Introducing AssuranceCR: A tool for Medicaid oversight at NAMPI

Medicaid Program Integrity leaders are facing no shortage of challenges this year — from tightening budgets to new compliance requirements. My colleague Jay Derby, Ph.D. will be at #NAMPI2025 in St. Louis to talk with states about two ways PCG can help: 1. Concurrent Enrollment Detector – A smarter way to safeguard Medicaid dollars by flagging members enrolled in multiple state programs in real-time through 270/271 checks. Pilot states are already seeing significant savings per check. 2. Eligibility Auditor – A streamlined approach to MEQC audits that gives agencies real-time compliance insights, reduces manual effort, and helps states stay aligned with HR1 requirements. If you’re a Medicaid Program Integrity leader thinking about how to protect resources while reducing administrative burden, stop by Booth #27 to connect with Jay and our team. Let’s talk about how these tools can help your state get ahead of the challenges coming your way. Looking forward to seeing you there! Jay Peck (he/his) Hannah Trate Patricia Perazzelli Public Consulting Group #Medicaid #ProgramIntegrity #NAMPI2025 #FraudPrevention #MedicaidCompliance #HealthPolicy #CostContainment

Secure, patient-centered interoperability starts with trust. The Centers for Medicare & Medicaid Services (CMS) requires HITRUST-level assurance — proof that your systems are robust, auditable, and ready for modern healthcare data exchange. Find out more. https://hubs.ly/Q03HMGgW0 #HealthcareSecurity #CMSInteroperability #SecurityFramework #HealthcareCompliance

Inaccurate provider data creates real friction for providers, payers and patients. Thanks to Curtis for highlighting ways to tackle this challenge, from simplifying provider engagement to prioritizing the most impactful data elements. 👉 https://ow.ly/yLIh50WIub4

CMS has introduced an optional MLR Plan to State Template, which offers states a standardized method for gathering data from MCOs, PIHPs, and PAHPs: https://okt.to/ZNw97s Our team is dedicated to assisting states in transforming this data into clearer transparency and accountability, providing comprehensive guidance and resources throughout the process. Feel free to contact us for more insights, and check out our alert on the CMS Medicaid Managed Care MLR Toolkit for further information: https://okt.to/Z0hvOc #MCOs #MyersandStauffer #ClientAlert #ManagedCare #MLR

Prior authorization reform is gaining momentum, with #HHS and major insurers pledging change by 2027. But real progress depends on modern #APIs, open data standards like #FHIR, and aligned incentives across the public and private sectors. Our CEO, Charles Jaffe, MD, PhD, explains why standards must be treated as public infrastructure to turn these industry commitments into real-world impact, in this new op-ed in MedCityNews. Read it here 👉 https://hubs.ly/Q03DWnds0 #Interoperability #PriorAuthorization #HealthITPolicy #PriorAuthReform #HealthEquity #FHIR #HL7

This week #CMS shifted the timeline for #SNPs starting in CY2027. Models of Care (MOCs) are now due May 29, 2026, aligned with Medicare Advantage bid submissions—tightening the window for planning and execution. What does this mean for health plans? Read our latest blog to see what’s changing and how to get ready 👉 https://lnkd.in/em4SsTTc

Prior authorization reform is gaining momentum, with #HHS and major insurers pledging change by 2027. But real progress depends on modern #APIs, open data standards like #FHIR, and aligned incentives across the public and private sectors. Our CEO, Charles Jaffe, MD, PhD, explains why standards must be treated as public infrastructure to turn these industry commitments into real-world impact, in this new op-ed in MedCityNews. Read it here 👉 https://hubs.ly/Q03DWqnN0 #Interoperability #PriorAuthorization #HealthITPolicy #PriorAuthReform #HealthEquity #FHIR #HL7

Excited to see the launch of CMS’s AHEAD (Achieving Healthcare Efficiency through Accountable Design) Model—a bold, voluntary initiative to transform state-level healthcare payment and delivery. The AHEAD model empowers states to manage their total cost of care, invest in primary care, and improve population health. Key features like hospital global budgets and enhanced primary care programs mean a greater focus on prevention, efficiency, and cross-sector collaboration. Participating states also receive up to $12 million in support, strengthening the infrastructure for broad health system change. One often-overlooked area is the impact of these models on healthcare security. As states align data systems, invest in care coordination, and leverage community resources, protecting sensitive patient information becomes even more critical. Effective security frameworks must be embedded in the planning and execution of these statewide efforts to maintain trust and safeguard data. Overall, AHEAD promises to accelerate innovation and improve outcomes—but robust healthcare security measures will be essential to realize its full potential. Exciting times for state health transformation! #HealthcareInnovation #ValueBasedCare #HealthIT #CMS #AHEADModel #HealthcareSecurity ASIS International International Association for Healthcare Security and Safety (IAHSS) https://lnkd.in/ePZCZhjr

ACO success requires hyper-localized strategies – here's why The chart below shows Medicare Part B spending distribution in 2024 for California vs. Georgia, grouped by BETOS codes (healthcare service categories). Notice the stark differences: California shows enormous spending on Other Drugs (O1E), while Georgia has concentrated spending on Ambulance services (O1A). Why these patterns matter: 1. Different patient populations 2. Varying Medicaid coverage policies 3. Different Medicare Administrative Contractors (MACs) and Local Coverage Determinations 4. Distinct provider coding patterns shaped by local practices 5. Regional fraud, waste, and abuse patterns that emerge locally before spreading nationwide Most ACOs focus their strategies on provider selection and care management. But how many factor in these fundamental utilization pattern differences? At falcon health, we're developing ACO-level reports based on regional exposures and spending patterns. Understanding your local landscape isn't just helpful – it's essential for ACO success. As we digest the 2024 MSSP results, it's time to rethink the strategies for the next year. Interested in a free ACO-level report for your region? Contact me, Neil Ahuja, or Prince Baawuah, DrPH, MPH, CSM® for more information. #ACO #Healthcare #Medicare #DataAnalytics #ValueBasedCare

The Centers for Medicare & Medicaid Services (CMS) has significantly expanded RADV (Risk Adjustment Data Validation) audits from about 60 plans annually to all 550+ Medicare Advantage plans, marking a new age of heightened regulatory compliance and oversight. At RAM Technologies, we assist Medicare Advantage plans in turning this scrutiny into opportunity. Our HEALTHsuite Advantage™ platform and BPaaS model integrate compliance, automation, and scalability across core operations—driving efficiency and strengthening audit readiness. Download our new white paper to learn how we're helping #healthplans stay ahead of the curve: https://lnkd.in/e--pkWrw #medicare #medicareadvantage #medicaid #saas #bpaas #healthcare #healthtech