Christopher Gengo

That’s a wrap on the 24th Risk Adjustment Forum! It was great seeing you all there. If you’d like to discuss your organization’s risk adjustment strategy further or we didn’t get a chance to connect, let’s set up a time. #DataLink #Events #RiskAdjustmentForum #Ri

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Medicare Advantage plans require an increased commitment to improving risk adjustment coding practices while optimizing medical record retrieval and interoperability. But health plans don’t have to handle these challenges alone! Watch our on-demand RISE webinar, where Cotiviti’s risk adjustment experts unravel trends shaping 2024 and beyond. https://bit.ly/49HsK7m #RiskAdjustment #HealthPlans

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Although "interoperability" may seem esoteric, and certainly not top of mind for the typical employee, employer HR/Benefit, and consultant teams - it's critical for improving the patient (and thus, employee) experience, as well as for providing the closer-to-real-time access necessary to support sophisticated clinical management initiatives. Thanks for posting, Frank! #healthmanagement #dataanalytics #employeeexperience #patientexperience #hrstrategy

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Price Transparency in Indiana for 2 Large Health Systems: IU Health & Parkview Focus is ER visits comparing Anthem PPO and UHC PPO contracted rates benchmarking to Medicare Adjusted Rates CPT 99283 Anthem Range % of Medicare: 366%-520% UHC Range % of Medicare: 410%-1,119% CPT 99284 Anthem Range % of Medicare: 639%-794% UHC Range % of Medicare: 631%-1,011% CPT 99285 Anthem Range % of Medicare: 440%-551% UHC Range % of Medicare: 490%-727% Additional Insight: CPT codes 99285, 99284, and 9923 generated $339,301,095 in billed charges through July 2024 YTD for IU Health System All three CPT codes were in the top 13 of utilization and generated the most in billed charges #employeebenefits #pricetransparency

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📈 CMS Disburses $10.3B in Risk Adjustment Payments for 2023 📉 The announcement of these risk adjustment payments for 2023 underscores the crucial role in maintaining stability and fairness within our insurance markets. 🎯 Highlights: ➖ Total Payment: $10.3 billion in risk adjustment payments. ➖ Purpose: To help insurers manage the financial risks of covering individuals with varying health statuses. ➖ Impact: A crucial mechanism to balance out costs across insurers, ensuring equitable access to care and preventing market destabilization. 💡 Why It Matters: For insurers, this means greater financial stability and the ability to focus on patient care without the heavy burden of risk-related uncertainties. For consumers, it ensures continued access to diverse and reliable insurance options. #Healthcare #CMS #HealthPolicy #Medicare #Medicaid

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Ohio Home Health Providers: Urgent EVV Compliance Update! The Ohio Department of Medicaid announced Phase 1 of their EVV claims denial approach. Starting October 1st, 2024, home health fee-for-service claims with missing or non-compliant EVV records will be denied. Now is the time to make sure you're ready. 1. Double-check your EVV setup. 2. If using an alternate EVV vendor, verify everything is functioning correctly. 3. Take action immediately to avoid claim denials. Don't wait until October to find out your revenue is impacted. Protect your EVV claims payments by ensuring EVV compliance today! #OhioHomeCare #EVV #Compliance #HomeHealth #Healthcare

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Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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In this video, the Indiana Department of Insurance (IDOI) Executive Director of Indiana All Payer Claims, Jonathan Handsborough, MBA, MBB-6σ, introduces Hoosiers to a new healthcare data system managed by the IDOI's Indiana All Payer Claims Database (APCD).  The Indiana All Payer Claims Database (APCD) collects and combines various types of data, including patient eligibility information, medical claims, pharmacy claims, alternative payment models data, and health care provider details. To learn more about the IDOI Indiana APCD website, visit: https://lnkd.in/gv4K5RpN #indiana #insurance #insuranceindustry #hoosiers #data #database

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The #MedicareAdvantage system is facing scrutiny as private insurers such as #UnitedHealth profit by manipulating patient risk scores, creating challenges for healthcare providers and patients. See how this impacts care and costs in this STAT video: https://hubs.li/Q02LLt-d0 #HealthcareHere https://hubs.li/Q02LLzMs0

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In one our latest webinars "The Future of Medicare Advantage," Wakely Consulting Group Principal Tim Murray, FSA, MAAA, points out that CMS should wait a couple years before taking any action on risk adjustments to see how health policy changes with the incoming administration. Watch the full replay: https://bit.ly/48rmRwa #MedicareAdvantage #healthpolicy #CMS #Election2024

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HOT TIP! 🔥 A fully optimized risk adjustment platform can have a direct impact on the health outcomes of your members. Watch the recording of our webinar to see innovative ways health plans are coordinating risk adjustment functions (like coding and advanced analytics) to identify and treat complex, hard-to-diagnose conditions.  https://lnkd.in/ewc22_5x   #RiskAdjustment #ClarityPlatform #Analytics #HealthTech #HealthOfYourHealthPlan

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The Centers for Medicare & Medicaid Services (CMS) confirmed that personal data for nearly 1 million Wisconsin Medicare beneficiaries was compromised due to a MOVEit vulnerability, first exploited in May 2023.    Here’s what you need to know: ■ Delay in detection: Despite patching the MOVEit vulnerability in June 2023, an additional review in 2024 revealed unauthorized access before the patch was applied. ■ Massive impact: Over 946,000 people are being notified, and CMS is offering free credit monitoring services for those affected. ■ Wider implications: The MOVEit breach is considered one of the largest data breaches, affecting thousands of organizations globally.   For IT professionals managing critical systems, this incident highlights the importance of continuous monitoring and re-evaluating cybersecurity measures after initial threats are addressed.   Link to full article: https://lnkd.in/eDw3MDU6 #CyberSecurityNews #CyberSecurity #SecurityNews #InfoSec #DataBreach #Medicare

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Next year, payers will need to increase member communication on supplemental benefits, per new rules from Centers for Medicare & Medicaid Services. Find our summary of the changes and ways to reduce related operational challenges: https://lnkd.in/gz6PN7g2

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When facing disruption due to the Change Healthcare cyberattack, Sanford Health turned to Availity Lifeline to restore critical operations within just four days. Now, Sanford Health has chosen Availity Essentials Pro™ to streamline seamless claim and payment processing while supporting innovative care delivery. Discover how this partnership is transforming healthcare operations: https://okt.to/eUGNML #RCM #RevenueCycleManagement #HealthcareEfficiency #HealthcareInnovation

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