Every Gen X’er listening to this is gonna be singing that Clash song in your head for the rest of the day. So, let’s turn our attention to Medicare Advantage policy. And on the show today, I grill the one and only Betsy Seals to find out which policies she thinks are going to stay and which are going to go.
For a full transcript of this episode, click here.
If you enjoy this podcast, be sure to subscribe to the free weekly newsletter to be a member of the Relentless Tribe.
Obviously, this is very much in the context of a new administration and also just other things that are going on. But today we talk about the following four “stay or go” policy areas.
Here’s the first policy area we talk about: changes and activities within the Stars program. How will the Medicare Advantage Stars program change or not? Not only with this new administration, but also there are lawsuits and how they will impact the goings-on moving forward.
Second policy, will it stay or will it go, that we talk about is risk adjustment and all of the activity in government oversight and focus on recoupment of improper payments as kind of the overarching bucket and what will be the incoming administration’s method around risk adjustment. This is certainly on many people’s minds.
The third “will it stay or will it go” policy that we discuss is the use of AI (artificial intelligence) by Medicare Advantage plans. What does the appropriate oversight of the use in AI look like? Lots of talk about those prior auth AI algorithms and the high levels of denied care.
A big topic of everybody’s collective mind is looking at how to ensure that oversight is appropriate and that we’re using AI for good and that it’s not having any adverse impact. So that’s the third will it stay or will it go.
Fourth, and lastly, the whole agent broker realm—additional CMS and government oversight over misleading or inaccurate information coming from the marketing or the agent broker marketing world. How will that look in 2025 and moving forward?
This last one, I’m kind of all over the nuance there after reading posts and comments by Samantha George, and I would recommend following her on LinkedIn would be my suggestion. I am reflecting back on the Ann Kempski episode (EP444), where we talk about the whole, really consider the downstream impact when making any policy changes, because there can be unintended consequences.
Now, in a show about carriers—in this case, Medicare Advantage carriers—I’d be pretty tone deaf not to mention the nation’s ire at carriers at this exact moment in time, some of it extremely well earned and some of it reflective of an extremely dysfunctional healthcare system.
I’d also be tone deaf not to mention the MedPAC (Medicare Payment Advisory Commission) report, which states that Medicare Advantage plans receive payments from CMS that are 122% of spending for similar beneficiaries in traditional Medicare. This translates to an estimated $83 billion in higher spending in 2024.
And I would lastly be remiss not to mention how Medicare Advantage plans are most carriers’ most profitable service lines, with average earnings of around $1800 per enrollee.
All of what I said is not some kind of grand revelation, of course, to most listeners of this show. And it’s also not the topic of the conversation today, although some of this did get asked and answered in the earlier shows (EP387, EP375, EP291) with Betsy Seals.
One thing I will remind everyone about is that there are regional carriers that are not the big five who may or may not be doing big five types of things. And also, it is actually really difficult to run a Medicare Advantage plan successfully. They call it risk for a reason.
One thing I really appreciated about the conversation with Betsy Seals that follows is her advice to contemplate value to the patient and make sure that anybody working on the carrier side, you have enough of a bead on what’s actually happening to be able to identify when things are going off the rails, which does not seem to be the case in some instances.
This also, by the way, having a bead on what’s actually happening on the ground, helps to ensure compliance and that’s piece of advice two.
Last piece of advice is to learn how to be proactive and not reactive. And this is eminently more possible vis-à-vis data that’s available and learning how to use it well.
Betsy Seals, my guest today, has had a very busy last couple of years since she was on Relentless Health Value the last time. Betsy is CEO and co-founder of Rebellis Group, a managed care consulting firm focused specifically in Medicare Advantage.
Rebellis was actually acquired in February of 2024 and joined as a family of a couple of other consulting firms that now Betsy heads up. So, in short, she’s really busy.
Also mentioned in this episode are Samantha George; Ann Kempski; Rebellis Group; and Vivian Ho, PhD.
You can learn more at rebellisgroup.com and alerionadvisors.com and by following Betsy on LinkedIn.
Betsy Seals is the CEO of Alerion Advisors, a family of companies dedicated to delivering unparalleled consulting services across the healthcare spectrum. As a parent organization, Alerion Advisors unites three specialized firms—Rebellis Group, Advent Advisory, and Toney Healthcare—to provide health plans and their partners with comprehensive, innovative, and results-driven solutions.
With over 25 years of experience in the managed care industry, Betsy is a nationally recognized leader known for her regulatory expertise and strategic insights.
Betsy brings to the table a solid mix of leadership and business acumen, as well as regulatory and strategic knowledge within the managed care landscape. Betsy’s expertise is focused in the areas of mergers and acquisitions, compliance, sales and marketing, strategy, supplemental benefit landscape, innovative benefit design that address social determinants of health (SDoH), and health plan operations.
05:09 Will the Star Ratings program stay in this new administration?
08:08 How will the lawsuits against CMS policies play out with this new administration?
10:24 Why is it hard for Medicare Advantage plans to survive, let alone thrive?
16:22 How does AI directly impact beneficiary lives?
21:38 What’s going on now with the override payments?
27:08 How is non-collaboration going to impact Medicare beneficiaries moving forward?
31:45 Why is it important to become more technologically savvy in compliance?
Recent past interviews:
Click a guest’s name for their latest RHV episode!
Wendell Potter (Encore! EP384), Dr Scott Conard, Stacey Richter (INBW42), Chris Crawford, Dr Rushika Fernandopulle, Bill Sarraille, Stacey Richter (INBW41), Andreas Mang (Encore! EP419), Dr Komal Bajaj, Cynthia Fisher
