Description: This article describes methodologies for detection and deterrence of Medicare fraud. It also describes the validation of PRIDIT for fraud detection in Medicare.

Description: In the course of consulting engagements, actuaries almost always find they need one or more of the following resources: -Healthcare data, which may be at the individual patient level or on a particular population. -Health services research studies which describe, summarize, try to alter, or predict patients’ use of health resources. -Health policy information, which describe public or private actions which affect the access, cost and quality of medical care. This document describes the ever-changing resources and specifies where they may be obtained.

Description: Part 1 of a 2-part series exploring implementation issues for the Mental Health Parity and Addiction Equity Act of 2008 MHPAEA. Part 2 addresses the new enforcement safe harbor, how the regulations could impact the business of behavioral health care and the impending decisions for payors, employers, providers, and insureds.

Description: On average, contracts receiving their first star rating receive 3.20 stars, compared to existing or established contracts receiving 3.90 stars on average. This 0.70 disparity in quality ratings creates significant hardship on new contracts when this lower star rating decreases their payments in the following calendar year. This article explores the disparity in Medicare Advantage Star Ratings between contracts receiving their first star ratings (“New” contracts) and existing contracts, including: 1. Understanding what happens to Medicare Advantage Payments when contracts receive lower star ratings? – What is the Star Rating cliff and why does it matter to new contracts? 2. Explaining when a contract receives their first star rating and how much enrollment this requires – When does the Star Rating cliff occur? 3. Noting which specific star measures “New” contracts struggle with, including those contracts under large parent organizations, contracts with rapid growth, and all other new contracts. – How can my contract avoid the Star Rating cliff?

Description: Discussion and Opinion on how randomness affects measurement of provider contracting risk-sharing agreements

Description: This article on IPV focuses on IPV during the COVID-19 pandemic