These are risky and uncertain times for Risk Adjustment programs. This presentation from Mile High Healthcare Analytics,explores current risk adjustment legislation and important legal cases and how these are impacting health plan operations.
Enrolling homeless people in HUD programs and other public benefits is a major hurdle in ending homelessness – and even more so if those being enrolled are immigrants. This workshop will focus on the eligibility requirements and disqualifications for several federal programs. Speakers will also touch on the difference between federal and local limitations on access to public housing.
Full text of the Supreme Court's 6-3 Obamacare rulingDaniel Roth
Chief Justice John Roberts: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.. IIf at all possible, we must interpret the act in a way that is consistent with the former, and avoids the latter.”
Scalia: "“We should start calling this law ‘SCOTUScare"
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Enrolling homeless people in HUD programs and other public benefits is a major hurdle in ending homelessness – and even more so if those being enrolled are immigrants. This workshop will focus on the eligibility requirements and disqualifications for several federal programs. Speakers will also touch on the difference between federal and local limitations on access to public housing.
Full text of the Supreme Court's 6-3 Obamacare rulingDaniel Roth
Chief Justice John Roberts: “Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them.. IIf at all possible, we must interpret the act in a way that is consistent with the former, and avoids the latter.”
Scalia: "“We should start calling this law ‘SCOTUScare"
This update is part of a Brown & Brown series summarizing the guidance issued in connection with the Patient Protection and Affordable Care Act. For this edition, we examine the recent resurgence and passage of the American Health Care Act (AHCA).
Heritage Foundation has issued a set of five simple actions Congress must take in order to meet the electoral mandate of the American people. These five priorities represent the bare minimum of what is expected of our new representatives.
CBO’s work follows processes specified in the Congressional Budget and Impoundment Control Act of 1974 (which established the agency) or developed by the agency in concert with the House and Senate Budget Committees and the Congressional leadership.
CBO is strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence, without regard to political affiliation. The agency does not make policy recommendations, and each report and cost estimate summarizes the methodology underlying the analysis.
Presentation by Keith Hall, CBO Director, at the 10th Annual Meeting of the OECD Network of Parliamentary Budget Officials and Independent Fiscal Institutions.
The Congress of the People wants to highlight a fundamental matter of national importance and calls for urgent action to be implemented to realise the Freedom Charter vision that "The People Shall Govern".
This presentation explains the process followed by CBO and the staff of the Joint Committee on Taxation (JCT) when estimating the costs of legislative proposals affecting health insurance coverage. An example is the agencies’ estimate of how repealing the individual mandate to have health insurance would affect federal deficits.
Presentation by Sarah Masi, an analyst in CBO’s Budget Analysis Division, at a Congressional Research Service seminar on CBO’s methods for developing cost estimates.
The federal government subsidizes health insurance for most Americans through a variety of programs and tax provisions. In 2017, net subsidies for people under age 65 will total $705 billion, CBO and the staff of the Joint Committee on Taxation (JCT) estimate.
This presentation provides an overview of CBO and JCT’s current baseline projections of health insurance coverage and how those projections have changed since March 2016, highlighting changes in Medicaid and CHIP enrollment and nongroup coverage.
Presentation by Jessica Banthin, Deputy Assistant Director in CBO’s Health, Retirement, and Long-Term Analysis Division, at a Congressional Research Service seminar on CBO’s methods for developing cost estimates.
Buried somewhere in the longest piece of legislation ever is the No Surprises Act. Signed into law on December 27, 2020, it expands restrictions on charging out-of-network rates for certain services. Discover what it means for your business: https://bit.ly/3cfmHg4
International Municipal Lawyers Association: HOW TO FIGHT CORRUPTION? U.S. EX...Kateryna Korobovtseva
How do municipal governments in the USA minimize corruption, increase the level of confidence, promote transparency and increase public access to government? How transparency of local government has been achieved historically?
The presentation from the July 2 Rally for Freedom hosted by TCCRI in Plano, featuring Attorney General Greg Abbott and conservative state legislators. This presentation was delivered by TCCRI Executive Director John Colyandro.
Heritage Foundation has issued a set of five simple actions Congress must take in order to meet the electoral mandate of the American people. These five priorities represent the bare minimum of what is expected of our new representatives.
CBO’s work follows processes specified in the Congressional Budget and Impoundment Control Act of 1974 (which established the agency) or developed by the agency in concert with the House and Senate Budget Committees and the Congressional leadership.
CBO is strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence, without regard to political affiliation. The agency does not make policy recommendations, and each report and cost estimate summarizes the methodology underlying the analysis.
Presentation by Keith Hall, CBO Director, at the 10th Annual Meeting of the OECD Network of Parliamentary Budget Officials and Independent Fiscal Institutions.
The Congress of the People wants to highlight a fundamental matter of national importance and calls for urgent action to be implemented to realise the Freedom Charter vision that "The People Shall Govern".
This presentation explains the process followed by CBO and the staff of the Joint Committee on Taxation (JCT) when estimating the costs of legislative proposals affecting health insurance coverage. An example is the agencies’ estimate of how repealing the individual mandate to have health insurance would affect federal deficits.
Presentation by Sarah Masi, an analyst in CBO’s Budget Analysis Division, at a Congressional Research Service seminar on CBO’s methods for developing cost estimates.
The federal government subsidizes health insurance for most Americans through a variety of programs and tax provisions. In 2017, net subsidies for people under age 65 will total $705 billion, CBO and the staff of the Joint Committee on Taxation (JCT) estimate.
This presentation provides an overview of CBO and JCT’s current baseline projections of health insurance coverage and how those projections have changed since March 2016, highlighting changes in Medicaid and CHIP enrollment and nongroup coverage.
Presentation by Jessica Banthin, Deputy Assistant Director in CBO’s Health, Retirement, and Long-Term Analysis Division, at a Congressional Research Service seminar on CBO’s methods for developing cost estimates.
Buried somewhere in the longest piece of legislation ever is the No Surprises Act. Signed into law on December 27, 2020, it expands restrictions on charging out-of-network rates for certain services. Discover what it means for your business: https://bit.ly/3cfmHg4
International Municipal Lawyers Association: HOW TO FIGHT CORRUPTION? U.S. EX...Kateryna Korobovtseva
How do municipal governments in the USA minimize corruption, increase the level of confidence, promote transparency and increase public access to government? How transparency of local government has been achieved historically?
The presentation from the July 2 Rally for Freedom hosted by TCCRI in Plano, featuring Attorney General Greg Abbott and conservative state legislators. This presentation was delivered by TCCRI Executive Director John Colyandro.
King v Burwell: The Supreme Court, Affordable Care Act, and the Real StoryHarry Nelson
Since 2012, the Supreme Court has issued three major decisions addressing the Affordable Care Act. This presentation provides an overview of those decisions, as well as the larger questions ahead with respect to healthcare reform.
This portion of Solutions for America discusses the problems with Congress and its mockery of Constitutional limits of its power, in addition to many other things. It gives guidelines for what can be done to resolve this issue.
Pad 525 Enhance teaching / snaptutorial.comHarrisGeorg61
Choose any federal statute that is currently in the news. You will have to research that statute and at least two court cases pertaining
Paper instructions:
Assignment 4: Presentation
Choose any federal statute that is currently in the news. You will have to research that statute and at least two court cases pertaining to the statute. Then, prepare a PowerPoint Presentation of 6 to 8 slides addressing the following:
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Chapter 13:The Bureaucracy
ADA Text Version
Learning Objectives
1. Describe the formal organization of the federal bureaucracy.
2. Classify the vital functions performed by the bureaucracy.
3. Explain the present Civil Service system and contrast it with the 19th century spoils system.
4. Identify the various factors contributing to bureaucracy's growth over time.
5. Compare the means by which Congress and the president attempt to maintain control over the bureaucracy.
6. Analyze and evaluate the problems that bureaucratic organization poses for American democracy.
Introduction
The very word "bureaucracy" often carries negative connotations. To refer to an institution as a "bureaucracy" or characterize it as "bureaucratic" is usually intended as an insult. But the national bureaucracy, sometimes called the "fourth branch of government", is responsible for practically all of the day-to-day work of governing the country. While bureaucracy in the United States, consistent with our tradition of more limited government, is smaller than its counterparts in other longstanding democracies, its influence extends to almost every corner of American society. From delivery of the mail to regulation of the stock market to national defense, federal employees plan, regulate, adjudicate, enforce, and implement federal law. Despite recurrent calls to "shrink" the size of government, the federal bureaucracy remains the largest single employer in the United States. This lesson examines the bureaucracy's formal organization, its critical role in the American economy and society, and its perceived weaknesses.
Study Questions
1. How did sociologist Max Weber define bureaucracy?
2. Identify the various functions federal bureaucracies perform giving at least one example each:
a. Implementation
b. Regulation
c. Adjudication
d. Enforcement
e. Policy-making
3. How many people does the federal government employ? For what percentage of GDP does federal spending account? How does this compare to other economically advanced democracies?
4. Classify and distinguish the major types of bureaucracy in the federal government:
a. Cabinet Departments
b. Independent Agencies
c. Independent Regulatory Commissions
d. Government Corporations
5. How does the federal bureaucracy select and recruit personnel? Contrast the present civil service system with the spoils system. What advantages does the present system provide?
6. What factors explain the growth of bureaucracy over time despite recurrent calls for limiting the size of government?
7. Identify those factors in the budget process making it difficult to cut bureaucratic funding.
8. Describe the way Congress authorizes funding for the federal bureaucracy.
9. How does Congress attempt to control the federal bureaucracy?
10. How does the president attempt to control the federal bureaucracy?
11. What special problems does bureaucratic independence present in a democracy? Discuss with re.
Dr. David Greene R3 stem cell Breakthroughs: Stem Cell Therapy in CardiologyR3 Stem Cell
Dr. David Greene, founder and CEO of R3 Stem Cell, is at the forefront of groundbreaking research in the field of cardiology, focusing on the transformative potential of stem cell therapy. His latest work emphasizes innovative approaches to treating heart disease, aiming to repair damaged heart tissue and improve heart function through the use of advanced stem cell techniques. This research promises not only to enhance the quality of life for patients with chronic heart conditions but also to pave the way for new, more effective treatments. Dr. Greene's work is notable for its focus on safety, efficacy, and the potential to significantly reduce the need for invasive surgeries and long-term medication, positioning stem cell therapy as a key player in the future of cardiac care.
This document is designed as an introductory to medical students,nursing students,midwives or other healthcare trainees to improve their understanding about how health system in Sri Lanka cares children health.
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
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LGBTQ+ Adults: Unique Opportunities and Inclusive Approaches to CareVITASAuthor
This webinar helps clinicians understand the unique healthcare needs of the LGBTQ+ community, primarily in relation to end-of-life care. Topics include social and cultural background and challenges, healthcare disparities, advanced care planning, and strategies for reaching the community and improving quality of care.
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardso...rightmanforbloodline
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
TEST BANK For Accounting Information Systems, 3rd Edition by Vernon Richardson, Verified Chapters 1 - 18, Complete Newest Version
INFECTION OF THE BRAIN -ENCEPHALITIS ( PPT)blessyjannu21
Neurological system includes brain and spinal cord. It plays an important role in functioning of our body. Encephalitis is the inflammation of the brain. Causes include viral infections, infections from insect bites or an autoimmune reaction that affects the brain. It can be life-threatening or cause long-term complications. Treatment varies, but most people require hospitalization so they can receive intensive treatment, including life support.
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In order to protect visitors' safety and wellbeing, Travel Clinic Leicester offers a wide range of travel-related health treatments, including individualized counseling and vaccines. Our team of medical experts specializes in getting people ready for international travel, with a particular emphasis on vaccines and health consultations to prevent travel-related illnesses. We provide a range of travel-related services, such as health concerns unique to a trip, prevention of malaria, and travel-related medical supplies. Our clinic is dedicated to providing top-notch care, keeping abreast of the most recent recommendations for vaccinations and travel health precautions. The goal of Travel Clinic Leicester is to keep you safe and well-rested no matter what kind of travel you choose—business, pleasure, or adventure.
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A feeding plate is a prosthetic device used for newborns with a cleft palate to assist in feeding and improve nutrition intake. From a prosthodontic perspective, this plate acts as a barrier between the oral and nasal cavities, facilitating effective sucking and swallowing by providing a more normal anatomical structure. It helps to prevent milk from entering the nasal passage, thereby reducing the risk of aspiration and enhancing the infant's ability to feed efficiently. The feeding plate also aids in the development of the oral muscles and can contribute to better growth and weight gain. Its custom fabrication and proper fitting by a prosthodontist are crucial for ensuring comfort and functionality, as well as for minimizing potential complications. Early intervention with a feeding plate can significantly improve the quality of life for both the infant and the parents.
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Empowering ACOs: Leveraging Quality Management Tools for MIPS and BeyondHealth Catalyst
Join us as we delve into the crucial realm of quality reporting for MSSP (Medicare Shared Savings Program) Accountable Care Organizations (ACOs).
In this session, we will explore how a robust quality management solution can empower your organization to meet regulatory requirements and improve processes for MIPS reporting and internal quality programs. Learn how our MeasureAble application enables compliance and fosters continuous improvement.
Michigan HealthTech Market Map 2024. Includes 7 categories: Policy Makers, Academic Innovation Centers, Digital Health Providers, Healthcare Providers, Payers / Insurance, Device Companies, Life Science Companies, Innovation Accelerators. Developed by the Michigan-Israel Business Accelerator
Risk Adjustment 2015 The Political and Legislative Climate
1. RISK ADJUSTMENT 2015 – THE LEGISLATIVE &
POLITICAL CLIMATE
The Risk Adjustment Forum
May 13, 2015
Richard Lieberman
Chief Data Scientist (aka “Mad Scientist”)
2. Today’s Agenda
• Is “My Majority” the same as “Your Majority”
• A framework for understanding King v. Burwell
• What happens if the Supreme Court rules in favor
of the Petitioners?
• Risk adjustment under siege? Well, maybe!
• Health plan responses to risk adjustment
shenanigans
3. Who Is Richard Lieberman?
In November 2014, founded a new population health enterprise, Mile High Healthcare Analytics
I have been actively involved in the development of risk adjustment systems for over 20 years
• Johns Hopkins ACG Development Team, 1991-2005
• Designed the risk-adjusted payment system for Maryland Medicaid
• Worked with CMS on development of the Medicare risk adjuster
• Architect of a data warehouse and decision support system that integrated quality measurement
and risk adjustment on the same web-enabled platform
I combine a unique array of expertise in provider profiling, risk adjustment, quality measurement,
and provider reimbursement strategies
5. A Certain Health Care Vote in the U.S. House of Representatives
220 – 215
(Hint: only one party voted for this bill)
6. A Certain Health Care Vote in the U.S. House of Representatives
220 – 215
Republicans – Democrats
(Hint: only one party voted for this bill)
7. House Vote on the Medicare Modernization Act (P.L. 108-173)
220 – 215
Republicans – Democrats
(Only Republicans Voted for this Bill)
8. Key Provisions of the Medicare Modernization Act
• The Medicare Modernization Act (MMA) produced the
largest overhaul of Medicare in the public health program's
38-year history
• The MMA's most touted feature is the introduction of
an entitlement benefit for prescription drugs, through tax
breaks and subsidies
• Beginning in 2006, a prescription drug benefit called Medicare
Part D was made available. Coverage is available only
through insurance companies and HMOs, and is voluntary
• Part D introduced the concept of risk corridors, which unlike
the ACA MA risk corridors, are permanent, and funded as an
entitlement
9. Key Provisions of the Medicare Modernization Act (cont.)
• With the MMA, new Medicare Advantage plans were established with several
advantages over the previous Medicare + Choice plans:
• Enrollees sign on for a whole year
• Care can be restricted to networks of providers
• Formularies can be used to restrict prescription drug choices
• Prescription coverage can be deferred to the patient or a Medicare Part D prescription plan
• Care other than emergency care can be restricted to a particular region
• Federal reimbursement can be adjusted according to the health risk of the enrollees
• Comprehensive risk adjustment was integrated into the program and began a 4-year phase-in
10. Another Certain Vote in the U.S. House of Representatives
219 – 212
(Hint: Only one party voted for this bill)
11. Another Certain Vote in U.S. House of Representatives
219 – 212
Democrats – Republicans
(Only Democrats Voted for this Bill)
12. House Vote on the Affordable Care Act (P.L. 111-148)
219 – 212
Democrats - Republicans
13. Which Party Voted for a Bill Does Not Matter!
• A law is a law if it is passed by majority
votes of both houses of Congress
(bicameralism) and is signed by the
President (presentment)
• If only one political party is in the majority,
a bill still can become a law
• As long as there is bicameralism and
presentment, then in our constitutional
system, we get a law
• Laws are supposed to be obeyed until
they are changed (by Congress or the
Courts)
15. Question to be Decided by Supreme Court
• “Whether the Treasury Department
permissibly interprets 26 U.S.C. 36B to
make the Affordable Care Act’s federal
premium tax credits available to eligible
taxpayers through the Exchanges in every
State.”
• This is a case requiring statutory
interpretation. The constitutionality of the
Affordable Care Act is NOT under review!
16. The Seven (Dirty) Words
• “established by the State under section 1311”
• Petitioners argue that these seven words foreclose tax credits on HHS-created
exchanges
• If Congress intended to give States a choice between receiving subsidies for their
residents and not receiving them, why did it hide the choice in a technical section
on the calculation of subsidies?
• “Congress does not alter the fundamental details of a regulatory scheme in vague
terms or ancillary provisions—it does not, one might say, hide elephants in mouse
holes.” Whitman v. Am. Trucking Ass’n, 531 U.S. 457, 468 (2001)
17. The “isms”
• Textualism: The only “law” to interpret is the text of a statute
passed by both houses of Congress and signed by the President
• Purposivism: the letter of the law must yield to legislative “intent”
• Purposivists argue that the statutory text can be augmented by
combing the legislative history for indicia of legislative intent
• Textualists explain that a search for legislative intent violates the
constitutionally prescribed process of bicameralism and presentment
• Hyperliteralism: reading the words of a statute in a vacuum
• Textualism is not hyperliteralism, and textualists do not read the
words of a statute in a vacuum
18. If You Prefer Literalism in Your Law, Then....
• “But there are two clauses in the Constitution which point directly and specifically to the negro race
as a separate class of persons, and show clearly that they were not regarded as a portion of the
people or citizens of the Government then formed.”
• “And these two provisions show conclusively that neither the description of persons therein referred
to nor their descendants were embraced in any of the other provisions of the Constitution, for
certainly these two clauses were not intended to confer on them or their posterity the blessings of
liberty, or any of the personal rights so carefully provided for the citizen.”
• They had for more than a century before been regarded as beings of an inferior order, and
altogether unfit to associate with the white race either in social or political relations, and so far
inferior that they had no rights which the white man was bound to respect, and that the negro might
justly and lawfully be reduced to slavery for his benefit.
19. Statutory Interpretation According to Justice Scalia
• One of the axioms of statutory interpretation, expressed strongly
and repeatedly by the nine Justices, especially Justice Scalia, is
that one looks at the whole statute and its context to review
meaning, rather than adopting a blinkered focus on a few words
• In interpreting a statute, courts must choose a textually permissible
reading that furthers the evident purpose of the law over one that
obstructs the statutory purpose
• As Justice Scalia expressly stated in one of his treatises, the
well-worn canon of construction follows from the facts that:
• Interpretation always depends on context
• Context always includes evident purpose, and
• Evident purpose always includes effectiveness
20. Chevron v. Natural Resources Defense Council
• “Chevron” is a pillar of modern administrative law
• When a court reviews an agency's construction of the statute which it administers,
it is confronted with two questions
• “First, always, is the question whether Congress has directly spoken to the precise
question at issue. If the intent of Congress is clear, that is the end of the matter; for the
court, as well as the agency, must give effect to the unambiguously expressed intent
of Congress”
Source: Chevron U.S.A. Inc. v. NRDC, Inc.,
467 U.S. 837 (1984)
• “If, however, the court determines Congress has not directly addressed the precise question
at issue, the court does not simply impose its own construction on the statute, as would be
necessary in the absence of an administrative interpretation. Rather, if the statute is silent or
ambiguous with respect to the specific issue, the question...is whether the agency's answer
is based on a permissible construction of the Statute.”
21. Chevron v. Natural Resources Defense Counsel
• Even under Chevron’s deferential framework, agencies must operate
“within the bounds of reasonable interpretation.”
• And reasonable statutory interpretation must account for both “the
specific context in which . . . language is used” and “the broader
context of the statute as a whole.” Robinson v. Shell Oil Co., 519 U. S.
337, 341 (1997). A statutory “provision that may seem ambiguous in
isolation is often clarified by the remainder of the statutory scheme . .
.because only one of the permissible meanings produces a
substantive effect that is compatible with the rest of the law.” Thus, an
agency interpretation that is “inconsistent with the design and structure
of the statute as a whole does not merit deference.”
22. If Chevron is the Law, Then Isn’t the Case Decided?
• Both the Chief Justice and Justice Kennedy expressed
concerns about the limits of “Chevron Deference”
• Roberts asked at oral argument, “If you’re right — if you’re
right about Chevron, that would indicate that a subsequent
administration could change that interpretation?”
• Justice Kennedy expressed concern that an ambiguous
portion of the statute gave the IRS tremendous power to
distribute billions of dollars of subsidies without an explicit
authorization from Congress
23. Utility Air Regulatory Group vs. EPA (134 S. Ct. 2427, 2442 (2014))
• Justice Scalia said, “it is a fundamental canon of statutory construction that the
words of a statute must be read in their context and with a view to their place in the
overall statutory scheme.’” FDA v. Brown & Williamson Tobacco Corp., 529 U. S.
120, 133 (2000).
• “Reasonable statutory interpretation must account for both ‘the specific context in
which . . . language is used’ and ‘the broader context of the statute as a whole.’”
• Example: “The sun may be a star, but ‘starry sky’ does not refer to a bright summer day”
• After all, true respect for Congress requires giving effect to the statute Congress
enacted, not just isolated words divorced from their context
24. Should Unelected Judges Make Decisions for the People?
• Excerpts from Article III of the Constitution:
• The judicial Power of the United States, shall be vested in one supreme Court, and in
such inferior Courts as the Congress may from time to time ordain and establish...The
judicial Power shall extend to all Cases, in Law and Equity, arising under this
Constitution, the Laws of the United States, and Treaties made, or which shall be
made, under their Authority
25. So, What Is Going to Happen?
• The Court may uphold the agency’s (the IRS) interpretation of the statute
• Courts have a duty to construe statues, not isolated provisions” (Graham County Soil
& Water Conservation Dist. v. United States, 559 U.S. 280, 290 (2010))
• The constitutional-doubt and constitutional-validity canons require judges to read statutes
in a way that would avoid rendering them unconstitutional or that would raise serious
questions about their constitutionality: “Every reasonable construction must be resorted to
in order to save a statute from unconstitutionality.” Hooper v. California, 155 U.S. 648, 657
(1895)
26. Or, the Court will Agree with the Petitioners
• If they rule in favor of King, in all likelihood they will rule narrowly
• Perhaps the Chevron Deference doctrine gets limited– this could have a significant
impact on future administrative law cases
• The severability doctrine provides that, “whenever an act of Congress contains
unobjectionable provisions separable from those found to be unconstitutional, it is
the duty of this court to so declare, and to maintain the act in so far as it is valid.”
Alaska Airlines, Inc. v. Brock, 480 U.S. 678, 684 (1987)
28. Who Would be Affected Should Subsidies Go Away?
• Subsidies in states with their own exchanges could continue (e.g., CA, NY, CO, etc.)
• Subsidy recipients are not the poorest people, who get help through the expansion
of Medicaid
• Most recipients of subsidies are low-income and middle-income workers
• Over 80 percent , are the workers themselves; The rest are families of workers.
• Over 60 percent of recipients are white
• Over 60 percent of recipients live in the South
• They’re also a voting population
29. What Happens Next?
• Chief Justice Roberts said, “It is not our job to protect the
people from the consequences of their political choices.”
• All Congress has to do is legislate a few additional
words!
• President Obama may take the position, “you broke it,
you fix it!”
• Republicans claim they will use a favorable decision to
get a repeal and replace of the ACA
30. ObamaCare
Offers subsidies to
purchase insurance and to
offset some copays for low-
and moderate income
Americans (up to 400
percent of the Federal
Poverty Limit (FPL)
31. Offers refundable tax credits for
low- and moderate income
Americans (up to 300 percent of
FPL; plus anyone who works for
an employer with less than 100
lives, or anyone else who doesn’t
have an offer of insurance. In the
form of an age-adjusted,
advanceable, refundable tax
credit
ObamaCare
Offers subsidies to
purchase insurance and
to offset some copays
for low- and moderate
income Americans (up to
400 percent of the
Federal Poverty Limit
(FPL)
Republican Alternative
33. Repeal individual and employer mandates
but assess a “penalty” on anyone who tries
to buy insurance after open enrollment. In
the case of individuals who have a health
tax credit, but who fail to choose a plan,
states would be allowed to utilize default
enrollment…would be given the authority
to designate insurance plans…to which
individuals could be randomly assigned
ObamaCare
Individual and employer
mandate to purchase health
insurance or pay a modest
fine (aka “tax”)
Republican Alternative
37. No one can be denied
coverage based on a pre-
existing condition…new
“continuous coverage”
protection…individuals
moving from one health plan
to another…could not be
medically unwritten and
denied a plan based on a
preexisting condition if they
were continuously enrolled
in a health plan
ObamaCare
Guaranteed issue and
renewability
Republican Alternative
39. Our proposal caps the
tax exclusion for
employee’s health
coverage at $12,000 for
an individual and
$30,000 for a family.
ObamaCare
“Cadillac tax” applies a
40% tax to employee
health coverage at
$10,200 for an individual
and $27,500 for a family
Republican Alternative
41. Insurance companies
are banned from
charging older
Americans more than
five times what they
charge younger
individuals
ObamaCare
Insurance companies
are banned from
charging older
Americans more than
three times what they
charge younger
individuals
Republican Alternative
45. United States v. SCAN
• This case originally had nothing to do with Medicare-Advantage risk adjustment
• Allegations of risk adjustment “fraud” were subsequently added in a fishing expedition
against every California MA Plan and at least one IPA
• In United States of America, et. al. v. SCAN Health Plan, et. al. (Case 2:09-cv-05013-JFW-
JEM), every allegation about risk adjustment fraud has been dismissed by the court.
• “For all the foregoing reasons, HealthCare Partners’ Motion to Dismiss, Aetna’s Motion to
Dismiss, WellPoint’s Motion to Dismiss, and the UnitedHealth Defendants and Health Net’s
Motion to Dismiss are GRANTED, and Swoben’s third and ninth claims for relief for violation
of the False Claims Act are DISMISSED…” (see, Case 2:09-cv-05013-JFW-JEM Document
133 Filed 07/30/13).
• Moreover, a request to amend the complaint (for the 4th time), was denied by the trial judge
(citing the “futility doctrine” established by the 9th Circuit)
46.
47. United States of America ex rel. Olivia Graves, v. Plaza Medical
Centers Corp., Humana, Inc. and Michael Cavanaugh
• Filed in the U.S. District Court for the Southern District of
Florida, Case No. 1:10-cv-23382
• Allegation: “Submitting False Claims in Violation of the
False Claims Act, 31 USC Section 3729(a)(1)(A), Against
All Defendants”
• This litigation has been set in for a trial on the merits
beginning in December 2015
• The parties must engage in mandatory mediation to be
completed by October 2015
48. “Choice Morsels” from U.S. v. Plaza Medical Centers Complaint
• In or about April, 2010 a former patient of Dr. Graves, who was now being
cared for by Dr. Cavanaugh, asked to be seen by Dr. Graves. During that
examination Dr. Graves noticed that Dr. Cavanaugh had listed several
diagnostic codes for the patient that did not apply, and had submitted
claims to Humana and Medicare with the false diagnoses that increased
the reimbursement by CMS to Humana. When Dr. Graves brought this to
Dr. Cavanaugh's attention, he told her that he "did not give a sh*t."
• Dr. Graves became concerned that Dr. Cavanaugh was improperly submitting false claims to
Medicare regarding other patients. Thus, Dr. Graves started reviewing other patients‘ charts and
found that Dr. Cavanaugh had similarly inflated the diagnostic codes for those patients as well and
had billed Medicare, through Humana, for the false diagnoses.
49. What Should MA Plans Do?
• Many of the alleged whistleblower lawsuits will be bogus. But not all of them!
• Get Your Head Out of ”the Sand”
• Providers need real training on optimal clinical documentation
• Not coding! Documentation!
• Providers need oversight
• Just because the contract transfers risk, doesn’t mean it transfers responsibility
• Risk adjustment is hard and has lots of nuances
• Medicaid and exchange risk adjustment are not just like Medicare!
50. In-Home Assessments
• CMS has decided that trying to disallow diagnosis
codes from HRAs that were not subsequently “treated”
represented a “third rail” (not worth stepping on!)
• Beginning in the 2016, CMS has adopted a,
“guidelines and surveillance” strategy that strongly
encourages MA Plans to change their in-home
assessment process
• And “Big Brother” will be watching!
51. The Guidelines and Surveillance Strategy
• EDPS will now see the light of day!
• By linking the diagnosis code flags from RAPS to the
treatment documented in EDPS, CMS can test for
the linkage between in-home assessment diagnoses
and subsequent treatment
• Hence, the guidelines should be taken seriously,
because the writing is on the wall
52. New Components of Health Risk Assessments
• All components of the annual wellness visit, including a health
risk assessment
• Medication review and reconciliation
• Scheduling appointments with appropriate providers and
making referrals and/or connections for the enrollee to
appropriate community resources
• Conducting an environmental scan of the enrollee’s home for
safety risks, and need for adaptive equipment
53. New Components of Health Risk Assessments (cont.)
• A process to verify that follow-up care is provided
• A process to verify that information obtained during the assessment is
provided to the appropriate plan provider(s)
• Provision to the enrollee of a summary of the information, including diagnoses,
medications, scheduled follow-up appointments, plan for care coordination,
and contact information for appropriate community resources; and
• Enrollment of assessed enrollees into disease management/case
management programs
54. Additional Sources of Potential Oversight
• While not specifically part of the current CMS audit
guidelines, these new HRA requirements can be evaluated
as a component of vendor oversight
• The OIG will now have requirements to build a work plan
item around
• Part C RACs, which still looming could have a field day
with these requirements
55. Responses to New In-Home Assessment Requirements
• These new requirements will require a substantial change in
how Plans approach in-home assessments
• HRA instruments used by vendors and plans will have to
undergo significant revision
• Just transferring the responsibility for risk score optimization to
vendors will no longer work
• Vendors can take on more of the burden, but many of these
requirements must be done directly by the plan
56. In-Home Assessments Begin Well Before the Clinician Arrives
• Refocus the member outreach/appointment scheduling process to be a key
component of the member targeting process.
• Integrate key instruments into the outreach—Patient Activation Measure, PHQ-9,
and/or SF-36
• The telephone outreach is part of the assessment, not just a vehicle to get member’s
to agree to a home visit
59. Mile High Healthcare Analytics Can Assist You…
• With Medicare-Advantage bidding season in full swing, do you have accurate risk
scores to produce the optimal bid?
• We design, transform, and load data into data warehouses
• Redesign of the HRA process and oversight of the process
• The Quality Rating System (QRS) beta test puts significant data requirements in front
of overworked issuers. The QRS measures pose significant complexities, particularly
around continuous enrollment requirements
• Do you have the data management acumen to maximize Star ratings?
60. Free Webinar Series
• Mile High Healthcare Analytics is committed to our free webinar series. We will
continue to present key risk adjustment and performance improvement topics to
health plans and provider groups on a monthly basis throughout the year.
• In the month of May, we will present two webinars:
• May 19th: A collaboration between MHHA and Oracle Health Insurance
• May 28th: “Predicting and Reducing Emergency Room Utilization and Preventable
Readmissions” (a collaborative presentation by Mile High Healthcare Analytics and
NextHealth Technologies)
• For more information about our free webinar series or to register, please go to:
http://www.healthcareanalytics.expert/news-and-events/free-webinar-series/
61. Oracle Health Insurance Webcast
Richard Lieberman will be the primary
presenter:
“The Changing World of Value Based
Payments”
Tuesday May 19, 2015
1p.m. Eastern (10 a.m. Pacific)
Registration page:
http://www.fiercehealthpayer.com/offer/oracl
e_may2015?source=oracle
62. THANK YOU FOR JOINING US!!
Our website continues to evolve:
www.healthcareanalytics.expert