Our Medicare Advantage Experts
Risk Adjustment
In the late 1990’s, Tom Peterson (CEO) and Pam Klugman (COO) were among the select few who contributed to CMS policy discussions in the initial phases of Risk Adjustment. They were responsible for developing Medicare Advantage Risk Adjustment processes and Best Practices for a large California health plan. Additionally, they were among the founding members of the Industry Collaboration Effort (ICE), and currently, Pam Klugman is co-chair for the ICE RADAR Team (Risk Adjustment Data and Reporting). Tom and Pam have spoken at CMS training conferences and Medicare Advantage/HCC conferences for the past decade. They have also worked with the US Department of Justice on Medicare Advantage fraud cases. They are nationally recognized as Medicare Advantage Risk Adjustment experts.
Tom and Pam play an active part in delivering CVInfosys’ Risk Adjustment, HCC Data Process Assessment and RADV Consulting Services. They achieve a thorough understanding of a client’s goals, and can propose numerous options for overcoming complex issues, taking into account best practices, budget and resources.
Tom and Pam have been involved in estimating mid-year and final settlements related to monthly changes in the RAPS return file. They also wrote a training manual for one of our clients on managing CMS or OFM Data Validation audits. Continually, they participate in national CMS calls and ICE think tank committees, and are always on the forefront of understanding how changes in the CMS risk model and data collection methods will impact the Medicare Advantage industry.
Regulatory Compliance
Donovan Ayers (VP of Compliance) has years of health plan and regulatory experience, dealing with CMS issues, HIPAA (Health Insurance Portability and Accountability Act), and OIG (Office of the Inspector General). As a result, he regularly provides expert consultative research, analysis, recommendations and process implementation.
Donavan’s has experience dealing with CMS on a number of regulatory issues due to his extensive involvement with the AHIP Medicare Industry Council, health plans, and numerous consulting assignments. He testified at the HHS subcommittee hearings on the Compliance Burden of the BBA, and for the Blue Shield of CA case that helped in the promulgation of changes in rulemaking within CMS. This involved Donovan managing a number of CMS audits and conducting routine monitoring visits and bid audits, including an OIG audit and dispute process with OIG and CMS. He has also assisted health plans in writing numerous Corrective Action Plans (CAPs).
Examples illustrate specific client or industry engagement
- Active representation of clients to CMS by replying in writing regarding discrepancies in final take-back dollars.
- Assisting clients with financial projections and identifying opportunities to submit additional member information to ensure right-sized CMS risk-adjusted revenue.
- Substantial, ongoing national involvement over the past 11 years with The Industry Collaboration Effort (ICE) as Co-Chairs of both the Risk Adjustment Data Acquisition and Reporting Team (RADAR), and the Contracting and Compliance Team.
- Ongoing contributors to ICE Clarification Request Log for CMS policy questions and interpretations.
- Ongoing inquiries and observations directly to CMS concerning policy.