Chike Nzerue

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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2024 CDI Week Some suggestions for those CDI professionals celebrating CDI week this year: 1- Begin the process of transforming and updating CDI's role as a collaborator and facilitator of better physician documentation, recognizing that the physician is the only individual who can improve his/her documentation. A reasonable starting point is asking physicians how you can help them master documentation and charting in the EHR. Inquire as to what physicians desire and expect in a helpful CDI program, making the physician the focus of our attention. In short, how can we help physicians work smarter not harder with more time doctoring in front of the patient versus doctoring in front of the computer screen 2- Prepare for CDI week by beginning to become more proficient and knowledgeable in best practice standards of documentation. An ideal starting point is becoming familiar with the 2023 E & M documentation requirements, and being able to apply these standards in your chart review process. The History of Present Illness and Medical Decision Making within the H & P is vital in driving the establishment of medical necessity, an area that is often overlooked by CDI. Yes, CDI plays a role through more effective documentation in guiding physicians to support their clinical judgment that the patient needs to be hospitalized in an inpatient level of care 3- Commit to working onsite, hand in hand with Case Management, Utilization Review, and Physician Advisors. Working remotely five days per week creates too many roadblocks to collaborating with physicians and others using a multidisciplinary approach to documentation excellence. Like a used car salesman, out of sight out of mind. I have found that onsite CDI activities allow for more interaction with physicians and the multidisciplinary team. Remote CDI does not allow for critical situational awareness including providing feedback through conversation with physicians on documentation tips to consider in the future to better capture the patient's clinical story and support of clinical judgment and medical decision-making. Real-time feedback and documentation education are not effective through email. Physicians are bombarded with emails, they want fewer emails and more education on documentation #CDIweek, #happyCDIweek, #CDIhelpingphysicians, Cesar M. Limjoco, M.D. https://acdis.org/cdi-week

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Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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An Outpatient Clinical Documentation Improvement (CDI) program offers substantial advantages to healthcare organizations by elevating patient care and operational efficiency. By integrating risk stratification with chronic conditions, enhancing quality measures, addressing social determinants of health, and establishing a collaborative team empowered by technology, such strategic initiatives result in improved patient outcomes and streamlined operations.

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CMS Proposes 2.8% Cut to Medicare Physician Fees for 2025 — One group calls the proposal "critically short-sighted" This summarizes the dire situation of CMS proposed reduction in the yearly decrease in physician payment when all physician practices are experiencing inflationary pressure and increasing expenses year after year. Patients potentially suffer with more and more physician practices limiting the number of Medicare patients in their practice. I see practices indirectly limiting Medicare patients by offering early morning appointments like 7 AM or 5 PM, knowing these patients do not do early appointments, knowing firsthand when I notice scheduling specialist visits for a family elderly parent that these were the times offered or providing a time months out. Here is for Congress to pass the Strengthening Medicare for Patients and Providers Act to implement an annual inflation-based physician payment update tied to the Medicare Economic Index, and modernize Medicare’s antiquated budget neutrality policies by enacting the Provider Reimbursement Stability Act. "A 2.8% reduction to the conversion factor would be alarming in the best circumstances, but to propose doing so at a time when 92% of medical groups report increased operating costs and are otherwise struggling to remain financially viable is critically short-sighted," Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association, said in a statement "Medicare physician reimbursement is on a dire trajectory and these ongoing cuts continue to undermine the ability of medical practices to keep their doors open and function effectively -- the need for comprehensive reform is paramount." #paymentreduction, #paymentdecrease, #physiciansworkingforless, #inflatioanrypressure, #diretrajectory https://lnkd.in/eVkGHBeM

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Bloomberg Businessweek has an article on the growing use of nurse practitioners in #healthcare. One driver is cost as you can see from the chart below nurse practitioners cost approximately half of primary care, physicians that they bill a similar amount of revenue and much higher margins for hospitals. It also highlights a trade off as the education for nurse practitioners as far less standardized than for #physicians. #theagiledashboard A link to the article: https://lnkd.in/dt3hZpZe

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While, we can debate whether the “payvider”model is most optimal to create value, what is clear is that the traditional relationship between provider and payer will continue to dominate in the near future so we need to find ways to continue to create high-level synergy between these healthcare partners to drive clinical efficiency and optimal health outcomes. #Payvider #healthinsurance #Valuebasedcare #Fiercehealthcare

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The latest Kaufman Hall National Hospital Flash Report reveals stable financial and operational hospital performance in October. While expenses declined on a volume-adjusted basis as discharges increased, supply and drug costs continued to rise. Stay informed on the latest hospital financial trends. #healthcareconsulting #hospitalperformance #healthcaremanagement #hospitaldata

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Sullivan senior consultant Shawn Craddock, DNP, RN, CNOR, NE-BC, discusses procedural sedation and analgesia considerations for ASC leaders and the effect on patients in this article from OR Manager. Hear from Shawn about balancing anesthesia practices based on therapeutic effects, patient safety, practitioners' skills and credentials, and cost-effectiveness. Read more from OR Manager here.

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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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Many organizations still rely on outdated and inefficient methods that are not suitable for the modern healthcare model. The journey toward a more efficient and profitable ambulatory care facility revolves around two pivotal strategies: process standardization and patient-centric care.

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The discussion around real-world, synthetic, and de-identified data in #HealthcareAnalytics highlights an essential truth: the data you use doesn’t just inform insights—it shapes the decisions that impact patient care and access. Each data type has unique strengths: real-world data provides depth and variability, while synthetic data offers scalability and privacy protections. However, the true power lies in integrating these sources with reimbursement and knowledgebase data. By combining these latter two data types, we can ensure that the best diagnostics are not only developed and validated but also reimbursed—making them accessible to patients who need them most. Adding real-world data further enhances this process to demonstrate clinical utility when new biomarkers are tested, paving the way for reimbursement frameworks to support the rapid translation of innovation to the practice of medicine. In healthcare, better decisions start with better data, applied strategically to advance #PrecisionMedicine and improve #PatientOutcomes.

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S&P: Medicare Advantage's growth a bad omen for hospitals - n8: and Many Health Systems Continue to Participate Under the Terms Dictated by the MA plans, Enabling this Abuse “Even beyond rates, MA adds more administrative and liquidity hurdles for providers. S&P pointed to MA plans’ “key strategy” of prior authorization requirements, which force providers to absorb associated refiling costs and sometimes keep patients locked in a longer hospital stay. That burden is exacerbated by insurers’ generally “high” denial rates, S&P wrote, which have led to instances where smaller providers without the resources to fight claim denials terminate their MA plan contracts and become more vulnerable to closure…. The report also notes that many MA plans have longer pay cycles than traditional Medicare. Combined with claims denials and payment uncertainty, the delayed reimbursement “can hurt cash flow and liquidity,” according to the report.” https://lnkd.in/g3-drT-S So it goes n8 #healthsystems #hospitals #valuebasedcare #medicareadvantage #valuebasedscam

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Attention All Coders and CDI Specialists: We are excited to preview the new ICD-10-CM codes for obesity, effective for discharges starting October 1, 2024! CDC Classification of Obesity: Based on BMI measurements, the CDC considers a BMI of 30 or higher to be obese. Obesity is further subdivided into three categories: Class 1: BMI 30–35 Class 2: BMI 35–40 Class 3: (sometimes called “extreme” or “severe” obesity): BMI 40 or higher New ICD-10-CM Codes: E66.8: Other obesity E66.81: Obesity class E66.811: Obesity, class 1 E66.812: Obesity, class 2 E66.813: Obesity, class 3 E66.89: Other obesity not elsewhere classified Added two(2) new pediatric obesity codes: Z68.55 Body mass index [BMI] pediatric, 120% of the 95th percentile for age to less than 140% of the95th percentile for age Z68.56 Body mass index [BMI] pediatric, greater than or equal to 140% of the 95th percentile for age Important Note: The tabular section has added:  Use Additional code to identify body mass index (BMI), if known, for adults (Z68.1-Z68.45) or pediatrics (Z68.5-). Reminder: ICD-10-CM coding guidelines remain unchanged. Physicians must continue to document the associated diagnosis. BMI greater than 40 will continue to be a CC. As always, Coders Get Paid to Think. Happy Coding!

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Great article breaking down what 340b is, what it was intended to do vs what it is doing and real strategies for solving the beast of the 340b complexities.

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The ability to be compensated for work carried out in the healthcare space has become increasingly difficult and complicated. It is imperative that our industry remains current on trends, changes, and projected challenges, to ensure our readiness in combatting them. The ambulance industry of today is far different from when our organization first opened in 2010, and we have continuously evolved to meet these challenges head-on. This will remain a big talking point for years to come, and/or until significant changes are made to the benefit of providers. In healthcare, you expend a great deal of capital to provide a service, and in return, you "hope" for reimbursement. Try doing that at a local restaurant - order and eat your food, and tell the staff you MIGHT come back with payment in 90-120 days. Let's see if you make it out of there without cleaning some dishes on your way...

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Increasingly requests for prior authorization are creating greater demands on physicians time, including Otolaryngology, even in the absence of strong evidence that such requests discourage low-value spending. A recent study by Lauren Miller, MD, MBA and co-authors from the department of Otolaryngology-HNS at the Ohio State Wexner Medical Center examined data comparing prior authorization policies across five major Medicare Advantage insurers for commonly performed otolaryngology procedures. The authors noted that prior authorization requirements for specific services varied widely among insurers and consequently raised concerns about their validity. These discrepancies are indicative of the challenges otolaryngologists face in navigating these discordant policies and likely play a role in physician discontent. Medicare Advantage Prior Authorization Requirements for Otolaryngologic Procedures in 2021 in Otolaryngology-Head and Neck Surgery https://lnkd.in/gQZUS7hC #otolaryngology, #ENT, #ohiostate,

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