Especially when it comes to the amount of documentation and compliance issues an insurance agent needs to deal with. Jeff De Los Reyes is a Senior Vice President of Healthcare Analytics and Risk Adjustment Solutions at GHG. In this capacity Tina leads the Compliance Solutions team and its engagements to ensure optimum solutions. WebSubject: 2021 Readiness Checklist for Medicare Advantage Organizations, Prescription Drug Plans, Medicare -Medicaid Plans, and Cost Plans . %PDF-1.7 % In her previous roles, Tina was responsible for compliance interpretation and implementation, member/marketing material review and submission, bid development and submission, internal audits and CMS audit preparation, implementing internal corrective action plans, and creating detailed trainings. Jean has analyzed policies affecting creation of the ACA Health Insurance Marketplace, Qualified Health Plans, and dual eligible initiatives. HEALTH CARE AUDITING & MONITORING TOOLS This checklist is intended to provide health care providers with a reference for use when responding to additional documentation requests for emergency ambulance transports. Every year, CMS releases an annual Readiness Checklist in an effort to remind Medicare Advantage (MA) Plan Sponsors of key contractual responsibilities in the upcoming plan year. A formulary is a list of medications that the plan covers. Compliance Program Policy and Guidance | CMS Ensure that you can afford any premiums and additional costs. Preceding CIOX, Eric spent 8 years at Optum implementing customized clinical consultative services for health plans. Here are facts to help you decide. License to use CPT for any use not authorized here in must be obtained through the AMA, CPT Intellectual Property Services, 515 N. State Street, Chicago, IL 60610. jlemasurier@ghg-advisors.flywheelstaging.com, cpawleymartin@ghg-advisors.flywheelstaging.com, eshapiro@ghg-advisors.flywheelstaging.com, jbeckett@ghg-advisors.flywheelstaging.com, amccreavy@ghg-advisors.flywheelstaging.com, jrogalla@ghg-advisors.flywheelstaging.com, cshortridge@ghg-advisors.flywheelstaging.com, jdelosreyes@ghg-advisors.flywheelstaging.com, krollins@ghg-advisors.flywheelstaging.com, This requirement was part of the Final Rule for Part D and. In this role, he leverages his extensive knowledge in information technology and organizational leadership to deliver technology, back-office operations, and re-engineering solutions to Medicare Advantage Prescription Drug (MAPD) plans across the United States Jim brings GHG clients more than 30 years experience aligning people, processes, and technology with business objectives. Her areas of expertise include compliance, applications, audits, readiness, delegation oversight, marketing materials, bid development, new plan implementation as well as appeal and grievance expertise. WebMedicare Benefit Policy Manual, chapter 15, section 80.6.1, state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation by the treating physician (e.g., a progress note) that he/she intended the Medicare Part D, Please see the Related Links section to view Medicare Advantage and Prescription Drug manual chapters and Program Audit related training. Enroll in the plan you choose, then pay your first premium. Her leadership skills allow her to effectively communicate across all organizational levels and enables those teams to reach consensus among diverse stakeholders to deliver better services for GHG healthcare clients. John Selby is a Senior Vice President at GHG Advisors, responsible for developing and executing growth strategies for GHG clients. Compliance and Enforcement | CMS - Centers for Share sensitive information only on official, secure websites. E"N*8Ypd' Contact GHG Advisors today to learn how we can help you be best prepared. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. Youll need to take additional steps if you want to enroll in other Medicare parts, such as Part C (Medicare Advantage) or Part D. However, if youre eligible for Medicare because youre turning 65 years old, youll need to take a few more steps. Contact GHG Advisors today to learn how we can help you be best prepared. You can learn more about how we ensure our content is accurate and current by reading our. Beth brings GHG clients more than 30 years of experience as a seasoned Medicare managed care professional as well as a knowledgeable resource in Medicare Advantage and Part D. Beth is certified as a Healthcare Compliance Professional (HCP) by Americas Health Insurance Plans (AHIP) Trade Association. She also was integral inadvising plans and employers on retiree options. In this role, she provides critical support and consulting services to clients in their market, as well as competitive and product analyses. Sponsors are also ultimately responsible for handling of sensitive beneficiary information including when it is processed by first tier, downstream and related entities (FDRs) and must report security and/or privacy breaches timely. Medicare certified? WebCMSrecommends that organizations review this checklist and take the necessary steps to ful fill requirements for the 2022 contract year. Before he joined GHG, David served as a health plan manager for commercial and Medicare lines of business for two national health plans, two start-up Health Maintenance Organizations (HMOs), and as a consultant to health plans, employers, hospital systems, and physician groups. AMA disclaims responsibility for any errors in CPT that may arise as a result of CPT being used in conjunction with any software and/or hardware system that is not Year 2000 compliant. Before GHG, Sandy served in multiple Compliance and Regulatory Affairs roles with responsibility for creation and implementation of compliance programs, delegation oversight, risk assessments, monitoring and auditing, and creation of P&Ps. WebMedicare Compliance identifies FDR status Vendor Oversight ensures initial FDR specific requirements are met Vendor Oversight and Medicare Compliance manage annual FDR auditing and monitoring Internal Audit conducts audit on FDR processes Vendor Oversight Committee reviews processes, auditing and prompts escalation to Compliance Officer She developed a diverse background by leading areas such as Membership Accounting, Fulfillment, Appeals & Grievances, and Star Ratings. 5 steps to help you get started with Medicare Determine when you can enroll. You can decide how often to receive updates. Youll generally be asked for proof of your age, work history, citizenship, and any military service. In addition, Cheri was integral to Centers for Medicare & Medicaid Services (CMS) audit activities, including universe preparation, performance monitoring and risk assessment, mock/actual audits, and sanction remediation. Gather any information and documents you might need. Audit Submission Checklist (XLSX) Audit Submission Checklist (PDF) 2022 MMP Audit Protocols And Data Requests (ZIP) 2020 MMP Audit Protocols And Data Also, applicable integrated plans should implement the integrated appeal and grievance processes and. Address: 100 SE 3rd Avenue, 14th Floor, Fort Lauderdale, FL 33394 | Phone: 202-364-8283. hbspt.forms.create({ Heidi received her MHA from the University of Maryland University College and her BS from the University of Connecticut School of Pharmacy. Jennifer Beckett is a Senior Consultant at GHG Advisors. If none of them work for you, you can select an Advantage plan without Part D, then purchase a separate Part D plan. Vanessas past careers in agent onboarding, sales reporting, and broker commissions have provided her with an excellent foundation for her work with GHG clients. Before Optum, Eric held leadership roles in Product Management and Network contracting at HealthFirst New York. Know that if you choose to enroll in Part D at a later date and go without Part D coverage, youll face a permanent late enrollment penalty. These steps will depend on how you become eligible, whether you already receive any kind of Social Security benefit, and which parts of Medicare you want to enroll in. In this role, she provides expertise to health plans regarding quality improvement, the CMS Quality Bonus Program, and Star Ratings improvement. Her diverse leadership expertise extends to managing people and leveraging team-building skills and situational leadership. Our website services, content, and products are for informational purposes only. Along with her many years of HEDIS and Star Ratings operational experience, she has expertise in developing and implementing CAHPS, HOS, and medication adherence improvement initiatives, as well as data analytics for member engagement, provider outreach, care management, and disease management. The ADA does not directly or indirectly practice medicine or dispense dental services. There, he led enterprise Product Development, managed the under 65 individual market prior to and following health care reform, and was responsible for Medicare Advantage, Part D and Medicare Supplement lines of business. DEPARTMENT OF HEALTH & HUMAN SERVICES Centers Eric led a regional consulting team focused on promoting provider engagement to drive the delivery of prospective programs. Compliance Checklist for Electronic Health Records Sandy Miller is a Senior Consultant at GHG Advisors. Debra Sullivan, Ph.D., MSN, R.N., CNE, COI, State Health Insurance Assistance Program (SHIP), Understanding Medicare enrollment periods, medicare.gov/sign-up-change-plans/get-started-with-medicare/join-a-plan/how-can-l-sign-up-for-medicare-and-choose-a-plan, medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans/how-to-join-a-medicare-advantage-plan, medicare.gov/sign-up-change-plans/get-started-with-medicare/year-1-your-medicare-checklist. WebThat's why we've created this simple checklist to help get you started. Patrick earned his Bachelors degree from the University of Cincinnati, and is certified by the American Association of Professional Coders. Medicare-covered sleep test that meets either: Apnea-hypopnea index (AHI) or Respiratory Disturbance Index (RDI) 15 events per hour with a minimum of 30 November 11, 2020 By GHG Advisors Every year, CMS releases an annual Readiness Checklist in an effort to remind Medicare Advantage (MA) Plan Sponsors of . WebN. Jessica is an accomplished nurse and brings clients over twenty years of diverse experience and achievement in managed care, quality improvement, and clinical care, in addition to strong Medicare, Medicaid, Marketplace, and Dual-Special Needs Plans (D-SNP) knowledge. Prior to joining GHG, Anita served as Director of Quality Assurance for a leading organization in a new industry of second-level review for appropriate hospitalization. In addition to his own consulting firm, Jim has developed and or managed more than a dozen health plans throughout his career. Offers the specific health care services I need, like skilled nursing services or physical Eric also directed coding services surrounding Medicare Risk Adjustment and Commercial/ACA coding initiatives. Decide whether you need Medicare Part A and Part B or just Part A. Anita brings GHG clients more than 38 years of experience in the healthcare industry. This included serving as the Director of Policy and Acting Director/Deputy Director of Operations and Regulatory Oversight. Home Health Agency Checklist - Medicare Documentation Checklists - JD DME - Noridian - Noridian Medicare You agree to take all necessary steps to insure that your employees and agents abide by the terms of this agreement. A. Access to Services and Information - Centers for Her professional background prior to GHG includes working for a large national health plan organization, a national Medicaid health plan, and two regional health plans. For example, if youre eligible through a disability that you receive SSDI for, youll be automatically enrolled in original Medicare (parts A and B) after 24 months of SSDI payments. IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK BELOW ON THE BUTTON LABELED "I DO NOT ACCEPT" AND EXIT FROM THIS COMPUTER SCREEN. John brings over 30 years of healthcare experience to GHG, including 15 years in Government Programs. Anne brings 30 years of progressive leadership experience in diverse ambulatory and cross continuum clinical practice arenas; population health management; care coordination and transition management; value-based care delivery; office practice management; patient safety; and quality and informatics. 404 0 obj <>/Filter/FlateDecode/ID[<2161110A8F0D66BCC774493327769234><096EADD629A2EC4DB634420EF351C498>]/Index[377 44]/Info 376 0 R/Length 128/Prev 323966/Root 378 0 R/Size 421/Type/XRef/W[1 3 1]>>stream Jeff received his MBA from the University of Connecticut and a Masters degree from Boston University. Jennifer Rogalla is a Senior Consultant in Compliance Solutions with GHG Advisors. Research Medigap and Part D plans in your area. She worked with the Compliance team on a variety of projects including mock CMS audits, focused audits, application and implementation assistance, gap analyses, marketing material review, and compliance program audits. KellyAnn created her own consulting company in 2004 and has been engaged in providing network development assistance to managed care organizations (MCOs). Effective 1/1/2021, admission notification requirements for MA DSNP plans meeting integration requirements for the notification of hospital and skilled nursing facility (SNF) admissions. formId: "9dc8a072-ea1a-4ce2-a35c-bf7d711ec7fc" Sponsors should carefully review the Checklist for regulatory changes and updates that may have occurred since the previous year. skip to content Thank you for visiting First Coast Service Options' Medicare provider website. A lock ( LockA locked padlock ) or https:// means youve safely connected to the .gov website. Beth Matel is Senior Director of Compliance Solutions at GHG Advisors. }); hbspt.forms.create({ CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. He has been responsible for a variety of turnkey health initiatives spanning the continuum from HIPAA compliance to operational managed care initiatives for Medicare, Medicaid, Marketplace Co-Ops, and Commercial throughout the country. Labcorp offers at-home collection kits for COVID-19 testing as an alternative to physical testing centers. The ACA also includes provisions intended to create a seamless, no wrong door, coordinated No matter how you become eligible for Medicare, there are some steps you need to take. hlK1K .B*8tt,-+BA?AB!Xp'_jry LLDBGtRd>Xs >h%w89&:V7 jA"~(39M;8cSpn%aY^S~8sY*))l0/,fFL>H jCFq t Summer Beach is a Senior Consultant at GHG Advisors. Measuring compliance program effectiveness is recommended by several authorities, including the United States Sentencing Commission. Patrick also authored a comprehensive provider documentation and coding education program that was launched at several integrated delivery systems across the country. She has held the role of Medicare Compliance Officer at a BCBS plan, with responsibility for the overarching Compliance and Regulatory Affairs program, which included building a delegation oversight work plan and chairing a Fraud, Waste & Abuse committee, the plans first formal Medicare Part D fraud program. In this role, she assists clients with sales-related program development, marketing materials analysis, and integrating regulatory guidance, to assure GHG clients initiatives have a strong foundation of compliance where required by the Centers for Medicare & Medicaid Services (CMS). Additionally, Jessica brings years of clinical, patientcare, and nursing experience in three states, working extensively with geriatric and disabled populations in a variety of roles including Director of Clinical Education and Manager of Alzheimers & Memory Care. This toolkit is part of the OIG's award-winning Health Care Fraud Prevention and Enforcement Action Team (HEAT) Provider Compliance Training initiative. click here to see all U.S. Government Rights Provisions, Home Health Documentation Checklist Tool, 26 Century Blvd Ste ST610, Nashville, TN 37214-3685. UnitedHealthCare of Texas (PDF) UnitedHealthCare Insurance Company, Texas (PDF) Current Status (as of April 8, 2016) The following states have notified CMS Use the PDF digitally or print it out as a reminder of all the things you need to be aware of. WebHandout: A Toolkit for Heath Care Boards This toolkit is part of the OIG's award-winning Health Care Fraud Prevention and Enforcement Action Team (HEAT) Provider Compliance Training initiative. Positive Airway Pressure (PAP) Devices - ResMed Prior to joining GHG, Jessica led the Medicare, Marketplace and Medicaid Star Ratings Programs and Quality Ratings Systems for an independent, nonprofit health plan in Minnesota, successfully achieving 4-, 4.5- and 5-Star Ratings for multiple Medicare and Marketplace contracts and product lines. How to join a Medicare Advantage plan. She brings expertise in Medicare Part D benefit administration, including Part D readiness assessment, payment validation, formulary development, and Centers for Medicare & Medicaid Services (CMS) Formulary Administration (FA) and Coverage Determinations, Appeals, and Grievances (CDAG) audit readiness. Official websites use .gov which documents: End Users do not act for or on behalf of the CMS. As a sales and marketing executive, Keitha drove a successful and sustainable $2 billion product suite serving Medicare, Individual, Small Group, and Federal Employee Program markets by developing new products and new sales distribution channels. These enrollment periods are specific to events in your life or to the parts of Medicare youre enrolling in. Prior to joining GHG, Roshan held several positions at Universal Health Care Group, including Senior Director of Medical Economics, where he oversaw the Effective Medical Management Committee, saving the company millions and included provider contract renegotiation and termination, utilization management program changes, benefit design changes, claims configuration and recoveries, and pilot programs. KellyAnn Laffey is a Senior Consultant of Network Development and Operations at GHG Advisors. Tina has also held management positions with several MAOs in the greater Los Angeles and Orange County markets. Jessica has been asked to speak at many national healthcare conferences on the topics of Star Ratings, social determinants of health, health plan operations, and beneficiary experience. She shares responsibility for leading GHGs efforts to advance the next generation of population health management and clinical innovation. While at GHG, Anita has guided plans in development and readiness for CMS audits, review of Models of Care and Chronic Care Improvement Programs. In this role, she manages client implementations and operational delivery of GHGs agent sales training, certification, agent oversight, and commissions platform, Sales Sentinel. Specific questions relating to Program Audits may be submitted at the following mailbox: part_c_part_d_audit@cms.hhs.gov. WebThis Accountable Care Organization (ACO) checklist identifies top issues to consider early in the due diligence and negotiation process, and can serve as a guide to the terms of 5 Steps to Getting Started With Medicare - The National Council You, your employees and agents are authorized to use CPT only as contained in the following authorized materials including but not limited to CGS fee schedules, general communications, Medicare Bulletin, and related materials internally within your organization within the United States for the sole use by yourself, employees, and agents. John and his wife, Gina, have four children and reside in Verona, N.J. Anita Green is a Registered Nurse with more than 30 years of health care experience, beginning her healthcare career in the U.S. Air Force. Apply for coverage along with your initial enrollment in Medicare. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. Prior to joining GHG, Jennifer was a CMS Account Manager at the Seattle Regional Office for nearly 10 years. Prior to joining the GHG team, Patrick was most recently a Manager within Optum Advisory Services. Summer holds a creative and positive approach toward team building, project management, education and fostering strong communication lines within all projects she participates. In this role, he is responsible for the execution and oversight of strategic projects across Government and State Sponsored Programs. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING.

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