Carla Ballou, MBA

Read this special report that provides a detailed review & validation process for the appropriate use of discharge status code 06 and Condition Codes 42 & 43 in claims involving home health services post-hospital discharge. Download your copy now: https://gag.gl/kkTLyy #TransferDRG #ConditionCodes

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JJ Part A and Part B Targeted Probe and Educate Active Medical Review List All CDI professionals must sign up for their Medicare Administrative Contractor list-serve to stay informed of updates to Medicare regulations & specific announcements geared towards the local region where the hospital operates. Pertinent relevant updates impacting the CDI profession include additions to the CMS Traegt Probed and Educate Program. From the Palmetto GBA website regarding TPE: "The Centers for Medicare & Medicaid Services (CMS) Targeted probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals by identifying provider errors, helping correct them, and preventing future errors. Medicare Administrative Contractors (MACs) have been tasked by CMS to identify high denial rates or unusual billing practices and work one-on-one with those providers to reduce claim errors and payment denials; MACs are also expected to review items and services that have high national error rates and are at a financial risk to the Medicare program." Notice in Palmetto GBA's JJ Part A and Part B Targeted Probe and Educate Active Medical Review List several common MS-DRGs DRG 470 - Major Joint Replacement DRG 291-293 Heart Failure and shock with or without CC/MCC DRG 682- 683 Renal Failure DRG 870–872-Septicemia or Severe Sepsis Greater than 96 hours These reviews incorporate elements of medical necessity, proper coding, & clinical validation. CDI must embrace the importance of situational awareness. Situational awareness requires a mindset beyond CC/MCCs, number of records reviewed, CMI, physician query rate, physician query response rate, etc. CDI must be aware of medical necessity denials, and clinical validation denials, taking a proactive preemptive denial avoidance approach to chart review. This approach by its very nature includes awareness of published MAC TPE Reviews & MAC published Medical Reviews. Being proactive entails conducting proactive audits of specific DRGs under review, ensuring documentation supports medical necessity, principal & secondary diagnoses are validated, and coding is accurate and compliant. Why wait to be a target for MAC review when proactive activity is more effective, warding off continued inaccurate/missing documentation, coding, and billing. Review payer denial letters involving clinical validation, incorporate payer-specific clinical criteria into physician documentation training, & consider creating dot phrases that contain payer-specific clinical criteria. An example is sepsis, subject to frequent denial due to "not meeting" Sepsis 3 criteria CDI- it is critical to be proactive versus reactive- stop chasing diagnoses and work with providers to become better documentarians, supporting diagnoses & warding off medical necessity & clinical validation denials. #CDI, #TPE, https://lnkd.in/eVHCtq3Q

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Revenue Cycle Audits Are the Key to Financial Health in Healthcare. Check out my blog below for more information on RCM audits. Follow Claims Theory for more weekly blogs on all things RCM. #RCM #Audits #FinancialHealth #Compliance

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⚠️ Top High-Risk Compliance Zones in Healthcare ⚠️ Do you know where your compliance risks are highest? Our comprehensive guide identifies the top high-risk zones in healthcare and provides strategies to mitigate them. 🧐 Assess your preparedness and gain actionable insights to enhance your compliance efforts. 📖 Read more: Top High-Risk Compliance Zones in Healthcare. https://lnkd.in/eRwkU3Qn

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⚠️ Top High-Risk Compliance Zones in Healthcare ⚠️ Do you know where your compliance risks are highest? Our latest article identifies the top high-risk zones in healthcare and offers strategies to mitigate them. 🧐 See how prepared you are and get actionable insights to boost your compliance efforts. 📖 Read more: Top High-Risk Compliance Zones in Healthcare. https://lnkd.in/eRwkU3Qn

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Complaints, Appeals, and Grievances (CAG) Software – GHIT Digital POV   What is Appeals and Grievances (ANG)? Appeals and Grievances (ANG) refer to the processes through which members of health plans or patients voice concerns about their healthcare services, claims, or administrative decisions. These mechanisms are critical to ensuring compliance, transparency, and member satisfaction. ·        Grievances: A formal complaint made by a member about non-claim-related issues, such as poor service, delayed responses, or inadequate care. Example: A patient complains about long wait times for approval of a pre-authorization request. Appeals: A request by a member or provider to review and overturn a denied claim or service. Example: A patient files an appeal to get coverage for a procedure that their health plan initially denied. What is Complaint, Appeals, and Grievances (CAG)? CAG expands the scope by explicitly incorporating complaints into the workflow, distinguishing them from grievances. This is more commonly adopted in systems where complaint handling is segregated as a lower-threshold concern. Click the link below to read the complete POV or reach out to us for ANG / CAG Software Demo Monika Vashishtha (MBA, PMP, ITIL) [email protected] 646.734.6482 https://lnkd.in/ef5UzY9Q

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🌟 Whether you’ve determined now is the time for you to begin the process toward FACHE or you’re still deciding, the next stop on your journey is our FACHE Overview Webinar. This webinar is free for you to attend but it requires registration. Learn more and save your place here: https://bit.ly/3MkxxT8

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#CMS asserts more centralized control over all states’ #MedicaidManagedCare programs through new rule-making. It’s a long timeline but there’s more important #HealthcareReform on the margins especially with respect to #quality measurement & reporting along with better tools for member choice of plans. #Medicaid #CHIP #HealthEquity #PrimaryCare #PublicPrivatePartnership #PublicPrivatePartnerships #healthcarequality

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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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Advantus Health Partners strategic partnerships surpass other national GPOs. Teaming up with Alliant Purchasing introduces an unprecedented solution to the market, revolutionizing healthcare supply chain solutions. Our partnership with Alliant highlights critical contracts in the surgical implant portfolio, offering unique advantages for GPO members and vendors. Additionally, we provide comprehensive purchased service agreements for activation, delivering programmatic value to hospitals, health systems, and vendor partners. Since our collaboration, member hospitals have enjoyed savings ranging from seven to 21%, a significant achievement amid ongoing financial pressures in healthcare. At Advantus, we strategically manage the supply chain, focusing on sustained value in surgical implants, cost reductions, and reliability. Like the Costco model, we prioritize reputable brands to drive standardization, enhance clinical care, and reduce expenses. #HealthCareInnovation #AdvantusAlliantPartnership #SupplyChainTransformation Learn more: https://lnkd.in/eMs9REYw

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OPERATIONS DEPARTMENT CONTRIBUTIONS IN PATIENT CARE EXCELLENCE Non-clinical operations departments, though not directly involved in patient care, play a pivotal role in ensuring patient care excellence. Here's how: 1. Efficient Operations and Streamlined Processes: Reduced Wait Times: Well-organized scheduling, registration, and billing processes minimize wait times, improving patient satisfaction. Improved Communication: Effective communication channels between departments ensure timely information flow, reducing errors and delays in care. Error Reduction: Standardized procedures and checklists minimize the risk of human error, enhancing patient safety. 2. Supportive Infrastructure: Reliable Technology: Up-to-date and reliable IT systems support clinical operations, enabling efficient data management and access. Clean and Safe Environment: Well-maintained facilities and adherence to infection control protocols contribute to patient well-being and reduce the risk of healthcare-associated infections. Adequate Staffing: Proper staffing levels ensure smooth operations and prevent burnout among clinical staff, leading to improved patient care. 3. Data-Driven Insights: Performance Monitoring: Data analysis helps identify areas for improvement in patient care delivery, leading to targeted interventions. Resource Optimization: Data-driven insights enable efficient resource allocation, ensuring optimal patient care with available resources. Quality Improvement: Tracking key performance indicators (KPIs) related to patient outcomes and satisfaction helps drive continuous quality improvement. 4. Strong Partnerships with Clinical Teams: Collaborative Culture: Open communication and collaboration between clinical and non-clinical teams foster a shared commitment to patient care excellence. Proactive Support: Non-clinical teams anticipate and address the needs of clinical staff, enabling them to focus on patient care. Shared Goals: Alignment of goals between clinical and non-clinical teams ensures a unified approach to patient care. 5. Patient-Centered Approach: Patient Experience: Non-clinical teams contribute to creating a positive patient experience through courteous interactions, timely assistance, and addressing patient concerns. Patient Education: Providing clear and concise information empowers patients to make informed decisions about their healthcare. Accessibility and Convenience: Streamlined processes and convenient appointment scheduling enhance patient access to care. By focusing on these areas, non-clinical operations departments can significantly contribute to patient care excellence, alongside the efforts of clinical teams.

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🔍 Key Considerations in Managed Care Contracts 🔍 From reimbursement policies to termination provisions, negotiating managed care contracts involves multiple critical factors. Providers must conduct market research, define clear goals, and involve key stakeholders to ensure successful contract negotiations. ➡️ https://smpl.is/9r54q #ManagedCare #HealthcareProviders #ContractNegotiation #SunlitCoveHealthcare

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One and Done? The Risks of Single-Time HCC Submissions in Risk Adjustment In risk adjustment, submitting a diagnosis once per year might technically meet inclusion criteria, but it also introduces a significant vulnerability. Regulatory audits, such as those by the OIG, only need to refute one date of service to deem a condition unsupported for risk scoring purposes. This makes single-time HCC submissions a high-risk area for organizations. Here’s how you can mitigate this risk and strengthen your documentation practices: 1. Run Reports to Identify Single-Time Submissions. Start by generating an internal report of all submitted codes tied to eligible CPT codes. Focus on conditions captured only once during a calendar year. Alternatively, collaborate with payers to receive reports for attributed patients where single-time captures are flagged. 2. Prioritize High-Risk Conditions for Review. Not all single-time submissions carry the same weight. Your top priority should be any high-risk conditions identified by the OIG, followed by: -Newly captured conditions not previously documented. -Acute conditions historically recorded in office settings. -These categories are more likely to be scrutinized during audits, making them essential for proactive review. 3. Collaborate with Payers. Single-time HCC submissions often occur because conditions are captured by multiple providers or across care settings. If your internal reviews reveal only one submission, coordinate with payers to determine if the condition was documented elsewhere. If not, consider submitting a supplemental file to remove unsupported codes or add missing ones. Why This Matters Failing to address single-time submissions can lead to significant compliance risks. An unsupported diagnosis could result in overpayments, penalties, and reputational harm. On the other hand, proactively identifying and correcting gaps demonstrates your organization’s commitment to accuracy and quality care. Take Action Today By implementing targeted reviews of single-time HCCs, you’ll not only reduce your risk of audit findings but also ensure fair and accurate reimbursement. Don’t leave your risk adjustment outcomes to chance—invest in processes that strengthen your documentation and coding practices. What steps is your team taking to review single-time submissions? Let me know in the comments… let’s exchange some ideas!

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NAIC is pushing #CMS to allow members to leave their #MA plan if their provider terminates their MA plan contract. If this is successful, what would you do? ⏩ Would you rethink Provider contracts, payments, engagement or incentives? ⏩ Would it change your UM/MM, denials or #PriorAuthorization strategy? ⏩ If member retention was suddenly on the line, would you change your approach to provider contracting vis-à-vis #CAHPS and #memberexperience to protect #StarRatings? As more providers leave #MedicareAdvantage and the industry outcry grows, this is a great time for reflection: Could your plan adapt fast enough to not only survive, but thrive, if NAIC is successful? The future of member trust, satisfaction, and retention could depend on it. H/T to Amy Lotven for this great find! #ItTakesAVillage to keep up with all of the moving pieces now that 50% of seniors are in MA!

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Infinite Opportunities: 2024 CDI Week State of the Industry Clinical Documentation Professionals must be committed to continual learning and dedication to expanding their knowledge and skills in all facets of documentation including awareness of trends in the revenue cycle that are impacted by physician documentation, both directly and indirectly. Maintaining a keen understanding and appreciation of situational awareness and the key roles CDI plays in a multidisciplinary approach to physician documentation excellence is paramount to partnering with physicians to achieve physician documentation excellence while strengthening the revenue cycle with optimal sustainable net patient revenue less prone to payer denials and costly takebacks. I am not convinced industry industry-sponsored webinars by ACDIS provide the best forum for ongoing worthy nonbiased information that can be utilized by CDI to drive meaningful operational performance of the revenue cycle with better physician documentation. #CDI, #industyrsponsoredACDISwebinars, #ACDISservingvendorsversustheneedsoftheprofession https://lnkd.in/ecRhTeWz

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The Office of Inspector General (OIG) has raised concerns about potential fraud in Medicare reimbursement for remote patient monitoring (RPM) programs, citing improper adherence to requirements like FDA-approved devices, data collection rules, and patient education. According to the OIG, 43% of RPM enrollees fail to meet Medicare’s criteria, creating challenges for Centers for Medicare & Medicaid Services in identifying and managing fraud. Despite the OIG's claims, digital health advocates refute these allegations, asserting there is no evidence of RPM-related fraud and criticizing the report for inaccuracies and bias. The Alliance for Connected Care, representing RPM supporters, argues that Medicare rules regarding RPM were misunderstood or misrepresented in the OIG report. For example, they noted RPM does have order requirements and internet-connected devices aren’t mandatory for reimbursement. The surge in RPM use from 2019 to 2022 is attributed to increased Medicare reimbursement, not fraud. Advocates urge the OIG to focus on genuine fraud concerns within Medicare while fostering RPM’s growth to enhance patient care. Our RCM team aids in mitigating potential fraud in RPM programs by ensuring compliance with Medicare’s reimbursement criteria, optimizing billing accuracy, and implementing advanced tracking systems. We assist healthcare organizations in adhering to RPM guidelines, improving transparency in claims, and collaborating with providers to maintain program integrity and financial sustainability. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner HealthLeaders

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