Edward Slingsby, MBA, FHFMA, PMP, CPHIMS

Major Changes Coming For The KC Market 📢 Blue KC to Exit Medicare Advantage Market by 2025 Due to Regulatory Demands 📢 Blue Cross and Blue Shield of Kansas City (Blue KC) has announced its departure from the Medicare Advantage (MA) market by the end of 2024, citing increased regulatory demands and financial pressures as primary reasons for the decision. The company will shift its focus to employer-sponsored health plans, Medicare supplement plans, and Affordable Care Act plans while ensuring uninterrupted, quality service to current MA members through 2024. With a smaller MA membership base, Blue KC finds it challenging to compete economically at scale, leading to the difficult but necessary market exit. In a statement, Blue KC's President and CEO, Erin Stucky, expressed disappointment, saying, “We explored every alternative path for our MA members and are disappointed we must exit this line of business.” This move aligns with industry trends, as other insurers, like Oscar Health, have also exited the MA market due to similar challenges, including the impact of regulatory changes such as the CMS's benchmark payment adjustments on the profitability of MA plans for smaller insurers. #Healthcare #MedicareAdvantage #BlueKC #RegulatoryChallenges #InsuranceIndustry #HealthPlans #CMS #MarketExit

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CMS Proposes Over 4% Cut to Home Health Medicare Payments in 2025: "To rebalance the Patient-Driven Groupings Model (PDGM) and make it budget neutral... CMS is proposing a permanent prospective adjustment to the CY 2025 home health payment rate of -4.067%." Let Bartlett Strategy Group, LLC help you navigate these cuts and ensure that you're maximizing your reimbursement with accurate coding and OASIS outcomes! https://lnkd.in/eTWtJBQG

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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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Healthcare systems must recognize the importance of both HHS-HCC and CMS-HCC risk adjustment models. While the CMS-HCC model remains crucial for Medicare Advantage plans, the HHS-HCC model provides essential insights for managing risks in the broader ACA market. Understanding and integrating both models ensures that healthcare systems can deliver high-quality care, maintain financial stability, and comply with regulatory requirements across different patient populations. By doing so, they can better navigate the complexities of modern healthcare delivery and funding, directly impacting our quality of care. Healthcare systems benefit from integrating knowledge of both models to: 1. Enhance Comprehensive Care: By addressing the needs of diverse populations. 2. Improve Accuracy: In risk assessment and resource allocation. 3. Ensure Compliance: With federal regulations and market requirements. 4. Promote Equity: In healthcare access and funding.

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Attention Founders! Wondering how to structure market based relationships with MA payers? Here are the plan groupings that align with H numbers. This is why there are times that payers ask you to work with plans in seemingly disparate markets. There is a method to the madness. Thanks Yubin Park, PhD for sharing your work.

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UnitedHealth Group is the latest Medicare Advantage provider to file another lawsuit against CMS challenging a drop in their Medicare Advantage star ratings, purportedly based on a single eight-minute call. According to their complaint, they stand to lose tens of millions in revenue due to this lower rating. "Unless corrected by this Court, that downgrade will misinform millions of current and potential customers...[t]he substantial adverse impact ...is imminent, because the Star Ratings will be published for customer consideration on or about October 10, 2024." They go on to argue that as lower-rated plans tend to lose enrollees during open enrollment and beyond, the impact will snow ball, further impacting their bottom line and revenue forecasts. For some background: the MA star rating system was introduced in 2007 and was supposed to be designed it to provide beneficiaries with a quick gauge of plan quality across categories like clinical outcomes, patient satisfaction, and customer service. While United makes it sound like the MA star ratings system is nothing more than a glorified Yelp review, star ratings are based on over 40 performance measures, including clinical outcomes, patient satisfaction, and call center responsiveness with data from HEDIS and CAHPS. Moreover, plans even have multiple preview periods to contest preliminary ratings before they’re finalized​. The star ratings translate directly into billions of dollars for plans like UnitedHealthcare. For instance, the average annual Quality Bonus Payment per Medicare Advantage enrollee in 2022 was $352—a substantial amount when scaled across millions of enrollees. UnitedHealthcare isn’t the first to fight CMS on star ratings. Similar lawsuits from Elevance Health and Scan Health were filed over perceived unfair treatment. UnitedHealthcare’s recent lawsuit and those before it underscore the fact that they’re more than willing to support this rating system when they are able to cash their bonus checks, but are quick to decry it when they receive a downgrade based on “shoddy service” caught in a secret shopper review. UnitedHealthcare would have no issue with these “Yelp-like” ratings if they were raking in five-star bonuses. Now that they’ve been hit with a lower rating due to a call they claim didn’t follow protocol, they’re ready to rewrite the rules. Do I believe the CMS’s rating system is perfect? No, but that’s the system they signed up for and have profited dearly from over the years —and now they're throwing a legal temper tantrum when they didn't get their way. Jeffrey HoganPreston AlexanderWendell PotterPatient Rights AdvocateLee LewisScott Conard, MDJohn TozziSara HansardWilliam SarrailleKimberly CarlesonNelson GriswoldShawn GremmingerKaren van Caulil, Ph.D.Gloria SachdevMarilyn BartlettPeter Hayes

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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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The impact of telemedicine on billing practices and reimbursement models across the US is a multifaceted topic. It involves exploring how virtual healthcare services affect traditional billing structures, reimbursement rates, and insurance coverage policies. Additionally, it raises questions about the need for updated billing codes and regulations to accurately reflect telemedicine services and ensure fair compensation for providers. Contact us for more #US #Medicalbilling #Bestpractices Virtual Medical Billing Solutions LLC

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#AI #HealthTech: AI Revolution: How BCBSM Became a Healthcare Leader -Blue Cross Blue Shield of Michigan BCBSM: It is Michigan’s largest health insurer, providing a wide range of health insurance plans, including medical, dental, and vision coverage. -BCBSM is known for its commitment to improving the quality and value of healthcare through continuous innovation. -They focus on health equity, ensuring members have access to quality healthcare when and where it’s needed most. -BCBSM transformed from least to most efficient in tech use. -Focused on responsible AI to enhance agility and efficiency. -Adopted incremental updates to manage costs effectively. - Leveraged 4 petabytes of unstructured data for insights. - Implemented AI to handle increasing complexity and demands. -Improved member services with AI-driven solutions. Maintained strict data privacy and regulatory compliance -Enhanced operational efficiency with AI and machine learning. - Focused on delivering clear business value through AI. Achieved significant cost savings and operational improvements. https://lnkd.in/dt5CJJD3

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How Much Variation Should There Be in the Pricing of a CT Scan, from the *Same​* Provider in Michigan? Here's a real life example of from one of finHealth's clients. The names have been changed to protect the innocent (until proven guilty).   This is the actual distribution of CT scan of the abdomen and pelvis with contrast in the Michigan region – all from the same provider. Typical cost at this facility is $400, but here we also see this same provider exceeding $2,700 on multiple occasions. Why does the contract allow much significant pricing variation for the same service from the same provider? Is your BUCA contract allowing for this? Do you know? 𝑯𝒐𝒘 𝒘𝒐𝒖𝒍𝒅 𝒚𝒐𝒖 𝒌𝒏𝒐𝒘? #healthcare #cost #fiduciary #howwouldyouknow

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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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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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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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Medicare Advantage offers options in flexible benefits and range of pricing, however it is not all sunshine and roses. An aging population and ever climbing cost of care is creating financial viability pressure. This is the first in a series of Medicare Advantage considerations and potential strategies in planning for providers, provider services, health plans and payer services . This article lays the foundation on the current Medicare Advantage Landscape. #Medicareadvantage #Heathcare #Healthcareaffordability

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Four Best Practices to Improve Risk Adjustment Compliance To thrive in the evolving risk adjustment regulatory environment, organizations must adopt proactive measures. While I have an entire list of how to ensure you are capturing conditions to depict complexity, here are four proven strategies to help drive risk score compliance: -Educate Providers: Offer regular training on documentation and coding. Make this a part of the norm, not an abnormality. A system in Arizona I partnered with brought education to providers in a one on one manner twice per year. They shared information about coding, performance, and use of technology. The investment paid dividends. -Pre-Bill Reviews: Evaluate high-risk diagnoses before claims submission. Additionally, through leveraging natural language processing technology (NLP) you can expand the volume of diagnoses reviewed to optimize reach. -Single-Time HCC Reviews: Audit conditions captured only once annually. (Note- I had another post on this one specifically so go scope it out) -Retrospective Reviews: Identify gaps and remove unsupported diagnoses. Retro reviews are a tremendous tool for MA and ACA populations. Not only should you be using those to capture missed conditions but this is the opportunity to correct for any over-capture. Success in risk adjustment isn’t just about capturing conditions—it’s about ensuring they’re defensible. The goal is a complete and accurate risk score. With audits increasing, these best practices aren’t optional; they’re essential. Which of these practices does your organization prioritize? Do you have any others you’d recommend, that you’ve found work better? I’d love to share ideas; let me know in the comments below.

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Understanding your health plan's prices or your managed care contract is a very challenging task. The multitude of variables in claim pricing is astounding. Zip codes, provider credentialing, past visits, diagnosis codes, and obscure administrative guidelines, etc. create significant difficulty in determining the contract prices and ultimately the sufficiency of those prices for your health plan or managed care contract. Network and HealthPlans guard their pricing methods as intellectual property. It is critical to understand the impact of the pricing system for everyone involved to reduce this industry wide cost of healthcare payments A network or payer provides the output of their pricing mechanism through the traditional claim's payment process. Using the site specific, Medicare index for each code or DRG will allow a health plan or healthcare provider to determine what the sufficiency and payment adequacy for their claims and procedures. Even when the plan uses an alternative or proprietary pricing index, a Medicare index analysis gives you the information necessary to evaluate your health plan or contract prices. For certain, this Medicare index process is much easier to use and evaluate versus a machine-readable file! The cost of not understanding and using a Medicare index for all healthcare plans and provider contracts arises in the continual high (and higher!) cost of healthcare payments. Unnecessary claim appeals, phone calls, legal expenses and credit balances underscore the need to reconcile the prices for healthcare at your employer plan, medical provider, and insurance company. Imagine the wasted costs involved in trying to resolve healthcare payments between health plans, providers, employers and various ERISA plans. Is it about time we change the cost of healthcare payments?

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Dr. Jain...THANK YOU for this insight and support for the kind of work I do every day! Building complex geriatrics longitudinal care programs is where I cut my value based teeth! These programs - when structured with attention to detail - can create a profoundly positive impact. A fully integrated program that is carefully facilitated, orchestrated, and navigated WITH a patient quite literally changes lives. As a system we have to shift our thinking and embrace the FACT that cookie cutter medicine is NOT effective as well as the notion that precision medicine is not scalable, replicable or sustainable....because it CAN be. Been there, done that (and continue to do it) and have the results to prove it! At Synergy 3C, THESE are the models we build and have a track record of success! We would love to have a conversation with you about HOW these models can and do work! #complexpopulationhealth #complexgeriatrics #medicareadvantage

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The latest news, are you aware? Vertical integration struggling in healthcare now demonstrated by the just announced CVS Health cost-cutting efforts. #employers need to stay aware and determine such impacts on their benefit design, plan offerings, and partners in executing a successful benefit program. #epcouncil.org

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