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Sep 21, 2021

Five steps to success through intelligent automation

The new SS&C Intelligent Automation Maturity Model provides a roadmap to companies to fully leverage emerging technologies and to establish the organizational structures to support continual innovation and evolution. The model is built on top of our experience of more than 30 years of providing technology and consulting services to hundreds of customers with a particular emphasis on those in complex, regulated industries, such as financial services, insurance and healthcare.

Aug 26, 2021

RAPS is retiring – are you prepared for the change?

CMS announced this year that Risk Adjustment Factor (RAF) will be entirely calculated through the Encounter Data Processing System (EDPS). This announcement comes ten years after CMS announced its intention to calculate 100% of risk adjustment payments using encounter data and more than six years past the originally planned implementation date. Beginning in 2022, CMS will cease using a blend of encounter and Risk Adjustment Processing System (RAPS) data and move to base 100% of the Risk Adjustment Factor on diagnoses from Medicare Advantage (MA) encounter data and fee-for-service claims. The long runway should lessen the industry impact, but the effects will be largely dependent on how organizations have prepared for the change.

Aug 6, 2021

What payers should know about convergence of administrative and clinical data

Technology for the sharing of health data between providers and payers is significantly changing, bringing the convergence of administrative and clinical data and new opportunities to improve care and value. With the breadth of administrative information and the depth of clinical information, blending this data can improve analytics and opportunities for care delivery, quality improvement and operational efficiencies.

Jul 12, 2021

HEDIS expansion of digital measures: preparing for 2022 reporting

In 2015, the National Committee for Quality Assurance (NCQA) initiated a multi-year process to transform Healthcare Effectiveness Data and Information Set (HEDIS®) quality measurement, beginning with the specification of the first Electronic Clinical Data Systems (ECDS) measure. ECDS measures are a subset of measures that NCQA specifies in a digital measure format that represent a new reporting method leveraging clinical data available at the point of care. 

Jun 8, 2021

HEDIS: public reporting is the next phase for ECDS

Each year, the National Committee for Quality Assurance (NCQA) takes measured steps to ensure that the Healthcare Effectiveness Data and Information Set (HEDIS) provides meaningful, patient-centric measures to ensure accountability at all levels. These measures are harmonized to share definitions across programs. The Electronic Clinical Data Systems (ECDS) framework, introduced with HEDIS 2016, was designed to increase the efficiency of quality reporting, while also providing an incentive to connect to primary clinical information systems. 

May 28, 2021

How health plans can responsibly delegate authority

Health plans often choose to outsource or delegate administrative functions to gain expertise, reduce administrative costs, increase capacity and increase speed to market.  However, delegating authority to perform services is not the same as delegating responsibility for the compliance of that service. If a plan chooses to outsource administrative functions, regulatory agencies and accrediting bodies have defined expectations regarding delegation. This includes the plan’s responsibility for structured oversight of the selected vendor and even any subcontractors to that vendor. Regardless of who performs the administrative function, the health plan retains the responsibility for compliance with all regulatory requirements and accrediting standards. Depending on the number of outsourced functions and overarching line-of-sight, it could be a cumbersome task to monitor compliance. What can a health plan do to overcome this challenge?

May 6, 2021

New rules would crumble “Berlin Wall” separating plan & provider data

Health plans and providers have traditionally operated in almost complete segregation, exchanging claims and authorization transactions but little else. Some of this separation stems from the adversarial relationship between “plans that pay” and “providers that cost.” This inherent division was expanded 20 years ago by the Health Insurance Portability and Accountability Act (HIPAA), shielding patient health information and demanding only the “minimum necessary” be exchanged between plan and provider trading partners.

Apr 1, 2021

COVID-19 vaccination monitoring: COVAX and considerations for Part D plans

The Centers for Medicaid and Medicare Services (CMS) plays an important role in facilitating access to COVID-19 vaccinations for Medicare recipients, protecting America’s senior citizens from COVID-19.  

Medicare Part D plans have an obligation to perform health care operations such as case management, care coordination or population-based activities to improve the health of their Medicare enrollees. For Part D plans to manage COVID-19 vaccine access and completion, those plans need to know when their enrolled Medicare members are receiving vaccinations.

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