of its strategy to cull cancer pipelines. AstraZeneca and Bristol Myers Squibb have reluctantly agreed to participate in the Medicare drug price negotiation program. Immunovant's stock has soared following positive Phase

Good morning from Pharma and Biotech daily: the podcast that gives you only what's important to hear in Pharma and Biotech world.According to predictions from Evaluate Pharma, the outlook for big pharma's top companies is expected to shift in 2028. Roche, Merck & Co., and AbbVie are predicted to be at the top based on annual worldwide sales, while Pfizer and Johnson & Johnson are expected to drop down a few notches. Eli Lilly and Novo Nordisk are projected to enter the top 10 with their diabetes and weight loss earnings, pushing Bristol Myers Squibb and GSK out of the ranking. However, accurately predicting the successes and failures in the pharmaceutical industry is challenging.Moderna's recent five-year plan, which involves multiple launches and clinical programs for a company with only one product on the market, is explored as an example of a bold vision among pharma giants. The article also mentions that the market for cell and gene therapies is expected to grow from $9 billion in 2023 to over $42 billion by 2030.Novartis has decided to halt work on a gene therapy treatment for geographic atrophy following a review by a trial monitoring committee which concluded that the data did not support further development. The decision comes after Novartis acquired the therapy through its deal with Gyroscope Therapeutics. Meanwhile, Moderna has announced an ambitious drug development plan, stating that it expects to launch up to 15 new products in the next five years. This goal will require significant success in research and development efforts.Otsuka has partnered with Shape in a deal to design eye gene therapies using machine learning and high throughput screening. The partnership aims to identify new AAV capsids for gene therapies. Additionally, AstraZeneca's Alexion unit is partnering with genomics biotech Verge Genomics to gain access to its AI technology and platform. These partnerships and developments highlight the continued advancement and interest in gene therapy research and development.GoodRx has partnered with pharmacy benefit manager (PBM) MedImpact to increase access to its drug discount coupons. This is GoodRx's third partnership with a PBM. The collaboration aims to provide more affordable prescription medications to patients.A report from the Blue Cross Blue Shield Association (BCBSA) found a wide variety in medical costs depending on the site of care. The data supports site-neutral proposals that aim to make healthcare costs the same regardless of where they are provided. However, these proposals face opposition from hospitals.A majority of ground ambulance rides in 2022 were out-of-network, according to a report. Patients often have little choice in selecting an ambulance provider, and federal law does not protect them from surprise bills from these rides.Labor pressures for nonprofits in the healthcare sector are showing signs of easing. Job openings, employee departures, and wage growth have declined as health systems continue to add workers to their payroll.CVS CEO Karen Lynch expressed optimism that payers will improve Medicare Advantage (MA) star ratings. She also questioned the $500 million in savings that Blue Shield of California expects from ending its partnership with CVS' pharmacy benefit manager.The text discusses two main topics. The first is the potential scaled-back production of COVID-19 booster shots due to low demand. Last year, only 17% of the US population received the booster compared to 50% who received the initial jab, leading to declining sales for vaccine producers Moderna and Pfizer. If this trend continues, investment and manufacturing strategies may need to change.The second topic focuses on a marketing campaign by a large pharmaceutical company, Sanofi, to raise awareness about flu vaccinations, particularly among older and marginalized groups. The campaign features rapper and actor Ice-T in a spooky ad campaign highlighting the complications of the flu for these

Good morning from Pharma and Biotech Daily, the podcast that gives you only what's important to hear in the Pharma and Biotech world. AstraZeneca has partnered with genomics biotech company Verge Genomics to gain access to its platform, which uses human tissue data to identify drug targets for nerve system diseases. This collaboration aims to help AstraZeneca's Alexion unit find new drug targets as it expands its pipeline. Advocates are pushing for increased funding for research into antimicrobial resistance, arguing that the proposed $6 billion in funding under the Pasteur Act is insufficient. They believe more needs to be done to combat antibiotic-resistant infections and develop better antibiotics.Roche's under-the-skin version of cancer immunotherapy drug Tecentriq has faced manufacturing delays in the US. The company will not be able to launch the subcutaneous formulation until 2024 as it works with the FDA on manufacturing updates.Otsuka has formed a partnership with Shape Therapeutics to develop gene therapies for eye diseases. Shape Therapeutics will use its machine learning and high throughput screening technologies to identify new adeno-associated virus capsids for gene therapies.Seagen has teamed up with Nurix to develop a new type of cancer drug. This alliance aims to combine Seagen's antibody expertise with Nurix's targeted protein degradation research. This partnership comes as Seagen awaits regulatory approval for its acquisition by Pfizer.CVS has announced a major corporate restructuring, appointing its CFO, Shawn Guertin, as the head of its suite of care delivery businesses. This move comes as CVS experiences declining profits.Medical credit cards are under scrutiny for exploiting loopholes in healthcare debt protection. These cards, often offered in hospitals and physician offices, can be deceptive and lead patients into significant medical debt.A report from the Kaiser Family Foundation (KFF) found that Medicare Advantage (MA) enrollment in rural areas has nearly quadrupled since 2010. However, these plans often have limited provider networks, posing challenges for beneficiaries who already have to travel long distances for care.Sanford Health, a nonprofit health system, has announced a shake-up in its C-suite. CEO Bill Gassen stated that the addition of new voices on the executive team will help the organization remain agile in the future.Walgreens has agreed to pay $44 million to settle claims over fraudulent blood tests conducted by Theranos. If approved by a judge, patients who purchased the tests will receive double the amount they paid plus additional compensation.Nationwide telehealth use remained steady in June, according to a report from Fair Health. Lawmakers have reintroduced legislation to make pandemic-era telehealth flexibilities permanent.The World Antimicrobial Resistance Congress celebrated a milestone in the fight against antibiotic-resistant infections with the FDA approval of Seres Therapeutics' microbiota-based therapy called VOWST for the prevention of recurrent Clostridium difficile. However, efforts to combat other antibiotic-resistant infections and provide sufficient funding through the Pasteur Act face challenges.Lundbeck CEO Dr. Deborah Dunsire shares insights on her recent wins and her favorite rule to break in a 5-minute interview. Gene therapy research is expected to revolutionize biopharma, with over 25 cell and gene therapy products already approved by the FDA.A poll asks whether the pharma industry's reputation is improving, with options for yes, no, and maybe. Last week's poll revealed that 60% of voters believe the drug pricing provisions in the Infrastructure Investment and Jobs Act will harm pharmaceutical R&D investments, while 30% disagreed and 10% were unsure.That's all for today's episode of Pharma and Biotech Daily. Stay tuned for more important news in the world of Pharma and Biotech.

Good morning from Pharma and Biotech Daily: the podcast that gives you only what's important to hear in the Pharma and Biotech world. In today's episode, we'll be discussing the importance of crystallization process development in drug development and manufacturing. Crystallization plays a crucial role in ensuring the quality and effectiveness of a final drug product. It helps control the physical form of a compound, which is directly linked to its biological activity. Drug manufacturers must demonstrate that they understand and can control the physical properties and chemical purity of a drug substance.Cambrex, a pharmaceutical services company, specializes in bridging the gap between bench-scale development and manufacturing. They provide controlled crystallization processes to help their clients achieve clinical delivery timelines. By leveraging their expertise, Cambrex assists clients in developing robust crystallization processes that meet regulatory requirements and ensure the quality of the drug product.Healthcare insurer Humana has filed a lawsuit against the US Department of Health and Human Services (HHS) over Medicare Advantage (MA) audits. Humana relies heavily on revenue from Medicare and is challenging a rule implemented earlier this year that aims to recover overpayments in the MA program. The rule allows the HHS to retroactively audit MA organizations and recoup any overpayments made.Moving on, Beam Therapeutics has begun testing its first-of-its-kind cancer drug that utilizes base editing technology. This marks progress for the company after facing trial delays, and it is the first time in the US that a patient has received a base editing treatment.In other news, Jacob Thaysen, a former executive at Agilent Technologies, has been appointed as the new CEO of Illumina, replacing Francis deSouza who stepped down in June following a proxy fight with activist investor Carl Icahn. Thaysen's experience in the life sciences industry, particularly in the diagnostics sector, makes him well-suited to lead Illumina during this critical time.Roche has recently experienced success in the field of oncology with the approval of the subcutaneous administration of its cancer drug Tecentriq in the UK. This approval gives Roche an advantage over its competitors in the race to bring subcutaneous versions of their drugs to market. Roche also had positive news with its ALK inhibitor Alecensa, which showed promising results in reducing disease recurrence in patients with early-stage non-small cell lung cancer.Lastly, the text discusses how new technology trends, such as AI, virtual reality, and robotics, have the potential to address long-standing challenges in the healthcare industry. Hospitals, payers, and other healthcare companies are using these tech trends to navigate workforce shortages, economic pressures, and consumer demands.And that's it for today's episode. Stay tuned for more updates in the Pharma and Biotech world.

Introduction of the guest Matt Gibson from 90 Days from Retirement, a platform educating about insurance post-retirement. Discussion about the prevalence of insurance agents buying leads of people turning 65 and how 90 Days from Retirement differs by providing education instead. People turning 65 often receive unsolicited mail and phone calls offering help with Medicare, which can be overwhelming. Explanation that data about people turning 65 is publicly available, and some businesses generate leads by buying and selling this data. Mention of the lack of enforcement of rules against unsolicited phone calls to sell certain Medicare products. Brief explanation of the main products sold by Matt's agency, including Medicare supplement plans also known as Medigap plans. Medicare and Medigap: Medigap plans supplement Medicare by covering deductibles and co-insurance that Medicare doesn't cover. This is one path individuals can take when they start Medicare. Medicare Advantage (Part C): Contrary to Medigap, Medicare Advantage acts as a replacement policy for Medicare. When someone signs up for a Medicare Advantage plan, their Medicare parts A and B are essentially turned off and the responsibility for payment and administration is transferred to the insurer. In exchange, Medicare pays the insurer a monthly fee. Medicare Advantage Plan Payment: Most Advantage plans have zero monthly premium for the individual because the insurer receives payment from Medicare, which can be a substantial sum. Becoming a Medicare Broker: To become a broker, one must be health insurance licensed, contract with specific insurance companies, and pass carrier-specific training and certification. The process can be time-consuming and complex. Commission Structure: Brokers must contract with insurance companies to earn commission. The commission rates are standardized and set by CMS. They do not directly negotiate these commissions but rather work under the structures set by larger field marketing operations (FMOs). Medicare Advantage (MA) plans and Part D drug plans are highly regulated, and insurance carriers cannot incentivize brokers to sell more products through bonuses or rewards. When a broker facilitates the signup of a client for an MA plan, their name and broker ID number are included in the application (paper or electronic), enabling the insurance carrier to attribute the commission. Brokers must be certified and part of the network of the plan they are selling. They can't start selling a plan for which they haven't taken certification. The availability of MA plans varies by zip code, influenced by factors such as population and medical resources. Brokers are licensed by state and may not have access to marketing materials or sell plans in states where they are not licensed. If a broker is certified with a limited number of MA plans available in a client's region, they are expected to inform the client about the existence of other plans, even if they don't earn a commission on them. Brokers often have to narrow down the choice of plans based on the client's needs, including preferred doctors, medications, and hospital networks. All telephonic or online consultations have to be recorded, and brokers are required to inform clients that they might not be licensed with every product in the area, even if they are. There were approximately 60,000 complaints to Medicare from call centers in the previous year, likely because brokers were not fully representing all available products in their market. Brokers use tools to compare the cost of medications across carriers and to search for doctors within each carrier's network. However, some carriers choose not to participate with certain tools, requiring brokers to go directly to the carrier's website. The discussion involves health insurance, Medicare Advantage (MA) plans, and how insurance agents/brokers operate. The speaker mentions a preference for checking a carrier's site when looking for doctors or dentists. Agents often receive an upfront commission when clients sign up, followed by smaller, ongoing commissions for renewals. After signing clients, the speaker's office offers full service, assisting with claims, billing, and more. They provide quarterly newsletters and communicate regularly, especially during annual election periods. If a client's MA plan is changing significantly, the agent may recommend exploring other options. However, if the plan remains largely the same, clients are advised to continue with it. Not many clients switch from one MA plan to another, or from MA to original Medicare, or vice versa. Changes typically occur due to network alterations, alteration in benefits, or advertisements. Switching from an MA plan to a supplement plan is not always easy and may involve health questions and underwriting. Outside of specific open enrollment windows, clients cannot switch. Churn within the MA system does occur, though it doesn't benefit the speaker's agency financially to regularly switch clients' plans. Other agents, however, may benefit from such churn. There is no cost to the consumer to work with an agent. Agents are also not allowed to buy meals or gifts for potential clients, though smaller items such as coffee or appetizers are permitted. There is no underwriting process for MA plans. Once you have Medicare and live within the service area, you are eligible. For more information or assistance, the speaker invites people to visit their website, 90daysfromretirement.com.

Physicians and other senior-serving professionals trying to operate within the complicated Medicare ecosystem must be constantly learning, as the landscape, rules, tools, and vendors are in constant flux. We interview eldercare and Medicare industry experts, do deep dives into their companies, services, and experiences, and share their stories and insights with you. - The Mastering Medicare Podcast is back from a long hiatus caused by both hosts taking W2 jobs during the COVID-19 pandemic. - During their time away, they learned a lot about the changing landscape of Medicare, especially with the rise of AI and value-based care models. - Value-based care was a particular focus in the discussion, with Dr. Mohseni sharing his experiences working at Optum and learning about the value-based care model, particularly within Medicare Advantage. - Value-based care is touted as the future care model for the US healthcare system. It aligns incentives for patients, providers, and health plans, reducing waste and delivering more effective care at lower costs. - The co-hosts contrasted value-based care with the fee-for-service model, pointing out that value-based care requires all parties to be financially invested in patient outcomes, incentivizing efficiency and effectiveness in care. - They also highlighted the importance of collaboration and communication in value-based care, contrasting it with the disjointed nature of fee-for-service care, where different health providers often work in silos. - An example of effective communication was shared from Dr. Mohseni's time at Optum, where real-time notifications were used to coordinate care for patients who arrived at the emergency department, leading to better outcomes for the patients and more efficient care delivery. - The speaker expresses curiosity about why the value-based healthcare system isn't prevalent, considering its beneficial aspects, such as better access to specialists and greater collaboration between healthcare providers. - Questions are raised regarding the incentives for primary care doctors to transition from the regular fee-for-service model to a more complex value-based model, with no clear motivation at the moment. - The discussion mentions gradual efforts by Medicare and CMS (Centers for Medicare and Medicaid Services) to encourage a move towards value-based healthcare, through strategies such as upside gain, share upside models, and ACOs (Accountable Care Organizations). - The Medicare Advantage (MA) model, which has been fully at risk for some time, is described as an effective example of a value-based system. - The complexity of intermediary programs in the fee-for-service model is noted, as many providers either can't understand the rules or choose not to participate due to the complexity. - The speaker then elaborates on the workings of MA plans, wherein health plans are paid by the federal government per member per month to take full global risk on a patient for all of their professional medical expenses. - These MA plans then delegate this risk to a selected medical group, which then uses the allocated funds to manage the patient's healthcare. The remaining difference between the allocated funds and actual healthcare costs becomes the medical group's profit. - This model incentivizes medical groups to keep patients healthy and manage their costs efficiently. - The allocation of funds enables medical groups to acquire services like dieticians or care managers, which are often missing in the traditional fee-for-service model. This allows for a more holistic, patient-centered approach to healthcare. - The conversation discusses a situation where a patient contacts their doctor's office after hours, and rather than being directed to the emergency room, the doctor is willing to solve the issue over the phone. This is because the doctor is being compensated monthly, rather than by individual visits or treatments. - It is stated that any company can start a Medicare Advantage (MA) plan and people can sign up for it. However, these companies often contract with groups like Optum to handle the provision of care. This is paid for by a fraction of the funding that Medicare provides to the MA plan. - Doctors are incentivized to provide extra value in their services and keep costs low because they receive a chunk of money to provide the necessary services, and they keep the difference of what they don't spend. - In the case of a patient with more serious health conditions, a system of risk adjustment is in place. This means that doctors annually document the patient's conditions, which contributes to their Health Condition Category (HCC) score. The higher the score, the more funding the medical group receives. - The conversation suggests that the Medicare Advantage world has been increasingly focused on risk adjustment, given its substantial impact on revenue. However, this has raised concerns about gaming the system and potential fraud. - In the future, it is suggested that there will be a greater focus on better patient outcomes and coordination to maintain profit margins, rather than on risk adjustment. This is expected to spur innovation and the creation of improved solutions for patients. - The conversation discusses the idea of reducing healthcare utilization with a focus on reducing Emergency Department (ED) visits and hospitalizations. - The speakers note that much of the current thinking centers on reducing the need for hospital care through better patient services, new tech, and addressing social determinants of health. - Two additional areas of potential reduction in healthcare spending are identified: pharmacy (particularly unnecessary use of expensive brand name drugs when generics would suffice) and unnecessary surgeries or inefficient surgical procedures. - The speakers emphasize that a lot of care currently delivered in hospitals could be effectively and more cost-efficiently delivered at home. - The conversation then transitions to discussing how the home-based care trend can connect with value-based systems and the opportunities for innovation this brings. There's a focus on how different players in the healthcare system (from family caregivers to healthcare professionals to tech innovators) can collaborate to improve patient care. - They mention the establishment of Medicare Advantage (MA) programs, where healthcare groups receive a capitated payment from Medicare based on a patient's Health Condition Categories (HCC) score. - The speakers then introduce a new initiative, AgingHere.com, a newsletter focused on facilitating a community around aging in place and home-based care. They invite ideas and stories from their audience to share in this platform.

In this episode, we dive deep into the world of healthcare to explore the transformative power of value-based care. We are thrilled to have Nicole Bradberry, a renowned healthcare expert and thought leader, as our guest. Nicole will share her invaluable insights into how Medicare Advantage (MA) evolved with the introduction of the Centers for Medicare & Medicaid Services (CMS), and the key differences between MA and Accountable Care Organizations (ACOs).In this episode, we discuss the origins of Medicare Advantage plans, how they have shaped the healthcare landscape, and their ongoing impact on patient care. Nicole also shares proven strategies to increase patient engagement rates and offers practical tips on how doctors can embrace value-based care.Whether you're a healthcare professional, policy enthusiast, or simply interested in understanding the future of healthcare, this video offers an informative and engaging look at the genesis of value-based care and its potential to revolutionize the industry. Don't forget to like, comment, and subscribe for more enlightening content!AboutNicole Bradberry is a highly accomplished healthcare executive with a proven track record of success in leading and transforming healthcare organizations. As a strategic visionary with over 20 years of experience, Nicole has garnered a reputation for her expertise in value-based care, population health management, and health information technology.Nicole holds a Bachelor of Science in Industrial Engineering from the University of Florida and an MBA from the University of North Florida. She began her career as a consultant with Accenture, where she honed her skills in the healthcare sector. Since then, Nicole has held several key leadership positions, including serving as the CEO of the Florida Association of ACOs, where she significantly impacted the development and implementation of accountable care organizations in the state.Nicole's commitment to value-based care and patient-centric healthcare has earned her numerous accolades and recognition as a thought leader in the industry. As a speaker and advocate for healthcare transformation, she is passionate about sharing her knowledge and experience to inspire others and drive meaningful change in the healthcare system.Learn more about Nicole Bradberry LinkedIn: https://www.linkedin.com/in/bradberry/Learn more about Previva Health Group:LinkedIn: https://www.linkedin.com/company/previva-health-group/Website: https://previva.com/

I hope you listened to episode 399, which was Part 1 of this two-part exploration of my manifesto, meaning my aims and my path or framework to achieve those aims. Regarding the first part of my manifesto, episode 399 from two weeks ago, here's the tl;dl (too long, didn't listen) version; but please go back and listen to that show (Part 1) because it's about you—and it's a compliment and a thank you, and you deserve both. Just to quickly recap, Part 1 of my manifesto is that I started this show because I want to, and wanted to, provide information to those in the healthcare industry trying to do the right thing by patients, to get you the insights that you might need to pull that off, to create a Coalition of the Willing, as I've heard it called. When we get reviews like the one from Megan Aldridge, a self-proclaimed Relentless Health Value binge listener, I feel very gratified because it makes me feel like I'm chipping away at this mission and in a non-boring way. Thank you, Megan. Along these lines, there was also a recent review from Mallory Sonagere, who says she listens to learn new things and to be a little sharper at how she approaches her day job. And just one more I'll mention: I loved the review from Mark Nixon calling Relentless Health Value the best healthcare podcast out there. Every review like this I take as validation that maybe I can count some measure of success toward achieving the mission to empower others on their journeys to make it better for patients or to transform the healthcare industry. But this whole endeavor to create a manifesto is also borne out of me struggling personally to figure out what “having personal integrity” in this business actually means when it comes to deciding what to do and what not to do, when it comes to deciding who or what to try to help or support or who or what to step away from either passively or actively. I mean, how this podcast gets funded is my business partner and I pay for it with money from our consulting business and from some tech products that we have on offer. Who do we choose to take on as clients, and what are we willing to do for them or help them with? These are questions that literally keep me up at night. And this is what this episode, Part 2, is all about. It's about my struggle and how I attempt to navigate my own path forward. And holy shnikeys, it's tough to find a path, especially when you have the sort of perspective that I've wound up with over these past however many years. It can feel like no matter what I do, there's negatives as it relates to the Quadruple Aim. You raise one of the quadrants, and something else for somebody else certainly has the potential to be negatively impacted. We cannot forget here in the short term, but, for sure, often in the longer term as well, it's a zero-sum game. Every dollar someone takes in profit under the banner of improving health or even saving money is a dollar that someone else paid for. Is the amount of profit fair? Where'd that money come from? Is there COI (conflict of interest), and if so, what's the impact? I think hard about things like this. An inescapable fact is that there has been a financialization of the healthcare industry, and that includes everybody who also gets sucked into the healthcare industry whether they want to be or not (ie, patients/members and plan sponsors and, oftentimes, physicians and other clinicians, too). But the financialization of healthcare means that most everybody at the healthcare industry party has a self-interest to either make money or save money. And sometimes the saving money means saving money for themselves, not necessarily anything that is ever gonna accrue to patients or members. Now let's say I'm trying to determine if I want to take on a new client or decide if I personally want to promote or do something or other. This self-interest that abounds all around matters here because it means it is often very tough to find some kind of “pure” initiative to hitch your wagon to. The crushing reality that we all face is you gotta earn a living. The other reality is that often the person that benefits from the thing you want to do (ie, the patient) is not gonna pay for it. And frequently, physician organizations won't either. If everybody was lining up to pay to get something fixed, the problem would not be a problem, after all. But the only way your moral compass is the only moral compass in play is if you're doing whatever you're doing for free, really, or by yourself—and thus you are not encumbered by anybody else or any self-interest beyond your own … and your own motives are the only motives that you can control. I hear all the time initiatives and coalitions and advocacy organizations and even research funded by grants … these things also get bashed as suspect because who'd that money come from and whose “side” are the funders on. Nikhil Krishnan wrote on LinkedIn the other day (and I'm gonna do a little bit of editing, but yeah). He wrote: “Patients have low trust in healthcare because they think every stakeholder is incentivized not in their best interest. Many patients think the hospitals want to keep them sick, the [carriers and plan sponsors] don't want to pay their claims, the drug companies want to keep them on their meds, etc. And we can't pretend like that … isn't true.” Every party, every stakeholder has some measure of self-interest. They have to; otherwise, they'd be out of business. It's all a matter of degrees. No big group, no entire category gets to stand on the high ground here when you think like a patient. There's great hospitals and great people who work at hospitals, and then there's people doing things that cause a strikingly large percentage of patients to fear going to the hospital for clinical and/or financial reasons. Pick any other stakeholder and I'd tell you the same thing. Any other stakeholder. It's basically up to us as individuals to do the right thing. In every sector of the healthcare industry, there's good eggs and there's bad eggs and there's eggs in the middle just doing their day jobs as instructed. Personally, I want to be a good egg, and that's what my manifesto is all about. Let me dig into this a bit further for just a sec and then I'll continue with my personal manifesto for how I find my own path of integrity through all of this confusion. Here's another anecdote. Stuff like this I make myself crazy thinking about: I was listening to a podcast, and one of the guests said, “I wanted to get my MPH [Master of Public Health] because I felt a personal calling to be altruistic.” Then, 120 seconds later, he says something like, “So then, when it came time to pick my internship, I hunted around to find the one that paid the most money—and that's how I wound up working for an HMO in the '90s.” Consider how that strikes you. How do you feel about that guy right now, who, by the way, has gone on to support some very interesting and probably impactful initiatives? There's this commonly used phrase, “Let's do well by doing good.” So, back to that HMO intern. Let's just say we all agree that these HMOs were not unconflicted organizations. We all know they had a reputation for putting profits over members, and a reason they went out of business was because they denied care. They refused to pay claims for patients who had AIDS. And it turns out that the friends and families of people with AIDS are incredibly well organized and sued the crap out of the HMOs, which may have expedited their demise. You know what the intern was doing at the HMO? He was helping them with data analytics, and his personal goal was to use that data to improve patient outcomes. So, okay … here's the thought experiment: Do we want this HMO taking money that they're gonna take anyway and then not adding the value that they potentially could add with their data because they don't have any smart, dedicated, highly compensated interns working there to keep the ship pointed in a decent direction? I mean, I guess if I know I'm gonna spend a dollar as a member of that plan, I'd prefer to get as much as possible for my dollar that is already being spent. Maybe from that perspective, this guy is doing well by doing good. You see how this gets messy when you take a theoretical statement and then apply everyone's real-world prejudices and predilections to it. Here's a last point to ponder, and this is another thought experiment … so, just heads up and then I'll get to the point here: Say you are asked to help with a program run by a Medicare Advantage (MA) plan to provide those in need of transportation a ride to their annual wellness exam. Do you help? Those who listen to this show will fully understand there's a lot of self-interest involved in getting patients to the annual wellness exam because … risk adjustment. Also, star ratings. Listen to the show with Betsy Seals (EP375 and EP387) if you need the full story here. Short version is, MA plans can't upcode, either fairly or aggressively (if they are so inclined), if the patients don't show up for their annual physical. So, there's a lot of money for them at stake. But, then again, are physicals important for patients? Do they improve patient care and health? If we think yes, then again, is this doing well by doing good to help patients get to their appointments? After literally years of asking myself questions like this—and most of them were not thought experiments—I came up with my manifesto. And there are three parts to it, and I will go through each of them. But here's my manifesto in full: If the thing results in a net positive for patients, then I will do it. The timeframe is short-term or medium-term. And the assumption is that it will take a village and I am not alone in my efforts to transform healthcare or do right by patients. Here's how I think about the first part of my manifesto: If the thing results in a net positive for patients, then I'll do it. And keep in mind, I could talk about this for seven hours; so everything I'm saying is oversimplified to some degree and has as many nuances as there are stars in the sky. So, to calculate the net-positive impact, I think through what good the thing could do and weigh that against the negatives. And there are always negatives because, most of the time, the work that I do anyway has to get paid for by somebody and that somebody has some self-interest. Self-interest means that they are attaining something that furthers their business goals. Let me list two major upside/downside contemplations: 1. How much good does the thing actually do for patients? I think about this. What's the value here? Is it a little? Is it a lot? Will this thing be a distraction for clinicians, because time is often the most precious currency? If we're talking about some kind of navigation or utilization management, what's the reason someone wants to do this? Is the reason clinically and, for reals, evidence driven? Or are we predominantly doing this to enrich shareholders or save plan sponsors money in ways that are not a win-win for patients in the clinic right now trying to get cancer treatments for their kid? I try to think like a patient and be as impartial as possible. 2. Money. Where's the money for this thing coming from, and who wins in this particular initiative (ie, is it a win-win and patients win something worthwhile)? Now, the company doing the funding has got to win, too; otherwise, they wouldn't fund the thing. That's where it gets subjective, and, as aforementioned, do I care if the company in question wins if the patient wins, too? Or is this company so damn evil at its core that I am willing to sacrifice the opportunity to do a good thing for patients in order to not have anything to do with said possible funding entity. Or am I cutting off my nose to spite my face because this is a really important thing for patients and this particular company is the only one that's gonna fund it? Because tragedy of the commons or whatever else. Again, this gets dicey really fast. Let me poorly paraphrase a little exchange I saw on LinkedIn the other day that had me completely preoccupied during my work-from-home midday walk around the block for at least three days. Somebody wrote (maybe that Master of Public Health intern), “Given how intractable it feels to me to try to reduce healthcare spend, I think I'm going to try to help patients get more value out of the dollars that are currently being spent by them or on their behalf.” Do you think that's a worthy goal? Well, not everyone does. Somebody in T-minus 8 seconds responded, “That's a toxic way of thinking. Everyone who is not actively working to reduce healthcare spend by putting patients in cash-pay models is part of the problem.” This is a good segue into the second part of my manifesto. The first part is: If the thing results in a net positive for patients, then I'll do it. Here's the second part: The timeframe is short-term or medium-term. And here's what I mean by that. My main focus is helping patients right now. This is what this has to do with the aforementioned exchange on LinkedIn wherein someone was trying to figure out how to get more out of the dollars we're currently spending and someone else said that's toxic, because we should rip it all down and build a better model. There's incremental change, and then there's disruptive change. These two things are not mutually exclusive. Apparently, Mr. This Is Toxic doesn't agree with me, but as I said in the last episode, there's that Buckminster Fuller quote: “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” And sure, I like to aspire to that as much as the next person. But does aspiring to a big hairy goal mean completely forgoing any incremental ways that patients can be helped immediately, like right now? If you ask me—and you're listening to this, so you de facto asked me—incremental change will probably actually support and beget disruptive change. So, incremental versus disruption is not a battle royale. These things are not diametrically opposed. They're probably actually aligned. I could go on a tangent here to explain why, but I'm not going to … except to say tipping points. But forget about that for a sec. Here's the more basic question: If all parties are interested in transforming healthcare, legit, how does someone trying to do it incrementally, or improve value for patients right now, in any way negatively impact someone trying to be disruptive and/or trying to change financial models? Keep all this in mind and now let me get back to my manifesto. I'm worried about patients, and I'm worried about them largely right now, short term to medium term. So, if I have the opportunity to help a patient—and I think about my two grandmothers (God rest their souls) here, but both of them would have died in the healthcare system multiple times in avoidable ways had my family not been there advocating for them—if I have the opportunity to help a patient, I will do so as long as I believe that the impact is a net positive in the shorter term. Disruption is a longer-term operation. Some have said it's a generational change. When I see stuff like Toxicity Guy wrote on LinkedIn, I really try to understand what his point is, as I always try to understand what people's points are. Could he be arguing that no one should work to improve care right now or try to maximize what we get for the bucks that we've already been shelling out? And, if so, for what reason … so that what happens? So that resentment about poor-quality care builds up to a boiling point such that everybody shuns the status quo and moves to a new care model and financial models faster? Is that the aim of Toxicity Guy? To force a let-them-eat-cake moment for the purposes of triggering a faster revolution? I've probably thought about this guy's motives and his potential impact harder than he has. In my manifesto, in my worldview, I don't let grandmas suffer right now so that someone else has a better narrative, even if I am in full support of what that person is trying to do and the mission that they are on, which, by the way, is a longer-term one. This gets me to the third part of my manifesto: The assumption is that transforming the healthcare industry will take a village and I am not alone. When I state this outright, it's gonna seem self-evident; but sometimes it's hard to not push blame here like Toxicity Guy, so I say this sort of in his defense. Here's the point of contemplation: There's maybe four big parts of the healthcare industry at a minimum. We have those trying to fix SDoH (social determinants [or drivers] of health). We have those trying to fix medical morbidity (ie, are patients on evidence-based pathways and taking meds appropriately, limiting polypharmacy side effects/cascades). Once a patient is in the healthcare system, what happens then? Then we have those working hard to improve behavioral/mental health. And lastly, everything going on with what I'm gonna call FDoH (financial determinants of health)—patients making decisions or having decisions made for them due to financial implications for them or for somebody else. Lots of stuff rolls up under these categories, but even just listing out these four things, we got a hell of a lot of work to do to improve the lot of patients and taxpayers and make it easier to do business in this country. I always try to keep in mind that it will take a village. Just because someone is working on getting patients housing or eating better does not imply that they don't care about employers struggling to curb claims billing waste, fraud, and abuse—and vice versa. It's just not everybody can do everything. For me personally, I tend to focus my attention on helping as many patients as possible get on what would be for them the optimal treatment plan or best care pathway. That does not mean I'm anti-someone working on getting more competition in the payer space. Nor does it mean I'm against trying to curb the price of overpriced (as per ICER [Institute for Clinical and Economic Review]) pharmaceutical products or legislate to rein in hospitals doing stuff that, in my book, they should not be doing. I am all for getting all of these things done. I just do not have the bandwidth or the depth of expertise to do everything myself. I would suspect that no one does. As my grandma used to say (and anyone who attended a slumber party seance in eighth grade might know), many hands make light work. You get 15 girls each holding out but two fingers, and you can lift up your friend, no problem. When I keep in mind that it takes a village, it helps me curtail the tendency to become paralyzed in my quest to help patients because I can see a potential problem it might create somewhere else in the industry or somewhere else down the line. I have to trust that one of my fellow villagers is holding down that end of the fort. Here's a quote from J. Michael Connors, MD, that he wrote in his newsletter: “When you point one finger, three are pointing back at you … It's like everything you learned in kindergarten seems to be so applicable to our approach to healthcare. Sadly, the game of finger pointing and pushing blame on others is killing real innovation in healthcare.” This is so real, which is why inherent in my manifesto here is my efforts to remember we are all on the same team (all the good eggs, anyway). That it takes a village, that there will be some things that some people are doing that I maybe don't fully agree with. There might be groups who don't accomplish much. There are certain people doing well (ie, doing self-interested things) but, at the same time, creating a better place for patients. As long as, in general, we are all following the same North Star, we'll achieve much more spending our time focused on our own missions and not worrying about what other people are doing. And when I say “not worrying about what other people are doing,” I mean people in the “good egg” village. I do not mean I intend to stop calling out conflicted and net-negative self-interested behavior, because this is what some people in the village should hopefully have their eyes on and get busy working against. The village here, it's a Venn diagram. At the point where other people's circles intersect with my mission or what I think would be better for patients, these are the people I can work with and collaborate with. These are the people that I'd take their business or I'd try to help them if I can. My manifesto is to determine when something is a positive for patients and then to find others who will win as a result of that thing happening. Then I can study why this is a win for those others, which is always going to be some self-interested why. And then I can think through what the negatives are if their self-interest comes to fruition. Is it still a net positive? If yes, proceed. Look, this making it better for patients, this transforming healthcare, it is hard, dispiriting work. It's a long slog. I'd like to suggest we encourage each other. Can we be the wind beneath each other's wings when we find a kindred spirit? Can we focus on the points of intersection and spend our energy deepening what's going on there? So again, here's my manifesto: If the thing results in a net positive for patients, then I'll do it. The timeframe I'm concerned about … short-term, medium-term. The assumption is that it will take a village to transform healthcare and I am not alone. I feel kind of exhausted having finished that. But let me ask you this: What is your manifesto? If you have one or if you have thoughts on this, go to our Web site and click on the orange button to leave a voice message. My hope is to do an upcoming show sharing what you think.   For more information, go to aventriahealth.com.   Each week on Relentless Health Value, Stacey uses her voice and thought leadership to provide insights for healthcare industry decision makers trying to do the right thing. Each show features expert guests who break down the twists and tricks in the medical field to help improve outcomes and lower costs across the care continuum. Relentless Health Value is a top 100 podcast on iTunes in the medicine category and reaches tens of thousands of engaged listeners across the healthcare industry. In addition to hosting Relentless Health Value, Stacey is co-president of QC-Health, a benefit corporation finding cost-effective ways to improve the health of Americans. She is also co-president of Aventria Health Group, a consultancy working with clients who endeavor to form collaborations with payers, providers, Pharma, employer organizations, or patient advocacy groups.   03:16 “It's a zero-sum game.” 03:26 Is the amount of profit fair? 03:37 What is an inescapable fact of the healthcare industry? 03:54 What does the financialization of healthcare mean? 04:19 Why does the self-interest in healthcare matter? 06:18 “It's basically up to us as individuals to do the right thing.” 10:03 What is the first part of Stacey's manifesto? 10:18 How does Stacey calculate the net positive of an impact? 10:41 What are two major upsides/downsides that Stacey contemplates? 13:31 Why are incremental change and disruptive change not mutually exclusive? 17:40 “I always try to keep in mind that it will take a village.” 19:19 Why finger pointing is killing innovation in healthcare.   For more information, go to aventriahealth.com.   Our host, Stacey Richter, discusses our #healthcarepodcast and where she sees the path moving forward. #healthcare #podcast   Recent past interviews: Click a guest's name for their latest RHV episode! Dawn Cornelis (Encore! EP285), Stacey Richter (EP399), Dr Jacob Asher, Paul Holmes, Anna Hyde, Dea Belazi (Encore! EP293), Brennan Bilberry, Dr Vikas Saini and Judith Garber, David Muhlestein, Nikhil Krishnan (Encore! EP355)  

Are there significant risks of potential fraud and abuse with Medicare Advantage (MA) by plans, vendors, and providers, with an emphasis on ICD-10-CM's impact on Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) risk adjustment?Evidently, the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) believes there are. Recently, Christi A. Grimm, Inspector General, issued a statement in which she addressed the concerns of the federal watchdog agency.In response to her speech, we invited Dr. James Kennedy, a 20-year veteran in clinical documentation integrity (CDI) consulting and a popular panelist, to share succinct advice on how a compliance plan can best prepare for OIG audits that are sure to come.   Programming note: Invite your compliance teams to hear what promises to be the best four minutes applicable to this challenge, during the next live edition of Talk Ten Tuesdays.The live broadcast will also feature these other segments:Coding Report: Laurie Johnson, senior healthcare consultant with Revenue Cycle Solutions, LLC, will report on coding colorectal cancer.SDoH Report: Tiffany Ferguson, a subject-matter expert on the social determinants of health (SDoH), will report on the news that's happening at the intersection of coding and the SDoH.News Desk: Timothy Powell, CPA, will anchor the Talk Ten Tuesdays News Desk.TalkBack: Erica Remer, MD, founder and president of Erica Remer, MD, Inc. and Talk Ten Tuesdays co-host, will report on a subject that has caught her attention during her popular segment.

The U.S. Department of Justice (DOJ) reports that fraud against the U.S. under the federal False Claims Act (FCA) has amounted to $2.2 billion recovered in settlements and judgments for the 2022 fiscal year.   As in past years, FCA recoveries in the healthcare and life sciences industries continued to dominate enforcement activity in terms of the number and value of settlements, with healthcare fraud cases comprising 80 percent of total recoveries. These involved a wide range of issues, including Medicaid fraud, unnecessary and substandard care, kickbacks, and Medicare Advantage (MA) fraud. During the next edition of the weekly Internet radio broadcast, whistleblower attorney and Monitor Mondays regular contributor and panelist Mary Inman will report on healthcare enforcement trends from 2022, including a record-breaking $266.4 million reward to the whistleblower who reached a $900 million settlement with Biogen for kickback allegations, 10 years after filing his qui tam case.     Broadcast segments will also include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds.The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Nelson Mullins, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.Legislative Update: Adam Brenman, a legislative analyst for Zelis, will report on current healthcare legislation.The Wrapper: John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning's top stories.

Medicare Advantage (MA) is a public-private hybrid health plan that allows eligible seniors to receive health insurance through a commercial insurer. It has a high satisfaction rate among enrollees and is projected to crest fifty percent of all Medicare enrollment this year. In part two of Radio Advisory's senior care series, Host Rachel (Rae) Woods talks with senior care expert Aaron Hill and health plan expert Max Hakanson about why Medicare Advantage is so popular, its impact on industry stakeholders, and why MA will likely be subjected to more oversight and regulatory scrutiny in the near future. The podcast team wants to know how we can make the podcast better for you. So, we created a quick listener survey at advisory.com/podsurvey. Please take it and let us know what you want to hear on Radio Advisory. Thanks for listening. Links: Health insurance 101: Medicare Advantage Achieving sustainable growth in Medicare Advantage Special Needs Plans (SNPs) 9 data-driven insights on senior preferences when selecting a Medicare Advantage plan What seniors want when shopping for Medicare Advantage supplemental benefits Ep. 149: Senior Care (Part 1): Specialized primary care for an aging population Ep. 109: Senior care: Why the next 10 years are critical Learn how healthcare competition is transforming (www.advisory.com/healthcarecompetition)

No more eggnog. Toss the champagne bottles. The good times are over, and now it's back to business. But not business as usual.As the rest of the nation's healthcare professionals clocked in for overtime, claims auditors were scrutinizing medical records, looking for the slightest inconsistency upon which to pounce. Now, nearly four weeks since its last news broadcast, Monitor Mondays will return this coming Monday with a cadre of the smartest minds in healthcare auditing. You'll hear auditing news you won't find anywhere else – except here and in RACmonitor.Broadcast segments will include these instantly recognizable features:Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds, during which he will report an exclusive auditing story in which he details news about a move by the Centers for Medicare & Medicaid Services (CMS) to clamp down on Medicare Advantage (MA).The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.SDoH Report: Tiffany Ferguson, a subject-matter expert on the social determinants of health (SDoH), will report on the news that's happening at the intersection of healthcare regulations and the SDoH.Legislative Update: Cate Brantley, a federal legislative analyst for Zelis, will report on current healthcare legislation.Docs and Regs: Monitor Mondays' own physician and attorney, Dr. John K. Hall, will report on how revisions to water down the Medicare Program Integrity Manual tend to increase liability for providers.Tip Sheet: RACmonitor investigative reporter Edward M. Roche will have another jaw-dropping story about audits, auditing, and a dismal outlook for 2023.Live Stream Chatting: Dr.John Zelem, founder and CEO of Streamline Consulting Solutions, will join the broadcast for a wrap-up on the morning's top stories.

In this episode:  What is Medicare Advantage (MA)? We examine the roots of this supplementary private health insurance coverage for seniors and its explosive growth, which now includes almost half of all Medicare beneficiaries (more than 28 million people).  There are increasing cases of abuse by insurance companies in charge of MA plans. Reports show they are denying and delaying doctor's requests for necessary – and in some cases lifesaving - care. We discuss how this harms patients and burdens the hospitals caring for them.  We dive into how COVID-19 compounded the issues with MA as insurers continued adding barriers to care for seniors during surges.  How can we address MA issues? We highlight bipartisan efforts in Congress to fix the problem, like the Improving Senior's Timely Access to care Act.  Important to note - not long after our recording - CMS released two separate proposed regulations that address some aspects of prior authorization in Medicare Advantage, as well as Medicaid and ACA private plans. The two rules address some of the challenges highlighted in this podcast and the proposals may help to ameliorate certain of the abuses directly affecting patients that you will hear outlined. The proposed regulations are open for public comment.     Guest: Sunitha Reddy, MBA, MPH, FACHE Chief Revenue Officer & Vice President, Operations, Prime Healthcare   Medicare Advantage (MA) is on a growth path to become the dominant part of Medicare in many states across the country. This means that many of our most vulnerable seniors will, on one hand, receive the added benefits and discounts that these plans offer up front, but may find pathways to receive care more difficult than they bargain for – as insurance companies delay or even deny necessary care. Chip speaks to Sunitha Reddy about how this can be more than an inconvenience for patients – it can be harmful. 

Josh and Brian are joined by Mike Stanzione, Aledade's Director of Medicare Advantage Network Performance, to discuss the state of Medicare Advantage (MA), its rapid growth, regulatory evolution, and how the Aledade model of care applies to MA.

Here's a big thing that Betsy Seals makes clear in this show: Big companies can be successful in Medicare Advantage (MA)—and I mean success in all of its financial glory—because they have experience and the scale and also the specialized departments who keep track of all kinds of intricacies that are rate critical to MA success. Specifically, things Betsy Seals talks about as critical success factors, for example, are having relationships with brokers and health systems and other provider organizations. She also makes it clear how much local market knowledge is necessary. A benefit design working great in one local market might be a medical trend disaster in another area with different levels of social determinants of health (SDoH) or different disease patterns, so scaling into new areas isn't a matter of just cutting and pasting. History has shown it's easy enough to go down in a flaming ball of unanticipated medical trend and/or OIG/DOJ scrutiny. So, this is one thing that big MA carriers can get right and potentially, for sure, benefit patients in their plans. Now I say this knowing full well that there's a brouhaha afoot in which there are some who are really pro-MA and there are some who are really not. In this show with Betsy Seals today, we do not get into this (ie, Do patients in MA plans fare better than patients in traditional Medicare?). But I have a point to make, and I'm just gonna make it here. Like most “Is this better than that?” questions in healthcare, there is not one answer; and anyone running around espousing pretty much anything as a broad-stroke holy grail is pretty much full of it—and I would say that as a general statement. Whether MA is better than traditional Medicare depends on who the patient is and also which MA plan we're talking about here. So, starting on the “not a fan” side of the house, Wendell Potter has said (with evidence) that if a patient is toward the end of his or her life or acutely ill or needs to go to an NCI-designated cancer center, it could easily be deduced that traditional Medicare is going to be better. On the other hand, there seems to be evidence, including a recent JAMA article by Ravi Parikh, MD, MPP, and Ezekiel Emanuel, MD, PhD, that concludes MA produces a 22% to 26% reduction in costs compared to MSSP (Medicare Shared Savings Program) arrangements. And this is across just a general patient population of all age ranges, if I'm reading the study right. The great results that are discussed in that JAMA article are what can happen when payers and providers align to tackle SDoH and preventative stuff and are willing to go out into the community to curb potentially avoidable downstream acute events. David Carmouche, MD, by the way, on episode 343 talked at length about this. But there are variables here, and let me mention one of them: how good the Medicare Advantage plan is at risk-based contracting with physician groups. How good are they at putting patients into accountable relationships with provider organizations who are getting paid to keep patients healthy, meaning the MA plan is offering budget-based prospective payment contracts to physician groups? This is the case in that Ochsner/JAMA article example that Dr. David Carmouche was talking about. Ochsner, the health system in Louisiana, and MA plans were working together; and both assumed risk for this population. Susan Dentzer, president and CEO over at America's Physician Groups (APG), does a great job at covering a bunch of these topics on the Race to Value podcast. Another thing that will impact care quality is how good the plan leadership is at balancing patient care and shareholder demand for profit. Bottom line, it is not productive to be indiscriminately pie-eyed about pretty much anything in healthcare or throw babies out with bathwater on a regular basis. As Ge Bai, PhD, CPA, has said on this show (and others have said), there's no angels and no devils in healthcare. Everybody is some combination of both. And, in general, the only reason anybody does anything in healthcare is because it appeals to their self-interest. So, not working with some other healthcare stakeholder because we perceive them as greedy or “industry” or whatever is gonna mean that nobody is working with anybody. Just keep your eyes wide open, check the math, and in your contracts, get actual dollar amounts and not discounts. In this healthcare podcast, as mentioned a few times now, I am speaking with Betsy Seals. Betsy Seals is CEO and cofounder of Rebellis Group, a managed care consulting firm working with Medicare Advantage plans. Oh, and one acronym alert before we dive in here: SNP stands for special needs plan. A special needs plan is a Medicare Advantage coordinated care plan that is specifically designed to provide targeted care and limit enrollment to special needs individuals. So, a special needs individual could be any one of the following: An institutionalized individual A dual eligible, meaning somebody who has Medicare and Medicaid An individual with a severe or disabling chronic condition, as specified by CMS SNPs are becoming a bit of thing in the MA space this year, and Betsy talks about this trend. You can learn more at rebellisgroup.com. Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations. Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations. Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs. Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits. 06:16 Is Medicare Advantage still a cash cow? 06:42 Why should Medicare Advantage be the most lucrative line of business? 07:07 “If there weren't a lot of money in it, nobody would do it.” 07:29 What should you know before jumping into the Medicare Advantage market? 14:04 What issues do upstarts overlook when getting into Medicare Advantage? 17:07 What is one of the next areas that Betsy thinks CMS will crack down on? 18:24 “Look at the data.” 19:53 “I think there's a lot of lessons that you could see over the past years in the industry.” 20:52 “That's what we see a lot of times is expansion without enough due diligence and thought put behind it.” 21:02 Why don't common business models always work in healthcare businesses? 22:29 What are the new key trends coming out of the Medicare Advantage space? 26:04 Why is it important to bring in your clinicians when entering a dual market? 27:52 What's going on in the chronic conditions space? 32:14 What's necessary to the infrastructure with any kind of SNP product? 32:56 What's Betsy's forecast for the future of Medicare Advantage? You can learn more at rebellisgroup.com. @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Is Medicare Advantage still a cash cow? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why should Medicare Advantage be the most lucrative line of business? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “If there weren't a lot of money in it, nobody would do it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What should you know before jumping into the Medicare Advantage market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What issues do upstarts overlook when getting into Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What is one of the next areas that Betsy thinks CMS will crack down on? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “Look at the data.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “I think there's a lot of lessons that you could see over the past years in the industry.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast “That's what we see a lot of times is expansion without enough due diligence and thought put behind it.” @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why don't common business models always work in healthcare businesses? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What are the new key trends coming out of the Medicare Advantage space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Why is it important to bring in your clinicians when entering a dual market? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's going on in the chronic conditions space? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's necessary to the infrastructure with any kind of SNP product? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast What's Betsy's forecast for the future of Medicare Advantage? @betsyseals of @GroupRebellis discusses #medicareadvantage on our #healthcarepodcast. #healthcare #podcast Recent past interviews: Click a guest's name for their latest RHV episode! Stacey Richter (INBW36), Dr Eric Bricker (Encore! EP351), Al Lewis, Dan Mendelson, Wendell Potter, Brian Klepper (Encore! EP335), Dr Aaron Mitchell (EP382), Karen Root, Mark Miller, AJ Loiacono, Josh LaRosa, Stacey Richter (INBW35), Rebecca Etz (Encore! EP295), Olivia Webb (Encore! EP337), Mike Baldzicki, Lisa Bari, Betsy Seals (EP375), Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter

Terry joins Sean to discuss the ins and outs of Medicare Advantage (MA) and what you really need to know about these plans. Why is the OIG investigating MA plans and what are they finding. Don't miss this one!

Much like urban legends, the recurring tales of Medicare Advantage (MA) plans being accused of manipulating diagnoses and denying care that otherwise would have been covered under traditional Medicare are gaining traction.They are now even being referred to as Medicare “Dis-Advantage” plans because of all the manipulation, much related to the fact that a MA patient is more expensive to the Medicare program than a traditional Medicare patient. The government pays MA insurers a set amount for each person who enrolls, with higher rates for sicker patients.But the Department of Justice (DOJ) recently uncovered irregularities in reporting accurate patient diagnoses, even accusing some insurers of developing elaborate systems to make their patients appear as sick as possible, often without providing additional treatment.During the next live edition of Talk Ten Tuesdays, nationally recognized healthcare consultant Terry Fletcher will report on the details.Other segments during the live broadcast will include the following:PSI Series:  The series on patient safety indicators (PSIs) continues with Dr. Jennifer Brettler and Kimberly Seery reporting on the PSI Inclusion and Exclusion criteria for PSI 04.Talk Law: Karen George, an attorney at Buchalter in Los Angeles, and a member of the firm's health care practice group, will file a report on the latest healthcare laws.News Desk: Timothy Powell, CPA will anchor the Talk Ten Tuesdays News Desk.TalkBack: Erica Remer,MD, founder and president of Erica Remer, MD, Inc., and Talk Ten Tuesdays co-host, will report on a subject that has caught her attention during her popular segment.  

Medicare Advantage (MA), otherwise known as the “money machine,” is often the most profitable parts of many payers' business lines. Medicare Advantage plans can make a lot of cash if they are good at what they do. Look at any of these large, consolidated carriers' financial statements to get the magnitude of that statement. Also, in 2022, Medicare Advantage plans have enrolled 28 million participants between them, which represents 45% of all Medicare beneficiaries. This marks a three-point improvement in penetration over 2021 and a total program enrollment growth of 9%.   All of this is not a secret. So, what's happening right now is that this administration is looking carefully at Medicare Advantage plans and what they have been up to. We have had an amping up of government oversight, including regulatory actions and program audits. In this healthcare podcast, I am speaking with Betsy Seals, who is CEO and cofounder of Rebellis Group, which is a managed care consulting firm working with Medicare Advantage plans. Betsy says (and this is what we talk about in the interview) that there's three main areas that the government is currently scrutinizing: Sales and marketing. There have been these third parties, it seems, these field marketing organizations who were hired to do marketing and sales for some of the Medicare Advantage plans. And because they were third parties, it seems that many of them felt themselves to be excluded from CMS (Centers for Medicare & Medicaid Services) regulations and able to basically mislead prospective members with sales pitches that were highly suspect. Betsy gives some examples of these, and when you hear them, you will see why CMS is cracking down. Recouping improper payments is another area that CMS is all over. Interestingly, as Betsy Seals says in this interview, this might be one area where the government is actually ahead of private sector plans from a technology and analytic standpoint. CMS seems to have better analytics capabilities and is better at detecting fraud schemes and improper payments than the plans themselves. These plans are not sophisticated enough to notice stuff that CMS detects when it gets ahold of the plan data. But as unusual as this situation is where the government is ahead of the business sector, I can't say I'm shocked. We have had one guest on this show after another talking about just how far in the past some of these health plans are lagging. Dan O'Neill probably said it most eloquently and notably (EP359).   But I digress. So, recouping improper payments has the eye of CMS. This means two things largely. It means finding “outlier” codes that some MA plan paid for but which are clearly errors and should not have been paid. Another improper payment is when plans themselves do a little fancy upcoding so that they make more money than they should in their risk-adjustment payments. This has gotten some major attention lately. Let me quote from an OIG (Office of Inspector General) report:   “Our findings raise concerns about the extent to which certain MA companies may have inappropriately leveraged both chart reviews and HRAs [health risk assessments] to maximize risk-adjusted payments. We found that 20 of the 162 MA companies drove a disproportionate share of the $9.2 billion in payments from diagnoses that were reported only on chart reviews and HRAs, and on no other service records.” The sneaky idea here to get more money than they should from taxpayers is that someone somewhere puts down that a member has major depressive disease because someone somewhere said they did. But the patient clearly doesn't have major depressive disease because they aren't getting any treatment for it and nothing anywhere would indicate that they are suffering from a major depressive disease. So, the plan winds up getting more money from the government to care for a patient who is suffering from major depressive disease, but the patient doesn't require any additional care because they don't have major depressive disease. It's a great way to make some dollars for shareholders that is coming right out of the pockets of taxpayers. In sum, the #2 area of additional oversight is recouping improper payments either from paying claims that should not have been paid for or by wild upcoding. This is just kinda like the general sort of compliance oversight that CMS does, meaning grievances and appeals and formulary administration and models of care for SNP plans (special needs plans), compliance program effectiveness—normal stuff like this—which will be interesting given all of the articles coming out right now about how patients on Medicare Advantage plans are less likely to get more costly diabetes treatments and how often there's denials for cancer care or NCI cancer centers aren't covered, etc. One point of note here that's kind of thought-provoking on a few levels: If you're an MA plan, it is super important for you to get members in for their annual screenings. For one, CMS requires that you document diagnoses each year; and you need to do this to reduce the chances that CMS will question a treatment being paid for because there's no underlying diagnosis to support it—and these diagnoses must be re-upped every year. Recall what I was just talking about re: improper payments and fraud schemes. If a patient isn't diagnosed with something, then why are taxpayers paying for its treatment? Also risk adjustment ... if you wanna upcode, it's not a bad idea to have a diagnosis documented in multiple different ways so that when the OIG/CMS/DOJ comes knocking, you can have your ducks in a row. Getting patients in for their annual screenings is how you can safely upcode. Further, one more reason why getting patients in for annual screenings matters to MA plans, member experience counts for an increasing piece of star ratings. Patients who never see their doctor and never interact with the plan don't usually give the plan they have nothing to do with stellar marks—and besides that, these members are tough to retain. Last big deal for an MA plan to get members in for their annual is this is when the doc gets into screening for care gaps, which is also part of star measures. All this about annual screenings is a bit of a sidebar, but it is kind of interesting to contemplate as we get into the conversation today about government oversight. (For a meme on this topic, check out this Tweet from Rik Renard.) My guest, as I mentioned earlier, is Betsy Seals. Listen to our conversation about how MA plans are in the hot seat right now. Later in the fall, Betsy will be coming back to talk about trends in the Medicare Advantage marketplace. You can learn more at rebellisgroup.com.   Betsy Seals is the CEO and cofounder of Rebellis Group, a consulting firm established to provide advisory and hands-on services to Medicare Advantage Organizations (MAOs) and their subcontractors. Betsy is a nationally recognized leader in the managed care industry with over 20 years of experience. Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy's expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health, and health plan operations. Prior to founding Rebellis Group, Betsy served as the chief consulting officer for Gorman Health Group (GHG). In this role, Betsy managed the Medicare consulting practice, including implementation of strategic initiatives, development of new practice areas, and oversight of day-to-day consulting operations. Prior to her role as chief consulting officer, Betsy served as senior vice president, compliance operations, where she assisted MAOs and Part D sponsors to attain and maintain compliance with the Centers for Medicare & Medicaid Services (CMS) regulations and guidance by conducting risk assessments, preparing organizations for CMS audits, performing mock CMS audits, and creating and implementing internal and delegated entity oversight programs. Before joining GHG, Betsy worked for MAOs, where she served in customer service and compliance with responsibility for creation and implementation of oversight programs, CMS audit preparation, implementation of internal corrective action plans, and the day-to-day management of compliance operations. Betsy has also worked as a CMS subcontractor to conduct CMS Compliance Program audits. 08:15 What's happening with sales and marketing in the healthcare industry? 11:04 What's happening with the focus on recouping improper payments? 13:32 “When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid.” 15:39 Are improper claim payments an administrative problem, or something more intentional? 16:20 “The health plan has a responsibility to catch those issues.” 20:10 What are specialty pharmacy prescriptions being scrutinized for? 22:12 “If this is where CMS is headed … the health plan should've already been doing this.” 23:58 Why do you see a bigger focus on social determinants of health? 25:54 Do these health plan audits actually have any teeth? 27:01 What is the biggest penalty a health plan can face from an audit? 29:57 “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” You can learn more at rebellisgroup.com.   @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's happening with sales and marketing in the healthcare industry? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What's happening with the focus on recouping improper payments? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “When you look at the fundamentals of it, these are federal dollars. And what we're talking about is federal dollars that were paid when they should not have been paid.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Are improper claim payments an administrative problem, or something more intentional? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “The health plan has a responsibility to catch those issues.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What are specialty pharmacy prescriptions being scrutinized for? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “If this is where CMS is headed … the health plan should've already been doing this.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Why do you see a bigger focus on social determinants of health? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth Do these health plan audits actually have any teeth? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth What is the biggest penalty a health plan can face from an audit? @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth “Navigating the Medicare program … was near to impossible. I know the program, and even for me, it was hours and hours and hours and hours on the phone.” @betsyseals of @GroupRebellis discusses #MedicareAdvantage plans on our #healthcarepodcast. #healthcare #podcast #digitalhealth   Recent past interviews: Click a guest's name for their latest RHV episode! Dave Chase, Cora Opsahl (EP373), Cora Opsahl (EP372), Dr Mark Fendrick (Encore! EP308), Erik Davis and Autumn Yongchu (EP371), Erik Davis and Autumn Yongchu (EP370), Keith Hartman, Dr Aaron Mitchell (Encore! EP282), Stacey Richter (INBW34), Ashleigh Gunter, Doug Hetherington, Dr Kevin Schulman, Scott Haas, David Muhlestein, David Scheinker, Ali Ucar, Dr Carly Eckert, Jeb Dunkelberger (EP360), Dan O'Neill, Dr Wayne Jenkins, Liliana Petrova, Ge Bai, Nikhil Krishnan, Shawn Rhodes, Pramod John (EP353), Pramod John (EP352), Dr Eric Bricker, Katy Talento