“Unprecedented” is a word you hear frequently these days and for good reason. Never in our lifetimes has the world experienced what is happening right now with the COVID-19 pandemic and its implications. This is especially true when it comes to emergency declarations and healthcare-related flexibilities and waivers in the United States. Staying on top…

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The COVID-19 pandemic of 2020 created an unprecedented time of mass closures…businesses, sporting events, school systems; you name it, it is likely closed. However, the business of healthcare is certainly not closed and nor are the businesses that support every aspect of it, including revenue cycle operations. These operations include risk adjustment, and risk adjustment…

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The 2020 poverty guidelines were released and published in the Federal Register with an effective date of January 14, 2020.   Payers and Providers wait for the release of the poverty guidelines each year to update patient financial assistance and eligibility information within their systems and forms. Controversy has surrounded the poverty guidelines and, more…

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Did you notice that during the current 2020 Open Enrollment Period (OEP), federal and state-based exchanges are publicly displaying their Five-Star Quality System (QRS) rating information on exchange health plans? The goal of the QRS is to increase transparency and competition by providing comparative information for consumers as they shop and select plans. The Centers…

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Fear and confusion have caused immigrants to disenroll from government programs or forgo benefits for which they are eligible. According to a December 2018 nationwide survey, about one in seven adults in immigrant families did not participate in a government program for fear of risking future green card status.1   What is causing this? “Public…

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There is a lot going on with Medicaid these days, but the biggest change may be with Section 1115 Medicaid Demonstration Waivers for work or community engagement. We frequently read or hear the terms “work requirement” and “community engagement” interchanged. For the most part, they are the same type of requirement. A state makes the…

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Social determinants of health (1) as a measurement of a person’s, or a population’s, overall health emerged in the last decades of the 20th century and have now become a recognized metric in US healthcare delivery.   In the still-ongoing process of improving the overall access and quality levels in American healthcare, social determinants, or…

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This is an overview on how to expand your Risk Adjustment renovation toolbox, so you can better construct and implement your data submission program. The following are the tools and strategies needed to implement the 12 CMS Best Practices and help ensure program success. Tool #1 – Magic Bullet – Analyze transactional reports to track,…

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1115 Waiver Activity: 2019 Q1 Overarching Developments There were some key developments in the first quarter of 2019 that have potential long-term impacts to the 1115 waivers: Federal judge blocks community engagement requirements in Kentucky and Arkansas A federal judge’s Mar. 27, ’19 ruling immediately suspended community engagement requirements for Medicaid recipients in Kentucky and…

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