Andrew Brown, MPA

If you build it, will they come? I’ve heard countless organizations - #MA plans, #Medicaid plans, risk-bearing providers, vendors, PBMs, and retail players - say “we need to build the capabilities to XX”. Many are looking to vendors for solutions, but few vendors are ready to invest in new capabilities without contracts.  Anyone else sensing this (problematic) new conundrum? Here’s my quick take and a few ideas to break through this barrier. Many sales meetings are often held with functional departments, and often do not include the #MedicareAdvantage #StarRatings, #RiskAdjustment, #HEDIS, IT or P&L owners. We must collaborate to get those departments’ urgent needs integrated into new vendor purchases in order for new activities to meet new and emerging needs, remembering that: 🌟 Vendors are vital to your success.  🌟 Vendors operate in a more volatile environment than plans. 🌟 Vendors have smaller budgets than plans. 🌟 Vendors need signed contracts to make significant investments.   🌟 Vague RFPs waste vendors’ time and resources. Collaboration creates win-win contracts which expand capabilities of both parties. I encourage plans to: ✅ Ask vendors about their roadmap; including timing and certainty of planned enhancements. ✅ Include the #Stars, Risk Adjustment and #PartD teams in new vendor discussions. ✅ Consider adding a vendor's roadmap capabilities to contracts. ✅ Co-create with trustworthy vendors. I encourage vendors to: ✔ Ask about the customer’s unmet needs. ✔ Offer to co-create solutions to new and emerging needs with willing customers. ✔ Offer to accelerate roadmap capabilities with willing customers.   ✔ Articulate the things you would be willing to do if a customer would be willing to contract for it. This is a #MarketMakingMoment as #CMS has thrown down the gauntlet with #NewNeedsOfStars and #NewNeedsOfMA. This is a stellar time for vendors to review current and planned capabilities with a broader lens on new and emerging MA, #Compliance, Stars, #ECDS, #Interoperability, #HealthEquity, Medicaid & #SNP Aligment, and Risk Adjustment needs. If you need help, reach out to us.  #WhatGotYouHereWontGetYouThere  ⭐ ⭐ ⭐ ⭐ ⭐

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A recent federal audit has highlighted concerns regarding Medicare Advantage home visits, citing $7.5 billion in 2023 payments tied to diagnoses that received no follow-up treatment. The HHS Office of Inspector General (OIG) recommended the Centers for Medicare & Medicaid Services (CMS) limit payments for these visits, which the agency declined. CMS stated Medicare recipients should access home-based care, while critics argue these visits may drive up costs without adding medical value. UnitedHealthcare, the largest contractor for Medicare Advantage, benefited significantly, with two-thirds of payments related to home visits and chart reviews—an approach known for boosting revenue through additional diagnoses. Assistant Erin B. called for an end to these payments without subsequent care. CMS audits only 30 out of 700 contracts annually, raising concerns over adequate oversight. Legal challenges continue, including a Department of Justice case against UnitedHealth for allegedly inflating payments by “mining” patient records. Our team aids healthcare entities by ensuring accurate billing practices and compliance, helping avoid improper overcharges in Medicare Advantage home visits. We conduct thorough reviews of coding and documentation, implement corrective actions, and provide education on best practices to enhance compliance, transparency, and effective resource allocation in patient care. #HomeHealthServices #HospiceCare #FrontEndServices #BackOfficeSolutions #HealthcareManagement #RevenueCycleManagement #HealthcareCompliance #PatientSupport #CareCoordination #MedicalBilling #ClaimsManagement #PatientEngagement #HealthcareOutsourcing #MedicalCoding #ProviderSupport #CliniqonCare #HealthcareSolutions #PatientCareExcellence #HomeHealthRCM #HospiceBilling HealthLeaders

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Changes to Medicare Advantage (MA) are placing financial strain on insurers and providers involved in risk-based arrangements, according to Everett Wilson, a healthcare regulatory attorney at Polsinelli. Recent enhancements to MA benefits have raised consumer expectations, leading to increased utilization of services. While these benefits make MA plans more attractive to enrollees, they drive up healthcare costs, directly impacting insurers' profitability. This situation particularly affects providers in risk-based contracts, as they share financial responsibility for patient care costs. The rising demand for services under MA plans results in higher-than-anticipated claims costs, which are compounded by the federal government's adjustments to reimbursement rates and risk adjustment criteria. As these costs continue to outpace reimbursement levels, insurers are pressured to manage profitability without compromising care quality, which ultimately impacts providers’ financial stability in shared-risk models. If left unaddressed, these dynamics may lead insurers to reduce benefits, raise premiums, or exit MA markets entirely, impacting patient access to affordable care options. Our RCM team supports providers in risk-based Medicare Advantage arrangements by optimizing reimbursement processes, managing risk adjustment, and analyzing utilization patterns. We help mitigate financial strain through data-driven strategies, enhancing cost efficiency and aligning provider operations with evolving MA requirements to maintain sustainable, high-quality care delivery. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Healthcare IT News

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My Friday good news celebrates the heroes of value-based care: primary care physicians and teams. The most successful #Medicare ACOs, those delivering value for Medicare and Medicare beneficiaries and sharing in that value, are primary care-centric #ACOs. We know how they do it; the playbook often includes support from enablers like Aledade, Inc.. Dr. Menard and his colleagues didn't give up when success wasn't immediate. How do we grow more primary care-centric ACOs and generate more value for Medicare and more access and quality care for beneficiaries? There are some health system ACOs investing in primary care and integrated teams. But it might take more forceful nudges from Medicare to get big health systems participating in total cost-of-care risk models. Or, we might need payment policies to give primary care more independence to practice comprehensive care. Congress could also consider restructuring the APM bonus to reward primary care "centricity". #primarycare #valuebasedcare Primary Care Collaborative David Raths David Muhlestein AAFP Foundation Thomas Culhane, MD, MMM, MS Darrin Menard, M.D. Stacey Richter https://lnkd.in/dThMvJrQ

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Centers for Medicare & Medicaid Services releases draft guidance for the second cycle of Medicare Drug Price Negotiation Program, aiming to lower drug costs and improve access for Medicare beneficiaries through price negotiations. Read at The Evidence Base® #heor #healtheconomics #marketaccess #pharma #biopharma #hta #healthtechnologyassessment #healthdata #healthequity #healthpolicy #inflationreductionact #drugpricing

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In J.D. Power's 2024 Medicare Advantage Study, plans from Centene Corporation's Wellcare Medicare, Humana, and UnitedHealthcare received some of the lowest customer satisfaction ratings across various markets. The study, released on August 20, evaluated Medicare Advantage (MA) plans based on a 1,000-point scale, with the average customer rating remaining at 652, consistent with 2023. Notably, customers rated Medicare Advantage plans higher than commercial health plans, which averaged a lower rating of 565 in 2024. Among the lowest-rated MA plans, Wellcare Medicare consistently scored poorly in multiple states: 581 in California, 538 in Florida, 580 in Georgia, 526 in Illinois, and 552 in Texas. Humana also had low ratings, with scores of 612 in Michigan, 596 in New York, 644 in North Carolina, and 635 in Pennsylvania. UnitedHealthcare's lowest rating was 652 in Ohio, matching the national average for MA plans but still placing it among the lower-ranked plans in its market. Our credentialing team ensures thorough vetting of Medicare Advantage plans, verifying compliance with regulatory standards and safeguarding against poor-quality contracts. By scrutinizing plan details and maintaining high standards, we help healthcare providers partner only with reputable insurers, ensuring better patient outcomes and avoiding affiliations with low-rated plans. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Becker's Healthcare

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📰 My latest Substack article, diving into Centene's impressive Q2 2024 earnings report. 📈 Despite challenging headwinds, Centene Corporation, under the leadership of Sarah London, has delivered one of its best quarters yet. Here are some key highlights: 💎 Revenue Growth: 5.2% increase through the first half of 2024 to over 80 billion. 💎 EPS Growth: 15% rise compared to Q2 2023, with EPS at $2.42, up from $2.10. 💎 Stock Performance: Almost 9% rally on Friday driven by strong EPS growth and a 34% surge in the ACA/Marketplace membership.. Sarah London's strategic shift away from vertical integration is proving to be a winning move, focusing on core strengths while divesting non-core assets. Here are some major takeaways from the earnings call: 🏥 Medicaid - Addressed acuity misalignment, Centene sees a brighter second half of 2024 as their PMPM rates will move upward. - Significant wins in Florida, Kansas, and Michigan. - Exciting LTSS launch in Arizona, with Oklahoma, Delaware, and North Carolina in launch mode. 👨‍⚕️ ACA/Marketplace - The Ambetter brand is shining as Centene is the largest domestic ACA/Markeplace provider with membership growth of 34%. - Premium subsidies are driving this explosive growth, with total enrollment now at 4.4 million beneficiaries - Premiums revenue hit $8.5 billion in Q2, a 49% increase quarter-over-quarter. 👵 Medicare (Wellcare) - Rebuilding the brand with an eye on growth in 2025/2026. - Focus on the dual-eligible market as a potential growth area. - STAR ratings improvements with the CMS adjustment but must feel good about their meta data for CAHPS/HEDIS -Strong PDP business positioning post-IRA as they feel good about their 2025 bids 💰 Investments/Divestments - Continued share repurchases with $851 million in Q2. - Divesting in non-core businesses like Magellan Rx, PantherRx , Apixio, etc. are now paying off for the company This quarter truly showcased Centene's execution on their longer term strategy. Impressive cause when everyone zigged....They zagged. Full article below: #Healthcare #Medicaid #ACA #Marketplace #Medicare #Centene #Earnings

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Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

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😳Humana faces a significant challenge following the release of preliminary 2025 Medicare Advantage (MA) Star Ratings data from CMS. Only 25% of its MA members are now enrolled in plans rated 4 stars or higher, a steep decline from 94% in 2024. 👉🏻The drop was driven primarily by the performance of contract H5216, which covers nearly half of Humana’s MA members, including over 90% of its Group MA plans, and saw its rating fall from 4.5 to 3.5 stars. 💴This will impact quality bonus payments in 2026. Humana is actively appealing some results and working to improve operating discipline to regain its industry-leading position. 🧘Key initiatives will focus on member engagement, customer experience, and technology enhancements to drive long-term value. Medicare Advantage open enrollment kicks off 10/15 and goes until 12/7. STAR ratings expected to be released to the public around 10/10! 📉Down 22% in premarket! https://lnkd.in/gUTT84tR

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New on our blog: The Centers for Medicare & Medicaid Services wants all #Medicare enrollees’ care paid based on quality, not volume, by 2030. LDI Fellows Amol S Navathe and Zeke Emanuel offer three ways to fix value-based payments and make that possible. Read more here: https://lnkd.in/dikarjNM

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NEW: The Biden Administration rejected calls to increase Medicare Advantage reimbursement rates for Puerto Rico, dealing a blow to lawmakers, doctors, and insurers advocating for payment parity with other US territories. In its 2025 Medicare Advantage Rate Announcement announced earlier this month, the Centers for Medicare & Medicaid Services said it had "limited discretion" to adjust Puerto Rico's Medicare Advantage rates, ignoring efforts made by over a dozen members of Congress urging the administration to directly address the widening gap between Medicare advantage payments in Puerto Rico and the mainland US. Currently, the base Medicare Advantage payment rate in Puerto Rico sits 39% lower than the national average and 21% below the Virgin Islands. The announcement comes as almost half of Puerto Rico's doctors have abandoned practicing in the territory due to low pay. The Medicaid and Medicare Advantage Products Association of Puerto Rico, which represents managed care organizations on the island, also predict that the funding shortfall coupled with projected rises in medical costs will be financially devastating to the island’s insurers. Plans told me they'd be left to shoulder a deficit of over $400 million on top of a record $500 million loss in 2023. While disappointing, the fight is not over. Healthcare advocates like Puerto Rico's non-voting member of Congress, Jenniffer González-Colón, say they plan to use the legislative and administrative tools available to put pressure on Washington to take concrete steps to improve the island’s encumbered Medicare program. You can learn more about the steps being made to address Puerto Rico's provider payment crisis in my story below: #Medicare #Puertorico #CMS #MedicareAdvantage #Healthnews #Doctors

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As we pass the one year anniversary of Medicaid continuous coverage being ended at the Federal Government level, it’s estimated nearly 20 million people have lost their coverage as a result. I suspect it’s still too early to measure the full implications but it’s not too early to be thinking about preparing for its impact. Paying close attention to a shifting payer mix and bad debt while revising patient financial processes and charity care policies are necessary to revenue cycles and healthcare finance. I’d like to be as optimistic as those interviewed for this article that state uninsured rates are relatively unchanged in thier payer mix but the real truth is somewhere in between the number of people who stopped seeking care with loss of coverage and rising bad debt that could be a slow realization. #healthcarefinance #revenuecyclemanagement

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Healthcare access challenges affect not just individuals, but entire communities and economies. @MedCityNews' latest article emphasizes the need for solutions that make healthcare universally available and equitable. Working at the intersection of technology and healthcare, I'm a huge believer in the potential for digital tools to reshape access—bringing critical information and resources to patients wherever they are, whether it’s a rural town or an urban center. But this isn’t a one-size-fits-all approach; it’s about tailored digital solutions that adapt to meet the unique needs of diverse populations. By collaborating across sectors, we can create a healthcare ecosystem where access to quality care becomes a given, not a goal. #HealthcareInnovation #DigitalHealth #HealthEquity

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The "Big Six Payors" are setting the stage for a revealing Q1 earnings and below are the highlights of the preview substack of storylines to follow: ➡ UnitedHealth Group (4/16): Starting strong, but bracing for impact with recent CMS rate stagnation and the scrutiny over acquisitions like Amedisys. Their first earnings post-Change Healthcare data breach will be pivotal in understanding the financial and strategic repercussions. ➡ Elevance Health (4/18): Fresh off a standout year, they're bolstering their portfolio with the acquisitions of Kroger Specialty and Paragon Healthcare to enhance CarelonRx. Watch how they navigate Medicare Advantage challenges with their diversified services. ➡ Humana (4/24): Facing the toughest quarter with significant stock declines and Medicare Advantage hurdles. Everyone is eager to hear about their strategic responses, including potential cost-cutting measures and workforce adjustments. ➡ Centene (4/26): With Medicaid redeterminations nearly behind them, Centene is expected to reveal some positive outcomes. Their retention of the Florida specialty services contract and updates on ACA plan margins will be key updates along with how it is going with ESI. ➡ CVS Health (5/1): Amidst MAPD challenges, CVS's diversified assets including significant PBM operations and biosimilars should provide some stability. Their management of new MAPD members and integration strategies post-acquisitions with Signify/Oak Street will be heavily questioned during the Q&A. ➡ Cigna (5/2): Climbing with a 12.5% stock increase this year, Cigna's strong performance in the commercial insurance and PBM space through Express Scripts and specialty pharmacy units stand out. Insights into employer reactions to their GLP-1 Financial Guarantee program and future M&A strategies are highly anticipated. 🚀 Sector Shifts: As FTC ramps up scrutiny on health and tech mergers, these earnings may hint at more share buybacks or shifts toward internal innovations instead of acquisitions. These earnings calls are not just about the numbers. They're about understanding strategic shifts and preparing for the future in a tightly regulated environment. #healthcare #marketaccess #earnings

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Do you know or are you one of the Healthcare Financial Management Association (HFMA) members who earned a certification in Q2 to validate expertise and demonstrate commitment to the profession? Some 2,115 individuals were honored in Q2 with HFMA certifications, with 101 people earning multiple certifications. Check out the story to see a list of all honorees.

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At the MGMA Leaders Conference as they discuss how IT needs to be maximized in ambulatory practice and serve patients with less staff. #operationalefficiencies #retainingstaff #improvehealthcareforeveryone #healthcaretransformation

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How's this for connecting the dots in #healthcare?   Imagine being a leader of a health system employing 20,000 people charged with caring for the nation's most densely populated state, a national cybersecurity expert, and a committee member of a GPO responsible for billions in hospital purchasing.   That's Brian Gragnolati.   Brian is President and CEO of New Jersey’s Atlantic Health System. He sits on an advisory committee of the Cybersecurity and Infrastructure Security Agency. And he chairs the executive committee of AllSpire Health Partners.   That’s a lot to type, let alone do.   A few months back I had the opportunity to catch up with Brian, chatting about the latest in healthcare. It got me thinking about his responsibilities and how he achieves so much.   It all comes down to relationships.   Here’s the thing: Strengthening ties between all of healthcare’s stakeholders is the only way we are going to overcome fundamental challenges and better serve communities across America.   That’s because, in this complex industry, every piece needs to fit together to keep operations running like clockwork. That requires intimate collaboration.   Take cybersecurity. We may not think much about back-end systems, but we sure notice when they go down. Remember the faulty CrowdStrike update that crashed computer systems around the world overnight? Banks, airlines, and hospital systems shuddered.   So, if we want to make the most of the technologies that support clinicians, empower health systems, and push this industry forward, we need robust cybersecurity that’s built specifically for healthcare.   And to create that kind of resilience, we need folks who understand this industry inside and out. We need folks like Brian.   Brian knows the rhythms of a hospital at 2 a.m., the flow of supply chains, and, most importantly, the profound responsibility of caring for millions of lives.   Brian is a rare breed. But everyone has the power to build relationships that lead healthcare to a brighter and more connected future.

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