Last month, my colleagues and I headed to the Centennial State to exhibit at RISE National 2023 in Colorado Springs, CO. The show is focused on all things Medicare Advantage, and it was good to be back again after attending last year’s conference in Nashville prior to joining Noridian.
More than 1,800 attendees came together to discuss the most pressing issues affecting the industry. This year’s sessions and speakers focused on risk adjustment strategies, integrating silos, payer/provider collaboration, quality & member experience, technology/data analytics, compliance and regulatory updates, and the future of health care. It was wonderful to hear colleagues and industry experts share insights on these items, while also connecting with potential health plans and companies to partner with on future work.
One of our main goals for the conference was sharing how smaller Medicare Advantage health plan can compete with the larger companies. How exactly? By partnering with Noridian to take advantage of our shared resources model, that includes:
- Technology: Shared technology lowers capital costs by improving efficiencies, enhancing data security and compliance, effectively implementing operational upgrades and automation, and minimizing the need for physical space.
- Human capital: Shared human capital lowers operating costs by enabling organizations to quickly scale up or down.
- Expertise: Shared expertise maximizes effectiveness by having access to clinical and compliance experts, which reduces risk, and lowers turnover and indirect costs.
However, we attend and exhibit at conferences to not only share our expertise with others, but to gain insights from our colleagues, which in my opinion, is one of the best things about trade shows. You get to connect in real life with people in your industry and that is valuable.
So, what were my key takeaways from RISE National 2023?
First, the Center for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG) are very focused on Fraud, Waste and Abuse (FWA) at both the payer and provider level. Risk adjustment is important for health plans to be compensated based on illness burden of membership and to avoid adverse selection, but Risk Adjustment Data Validation (RADV) audits have exposed numerous cases of Hierarchical Condition Category (HCC) Coding-related misrepresentation, costing taxpayers billions of dollars since HIPAA was enacted in 1999. Specific examples, include:
- In home health, providers revealed 69% of the diagnoses submitted were not substantiated in any other claim via audit, which equates to $113 million dollars since 2019.
- Inappropriate Prior Authorization (PA) denials, which were around 13%, met criteria. Plans often request duplicative or unnecessary documentation which delay treatment.
Second, the Medicare Advantage proposed changes to the PA process, utilization management, marketing, risk adjustment models and Star Ratings aim to address FWA and health equity.
Third, scarcity of providers remains an issue, especially in rural areas and in certain specialties such as behavioral health providers. This impacts network adequacy requirements for health plans. A memorable quote that stood out to me was “You can’t contract with providers that don’t exist.”
And finally, the Medicaid focus in 2023 is on redetermination, duals, and access/health equity in every level of health care. We share that goal with Medicaid agencies because enabling access to care is a priority for Noridian. We do this by supporting states’ administration operations, such as efficiently enrolling providers and processing claims, so they can help the 15 million people who are expected to lose coverage, half of which are children, either stay enrolled or find additional coverage.
If you’re interested in learning more about how to implement shared resources to increase operational efficiencies within your health plan, to discuss my key insights from the conference further, or to simply connect, I’d love to hear from. Please contact me through the Contact Us page on our website.