Podcasts about risk adjustment

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Play Episode Listen Later Apr 21, 2023 60:06

CDPHP, Johns Hopkins Medicine, Priority Health, ATRIO Health Plans and Vatica Health share successful strategies and best practices for provider-centric risk adjustment programs, which enable health plans to enjoy higher compliance, enhanced quality of care, improved risk score accuracy, higher Star and quality ratings and better financial performance. Learn how your plan can empower physicians to close care gaps, avoid common pitfalls and maintain compliant record documentation proactively. Panelists: Gregg Kimmer, President & CEO, ATRIO Health Plans; Michelle Ilitch, MPH, Vice President, Vice President of Network Solutions and Value-Based Programming, Priority Health,; Colleen Gianatasio MHS, CPC, CPC-P, CPMA, CRC, CPCO, CDEO, CPPM, CCDS-0, CCS, and AAPC Approved Instructor, Director Clinical Documentation Integrity and Coding Compliance, Capital District Physician's Health Plan (CDPHP); Frank Shipp, FACHE, MBA, Executive Director, Johns Hopkins Clinical Alliance, Johns Hopkins Medicine; Hassan Rifaat, MD, CEO, Vatica https://www.sharedpurposeconnect.com/events/boosting-plan-performance-improving-provider-centric-risk-adjustment-staying-compliant/ For more information on our Payer & Provider Roundtable Summit: https://brightspotssummit.eventbrite.com This episode is sponsored by Vatica Health Vatica Health is the #1 rated risk adjustment and quality of care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge technology, Vatica increases patient engagement and improves coding accuracy and completeness. It helps identify and facilitate closure of care gaps and enhances communication and collaboration between providers and health plans. The company's unique provider-centric solution helps payers, providers and patients achieve better outcomes, together. Vatica is trusted by many leading health plans and thousands of providers nationwide. Healthcare research firm KLAS named Vatica “Best in KLAS” for risk adjustment in 2023. KLAS also named Vatica to its Emerging Solutions Top 20 list for innovative companies that have the greatest potential to impact and disrupt the healthcare market. For more information, visit VaticaHealth.com.

2024 Advance Notice: Proposed Changes to the Medicare Advantage Risk Adjustment Model

Business Better

Play Episode Listen Later Mar 21, 2023 34:45

In this episode, we discuss the Centers for Medicare and Medicaid Services' proposed changes to the Medicare Advantage risk adjustment payment model, which will take effect in 2024 if finalized. We're joined by special guest Alex Oliphant, Director of Berkeley Research Group's Health Analytics practice, who has extensive experience in the workings of the Medicare Advantage payment model. Phil Legendy, Of Counsel in Ballard's New York office and a member of our Health Care Group, hosts the discussion.

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Probing the ICD-10 Impact on CMS-HCC Risk Adjustment

Talk Ten Tuesdays

Play Episode Listen Later Mar 21, 2023 31:36

Are there significant risks of potential fraud and abuse with Medicare Advantage (MA) by plans, vendors, and providers, with an emphasis on ICD-10-CM's impact on Centers for Medicare & Medicaid Services Hierarchical Condition Category (CMS-HCC) risk adjustment?Evidently, the Office of Inspector General (OIG) for the U.S. Department of Health and Human Services (HHS) believes there are. Recently, Christi A. Grimm, Inspector General, issued a statement in which she addressed the concerns of the federal watchdog agency.In response to her speech, we invited Dr. James Kennedy, a 20-year veteran in clinical documentation integrity (CDI) consulting and a popular panelist, to share succinct advice on how a compliance plan can best prepare for OIG audits that are sure to come. Programming note: Invite your compliance teams to hear what promises to be the best four minutes applicable to this challenge, during the next live edition of Talk Ten Tuesdays.The live broadcast will also feature these other segments:Coding Report: Laurie Johnson, senior healthcare consultant with Revenue Cycle Solutions, LLC, will report on coding colorectal cancer.SDoH Report: Tiffany Ferguson, a subject-matter expert on the social determinants of health (SDoH), will report on the news that's happening at the intersection of coding and the SDoH.News Desk: Timothy Powell, CPA, will anchor the Talk Ten Tuesdays News Desk.TalkBack: Erica Remer, MD, founder and president of Erica Remer, MD, Inc. and Talk Ten Tuesdays co-host, will report on a subject that has caught her attention during her popular segment.

Ep 18: Dr. Jeffrey Kang on CVS/Walgreens' Role in Healthcare and The Future of Risk Adjustment and Senior Care

Vital Signs

Play Episode Listen Later Mar 16, 2023 39:11

Jacob and Nikhil sit down with Dr. Jeffrey Kang, CEO of WellBe Senior Medical, and former President of ChenMed, SVP Health and Wellness Solutions at Walgreens, CMO at Cigna, CMO at CMS and CEO of Urban Medical Group. They discuss risk adjustment, retailers in healthcare and how healthcare has/hasn't changed since his work doing risk-based care for complex patients and at CMS in the 80s and 90s.

Ep. 37 "Best of" Episode: Optimizing Risk Adjustment

Medical Advantage Podcast

Play Episode Listen Later Feb 21, 2023 30:17

Optimizing Risk Adjustment is one of our most downloaded episodes. In case you missed it, we are running it once more. Tune in for a conversation with two of Medical Advantage's very own risk adjustment experts, Angela Hale and Kyle Enger, to learn more about what risk adjustment in healthcare is, how it works, and strategies for optimizing risk adjustment. Topics include risk scores, the importance of capturing a population's score accurately, the meaning behind acronyms like HCC, RAF, RADV, and more – not to mention the way Medical Advantage's consultants are working hand-in-hand with organizations today to optimize their risk adjustment techniques. Have questions? Email us at info@medicaladvantage.com for more information. Thank you for listening to the Medical Advantage Podcast, where each we take time each episode to discuss the ideas and technologies changing healthcare, and the best practices your organization can take to stay productive and profitable. Subscribe wherever you get your podcasts to ensure you never miss an episode.

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Consultants Corner: Risk Adjustment Audits and the Costly Nature of Nuances in Coding

MGMA Podcasts

Play Episode Listen Later Feb 15, 2023 21:02

This episode features MGMA independent consultant Rhonda Buckholtz. Rhonda talks about her consulting experience as well as her thoughts on risk adjustment audits and the costly nature of nuances in coding. Resources: MGMA Consulting: https://www.mgma.com/consulting/overview Rhonda Buckholtz LinkedIn: https://www.linkedin.com/in/rhonda-buckholtz-28305a7/ Sponsors: Humana: The latest Value-Based Care Report from Humana outlines many interesting findings and highlights how some physician practices found creative paths to success. Check it out now at Humana.com/VBC. Humana is working closely with physician practices on their value-based journeys. MGMA Events: This episode is brought to you by the Medical Practice Excellence: Financial and Operations Conference 2023, which will be held in Orlando, FL, March 19-21. During our premiere spring event, attendees will gain key insights from both disciplines and learn about topics that shape the future success of medical practice organizations. Go to mgma.com/mpe23 to learn more and to register today. If you would like additional tools and resources related to medical practice leadership email us at podcasts@mgma.com. Thank you again for taking the time to listen to MGMA's podcast network. If you have opportunities you'd like to share with the MGMA audience, go to www.mgma.com/marketing-with-mgma/advertise to find out how you can connect with the MGMA audience.

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CMS to Finalize Major MA Risk Adjustment Rule + More

Becker’s Payer Issues Podcast

Play Episode Listen Later Jan 31, 2023 4:51

Tune in for today's industry updates.

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"North Star" 12.20.22

north star david meyer risk adjustment

Play Episode Listen Later Dec 21, 2022 14:27

David Meyer joins Lance to discuss the importance of having internal audit policies for Risk Adjustment and how multiple departments stakeholders and leaders need to be involved in these conversations.

2022 Health IT Recap and Look forward to 2023

The Dish on Health IT

Play Episode Listen Later Dec 8, 2022 48:09

Pooja Babbrah, Pharmacy & PBM lead with Point-of-Care Partners (POCP), NCPDP Board of Trustees Chair, and host of The Dish on Health IT kicked off the episode. This last episode of 2022 featuring POCP Regulatory Resource lead, Kim Boyd and Payer & Provider Practice Lead and Da Vinci Program Manager, Jocelyn Keegancame together to break down all the big things that have happened in 2022 and what we expect for 2023. Pooja explained that while this episode's discussion will primarily be policy related, the panelists will also talk about some of the real progress being made in the standards world and the interconnectedness between federal and state health IT policy and legislation and between standards and policy, and what it means to the industry. Pooja asked Jocelyn and Kim to briefly introduce themselves and to tell the audience what topics they are most excited about discussing. Jocelyn introduced herself as the POCP payer practice lead, devoted to positive change and building/getting stuff done. She went on to say that her focus at POCP is on interoperability, prior authorizations, and the convergence of tech, standards, and product strategy. She explained that she has spent her career moving people and organizations towards APIs, unleashing data for their highest, best-purpose uses. She expressed that she couldn't be more excited about where we've been this year and the precipice of where we are headed next year.Kim expressed that it's always a pleasure convening with Pooja and Jocelyn to discuss the exciting world of health IT. She went on to share her background which has spanned medical and pharmacy operations and implementations, with years of policy, industry, and standards development work on ePA, cost transparency, ePrescribing, and taking what she learned in these areas to work with policymakers on smart policies to advance interoperability and patient care. Kim stated that it has been an exciting year leading POCP's Regulatory Resource Center and that so much is happening in the state and federal regulatory spaces that ties to the innovations and acceleration the industry has been experiencing in health care. Pooja thanked them both for their introductions and then dug into the discussion by asking each of them to share the biggest Health IT highlights of 2022. Kim explained that four things really stand out in 2022:the requirements of the transparency in coverage and no surprises act going into effect and the various provisions requiring data and cost transparency and giving patients and their care teams access to information that will help them make informed decisions. Many in the industry have been clamoring for transparency of this type for some time.The incredible work happening to advance interoperability via the SDOs and Accelerators, like HL7 Da Vinci, CodeX, FAST, and NCPDP's Pharmacy Technology and Innovations group. how Federal agencies are collaborating on aligning requirements for interoperability, like the use of standards and FHIR-based standards specifically. This collaboration and proceeding regulatory action will help align the technical and interoperability stars. the all-hands-on-deck focus on patient health equity is a big area of concentration for not only innovators in the market but the White House, HHS, standards organizations like NCPDP and HL7, and community and public health organizations. There is just so much happening to try and close gaps in equitable care and the data/digital transformation that needs to happen to help facilitate change. Jocelyn followed Kim to share her perspective on the biggest highlights of 2022 first joking that Kim got to go first and steal some of the things she was going to say.She laughingly shared that she agrees with all of Kim's points and then said that she wanted to focus more on the tone and the tenor of the work happening in the industry. Jocelyn shared that from her perspective it feels as though the industry has moved from thinking about interoperability projects as something that will happen "someday" to action and reality. She clarified that this may not be the case for everyone, but many organizations and projects are moving forward to not only do the IT work but the business transformation. The examples she gave included the real progress made on TEFCA, real-world deployments of FHIR guides, live usage of APIs, prior authorization (PA) on pharmacy getting an infusion with last year's Medicare Part DJocelyn added that she wanted to focus on and add to Kim's comment about coordination at the federal level. She explained that policymakers at the federal level have been working for well over a decade and using their levers to make change extraordinarily well. Jocelyn went on to say that as she sees it there are three camps of folks; people and organizations who are working ahead of policy by paying attention to published roadmaps and reading between the lines of public statements, folks trying to get their organizations prepared to respond to the next wave of policy, and others playing the waiting game to see if it's real and if they'll have to follow or if another path will emerge. Finally, she added, that the last highlight from 2022 is all the waiting! The industry keeps waiting for certain regulations to drop. She explained that she doesn't think she remembers another year where there has been this much policy anticipation at year-end. Pooja thanked Jocelyn and Kim for sharing their perspectives. She shared two important topics that have been more under the radar but are growing in importance and focus. The first is consent, specifically eConsent. Stewards of change published the report “Modernizing Consent to Advance Health and Equity” to bring more attention to the need to solve this issue – not only in the context of healthcare but also social services as those are such an important tie-in to health outcomes. Add to that, the ONC half-day discovery workshop on eConsent. Pooja explained to those who may not have attended – that it was an amazing session that brought together so many different people across the continuum of care in addition to the people working in the social services arena.The other area is pharmacy and the growing role of pharmacists in the care team and the work that is being done to ensure that they have access to more data and information to support care teams and support patients. Pooja explained that there has been a lot of movement by retail chains to add primary care services to their offering and community pharmacies are supporting more clinical services. This has led to more focus and a flurry of discussion around interoperability in the pharmacy space. Pooja gave the example of the Health Information Technology Advisory Committee (HITAC) recently proposing adding a pharmacy-focused subcommittee which is a huge indicator. Pooja shifted the discussion to policy highlights, specifically, requirements that went into effect and whether the industry met the deadlines or is still working on it. She explained that she is thinking specifically of: No Surprises ActTransparency in Coverage RuleInformation BlockingKim jumped in by saying that with the No Surprises Act there is still some pushback and uncertainty about how providers are going to comply with having to pull together all the data to provide Advanced EOBs (AEOBs) and good faith estimates (GFEs) when there are multiple providers involved in delivering the expected care; however, the Da Vinci Project is working on advancing implementation guidance to support patient cost transparency. Kim encouraged folks and organizations listening to this episode to get involved in these efforts. Kim added that she expects to see more price transparency-related policies, especially given the latest request for information on AEOBs. Kim went on to say that compliance with the ONC 21st Century Cures Final Rule on information blocking has been a mixed bag. She added that she wished ONC had called this "information sharing" instead of information blocking. Kim went on to say that most of the non-compliance has been on the provider side because it is challenging when a provider falls under the rule as an actor but maybe the health system they work in does not, especially when the health system may hold the data being requested. She added that most of the EHRs have spoken with are up-to-speed on the full EHI sharing requirement. Jocelyn added her perspective on information sharing specifically around EHI. Technically all of this information needs to be put out there, while the industry waits for USCDI to fully encapsulate patient information, there is probably a lot of non-codified data in the system that isn't actionable or really useable. The EHR certification requirements will likely do more to move the industry forward. Jocelyn confessed that she fell down the RFI response rabbit hole and spent an hour looking at the feedback to the RFIs. She thinks there is a disconnect between the goal of the rule and how to operationally do the work. An example she provided was around PA and that it isn't automating the submission of the PA alone but how to automate the 10 steps that need to happen before a PA is submitted. Pooja shifted the conversation to ask Kim to talk a little about the state activity around price transparency and why it's so important for stakeholders to pay attention not only to federal policy but what's happening in the states.Kim agreed that so many organizations forget that state policy is a big part of the equation too. She shared that on the data and cost transparency side, states doubling down to move the needle on data fluidity. The POCP Regulatory Resource center has its finger on this pulse. From the required patient-specific cost, benefit, coverage, and eligibility data sharing to confirmation of compliance enforcement of the No Surprises Act and Hospital Transparency, just to name a few.Pooja concurred and added that many people forget the states can add enforcement teeth above and beyond federal enforcement. She then remarked that this has been a year of anticipation and asked Kim to share where the burden reduction and prior authorization rule that was shelved back in 2020 is currently. Kim responded by explaining that there has been so much anticipation and even angst for some when the original rule came out in 2020 but then was pulled back.So many in the industry have been endeavoring to fulfill the promise the Da Vinci CRD, DTR, PAS IGs provide on solving for medical PA. Probably the most promising sign from CMS is the rule sitting at OMB since mid-October, waiting for review and then ultimately release. Given OMB has a max of 90 days to take action on the review, health plans, vendors, providers, and their partners should be closely monitoring for OMBs response and action. Jocelyn joined in to say that the rule that came out in 2020 was definitely more than just burden reduction and it would have codified the use of patient-access APIs. She added that the 2020 rule didn't just require FHIR but named a particular implementation guide or "recipe" for the industry to use. Jocelyn anticipates that the version of the rule that has reemerged and is sitting with OMB likely includes Medicare Advantage plans which weren't included in the 2020 version. She's really interested to see what the NPRM will include. Jocelyn added that there is legislation pending that includes prior authorization and many are hoping the proposed rule drops before the legislation passes. Pooja thanked Jocelyn for bringing up the pending legislation and then moved on to ask about the recent CMS requests for information out there. She asked about what kinds of questions is the government asking and what do these questions tell us about where their heads are at? Jocelyn started by saying that the industry is seeing an unprecedented amount of coordination and policy-making activity. It has been a challenge to marshall the resources to respond to these RFIs and participate in the conversations and discussions these RFIs generate. Clearly, the industry is leading and the RFIs are an indication that CMS and ONC want industry input into their policymaking. Jocelyn went on to say that after reviewing the comments to these RFIs, the common themes were that the industry needs time and an incremental approach is needed but no one is saying what is being explored can't be accomplished. Kim added that she was struck by how aligned the agencies releasing these RFIs seemed to be on solving for interoperability, digitization, using/reusing or referencing FHIR resources for use and across different areas of health care, from the public health infrastructure, TEFCA, Certification of HIT, PAs and more, even the RFI from CMS related to the National Directory wants to hear from health care on the applicability of the use of FHIR standards. In transition, Pooja remarked that POCP and everyone on the podcast work in the standards development space through the support of some of the Accelerators like FAST, CodeX, CARIN Alliance, and of course, Da Vinci. She asked for the discussion to now cover the biggest accomplishments so far and what's expected in 2023. Kim responded by saying that while not officially announced, the CodeX PA in Oncology Use case – focused on solving for automating PA for cancer patients using the Da Vinci IGs is progressing to the Execution Phase. Members represented in this use case are payers, EHRs, physician groups, and health systems and they have collaboratively moved the needle on this use case and will execute the proof of concept for prostate cancer in 2023. Kim added that she is proud that NCPDP for their October Pilot launch announcement of the National Facilitator Model to strengthen pandemic and epidemic preparedness using industry standards and technology to enable pharmacies, prescribers, and government agencies to access real-time information on prescription, testing, immunization, and related data – across state lines - to support patient health interventions during public health crises. The model can also be used to effectively support public health surveillance.Jocelyn chimed in to express her awe at the pace of work on IGs and new use cases. She added that another big milestone is that FHIR at Scale Taskforce (FAST) transitioned out of ONC into the HL7 Accelerator program. FAST progressed work on Security, Identity, and Exchange and they are pulling the TEFCA team in to align their work. She added that Da Vinci has made a lot of progress on Risk Adjustment, allowing payers and providers to share information to inform a change in a patient's risk status. Jocelyn went on to say that there are also some exciting real-world implementations happening with a specific shout out to the team comprised of MultiCare, Providence, Regence, leadership from Optum, and Da Vinci champions launching the first in the nation FHIR-based pre-authorization embedded into the clinical workflow. Pooja seconded the kudos for the NPCPD vaccine pilot and she also mentioned the CodeX REMS use case which is marching toward a pilot and is once again bringing NCPDP and HL7 together. Pooja went on to recognize Helios as an Accelerator that is starting to gain traction and the industry should pay attention to their work. Pooja commented that while price and cost transparency for the patient will always be a passion of mine, the growing role of pharmacists in the care team is another area she is really excited about. Additional services are being performed by pharmacists, the prescribing authority is being extended to pharmacists, and the need for standards and technology to enable clinical data to flow from pharmacists to care team members in other environments like doctors' offices and hospitals. Pooja continued by saying that the pandemic and really the Federal PREP act accelerated this movement. Now pharmacists can administer pretty much any vaccine on CDC's list, and there are around 25 states that allow pharmacists to prescribe HIV medications. Pooja explained that this expanding role and some of the regulatory requirements make pharmacy interoperability and connection with the rest of the care team critical. For example, for pharmacists to prescribe Paxlovid, they must order or access labs for the patients. Unless pharmacists are in a health system they will likely not have access to a patient's lab report. If the industry wants pharmacists to continue to support providers and patients with more clinical services – there has to be a focus on interoperability. Kim agreed that it is an exciting time for the pharmacy community. The need for clinical and administrative data access, use, storage, and exchange to improve and coordinate patient care knows no boundaries – the whole of the care team, including the pharmacist, must be able to operate in an environment where this takes place. Kim added that the NCPDP Strategic Planning Committee Value-Based Care Subcommittee acknowledged that the industry is well positioned to support pharmacists as a part of a value-based arrangement and we have the standards to support all types of clinical care and exchange so pharmacists can provide services like dispensing, screening for Social Determinants of Health or taking and reporting labs or blood pressure, etc. 2023 will be filled with opportunities within the NCPDP standards development process, the industry, and policy, to further the role of the pharmacist, closing gaps in care and the innovations needed for the future of pharmacists as part of the care team.Pooja asked to do a round-robin weigh-in on TEFCA, HIPAA 2.0, and Health Equity. What's new, what's real, and what should our listeners be on the lookout for in 2023? Jocelyn responded by saying that each of these topics has so many sub-topics and what will be interesting is to see how these all intersect with one another. She added that there is a movement to the platform where companies are partnering to solve some of the challenges related to these areas and make data fluid but secure. Kim responded by saying that there is still confusion and conflict between HIPAA and the ONC Information blocking rules. Technology has evolved and new interpretations and requirements are needed that provide patient data security without limiting data sharing. The industry will see some movement from OCR in 2023.TEFCA is real and moving forward in establishing the infrastructure model and rules that will govern how different networks and their stakeholders (including providers, payers, and public health) securely share clinically relevant information with each other. Nine organizations have provided letters of intent to the Sequoia Project, the recognized coordinating entity on behalf of ONC, to apply to become QHINs including EHR vendors such as Epic and Nextgen, national networks such as the eHealth Exchange and the CommonWell Health Alliance, and tech vendors such as Health Gorilla. More organizations are expected to apply. It will be interesting to see how successful TEFCA will be in incorporating FHIR into the framework over the next few years There is a united effort that includes government entities, health systems, pharmaceutical companies, private payer groups, and community organizations working together to overcome disparities and improve equity. This requires improved access to shared clinical and social needs data. Just last week CMS released its “Path Forward to improving data to advance health equity solutions” which aims to increase the collection of standardized sociodemographic and social determinants of health (SDOH) data across the healthcare industry as an important first step towards improving population In closing, Pooja asked everyone to share what they are most hopeful to see in 2023. She kicked it off by saying that for her it's the continued focus on pharmacists. Kim responded by saying many great things are happening in health care and that she is excited as a patient. There is more focus on helping patients grow as consumers of their own health care, providing data and insights into what options are available to obtain quality, timely and cost-effective care. She also expressed excitement about working with industry and policymakers to advance medical ePA in 2023 via the HL7 Da Vinci standards and leading the CodeX work on a pilot to advance PA for cancer patients. She concluded by echoing what Pooja said about her excitement about leading and partnering with others at NCPDP to promote and advance the role of the pharmacist as a part of the care team. Jocelyn joined in to say that she is hopeful for the momentum that has built up and she is super excited to see stakeholders build their toolboxes and embark on real-world implementations. Pooja closed out the episode by thanking her POCP cohosts, Jocelyn and Kim, and wishing our audience the happiest of holidays and the best for 2023. She reminded listeners that they can find The Dish on Health IT on Apple Podcast, Spotify, or whatever platform they use to pick up their podcasts, including HealthcareNOW Radio and the Podcast Channel. And that videos of the podcast episodes can be found o on the POCP YouTube channel. Adding, Health IT is a dish best served Hot!

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$660-$840 Per Week Remote Part-Time Risk Adjustment Medical Coder (CRC, CPC, CCS-P)

Real Work From Home Jobs With Thressa

Play Episode Listen Later Dec 5, 2022 5:19

In this podcast today, I will discuss the company CSI Companies! Listen to the podcast for details! --- Support this podcast: https://anchor.fm/thressa-sweat/support

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The role of risk adjustment in value-based care

Inside Angle

Play Episode Listen Later Nov 29, 2022 22:02

Is your health system considering taking on more downside risk? In this episode, join Dr. Sandeep Wadhwa, global chief medical officer at 3M Health Information Systems, as he dives into key Medicare, Medicaid and commercial insurer payment trends that will influence risk adjustment, quality and population health.

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TCG - Season 4 - Episode 39 - HCC / Risk Adjustment Coding with Dawn Carter

The Compliance Guy

Play Episode Listen Later Nov 3, 2022 28:03

Dawn Carter, Director of Product Strategy of Centauri Health Solutions joined Sean to discuss Risk Adjustment Audits and the ins and outs of these often times annoying administrative requirements if you participate with an MA Plan... This was such an interesting discussion and we believe you will think so too! Links to articles from the show: Article 1: Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,' Part 1: The Risk-Score Game - https://www.healthaffairs.org/do/10.1377/forefront.20210927.6239/full/ Article 2: Medicare Advantage, Direct Contracting, And The Medicare ‘Money Machine,' Part 2: Building On The ACO Model - https://www.healthaffairs.org/do/10.1377/forefront.20210928.795755/full/ Article 3: Halvorsen/Crane rebuttals: https://www.healthaffairs.org/do/10.1377/forefront.20220106.907235and https://www.healthaffairs.org/do/10.1377/forefront.20220203.915914/ Article 4: Gilfillan and Berwick rebuttal to Halvorsen and Crane: The Emperor Still Has No Clothes: A Response To Halvorson And Crane - https://www.healthaffairs.org/do/10.1377/forefront.20220602.413644 Article 5: Kang/Duncan/Hunh response: Making The Right Diagnosis: A Response To Berwick And Gilfillan - https://www.healthaffairs.org/do/10.1377/forefront.20220706.909897/ About Dawn Carter: Her career in healthcare spans 28 years, which most recently includes extensive experience in developing revenue integrity and quality software solutions, with a focus on encounter management, risk adjustment, and social determinants of health solutions for Medicare Advantage, Medicaid and Commercial health plans, as well as providing risk adjustment strategic advisory services for these markets. Prior to that, her experience spans all domains of health care including health plan and provider systems administration, finance, compliance and healthcare applications development inclusive of EDI and X12 and HL7 development. Her experience also includes multiple teaching engagements in medical administration, billing and coding. Dawn holds a Bachelor's degree in Business Administration, and she holds the American Association of Professional Coders CPC (Certified Professional Coder), CRC (Certified Risk Adjustment Coder), and CPMA (Certified Professional Medical Auditor) credentials. She is also a Certified Scrum Product Owner (CSPO). Dawn is a passionate and prolific industry speaker, author, blogger and subject matter expert in claims, EDI management, and risk adjustment.

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"Service Level Agreement" 10.31.22

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Play Episode Listen Later Oct 27, 2022 13:58

#HealthCast segment on one of the most overlooked components of Star Rating and Risk Adjustment strategy which is Vendor Management. Your partnerships are critical to the long-term success for managed care and clinical outcomes.

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Amber Malone-Wright - Why Risk Adjustment Matters in Clinical Documentation and Coding

Move to Value

Play Episode Listen Later Oct 20, 2022 10:26

This episode is first in a two-part series about Clinical Documentation and Coding. In part one, we talk about the importance of Risk Adjustment with Amber Malone-Wright, Director of Clinical Documentation Integrity at CHESS Health Solutions. What is risk adjustment and why is it so important? So risk adjustment is really a way to describe funding for resources and care to manage patients chronic or serious illnesses. It really helps to identify the risk that the patient is going to incur when medical costs that are above or below average for the year. It's really a financial forecasting that the health plans use to predict the future medical needs for the patients. So for example, a health plan receives payment from the government to help pay for the services that that patient is going to seek, whether that's an outpatient visit for chronic condition or an inpatient visit for a serious or acute illness, such as sepsis or a serious infection. And the funding to the health plan that they receive from the government pays those services at the hospital and office visit or primary care level. Risk adjustment matters because it's a way for the providers to report how sick their patients are and to ensure that there are resources available to those patients are there at their fingertips. So when a provider is able to manage their patients chronic conditions and prevent the hospitalizations the health plan actually ends up in a surplus and is able to share those funds with the provider, who is controlling the costs, and those patient chronic conditions. Health plans generally are going to use the funding to offer patients better premiums and other resources as well, such as Meals on Wheels or transportation and ways to lower prescription costs and many other different programs.And how does risk adjustment work?So in risk adjustment, value is assigned to each diagnosis code that falls into this payment model that's used by the government for the health plans. The ICD-10 codes are grouped in what we call HCC's or hierarchical condition categories. And these HCC categories are related to both clinical and financial resources available for those patients. Each diagnosis code that's mapped to one of these categories provides a risk adjustment factor score to identify the acuity or the sickness of that patient. Those risk scores are then calculated and converted into our financial resource for the health plan to cover those services for those patients.How are providers impacted by risk adjustment?So many providers are not directly impacted by risk adjustment because it's a way for the health plan to receive funding. A majority of providers are still part of what we call the fee-for-service reimbursement model, where they're reimbursed for a service they provide to the patient using a procedure code or an office visit code, for example. Most hospitals are reimbursed based on what we know is the MSDRG system when a patient is admitted to the hospital. It's a similar reimbursement methodology to risk adjustment in that the hospitals are paid a lump sum based on the diagnosis to cover the cost of care provided for those chronic or acute conditions that are being treated in the inpatient setting. Value-based care is really shifting the providers to be more responsible with managing the patients more effectively and coding more accurately. This means that providers need to be aware of what specialists are they are referring to how, often the patients are seeing their specialists, if they're going to the ED for unnecessary illnesses, such as urinary tract infections, and how many times they've been admitted to the hospital. All of those are you know primary care gatekeeper responsibilities. This also means that providers need to document and code all of the chronic conditions to the highest level of specificity and this is to...

Why You Shouldn't Settle for Partial Duals

Play Episode Listen Later Aug 25, 2022 39:42

Josh Weisbrod from Network Health and Keslie Crichton and Sean Libby from BeneLynk join Eric to discuss opportunities and challenges in identifying and converting members to full dual status, including specific examples and an outlined roadmap into this additional revenue stream. After listening to this episode, you will understand: Why identifying members as “full or partial” matters How much revenue you may be leaving on the table What components need to be in place to convert members Our Guests Josh Weisbrod, Vice President, Risk Adjustment, Network Health Josh has over 20 years of healthcare, health insurance, healthcare analytics and human service experience working with local and national companies and state and federal agencies, specializing in health plan operations and data analytics. Sean Libby, President and Co-founder, Benelynk Sean has worked at the intersection of managed care and government benefit programs for the past 19 years. Before BeneLynk, Sean served as the President of Freedom Disability and Alpha Disability, one of the nation's largest Social Security Disability and Veterans Advocacy companies. Before that, Sean served as Vice President, Sales for SSC Disability, providing government program benefit services for Managed Care Organizations. Keslie Crichton, Chief Revenue Officer, BeneLynk Keslie has over 25 years of comprehensive managed care and healthcare technology experience. Before BeneLynk She spent 13 years as Vice President of Sales at Change Healthcare and its predecessor companies Altegra Health and Social Service Coordinators, helping plans improve risk-adjusted revenue and quality performance scores through dual enrollment and retention, as well as health education campaigns. Acronym Glossary MSP - Medicare Savings Programs ABD- Age Blind and Disabled MAPP - Medicaid Purchase Plan SSI - Supplemental Security Income QMB - Qualified Medicare Beneficiary SLMB - Specified Low-Income Medicare Beneficiary QI-1 - Qualifying Individual SNAP - Supplemental Nutrition Assistance Program LIS - Low-Income Subsidy SSA - Social Security Administration CMS - Center for Medicare and Medicaid Services MAO - Medicaid Add On MA - Medicare Advantage HCC - Hierarchical Condition Category FPL - Federal Poverty Level MAGI - Modified Adjusted Gross Income PMPM - Per Member Per Month HRA - Health Risk Assessment D-SNPs - Dual Eligible Special Needs Plans We are pleased to provide you with this copy of the white Hi Sherry, Are you leaving revenue on the table? Find out by listening to our new episode, Why You Shouldn't Settle for Partial Duals, now live on Apple, Google, Spotify, Amazon Music or your favorite podcast app, and YouTube. Josh Weisbrod, Vice President, Risk Adjustment, Network Health, Keslie Crichton, Chief Revenue Officer, BeneLynk and Sean Libby, President and Co-founder, BeneLynk, join me for an insightful discussion on the opportunities and challenges in identifying and converting members from partial dual to full dual status. Hear specific success stories and walk away with an outlined roadmap for capitalizing on this additional revenue stream. In addition, we are pleased to provide this whitepaper, Are You Getting Partial Dual Premiums for Partial Dual & Full Dual Risk?, from our partner BeneLynk. I hope you find it valuable. BeneLynk sponsors this Episode of Bright Spots in Healthcare. BeneLynk is arguably the most innovative Dual Advocacy organization in the country. Benelynk's mission is to improve people's lives and positively impact social determinants of health barriers by granting their healthcare partners the necessary information while providing healthcare consumers with the advocacy they deserve. They use innovative technology that enables their people to have a dynamic conversation that flows organically to meet social determinants of health challenges and, as such, can build stronger human connections. This carefully planned combination generates exceptional results. Visit their website at www.benelynk.com

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Front and Center: Medicare Advantage Audits, Medical Necessity to Ensure Payments, and the Two-Midnight Rule

Play Episode Listen Later Jul 6, 2022 9:23

Medicare Advantage Audits, Establishing Medical Necessity to Ensure Payments, and the Two-Midnight Rule are three outstanding RACmonitor webcast topics discussed by Dr. John Zelem and Chuck Buck in this current episode of Front and Center.

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Elevate Risk Adjustment by Activating Providing Participation

Play Episode Listen Later Jun 24, 2022 61:10

Risk adjustment is much more than a regulatory requirement for Medicare Advantage plans – it can improve the quality of care by providing an accurate picture of each member's health status and ensuring each member receives the right interventions and treatment. Providers play an important role in risk adjustment, too. An engaged partnership between health plans and providers is vital to ensure beneficiaries receive valuable benefits. Our panel of experts from Blue Cross Blue Shield of Illinois, CommuniCare Health Centers, Priority Health, SelectHealth and Vatica Health will share successful strategies and best practices for payers and providers to work in partnership to close gaps in care, achieve better clinical and financial performance, and support value-based care. Hear both payer and provider perspectives on building a successful relationship. Confirmed Panelists: Jeslie Jacob, Divisional Vice President, Provider Analytics, Reporting & Connectivity, Blue Cross and Blue Shield of Illinois. Rebecca Welling, Associate Vice President, Risk Adjustment & Coding, SelectHealth Lisa Wigfield, RN, BSN, CCM, CRC, CDEO, Clinical Advisor, Risk Management, Priority Health Janie Reddy, DNP, FNP-BC, Director of Family Medicine, CommuniCare Health Centers Hassan Rifaat, MD, CEO, Vatica Health Bios: https://www.sharedpurposeconnect.com/events/elevating-risk-adjustment-by-activating-physician-participation/ This episode is sponsored by Vatica Health Founded in 2011, Vatica Health is the leading provider-centric risk adjustment and quality of care solution for health plans and health systems. By pairing expert clinical teams with cutting-edge, HITRUST-certified technology at the point of care, Vatica increases patient engagement and wellness, improves coding accuracy and completeness, facilitates the identification and closure of gaps in care, and enhances communication and collaboration between providers and health plans. The company's unique solution helps providers, health plans, and patients achieve better outcomes together. Vatica Health is trusted by many of the leading health plans and thousands of providers nationwide. Vatica Health is a portfolio company of Great Hill Partners. For more information, visit www.vaticahealth.com/.

SDOH and DE&I: Knowing Your Veteran Population

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Play Episode Listen Later May 20, 2022 61:27

Featuring: David Shulkin, MD, Former U.S. Secretary of Veterans Affairs Kacey L. Serrano, MPA, CPC, CRC, Director, Medicare Stars and Risk Adjustment, Arkansas Blue Cross and Blue Shield Sean Libby, President, BeneLynk Today, 22% of Medicare Advantage members are veterans of the United States Armed Forces and 5% of Medicare Advantage members use the Department of Veterans Affairs (VA) for some of their healthcare needs. However, many health plans don't have a full understanding of the care their veteran population needs. Panelists share how Medicare Advantage plans can address social determinants of health (SDOH) for its veteran members by identifying their veteran populations and coordinating care with the VA. Topics for Discussion include: Identifying your Medicare Advantage veterans, discovering the value of documenting VA care and understanding military service as a Social Determinant of Health. This episode is sponsored by BeneLynk, a national provider of social determinants of health (SDoH) solutions for Medicare Advantage and Managed Medicaid health plans. We serve plans and their members by creating a human-to-human connection and providing the assistance a member needs to get the benefits they deserve. By employing one dynamic conversation that flows organically to meet social determinants of health challenges, we build stronger human connections that are supported by innovative technology. We help Medicaid members to retain their benefits through a comprehensive outreach campaign providing information and assistance. All of our services are customized to the specific geography where we provide services and provide the members with the specific information they need to keep their benefits in place. Our mission is to improve lives and positively impact social determinants of health barriers by providing our healthcare partners with the information they need, and people with the advocacy they deserve. Panelist bios available at: https://www.sharedpurposeconnect.com/events/medicare-quality-and-risk-knowing-your-veteran-population/

Locums Tenens Physicians

CodeCast | Medical Billing and Coding Insights

Play Episode Listen Later May 10, 2022 29:44

In this episode of the CodeCast Podcast, Terry gives regulatory guidance for Fee-For-Service Time Compensation (previously known as Locum Tenens) billing and coding. She also covers the rules surrounding how to document these services. Plus, CMS updated their COVID-19 FAQ sheet again, and this time it includes HCC's and Telehealth inclusion for Risk Adjustment. You […] The post Locums Tenens Physicians appeared first on Terry Fletcher Consulting, Inc..

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98: Paige Kilian of Inovalon Addresses the Challenges of Risk Adjustment and how Solutions Can Be Found Through Data and Analytics

Tuning Into The C-Suite

Play Episode Listen Later Apr 15, 2022 14:17

In this week's episode, Briana Contreras, editor of Managed Healthcare Executive, spoke with Dr. Paige Kilian, chief medical officer at Inovalon. In the discussion, Dr. Kilian broke down the current issues health plans are facing when it comes to risk adjustment and how it's affecting members of these plans. She also shared some solutions that can help plans improve risk adjustment and quality programs with one in particular being health plans identifying care gaps through data and analytics.

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"ALL CAPS" 4.15.22

The ACDIS Podcast: Talking CDI

Play Episode Listen Later Apr 14, 2022 14:25

(Part II) Of Lance's #healthcast series interview with RaeAnn Grossman Cotiviti's EVP of Risk Adjustment....

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Risk adjustment and comorbidity indices

Play Episode Listen Later Apr 13, 2022 27:46

Today's guests are Cassi Birnbaum, MS, RHIA, CPHQ, FAHIMA, senior enterprise director for HIM, CDI, and coding at CDI PeaceHealth based in Vancouver, Washington and Cheryl Manchenton, RN, CCDS, CPHM, is a senior inpatient consultant/project manager/quality services lead overseeing CDI at 3M Health Information Systems based in Salt Lake City, Utah. Today's show is hosted by ACDIS Editorial Director Melissa Varnavas and is a part of our “Membership with Melissa” series. Our intro and outro music for the ACDIS Podcast is “medianoche” by Dee Yan-Kay and our ad music is “Take Me Higher” by Jahzzar, both obtained from the Free Music Archive. Today's show is sponsored by 3M Health Information Systems. 3M Health Information Systems is committed to eliminating revenue cycle waste, creating time to care, and leading the shift from volume to value-based care through innovative software and services across the continuum of care. Get started today and improve your CDI team's impact on financial and quality metrics. Learn more at www.3m.com/cdi. Featured solution: Today's featured ACDIS solution is Imagine: 2022 ACDIS Conference. Imagine the possibilities and join your CDI peers in Orlando May 2–5, 2022, at the Gaylord Palms Resort & Convention Center! As we reconnect after the COVID-19 pandemic, we all need a little magic in our lives, and we all need to Imagine what might be in store for us professionally. Learn more or register by clicking here. (http://ow.ly/rG5Y30s7Pzt) ACDIS update: Register for the 2022 ACDIS National Conference and be entered to win $5,000 for your CDI department! Read more on the ACDIS website. (http://ow.ly/Cb7X30sg7gs)

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The Behavioral Health Crisis: Social Determinants of Health and Risk 1 CEU

Life as a Coder

Play Episode Listen Later Apr 6, 2022 55:59

In this episode I am joined by my colleague and friend Barbara Shaw, CPC, CPCO, CDEO, CRC, CEDC . W will discuss Risk adjustment and Social Determinants of health as it relates to Mental Health Services What is Risk Adjustment? Important reminders about SDOH Risk Adjustment Documentation Mental Health and SDOH Join the Risk Adjustment Masterclass created by Risk Adjustment leaders and educators. Ask us about our special programs for Hospital Employee education This episode qualifies for 1 CEU for our Patreon Squad Members. Jump over to www.patreon.com/lifeasacoder --- Send in a voice message: https://anchor.fm/lifeasacoder/message Support this podcast: https://anchor.fm/lifeasacoder/support

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"Global Cap" 4.7.22

Play Episode Listen Later Apr 5, 2022

(Part I) RaeAnn Grossman EVP of Risk Adjustment of Cotiviti joins the show to discuss her career in managed care and shares wisdom on leadership and the healthcare industry...

global risk adjustment

Front and Center: Payer Contracts and 2022 Audits on Implantable Device Credits

Play Episode Listen Later Apr 4, 2022 7:47

The latest essential webcasts by RACmonitor are “Payer Contracts: Keys to Increasing Your Leverage,” led by Tiffany Ferguson and Marie Stinebuck, and the perennially popular on-demand webcast, “Implantable Device Credit Reporting and Outlier Payments: Audits Reviving up in 2022.” Both are given high marks in this current episode of Front and Center.Great topics. Great analysis. More great educational opportunities now await you. So now get everyone on your team Front and Center.Use code FRONTANDCENTER for 15% off your RACmonitor webcast purchases.

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Risk Adjustment, Equity, Movement. Jumping in the Deep End

Health Hats, the Podcast

Play Episode Listen Later Mar 13, 2022 13:08

Why measure health outcomes? What information comes from outcome data? What action does the information motivate? How do disparities figure in? Why risk adjust? Blog subscribers: Listen to the podcast here. Scroll down through show notes to read the post. Subscribe to Health Hats, the Podcast, on your favorite podcast player Please support my blog and podcast. CONTRIBUTE HERE Episode Notes Prefer to read, experience impaired hearing or deafness? Find FULL TRANSCRIPT at the end of the other show notes or download the printable transcript here Contents with Time-Stamped Headings to listen where you want to listen or read where you want to read (heading. time on podcast xx:xx. page # on the transcript) Proem.. 1 Knowing enough to be dangerous 02:21. 1 Why measure health outcomes? 04:28. 2 Information from measurement 05:20. 2 Action from information (plus money) 06:07. 2 How do disparities fit in? Look past your nose. 08:12. 2 Risk adjustment 10:29. 3 Reflection 11:44 3 Please comments and ask questions at the comment section at the bottom of the show notes on LinkedIn via email DM on Instagram or Twitter to @healthhats Credits Music by permission from Joey van Leeuwen, Drummer, Composer, Arranger Joey van Leeuwen Quartet playing Black Narcissus by Joe Henderson Web and Social Media Coach Kayla Nelson @lifeoflesion Photo by Elise Wilcox on Unsplash The views and opinions presented in this podcast and publication are solely the responsibility of the author, Danny van Leeuwen, and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute® (PCORI®), its Board of Governors or Methodology Committee. Sponsored by Abridge Inspired by and grateful to Matthew Pickering, Cary Sanders, Rebekah Angove, Lina Walker, Adam Thompson, Ben Zola, Amanda Brush, Ellen Schultz, Laura Marcial, Juhan Sonin, Jennifer Bright, William Lawrence Links Risk Adjustment - Factors Affecting Adjustment CMS Physician Cost Measurement and Patient Relationship Codes Technical Expert Panel National Academy of Medicine DIgital Health Learning Collaborative, National Quality Forum's Cost and Efficiency Standing Committee GoInvo Determinants of Health Related podcasts https://health-hats.com/pod145/ https://health-hats.com/pod140/ https://health-hats.com/pod133/ About the Show Welcome to Health Hats, learning on the journey toward best health. I am Danny van Leeuwen, a two-legged, old, cisgender, white man with privilege, living in a food oasis, who can afford many hats and knows a little about a lot of healthcare and a lot about very little. Most people wear hats one at a time, but I wear them all at once. I'm the Rosetta Stone of Healthcare. We will listen and learn about what it takes to adjust to life's realities in the awesome circus of healthcare. Let's make some sense of all this. To subscribe go to https://health-hats.com/ Creative Commons Licensing The material found on this website created by me is Open Source and licensed under Creative Commons Attribution. Anyone may use the material (written, audio, or video) freely at no charge. Please cite the source as: ‘From Danny van Leeuwen, Health Hats. (including the link to my website). I welcome edits and improvements. Please let me know. danny@health-hats.com. The material on this site created by others is theirs and use follows their guidelines. The Show Proem Can grasping risk adjustment contribute to a profound understanding of health inequities and motivate action to improve? Whaaattt are you talking about, you ask? As I write this episode, I'm preparing to join an NQF (National Quality Forum) Risk Adjustment Special Populations focus group. Understanding health disparities through measurement and experience and then acting on that information to improve equity ranks high on my list of advocacy priorities. I'm holding my nose,

Prior Authorizations: Problems When in the Wrong Hands

Play Episode Listen Later Mar 7, 2022 33:50

Medicare initiated the prior authorization process for select services for dates of service on or after July 1, 2020. Yet when “prior auths” are in the wrong hands, a potential crisis looms. And that's apparently the case involving Recovery Auditors (RAs) and some providers. In the FAQ related to the prior authorization process released by the Centers for Medicare & Medicaid Services (CMS), it states that generally, claims that have a provisional affirmation decision will not be subject to additional review; however, CMS contractors, including Uniform Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) may perform reviews based on evidence of potential fraud or gaming, and the Comprehensive Error Rate Testing (CERT) contractor may review a random sample for the purposes of estimating the Medicare improper payment rate. The RAs, however, are not listed as audit contractors allowed to audit these claims – nor should they be. So why are providers receiving audit requests for these services from their Recovery Auditors?Reporting our lead story during the next live edition of Monitor Mondays will be Marcy Andersen, director of account management at SAI360.Other segments to be featured during the live broadcast include the following:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the RAs.Risky Business: Healthcare attorney David Glaser, shareholder in the law offices of Fredrikson & Bryon, will join the broadcast with his trademark segment.Monday Rounds: Ronald Hirsch, MD, vice president of R1 RCM, will be making his Monday Rounds with another installment of his popular segment.Legislative Update: Former CMS official Matthew Albright, now chief legislative affairs officer for Zelis, will report on current healthcare legislation.SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that's happening at the intersection of healthcare regulations and the SDoH.

The Enigma – The Case of Richard Bagnall