Carole Ann Klove, RN, JD

📢 This is going to be another timely, FREE webinar put on by American Bar Association Health Law Section that you don't want to miss. Register now and I'll see you there! 🤓 #privacy #healthlaw #dataprivacy #healthcaredata #healthcaredataprivacy

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🚨 Top 10 #PatientSafety Concerns for 2024. 📌 Have significant changes been made over the last decade? An important question is to reflect on what has been done, what we are doing, and what remains to be done.

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Another section of the #FinalRule has been released by #CMS aimed at enhancing #access to and #transparency of #Medicaid services, including #HCBS. This rule pairs with two other final rules published in April 2024 that focus on improving Medicaid #eligibility and access to Medicaid services. This rule is focused on an #FFS system, but the impact could involve changes to underlying FFS rates in base #data for #ratesetting and program #oversight in #MLTSS. Dianne Heffron and Meredith Mayer of Mercer US Government have conducted a review of the proposed and finalized rules. https://bit.ly/3QuGRXe

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NEW MEDICARE APPEAL RIGHTS OVER HOSPITAL DECISIONS TO SWITCH PATIENTS TO OBSERVATION STAY In January 2025, Medicare patients will have the right to appeal hospital decisions to reclassify them from inpatient care to outpatient observation. The Centers for Medicare and Medicaid Services ("CMS") has issued a new rule that will expand the administrative appeals process to allow patients to appeal these decisions. The significance of this rule cannot be overstated; Medicare beneficiaries and to a lesser degree, hospital systems will benefit. Previously, Medicare auditors, Recovery Auditor Contractor ("RAC") audited hospitals to determine whether patients were properly classified as inpatient. If not, the RAC would reclassify the patient as outpatient observation. Here's the reason this distinction is important. Medicare Part A covers inpatient services performed at a hospital and not outpatient observation. When Medicare Part A pays, the patient's out-of-pocket costs are much lower. When Medicare Part B pays, the patient's out-of-pocket costs are significantly higher. In addition, RAC decisions to reclassify patients from inpatient to outpatient observation also cost hospitals significant revenue. Hospitals were required to refund the money back to Medicare and could not bill the patient for the money. As a result, hospitals started to classify patients as outpatient observation to avoid the cost of reclassification by the RACs. This caused increase costs to patients and disputes with the hospital over their classification decisions. Even if a treating doctor classified a patient as inpatient, the hospital's administration could overrule the doctor and reclassify the patient as outpatient observation. Worse, patients who did not meet Medicare's 3-day inpatient rule, could not get Medicare Part A to pay for post-hospital stays at Skilled Nursing Facilities ("SNF"). The result caused patients to be stuck with bills over $10,000. Unfortunately, patients could not appeal the hospitals' reclassification decisions. Until now. Thanks to a lawsuit, Alexander v. Azar, CMS adopted a new rule that will now allow patients to appeal these decisions. The result of the appeals will help patients get the appropriate level of care, save the patients money, and allow hospitals to get paid without fear of RAC readjustments and lost revenue. https://lnkd.in/gEc23w3w #medicare #healthcare #doctors #physicians #hospitals #medical #medicalpractice #dme #labs #imaging #prescriptiondrugs #pharmacy #labtest #pharmaceutical #drugs #mfcu #skillednursingfacility #longtermcare #fraud #healthcarefraud #fca #ceo #president #coo #cfo #cpa #investigation #audit #generalcounsel #oig #whitecollar #health #doj #medicine #healthlaw #healthcarecompliance #chiefcomplianceofficer #compliance #medicalbilling #managedcare #healthprofessional #privateequity #healthinsurance #hhs

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#Dems, Behold that Which You Have Wrought! Adam Fein’s brilliant visual says it all. The #Democrats’ #AffordableCareAct was the capstone to decades of government subsidies that funded the creation of #BigInsurance. What began, with #Republican sponsorship in #MedicareAdvantage and #Medicaid #managedcare, reached its one party zenith in the #ACA. Collectively, those government markets have brought #BigInsurance control over the health care of more than 110 million Americans—roughly a third of the entire U.S. population. The profits from those contracts, replete with massive #governmentsubsidies, have been the engine of Big Insurance #consolidation and #verticalintegration. #Democrats, in #Congress and in the #BidenAdministration, have long railed against #BigInsurance, but #Dems need only look into the mirror to see where a good deal of the blame lies for its creation and massive stranglehold on our economy. They—and they alone—made insurance companies the big winners in passing the #ACA, now the fastest growing source of Big Insurance dollars to fund further vertical integration. But it’s worse than that. The #Dems actually we’re duped by Big Insurance into legislating a vertical integration con. In the #ACA, Dems naively comforted themselves that their embrace of insurance companies could be mitigated by their imposition of “caps” on the profits and admin costs of plans. It was a wonderful piece of politically self-interested self-delusion. What those caps actually did was provide Big Insurance with the means, through vertical integration, to gorge on government subsidies, without really being restrained by the “caps” at all. The caps were effectively evaded simply by pushing profits from the plans down to captive #PBMs, specialty, #mailorder, and retail #pharmacies, #physician practice, #ASC, and other provider affiliates—a strategy the companies pursued with self-interested vigor. This #ACA dynamic, at the core of President #Obama’s signature legislation, is what has led, inevitably, inexorably, and directly, to Adam’s visual.

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New #ManattOnHealth Insight by Julian Polaris, Anne Karl, Patricia Boozang, Tracy Johnson, Ph.D. and Melinda Dutton: Exciting News – #CMS has finalized significant new rules for #Medicaid and #CHIP, impacting over 85 million beneficiaries nationwide. With some notable exceptions, CMS finalized the 2023 proposed rule with only modest changes. #Healthcare #PatientAccess #HealthEquity #HealthPolicy 

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Six months after implementing new AI transparency and interoperability requirements, the Office of the National Coordinator for Health Information Technology (ONC) has proposed another major policy update with significant implications for public health and payer health IT. The HTI-2 proposed rule implements provisions of the 21st Century Cures Act and introduces new standards and updates to enhance healthcare interoperability and data sharing. It also supports the technical requirements of the CMS' Interoperability and Prior Authorization final rule, which aims to transition payers to electronic prior authorization. Learn more in Fierce Healthcare: https://lnkd.in/ghZ8GeW5 I #Interoperability #PriorAuthorization #CMS #DataSharing #HealthcareInnovation 

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In their new Forefront article, Rachel Bonesteel, Sara Debab, William K. Bleser, Frank McStay, Robert S. Saunders, and Mark B. McClellan from the Duke-Margolis Institute for Health Policy present timely guidance and recommendations for CMS on the design and implementation of REACH, informed by literature review and conversations with REACH participants and other expert stakeholders about successes, challenges, and opportunities for improvement. "ACO REACH is the largest Innovation Center model and has seen an increase in beneficiaries from GPDC’s 2.0 million in 2022 to 2.6 million in 2024, including significant increases in safety-net provider participation. It is a more advanced alternative payment model than the Center for Medicare’s (CM’s) permanent ACO model, the Medicare Shared Savings Program (MSSP), offering prospective payments and global risk. Experts have noted the REACH program is a major step forward in incorporating multiple equity design and implementation elements directly into an advanced VBP model. Finally, it provides an opportunity to expand benefits available to traditional Medicare beneficiaries as an alternative to the additional benefit flexibility in Medicare Advantage (MA) plans." Read the full article here: https://bit.ly/3Uy1SSP

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Policy cheat sheet provides a high-level summary of CMS’ requirements for two new advisory groups: Medicaid Advisory Committees (MACs) and Beneficiary Advisory Councils (BACs). States can use this info to establish structures that center the #livedexperience and perspectives of Medicaid members in decision-making processes. More via CHCS: https://hubs.la/Q02v3v_l0

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Policy cheat sheet provides a high-level summary of CMS’ requirements for two new advisory groups: Medicaid Advisory Committees (MACs) and Beneficiary Advisory Councils (BACs). States can use this info to establish structures that center the #livedexperience and perspectives of Medicaid members in decision-making processes. More via CHCS: https://hubs.la/Q02v5JD70

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We're excited to share that Jack Rollins, Director of Federal Policy at the National Association of Medicaid Directors (NAMD), recently participated in a high-profile panel discussion at the Medicaid Health Plans of America (MHPA) annual conference. The panel, titled "2024 CMS Regulatory Sprint: A Panel Discussion on the Medicaid Impacts of Recently Finalized Rulemaking," brought together key industry leaders to discuss the implications of recent CMS regulations on Medicaid programs. Jack shared the stage with distinguished experts: Andrea Bennett, Kate Paris and Nicolas Wilhelm. The discussion covered critical areas affecting Medicaid programs: ▪️ Implementation Challenges: Jack highlighted the complexities Medicaid programs face in managing multiple significant regulations simultaneously. ▪️ Collaboration Opportunities: He emphasized the potential for partnerships between Medicaid programs and managed care plans to support effective implementation. ▪️ Financing Changes: Jack provided an in-depth analysis of the financial implications in the new managed care rule. ▪️ Access Standards: Andrea Bennett offered insights on evolving access standards in managed care for Medicaid beneficiaries, including home- and community-based services and required use of secret shopper surveys. ▪️ Eligibility and Integration: Kate Paris discussed important changes to eligibility criteria and efforts to integrate dual-eligible beneficiaries. ▪️ IT Systems Impact: Nicolas Wilhelm underscored the significant technological implications these new rules have across Medicaid systems. NAMD continues to be at the forefront of Medicaid policy discussions, ensuring that state Medicaid directors' perspectives are heard and considered in national forums. We're grateful for the opportunity to contribute to this important dialogue and remain committed to fostering collaboration between Medicaid programs and managed care organizations.

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NEW JOURNAL ARTICLE: This article explores why regulatory focus on health care websites' use of third-party technologies has increased, examines recent government guidance and its impact, and offers steps to mitigate risk. Read the full article: https://lnkd.in/e_wd5ftq

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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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The ever-growing world of health care data protection laws is dramatically broadening the kinds of companies that have to comply. Your organization may be subject to Consumer Health Data laws and regulations without realizing that you are now considered to be using consumer health data.

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📣 DEA and HHS Announce Third Extension of Telemedicine Flexibilities for Controlled Substances 📣 In a pivotal move, the DEA and HHS have announced a third temporary extension of telemedicine prescribing flexibilities for controlled substances, running from January 1, 2025 to December 31, 2025. This decision ensures millions of patients continue to have access to critical care while regulators refine long-term policies. 🌐💊 First introduced during the COVID-19 pandemic, telemedicine flexibilities have been a lifeline for patients managing chronic pain, mental health conditions, and opioid use disorder. Now, this extension continues that legacy of care, especially for underserved populations. What This Means: ✔ Access for Vulnerable Populations: Telemedicine ensures uninterrupted care for those in remote areas or managing opioid addiction, saving lives and bridging gaps in healthcare. ✔ Support for Healthcare Providers: This extension gives providers the time needed to prepare for future regulations, ensuring smooth transitions and sustained care for patients. ✔ Enhanced Public Safety: Balancing access with safety, robust patient verification and monitoring systems are in the works to prevent misuse while continuing to meet patient needs. Why It Matters: ◾ Over 38,000 public responses highlighted the need for expanded telemedicine access. ◾ Native American communities' needs have shaped the inclusivity of this policy. ◾ Telemedicine is vital for rural and underserved communities, where it’s often the only way to access specialty care. While this is a temporary extension, it underscores the transformative potential of telemedicine in healthcare. We’re on the path to a permanent solution by 2026, one that will make telehealth an essential and reliable part of our healthcare system. 🔗 Read the full announcement and stay updated on what’s next. #Telemedicine #HealthcareInnovation #DEA #HHS #PatientCare #Telehealth #PublicHealth #Regulation #HealthcareAccess #ChronicPain #OpioidUseDisorder #HealthEquity #TelehealthPolicy https://lnkd.in/e9vBfGZ7

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Check out Carrie Nixon's post below on the newly proposed Advanced Primary Care Management Codes from the 2025 Medicare Physician Fee Schedule Proposed Rule! #CMS #caremanagement #digitalhealth #healthcareinnovation

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CMS has extended unwinding-related waivers through June 30, 2025. This extension aims to protect coverage for individuals enrolled in Medicaid and CHIP. Here’s what you need to know: 💡 Why it Matters: Since the unwinding of the continuous coverage provision in April 2023, over 20 million people have been disenrolled. This extension allows states more time to ensure eligible individuals retain coverage and reduces inappropriate disenrollments. 👍 State Actions: States can continue using flexibility to streamline renewals, shifting resources to process applications faster, and conducting targeted outreach to encourage beneficiaries to return renewal forms. 🏥 Impact on Health Plans: This extension provides an opportunity to enhance member retention strategies and support vulnerable populations in maintaining their health coverage. Stay informed and take action to ensure continuous coverage for your members. https://bit.ly/3QQAIEC via Healthcare Finance News #Medicaid #Healthcare #HealthPlans

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🌟 New Medicaid & CHIP Managed Care Rule Released 🌟 The release of the Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F) signifies a significant development in #healthcareadministration. 🚨Key highlights include: 1. Access Enhancement: Establishment of standards for timely care access, including maximum wait times and independent surveys. 2. State-Directed Payments: Streamlining of payment processes to ensure fair rates and compliance. 3. Medical Loss Ratio: Mandate for transparency in expenditures and revenue reporting. 4. In Lieu of Services: Permission for innovative approaches to address health-related social needs. 5. Quality Strategies: Promotion of public engagement and robust quality assessments. This initiative underscores a commitment to #transparency, #accountability, and #qualityimprovement in #healthcare delivery. ▶️READ FULL #CMS REPORT: https://lnkd.in/eaQTVeMm Centers for Medicare & Medicaid Services HealthCare.gov #Medicaid #CHIP #ManagedCare #HealthcareQuality #AccessForAll

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🌟 New Medicaid & CHIP Managed Care Rule Released 🌟 The release of the Medicaid and Children’s Health Insurance Program Managed Care Access, Finance, and Quality Final Rule (CMS-2439-F) signifies a significant development in #healthcareadministration. 🚨Key highlights include: 1. Access Enhancement: Establishment of standards for timely care access, including maximum wait times and independent surveys. 2. State-Directed Payments: Streamlining of payment processes to ensure fair rates and compliance. 3. Medical Loss Ratio: Mandate for transparency in expenditures and revenue reporting. 4. In Lieu of Services: Permission for innovative approaches to address health-related social needs. 5. Quality Strategies: Promotion of public engagement and robust quality assessments. This initiative underscores a commitment to #transparency, #accountability, and #qualityimprovement in #healthcare delivery. ▶️READ FULL #CMS REPORT: https://lnkd.in/eaQTVeMm Centers for Medicare & Medicaid Services HealthCare.gov #Medicaid #CHIP #ManagedCare #HealthcareQuality #AccessForAll

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