HMA recently performed an assessment for a Medicare Advantage (MA) plan to analyze and measure the effectiveness of its Part D operations. This effort brought together HMA鈥檚 expertise in MA, Part D, pharmacy, quality and accreditation programs, on the ground leadership experience in health plans, and financial and actuarial expertise. The final report recommended a series of organizational changes and quality improvements to enable the client to optimize their Part D operations.
27 Results found.
Applied Behavior Analysis (ABA) Auditing Services聽
HMA鈥檚 team of expert behavioral health auditors from Crestline Advisors performs audits of behavioral health 杏吧视频, including applied behavior analysis (ABA) 杏吧视频, for a Medicaid health plan in Virginia (鈥渢he client鈥�). The client refers cases to HMA when there are allegations of possible fraud, waste, or abuse (FWA) concerning documentation and/or billing practices for these 杏吧视频.
ABA is an evidence-based behavior therapy for people with autism spectrum disorder (ASD) and other developmental disorders. In recent years, the diagnosis of ASD and subsequent demand for ABA 杏吧视频 has increased. State Medicaid administrations and Managed Care Organizations (MCOs) are tracking increased ABA utilization and wait times for these 杏吧视频, and in some situations are investigating quality of care and/or FWA concerns. Types of FWA concerning ABA therapy 杏吧视频 may include billing for 杏吧视频 not rendered, billing for ABA 杏吧视频 without documentation of ABA-specific interventions, billing for 杏吧视频 by unqualified individuals, or billing more units than the documentation supports, to name a few.聽
We have a deep bench of licensed behavioral health clinicians and coders with many years of experience in conducting audits for MCOs, state Medicaid administrations, and providers. Given our expertise, we understand the importance of the golden thread of documentation that should underlie billing, including assessments and treatment plans which identify the need for ABA 杏吧视频 and documentation of ABA service interventions, supervision, and family training.
State of Rhode Island: Advancing Health System Resilience Through Capacity Assessment
The Rhode Island Attorney General鈥檚 Office (the Office) engaged 杏吧视频 (HMA) to assess the current capacity of the state鈥檚 healthcare delivery system and identify policy considerations to ensure access, quality, and sustainability across hospital, long-term care, and primary care settings.
Amid growing public concern about emergency department crowding, long-term care access, and delays in primary care, the Office commissioned a statewide assessment to understand systemwide strain and inform proactive policymaking. The goal was to quantify key pressure points across care sectors and identify interrelated trends that affect patient access and outcomes.
A Revenue Cycle Management Success Story: Advanced Diabetes Supply/US Medical Supply
The Client
Advanced Diabetes Supply (ADS) acquired US Medical Supply (USMed), a Florida-based durable medical equipment provider, in 2021. At the time, ADS and USMed generated $400 million and $250 million in revenue, respectively. Over the next three years, the combined organization experienced rapid growth, reaching over $1 billion in annual revenue.
Background
While the top-line growth was significant鈥�59% over a three-year span鈥攃ash collections failed to keep pace. This created a classic case of an organization outgrowing its infrastructure. The foundational tools, technology, and operational structure simply weren鈥檛 in place to support the accelerated growth, particularly on the revenue cycle side.
Compounding these challenges were issues stemming from the integration of the two companies, including billing inconsistencies and reimbursement delays. USMed, like many in the industry, was severely impacted by the Change Healthcare ransomware attack, disrupting billing and collections operations nationwide. At the time this project began, USMed was facing a $40 million backlog in accounts receivable and struggling to meet payroll. The revenue cycle team was understaffed and overwhelmed.
HMA had previously performed a successful revenue cycle gap assessment at an ADS office in California. Based on those results, the newly hired CFO of ADS/USMed asked HMA to replicate the process for the Florida office. The goal: support the recently appointed VP of Revenue Cycle in stabilizing operations, implementing recommendations, and aligning practices to industry best standards.
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Strategic Expenditure Planning: Empowering County Government Agencies to Optimize Opioid Settlement Funds
The Client
The Lake County Behavioral Health Services Department and the residents of Lake County, California.
Background
In 2021, opioid manufacturer Janssen Pharmaceuticals along with three opioid distributors, McKesson, Amerisource Bergen, and Cardinal Health (collectively known as The Distributors) reached settlements for their roles in the opioid epidemic that amount to $26 billion. These settlements will be distributed to states that participated in the joint lawsuits. It is estimated that California will receive approximately $2.05 billion over 18 years to focus on opioid abatement activities within the state. As a participating subdivision, Lake County is set to receive a portion of California鈥檚 Abatement Fund and began receiving payments on November 15, 2022. The County will receive approximately $18 million over the course of eighteen years.
HMA was tasked with creating an expenditure plan for the opioid abatement settlement funds distributed to the Lake County Behavioral Health Services Department and the residents of Lake County. HMA facilitated community engagement to gather stakeholder feedback and align community priorities with the High Impact Abatement Activities (HIAA) and goals as defined by the California Department of Healthcare Services.
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Laguna Honda Hospital and Rehabilitation Center: A Comprehensive Assessment
The Client
Laguna Honda Hospital and Rehabilitation Center (LHH) is the largest publicly owned and operated nursing facility in the United States and has cared for those most in need for more than 150 years. Licensed at 780 beds, LHH serves patients with complex medical needs who are low or very low income as part of the San Francisco Health Network. 杏吧视频 (HMA) was engaged by the San Francisco Department of Public Health (SFDPH) to conduct a comprehensive, top-to-bottom assessment in support of its effort to attain Centers for Medicare & Medicaid Services (CMS) recertification.
Background
For this engagement, HMA brought together a team of experts with decades of national experience leading public health systems and organizations, including skilled nursing facilities. HMA鈥檚 subject matter experts included a long-term care physician specialist, a quality expert, long-term and acute care administrative and nursing.
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Helping North Carolina create a sustainable public health workforce
North Carolina Association of Local Health Directors Region 7 comprises seven Local Health Departments (LHDs) in north/central North Carolina. Participating counties include Franklin, Granville, Johnston, Nash, Vance, Wake, Warren, and Wilson representing 1.78 million residents. The Lead LHD for Region 7 is Granville Vance Public Health, a district health department which serves both Granville and Vance counties. Region 7 is representative of North Carolina in terms of county population, population density, and economic viability.
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Enabling county governments to plan for use of opioid settlement funds
Cabarrus County engaged HMA to support the development of a strategic plan that will guide the use of the County鈥檚 opioid settlement funds. In partnership with applicable cities and municipalities, the collaborative planning process provided opportunities to engage the community鈥攂oth professionals working in and around the opioid space as well as those with lived experience鈥攖o hear the needs of residents, understand current 杏吧视频 offered and existing strengths, and explore barriers to accessing care.
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Helping life science manufacturers navigate Medicare payment systems
The HMA Medicare team was asked to apply our subject matter expertise鈥攁nd access to Medicare
claims information鈥攖o provide a fully formed picture of the reimbursement process for this new
drug formulation. Our work involved researching other precedents and the implications of those
precedents for the reimbursement of this new formulation, as well as the existing product.
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Patient journey analysis for a new oncology drug
Bundled payment can serve as a disincentive to provide high-cost drugs, so the client was interested
in pursuing reimbursement policy options that would ensure appropriate reimbursement to these
facilities, thus ensuring patient access to the drug during the treatment regimen.
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Ensuring appropriate payment for transformative therapies to secure patient access to CAR Ts
CAR T therapies first entered the market in late 2018. These transformative treatments for certain
types of cancer involve modifying a patient鈥檚 own cells to fight the cancer鈥攑roducing a long term,
potentially curative response. Initially, CAR T therapy was administered to patients in the inpatient
hospital, where Medicare payments are bundled so that the hospital gets a single payment for the
entire hospital stay. The cost of the CAR T therapy greatly exceeded the payment rate the hospital
would receive, leading to concerns that hospitals would be reluctant to provide CAR T.
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New Mexico: Hospital Global Budgeting
The Client
The New Mexico Office of the Superintendent of Insurance (OSI) was directed by its state legislature to explore hospital global revenue budgets and other innovative hospital payment models over several years, and to explore key elements of affordability and accessibility of coverage and care, including hospital global budgeting.
Background
OSI contracted with HMA to build on previous hospital global budgeting research and provide technical assistance in resolving the complex issues surrounding global budgeting, including development of a potential global budget payment model framework. The contract also called for HMA to prepare an implementation framework that involves stakeholder engagement, including a plan for engagement with the Centers for Medicare and Medicaid Services (CMS) Innovation Center and to identify key administrative and data challenges.
Approach
HMA divided the project鈥檚 scope into two phases:
Phase 1
Develop preliminary policy and model options, including submission of two deliverables:
- Global Budgeting Principles and Experience in Other States Report
- Hospital Global Budget Options Paper
Phase 2
Refine the hospital global budgeting model based on OSI鈥檚 input on the Hospital Global
Budget Options Paper and develop and submit three additional reports:
- Recommendations for a Proposal to the CMS Innovation Center, which supports the development and testing of state-based innovative healthcare payment models
- Implementation and Stakeholder Engagement Plan
- Administrative and Data Challenges Report on implementing the payment model
Results
HMA developed an overview of principles and global budgeting models developed by other states, policy options, recommendations for how to work with CMS, a blueprint for stakeholder engagement, and an assessment of data needs and challenges. The proposed hospital global budget payment model was informed by the HMA team鈥檚 expertise and research on three states鈥� experience with CMS Innovation Center payment models (Maryland, Pennsylvania, and Vermont). The five public reports can be found at . These reports detail a plan for budgeting and governance that will enable the creation of a value-based payment system that supports a delivery system in which hospitals provide 杏吧视频 that their communities need, rather than focus on the 杏吧视频 most likely to merely enhance revenue. Through leadership and innovation, the state can help ensure a sustainable provider network is available to deliver high-quality and efficient care to all New Mexicans.
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