3 IT-intensive Medicare Reporting Programs Few People Know or Talk About

The complexities  and overhead associated with implementing EHR’s, health insurance exchanges (HIX), ICD-10, health information exchanges (HIE) and ACO’s all get a lot of attention among those involved with health information technology. And there are a few other programs that many health care entities – mainly health plans and payers – have been scrambling to implement the last few years; all in an effort to comply with government regulations. 

Medicare STARS Measures

STARS is intended to help educate consumers on quality and help make quality data more transparent to Medicare enrollees. Stars ratings consist of over 50 measures originating from 5 different rating systems: HEDIS (Healthcare Effectiveness Data and Information Set) , CAHPS (Consumer Assessment of Healthcare Providers and Systems), CMS (Centers for Medicare and Medicaid Services) http://www.cms.gov/, HOS (Health Outcomes Survey), and IRE (Independent Review Entity).

   Learn more about STARS here.

Risk Adjustment & Reporting - Edge Server and 3R’s

Part of the ACA, the "3R's" program is designed to protect health plans against adverse risk selection and mitigate the impact of high cost membership. It’s required of those selling individual plans within and outside of the exchanges.  The mechanism creates substantial data collection and processing challenges.

   Learn more about 3R's here.

Coordination of Benefits Agreement (COBA)

The Coordination of Benefits Agreement (COBA) Program establishes a standard method of sharing enrollee eligibility data and Medicare adjudicated claim data between CMS and other health insurance organizations. It provides for the establishment of unique identifiers (COBA IDs) to be associated with each contract and creates a national repository for COBA information.

   Learn more about COBA here.

So What’s the Big Deal?

The above programs include complex data capture, processing and exchange requirements that are exacerbated by the need to collect data from disparate source systems - some of which are maintained by external business partners. Addressing the data access, quality assurance and data transfer challenges associated with these programs – while simultaneously addressing other mandates like health insurance exchanges, ICD-10 and health information exchanges is (HIE) and ACO’s – is a big deal; particularly in light of the dearth of knowledgeable, experienced resources.