Last medically reviewed on September 29, 2020. Preceding CIOX, Eric spent 8 years at Optum implementing customized clinical consultative services for health plans. 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. Her strategic planning and consulting services have been critical inputs for Medicare Advantage (MA) Plans and Prescription Drug Plans (PDPs), Medicaid managed care plans, pharmaceutical companies, and employers on legislation and regulatory impacts of changes in Medicare and Medicaid. Throughout her career, Cheris focus has been on streamlining operations to ensure cost-effective, compliant processes are in place, taking into consideration appropriate staffing levels, key controls, and automated solutions. Heidi Harmon is a Senior Consultant at GHG Advisors. Eric has extensive insight into risk adjustment activities including medical record retrieval, diagnosis coding solutions, encounter data submissions, provider engagement and suspecting analytics. Youll also need to provide Social Security and Medicare with some information that proves youre eligible. Kate earned her MSN and BSN from The Catholic University of America and a post-masters certificate from Duke University focusing on trajectories of chronic illness. Compliance, Privacy Policy | Terms & Conditions | Compliance, 2023 Precision Senior Marketing | 11940 Jollyville Rd #200 South, Austin TX 78759 | Phone: (800) 998-7715. Prior to joining GHG, Heidi was a consultant to CMS Division of Payment Validation as part of the team who develops the annual Part D payment error for Office of Management and Budget and Congress. The AMA is a third party beneficiary to this Agreement. Prior to joining the GHG team, Patrick was most recently a Manager within Optum Advisory Services. Make sure your doctor and other providers accept Medicare. portalId: "4332662", Secure .gov websites use HTTPSA Further, Jean served as Senior Advisor in the Employer Operations and Policy Group, implementing employer provisions of the Medicare Modernization Act. Anne earned her BSN from the University of Virginia, MSN from Jefferson College of Health Sciences and DNP from Loyola University, Chicago. Cheri holds a BA from Texas A&M University and a JD from Oklahoma City University School of Law. We avoid using tertiary references. WebCompliance Checklist for Electronic Health Records Introduction The implementation of electronic health records (EHRs) requires, in part, selecting the appropriate software and following applicable Federal and State privacy and security regulations and guidance. Jims career has included working with the Centers for Disease Control (CDC), Ochsner Clinic, Kaiser Permanente, Partners Health Plan, New West Health Plan, Cigna HealthSpring and Blue Cross and Blue Shield of Colorado. Jennifer is a proven collaborative leader with a technical and analytical background. Summer holds a creative and positive approach toward team building, project management, education and fostering strong communication lines within all projects she participates. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a)(June 1995) and DFARS 227.7202-3(a)June 1995), as applicable for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department Federal procurements. Especially when it comes to the amount of documentation and compliance issues an insurance agent needs to deal with.So weve put together a detailed 10 page checklist with interactive check boxes to help remind you of all the things that are required to remain compliant before, during, and after a sale. Tina has also held management positions with several MAOs in the greater Los Angeles and Orange County markets. Heidi was a benefit administration pharmacist for a large managed care organization before consulting to CMS. A .gov website belongs to an official government organization in the United States. lock John graduated from Seton Hall University and completed executive education programs at the University of North Carolina at Chapel Hill, Babson College, the Kellogg School of Management at Northwestern University, and the Center for Creative Leadership. Beth leads a team of highly-skilled Senior Consultants with a range of expertise, including the areas of Appeals & Grievances, Sales & Marketing, and Compliance. Medicare is available to Americans ages 65 or older and those who receive Social Security Disability Insurance (SSDI). With physical, occupational and speech therapy under review by Medicare auditors, its important to ensure the medical necessity of your services (With Payment Changes and Medicare Audits, Therapy Services License to use CDT-4 for any use not authorized herein must be obtained through the American Dental Association, 211 East Chicago Avenue, Chicago, IL 60611. It helps to be prepared with the information and documents you need to enroll before starting the process. The ADA expressly disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. .gov CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Youll need to take some actions when you first become eligible for Medicare. That's why we've created this simple checklist to help get you started. Public Health Emergencies and States of Disaster CPI Center for Program Integrity POEG/DEPO Provider and Enrollment Oversight Cheri brings GHG clients more than 10 years of experience in Medicare Advantage Operations. Apply for your selected Medigap plan and pay your first premium. These checklists include the documentation required for payment and retention of that payment in the event of a review by entities looking at documentation WebSupplier Requirements Checklist Organizations should use this checklist asatool to understand the requirements to enroll and maintain enrollment as MDPP suppliers. N(8QpxgHW)RYp>A1eY2e)S2$]~:nf#oj9:oeg`0BZ Emt The ACA also includes provisions intended to create a seamless, no wrong door, coordinated These actions will depend on why youre eligible for Medicare. CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CDT-4. }); hbspt.forms.create({ Instead, you must click below on the button labeled "I DO NOT ACCEPT" and exit from this computer screen. We've explained what you need to know about Medicare Part C. Here's help to understand what it covers, plan options, enrollment requirements, Medicare is the U.S. health insurance program for people 65 years old and over. She brings over 20 years of experience in healthcare and health plan innovations to GHG, including clinical strategy development, program development, implementation, start up and ongoing operations, and performance management/evaluation. Anita brings GHG clients more than 38 years of experience in the healthcare industry. David is also a database developer and has served as an expert witness on healthcare reimbursement. hlK1K .B*8tt,-+BA?AB!Xp'_jry LLDBGtRd>Xs >h%w89&:V7 jA"~(39M;8cSpn%aY^S~8sY*))l0/,fFL>H jCFq t CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Keitha Lackey is a Senior Consultant of Sales, Marketing and Strategy at GHG Advisors. 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. Patrick Petty is a Certified Professional Coder (CPC) with over 18 years of healthcare experience in the Managed Care/Payer setting. Many of GHGs clients have turned to Diane to provide marketing analysis, marketing and sales plan development, operational assessments of marketing, and marketing compliance and sales areas. 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. If you dont receive Social Security benefits, you should do the following: If youre considering a Medicare Advantage plan, you should: To get prescription drug coverage, you should: You can enroll in Medicare during certain times. Recently CMS requires plans to report any requirements where they are at risk or where technical assistance is needed. Jennifer brings GHG clients more than 20 years of experience as a HEDIS and health plan quality management professional, working with Medicare, Special Needs Plans, Commercial, Medicaid, and Exchange populations. 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 Jeff De Los Reyes is a Senior Vice President of Healthcare Analytics and Risk Adjustment Solutions at GHG. She developed a diverse background by leading areas such as Membership Accounting, Fulfillment, Appeals & Grievances, and Star Ratings. 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. CMS expects that Sponsors are utilizing the Checklist for the upcoming contract year. Prior to joining GHG, Cheri worked for a business process outsourcer as well as several health plans. 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. Erics efforts concentrated on project implementation and management, client development and RFP response. This means they dont cover costs from Medicare Part C (Medicare Advantage) or Part D. In fact, you cant have a Medigap and Advantage at the same time; you can only choose one or the other. An articulate interpreter of the complexities of todays healthcare environment, she navigates fluidly from strategy to execution and from the big picture to day-to-operations. The AMA is a third party beneficiary to this license. His responsibilities have included executive management (P&L responsibility), operational performance, new market development, nationwide plan expansions, governmental compliance, provider reimbursement strategies, network development, as well as staff and management training and mentoring. Is your MA Plan ready for 2021? (n.d.). She has experience with CMS audit preparation, mock audits, and application filing. 420 0 obj <>stream While at GHG, Anita has guided plans in development and readiness for CMS audits, review of Models of Care and Chronic Care Improvement Programs. Determine whether youll be automatically enrolled in parts A and B or will need to take additional steps. Sign up to get the latest information about your choice of CMS topics. In this role, she provides expertise to health plans and provider practices regarding Quality Improvement (QI), the Centers for Medicare & Medicaid Services (CMS) Quality Bonus Programs, Quality Rating System, and Star Ratings. Use the Home Health Documentation Checklist Tool to ensure you have all the following documentation you need! KellyAnn created her own consulting company in 2004 and has been engaged in providing network development assistance to managed care organizations (MCOs). ( Her areas of experience include Medicare and State clinical operations compliance, managed care, case and disease management, quality management and improvement, clinical practice, and government audits. This also included developing Value Based Payment and risk sharing arrangements. OIG has developed two toolkits that provide detailed steps for using prescription drug claims data to analyze patients' opioid levels to identify certain patients at risk of opioid misuse or overdose. 2. CGS has developed a new tool for home health clinical staff to use as a checklist of all the coverage criteria for the Medicare home health benefit. Official websites use .govA KellyAnn brings GHG clients more than 20 years of experience in provider network development, contracting, business development, Medicare Advantage (MA) Star Ratings assessments, and healthcare marketing. Most recently she assisted plans with process improvements for Star Ratings in appeal and grievances. Collaborating with other members of the GHG leadership team and across the Convey Family of Companies, John helps clients improve financial, clinical, and operational performance while generating enrollment growth in Government and State Sponsored Programs. This Agreement will terminate upon notice if you violate its terms. She was instrumental in the success of several major health plans being awarded contracts to operate provider networks across the country. Jim Clark is a Senior Consultant with GHG Advisors. The responsibility for the content of this file/product is with CGS or the CMS and no endorsement by the AMA is intended or implied. CPT is a trademark of the AMA. 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. New Home Health Documentation Checklist Tool. Check that your pharmacy is part of the plans network. means youve safely connected to the .gov website. 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. KellyAnn Laffey is a Senior Consultant of Network Development and Operations at GHG Advisors. Healthline has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. As a senior CMS official, Jean managed the $40 billion Medicare Managed Care programs for many years. BY CLICKING BELOW ON THE BUTTON LABELED "I ACCEPT", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THIS AGREEMENT. CDT is a trademark of the ADA. Here are facts to help you decide. Eric Shapiro is a Senior Director of Healthcare Analytics and Risk Adjustment at GHG. Share sensitive information only on official, secure websites. Healthline Media does not recommend or endorse any third parties that may transact the business of insurance. These enrollment periods are specific to events in your life or to the parts of Medicare youre enrolling in. Diane has published several articles providing marketing and sales guidance within the Medicare Advantage market. There are many advantages and disadvantages to Medicare Advantage. Cynthia is a Registered Nurse certified in Healthcare Quality and brings GHG clients more than 15 years of experience in the healthcare industry. Her background includes over 30 years of experience with Medicare and health insurance. Make sure both plans fit into your budget. Plans that may have implemented changes to their temporarily absent policies due to the public health emergency (PHE), allowing out-of-area members to remain enrolled, ends on 12/31/2020 or at the end of the public health emergency, whichever is earlier. 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. The purpose of this web page is to increase transparency related to the Medicare Advantage and Prescription Drug Plan program audits and other various types of audits to help drive the industry towards improvements in the delivery of health care services in the Medicare Advantage and Prescription Drug program. GHG conducts readiness assessments for its clients to help identify any areas of risk related to upcoming plan year preparedness. Pandemic Flu information. End User/Point and Click Agreement: CPT codes, descriptions and other data only are copyright 2009 American Medical Association (AMA). Vanessa offers a strong attention to detail and seven years of experience in sales operations and commissions with a competitive Medicare Advantage plan. Enroll in both plans and pay your initial premiums. OIG Toolkit to Identify Patients at Risk of Opioid Misuse Which steps you take will depend on the parts of Medicare you want and whether you already receive any kind of Social Security benefit. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. Sandy has also managed multiple regulatory affairs teams, assuring appropriate operational implementation to promote compliance with federal and state laws, rules, and regulations. 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. Federal regulations at 42 C.F.R. Apply for coverage along with your initial enrollment in Medicare. You may also want to research which Medicare parts you want and what coverage is available in your area before enrollment. click here to see all U.S. Government Rights Provisions, Home Health Documentation Checklist Tool, 26 Century Blvd Ste ST610, Nashville, TN 37214-3685. She and her husband have 5 children and reside in Roanoke, Virginia. Especially when it comes to the amount of documentation and compliance issues an insurance agent needs to deal with. The AMA does not directly or indirectly practice medicine or dispense medical services. This includes meeting: legislative requirements Posted by Applications are available at the AMA website. Please see the Related Links section to view Medicare Advantage and Prescription Drug manual chapters and Program Audit related training. Keitha received an MBA in Finance from Radford University and a BA in Communications from Virginia Tech. Her clinical experience includes critical care nursing in both military and civilian settings, case management, utilization review, discharge planning and diabetic nurse educator. So, if you turn 65 years old in April 2021, youd have from January 2021 through July 2021 to enroll. Miru provides invaluable support to the GHG Pharmacy team through her insight of operational implementation of CMS guidance and oversight. Jennifer is also highly skilled with CMS audit universe data validation, healthcare systems evaluation, vendor/software selection processes, software implementation, vendor management and oversight, healthcare claims data analysis, and data warehouse implementation. Official websites use .gov She also performed FA and CDAG audits and participated in a two-year review of federal agency pharmacy benefit formularies for CMS. This guide includes ways to measure the effectiveness of compliance programs. In the role of Senior Consultant, Stephen has assisted a number of clients in fulfilling provider network needs, including contracting relationships with hospitals, primary care physicians, specialists, and ancillary providers. You shall not remove, alter, or obscure any ADA copyright notices or other proprietary rights notices included in the materials. Heres how you know. WebCompliance Monitoring Checklist OIG Workplan Response Policies and Tools Faculty Practice Plan OIG Work Plan Policy OIG Risk Areas Worksheet BILLING & CODING Policy on Review of Compliance Concerns Related to Coding and Billing Revenue Cycle ReviewDraft Program Guide Procedure Coding of Outpatient and Physician Services With her varied background, she is able to work cross-departmentally to identify both opportunities and areas of risk. 5 steps to help you get started with Medicare Determine when you can enroll. 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 Anita has functioned in the role of hospital administrator for a 200+ bed hospital, also serving as a member of the senior leadership team and director of risk management with oversight accountability of patient advocacy, hospital security, and provider credentialing. She has worked across many clinical settings and lines of business, including Medicare Advantage, Chronic Condition Special Needs Plans, Dual Special Needs Plans, Medicare Shared Savings Plans, Medicaid, Commercial/Employee, and Exchange. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THIS AGREEMENT CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. Use is limited to use in Medicare, Medicaid, or other programs administered by the Centers for Medicare & Medicaid Services (CMS). %PDF-1.7 % Anne Jessie, DNP, RN, is the Senior Director of Population Health Management and Clinical Innovations. In some cases, such as if youre receiving Social Security retirement benefits, Social Security might already have this information; in other cases, youll need to provide it. This toolkit provides detailed information on methods to analyze telehealth claims to identify program integrity risks associated with telehealth services. Worth, Chicago, Philadelphia, and multiple sites in Florida. Applications are available at the, Applicable Federal Acquisition Regulation Clauses (FARS)\Department of Defense Federal Acquisition Regulation Supplement (DFARS) Restrictions Apply to Government use. Also, applicable integrated plans should implement the integrated appeal and grievance processes and. %%EOF There she was responsible for Medicare Advantage (MA) application review, and audit and oversight of MA plans and was part of CMS national teams who developed audit protocols and application requirements for Private Fee-for-Service contractors. yB. MPA`LuYSWERl^jjp}$yT%#].fqJsu"`,\euE8*L:x://wt[ }nS_.S=G d3 }); hbspt.forms.create({ She is a member of Upsilon Phi Delta Honor Society for academic achievement in healthcare administration and Phi Kappa Phi Honor Society for academic excellence. Please note, the checklists and information under this page may pre-date the Emergency Preparedness Final Rule and does not guarantee Pixel by LabCorp OnDemand Review for 2023, proof of citizenship, or permanent residency if you werent born in the United States, discharge papers or other records of any military service before 1968. We all need help remembering tasks that need to be completed throughout the week. Offers the specific health care services I need, like skilled nursing services or physical Know that Medigap plans apply only to Medicare parts A and B coverage. Contact GHG Advisors today to learn how we can help you be best prepared. Sandys core competencies include compliance program development and oversight, risk management, monitoring and auditing, policy and procedure (P&P) development, regulatory affairs, product implementation, Pharmacy Benefit Manager (PBM) operations, and Centers for Medicare & Medicaid Services (CMS) audit preparation. Compliance Risk Analysis 3. These are steps to take a few months before your enrollment to help you prepare: Medicare includes five main types of benefits, including: If you already receive Social Security benefits, youll be automatically enrolled in Medicare Part A (hospital insurance) and Medicare Part B (medical insurance), also called original Medicare. He has directed start-up operations for companies desiring to enter the Medicare Advantage market as well as service area expansions of existing plans. Healthline Media does not transact the business of insurance in any manner and is not licensed as an insurance company or producer in any U.S. jurisdiction. His Medicare operations and technology experience has been applied to recent projects including technology readiness assessments, designing shared services environments, providing systems integration strategies, best practice business process improvements, and knowledge transfer to Medicare Advantage plans. Prior to her role at GHG, Tina held a management position with a SNP where she was responsible for the organizations day-to-day Medicare operational compliance. David Giles is a Senior Consultant at GHG Advisors. You can do this online by creating a. Jean has analyzed policies affecting creation of the ACA Health Insurance Marketplace, Qualified Health Plans, and dual eligible initiatives. These checklists include the documentation required for payment and retention of that payment in the event of a review by entities looking at documentation today and in the future. Prior to joining the Sales, Marketing, and Strategy Practice, Angela was a noted member of GHGs Compliance team. Cheri Shortridge is a Senior Consultant at GHG Advisors. Sponsors should carefully review the Checklist for regulatory changes and updates that may have occurred since the previous year. Eric led a regional consulting team focused on promoting provider engagement to drive the delivery of prospective programs. Anita has a proven track record in developing various quality assurance programs, public health online web-base, and written educational tools. This requirement is only for applicable integrated plans. formId: "6f7931e5-48a9-40f1-a779-cbb12a286395" You acknowledge that the ADA holds all copyright, trademark and other rights in CDT-4. 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. Sandy Miller is a Senior Consultant at GHG Advisors. David brings GHG clients more than 30 years of healthcare experience encompassing new market development, management, operations, and consulting for Medicare, Medicaid, commercial, and employer health plans. Our website services, content, and products are for informational purposes only. In this role, he is responsible for the execution and oversight of strategic projects across Government and State Sponsored Programs. Youll take some of these actions during your enrollment window and others during your first year of Medicare membership. This included serving as the Director of Policy and Acting Director/Deputy Director of Operations and Regulatory Oversight. Prior to joining GHG, Cynthia served as Director of Star Ratings for a leading organization and has held numerous positions in Quality and managingHEDIS for multiple products in the managed care arena. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. WebBefore using the self-audit checklist, gather the following information and review the documentation: Licensespharmacist, intern, and technician; Pre-hire screening and Jean was also a professional staff member on the U.S. Senate Finance Subcommittee on Health. She leads the Clinical, Pharmacy, Stars, and Network practice areas. 377 0 obj <> endobj Tina has also held management positions with several MAOs in the greater Los Angeles and Orange County markets. Cynthia comes with a solid record of success leading and supporting QI programs across healthcare delivery systems, including health plans and large physician practices. Health plans and providers look to Jeff to provide consulting services to ensure superior outcomes related to revenue accuracy and compliance across all Government and State Sponsored Programs. In this role, she provides expertise to health plans regarding quality improvement, the CMS Quality Bonus Program, and Star Ratings improvement. The ADA does not directly or indirectly practice medicine or dispense dental services. Keitha brings GHG clients over 20 years of health insurance leadership experience across sales and marketing, product development, and operations. Prior to joining the GHG team, Jeff led a team responsible for enterprise risk adjustment, revenue management and encounter data submissions at EmblemHealth. No fee schedules, basic unit, relative values or related listings are included in CDT-4. 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.
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