Elizabeth Woodcock

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

22

9 Comments

New Episode #354 of the CodeCast Podcast. Join us as Terry covers questions covering risk support for E/M, Telehealth in the hospital setting, missed appointments, follow-up testing protocols, shared visit modifiers, and more. Tune in here:https://lnkd.in/gnW3-heX #TerryTuesday #CodeCast #Top10Tuesday #podcast

38

3 Comments

Not fair and balanced Advertorial for Private Equity A total conflict of interest Immoral to destroy healthcare for opportunity to work for companies that profit on ultimately destroying USA 🇺🇸 healthcare as we knew it. People that worked for CMS should be banned from working in industries that profited from the decisions and have connections for future decisions to destroy the healthcare fabric No discussion of the negatives only the positives Consolidation leads to fewer choices for patients The cons for patients outweigh the pros for the investors. Profits over care ultimately leads to rationing of the care that is not profitable Management of PE selects doctors to interface that benefit from a hard line approach over providers that see quality issues and patient safety as important Cheerleaders 📣 for the profiteers

2

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

17

1 Comment

Find out how WVU creates a culture of EBP enabling transformation of patient care. Watch the full webinar: https://gag.gl/53xl9e #EBP #Nursing WVU Medicine

4

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

5

Off-Cycle SNF Provider Revalidation: Mandatory Form CMS-855A Top 7 Things To Know: 1. Mandatory Revalidation: Starting October 1, 2024, all SNFs must revalidate their Medicare enrollment by the end of the year. This process requires completing an updated CMS provider enrollment form, which now asks for more detailed information than before. 2. Off-Cycle Revalidation: Normally, provider revalidation happens on a regular cycle. However, this "off-cycle" revalidation is a one-time requirement starting this year, impacting 100% of SNFs, regardless of their size or ownership structure. 3. CMS Enrollment Form 855A: The new form, which must be completed by SNFs, is longer (20 pages compared to the previous 14 pages) and includes additional sections about "Additional Disclosable Parties" (ADP). SNFs must provide detailed information about all ADPs that have a significant operational or financial role in the facility. Providers can access the form via the PECOS (Provider Enrollment, Chain, and Ownership System) online platform. ·     Visit the PECOS website: https://lnkd.in/g5kBTqfW ·     Log in using your CMS credentials. ·     Locate the revalidation section. ·     Link to CMS 855A Form: chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://lnkd.in/gqAvEnZk 4.    Timeline: ·     CMS will send letters to SNFs starting on October 1, 2024, and through the end of the year. ·     Providers have 90 days to respond after receiving the letter. ·     Failure to complete the revalidation in time could disrupt the facility's ability to bill Medicare.   5.    Additional Disclosable Parties (ADP): This is a key new requirement. An ADP is anyone or any entity that: ·     Has significant operational, financial, or managerial control over the SNF. ·     Owns, leases, or subleases property to the SNF. ·     Provides management, consulting, or financial services to the SNF. This information must be disclosed in the new enrollment form. 6. Importance of Compliance: SNFs must complete this revalidation within the specified timeframe to avoid disruptions in their Medicare billing. Providers are advised to consult legal counsel to ensure they correctly interpret the reporting requirements and avoid errors in their submissions. 7. PECOS System: The information must be submitted through the PECOS system, which is the online system used by CMS for provider enrollment. This process requires more detailed reporting, especially concerning the ownership and operational control of SNFs and the ADPs involved with the facility. Since all SNFs are affected, every provider should be prepared for this and take timely action to prevent any interruption in Medicare billing. Failure to comply could result in significant financial issues for the facility. #SNFCompliance #MedicareRevalidation #CMSUpdates #HealthcareProviders #HealthcareCompliance #CMSFrom855A

20

3 Comments

☝ Don't Miss the Application Deadlines for the ACO Primary Care Flex Model! CMS is accepting applications for the ACOs Primary Care Flex Model until August 1, 2024. Interested organizations must apply as new or renewing ACOs to the Medicare Shared Savings Program (MSSP) by June 17, 2024. The ACO PC Flex Model will launch on January 1, 2025, and run for five years. Low-revenue ACOs participating in the Shared Savings Program can apply to the ACO PC Flex Model. This innovative model aims to increase the number of low-revenue ACOs and enhance primary care payment through a Prospective Primary Care Payment (PPCP) option, shifting payment from fee-for-service to a predictable, monthly payment. 💲 Enhance primary care payment and innovative care delivery  📉 Narrow Disparities in health care outcomes  🔻Reduce program expenditures while preserving the quality of care  💪 Strengthen participation incentives for new and low-revenue ACOs 💰 Base Rate and Payment Enhancements  💴 One-time Advanced Shared Savings Payment Health Equity Strategy to drive accountable care and advance health equity #ACOPrimaryCareFlexModel #HealthcareInnovation #PrimaryCare #AccountableCare #Medicare #HealthEquity #SustainableHealthcare #ValueBasedCare #VBC #RiskAdjustment #PPCP #SharedSavings #CMS https://lnkd.in/gmiKZsHM

5

Check out Briauna Driggers and I's latest HCCA/SCCE compliance article on Navigating AI Reimbursement in Healthcare Revenue Cycle Coding Strategies Regents Health Resources, LLC

13

Very important article on the secondary impacts of the pandemic on our healthcare system. They are not good!!     Hospital COVID-19 Burden and Adverse Event Rates "After risk adjustment, the relative risk (RR) for AEs among patients admitted during weeks with high compared with low COVID-19 burden for all patients was 1.23 (95% CI, 1.09-1.39; P < .001), with similar results seen in the cohorts with (RR, 1.33; 95% CI, 1.03-1.71; P = .03) and without (RR, 1.23; 95% CI, 1.08-1.39; P = .002) COVID-19 individually."   "Conclusions and Relevance In this cohort study of hospital admissions among Medicare patients during the COVID-19 pandemic, greater hospital COVID-19 burden was associated with an increased risk of in-hospital AEs among both patients with and without COVID-19. These results illustrate the need for greater hospital resilience and surge capacity to prevent declines in patient safety during surges in demand." Jama Network: https://lnkd.in/e23HcJkm  

22

4 Comments

CMS recently issued its Medicare Hospital Inpatient Prospective Payment System (IPPS) final rule for FY 2025. In addition to Medicare fee-for-service payment rate changes, the rule establishes a number of other updates, including changes to required quality data reporting. Key highlights related to reporting changes within the IQR program: • Two new healthcare-associated infection measures applying standards used in other areas of care to oncology locations, beginning calendar year 2026. • Two new electronic clinical quality measures (eCQMs) options relating to falls and postoperative respiratory failure patient-safety practices, beginning calendar year 2026. • Renewed requirements for sustained data collection and reporting of respiratory illnesses—COVID-19, influenza, and RSV—with the requirement that this information be reported electronically by Nov. 1, 2024. See the CMS IPPS fact sheet for a full summary of the final rule: https://bit.ly/3WzrD5f At Q-Centrix, we work with hospitals and health systems to prepare for changes stemming from the final rule updates each year while improving their public quality measures reporting efforts with respect to core measures, eCQMs, Infection Prevention, and other types of required reporting. It's my passion to see hospitals improving patient care by utilizing the high-value data being collected as part of these programs. Comment or message me if you think we can help you with better leveraging your data!

25

The HCC (Hierarchical Condition Categories) V28 update brings changes to how healthcare providers, including primary care physicians (PCPs), need to document and report patient conditions for risk adjustment in value-based care models like Medicare Advantage. Here’s how a PCP practice can adapt: 1. Review the Changes: The practice must first understand what HCC V28 changed, such as added, removed, or restructured condition categories. Some conditions may now have different weights or may not be included at all. For example, chronic conditions that were previously grouped together may now be split for more precise coding. 2. Accurate Documentation: PCPs must ensure their documentation reflects the most up-to-date diagnostic codes and levels of specificity required by HCC V28. This involves: • Training staff: Ensure doctors, nurses, and coders are trained on the new requirements. • Regular Audits: Review patient records to make sure all relevant conditions are documented and coded accurately. 3. Risk Coding Adjustments: Risk adjustment relies on capturing the full scope of a patient’s health status. PCPs should focus on thorough annual assessments and revisiting patients with chronic conditions to ensure all diagnoses are captured under the new system. 4. Technology Updates: Make sure the Electronic Health Record (EHR) system is updated with HCC V28 changes, so physicians can select the correct diagnosis codes more easily during patient visits. 5. Collaboration with Coders: It’s important to collaborate closely with coding teams who will submit claims. They can help flag documentation that may be incomplete or unclear and ensure it meets the HCC V28 criteria. 6. Patient Care and Outcomes: Since reimbursement is tied to accurately capturing patient complexity, PCPs should continue to focus on managing chronic conditions effectively. The right coding helps align payment with the level of care provided. By staying on top of these changes, PCP practices can ensure compliance, optimize their risk scores, and receive appropriate reimbursement #Risk Adjusment #Axial Health Consultant Pvt. Ltd

19

Recent court decisions have caused CMS to recalculate Medicare Advantage Star Ratings - which will generate increased bonus payments for some plans as extreme outliers are not discounted from the calculations. But note: this decision was made based on the Administrative Practice Act (a federal law governing how federal agencies do their work) rather than the substance of the action; smart money will expect future rulemaking to comply with the decisions and further modify the calculations. The takeaway for practices and plans is to take the win today but not rest on these decisions: Providers, do your absolute best to deliver the best care, and Plans, invest in practices doing the work with your patients now for long-term success. https://lnkd.in/gSRFcuMs

12

Thank you to our wonderful participants this afternoon in the HCT Consulting Group Healthcare Transformation Executive Roundtable. Brian D. Washburn, DHA, MHA, FACHE, FACMPE, CHFP, PMP Chris Saxman Elizabeth Crawford Restat Elya Prystowsky, MS, PhD Mark Korth. I was encouraged by several insights from this amazing group: 👉 #Transformation - we know it when we see it! 👉 #Valuebasedcare - we know it when we don't! 👉 #Valuebasedcare means different things to #patients and #providers but we should not lose sight that like or not, we have to play by the language and definitions being proposed by the Centers for Medicare & Medicaid Services 👉 #Transformation towards #VBC should be keeping healthcare simple, local and well-coordinated - what 99% of people are trying to do today. Organizing to stop the despicable 1% is adding 30% of costs to everyone - especially #ruralhealth 👉 #EMR Transformation has put some hospitals out of business and in some communities, when the hospital closes, the whole community shuts down 👉 #Transformation this group sees on the horizon includes demand for change only intensifying, doing more with fewer providers, addressing #documentation challenges, #AI should focus on removing the hassle of the little things 👉 MAJOR RISK AHEAD - Will #transformation defined by CMS + #BigTech lead to a loss of simplifying the provider-patient experience? Will documentation to meet #VBC demands only escalate due to the 'potential' of what technology offers? And therefore, will health disparities only expand due to the inability of #ruralhealth to keep up? Ultimately - will we eventually have to unwind many of the current technology investments to one day return to a simpler provider-to-patient connection? Thanks again to our amazing participants. DM me if you'd like to be on our roster to participate in the next one!

12

What is the bottom line if you have financial responsibility for a provider group? Your competitors have the ability to know your contracted rates for everything you do. That's the bad news. The good news is that you can know theirs to help you in your next negotiation.

7

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

34

4 Comments

If you build it, will they come? I’ve heard countless organizations - #MA plans, #Medicaid plans, risk-bearing providers, vendors, PBMs, and retail players - say “we need to build the capabilities to XX”. Many are looking to vendors for solutions, but few vendors are ready to invest in new capabilities without contracts.  Anyone else sensing this (problematic) new conundrum? Here’s my quick take and a few ideas to break through this barrier. Many sales meetings are often held with functional departments, and often do not include the #MedicareAdvantage #StarRatings, #RiskAdjustment, #HEDIS, IT or P&L owners. We must collaborate to get those departments’ urgent needs integrated into new vendor purchases in order for new activities to meet new and emerging needs, remembering that: 🌟 Vendors are vital to your success.  🌟 Vendors operate in a more volatile environment than plans. 🌟 Vendors have smaller budgets than plans. 🌟 Vendors need signed contracts to make significant investments.   🌟 Vague RFPs waste vendors’ time and resources. Collaboration creates win-win contracts which expand capabilities of both parties. I encourage plans to: ✅ Ask vendors about their roadmap; including timing and certainty of planned enhancements. ✅ Include the #Stars, Risk Adjustment and #PartD teams in new vendor discussions. ✅ Consider adding a vendor's roadmap capabilities to contracts. ✅ Co-create with trustworthy vendors. I encourage vendors to: ✔ Ask about the customer’s unmet needs. ✔ Offer to co-create solutions to new and emerging needs with willing customers. ✔ Offer to accelerate roadmap capabilities with willing customers.   ✔ Articulate the things you would be willing to do if a customer would be willing to contract for it. This is a #MarketMakingMoment as #CMS has thrown down the gauntlet with #NewNeedsOfStars and #NewNeedsOfMA. This is a stellar time for vendors to review current and planned capabilities with a broader lens on new and emerging MA, #Compliance, Stars, #ECDS, #Interoperability, #HealthEquity, Medicaid & #SNP Aligment, and Risk Adjustment needs. If you need help, reach out to us.  #WhatGotYouHereWontGetYouThere  ⭐ ⭐ ⭐ ⭐ ⭐

70

8 Comments

A very nice article highlighting and summarizing 'real world' insights and strategies for success in #MedicareAdvantage by leading healthcare organizations, including Henry Ford Health. Worth the read!

22