Evan Machusak

Our podcast series continues.....Navigating the dynamics between payers and providers presents unique challenges. In this episode of The MRO Exchange, Matt and Christopher delve into these complexities, exploring the vital role of patient data and the responsibilities surrounding data access. Tune in for insights: https://okt.to/BGyAD2

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It's been 8 months since CMS announced its final rule on prior authorization (PA) and interoperability. As we come closer the implementation deadlines, it's crucial to assess our readiness and understand the broader implications. The CMS rule on PA requires some key things: 1️⃣ Faster PA decisions (72 hours urgent, 7 days standard) start in 2026 2️⃣ FHIR-based Prior Authorization API implementation 3️⃣ Expanded Patient Access API and new Provider Access API from 2027 4️⃣ Affects Medicare Advantage, Medicaid, CHIP, and certain QHP issuers 🔗 The FHIR APIs Required by 2027: Enhanced Patient Access API: Now includes prior authorization data Provider Access API: Allows providers to access patient data from payers Payer-to-Payer API: Facilitates data exchange when patients switch payers Prior Authorization API: Streamlines the prior auth process 🔍 What's Missing? 1️⃣ FHIR Standard Adoption: Payers must use FHIR standard queries, but EHR changes aren't mandated. 2️⃣ EHR Integration Gap: The rule doesn't require direct EHR interrogation for PA requests, which could have eliminated most administrative friction. 3️⃣ Digital Endpoint Challenge: Payers need to discover digital endpoints for each entity, but there's no centralized database yet. 4️⃣ Medication-related PA inclusion 5️⃣ Other revenue cycle FHIR standards: While the rule addresses PA, it doesn't tackle the myriad other reasons for claim denials (e.g., coding errors, eligibility issues, medical necessity disputes). 🔍 Where are we now? - Many organizations are in the planning or early implementation stages - CMS is exploring a National Directory of Healthcare Providers and Services, potentially including payer endpoints. (https://lnkd.in/ghf28bDF) - Prior Authorization support has been built in to some of the most common implementation guides for FHIR (https://lnkd.in/gKP4Qdzn) 🤔 Critical questions at this stage: 1. How far along is your organization in preparing for these changes? 2. What unexpected challenges have you encountered in the implementation process? 3. How are you balancing these PA improvements with other revenue cycle optimization efforts? Let's share experiences and best practices. What insights can you offer to peers navigating this transition? #HealthcareIT #PriorAuthorization #Interoperability #RCM #RevenueCycle #CMS https://lnkd.in/gHB_i9Gu https://lnkd.in/gjegKF4g

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The grass is always greener where you water it. The same is true for EHR implementations. Organizations that take the time to continually optimize systems often realize better outcomes and minimize end-user disruption. Check out this video interview with John Lynn and North Country Healthcare where they discuss the advantages of watering your EHR. #healthit #ehroptimization

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The CMS Interoperability and Prior Authorization Final Rule is setting the stage for a major transformation in healthcare operations and technology. Are you ready for faster PA decisions and advanced data sharing? 💡 In this blog, Lisa Hebert, HealthAxis' Senior Vice President of Product Strategy and Management, dives deep into what this means for Medicare, Medicaid, and ACA issuers and why even commercial plans should take note. 📈 With changes rolling out between 2026-2027, now is the time to assess your technology and operations. From speeding up PA processes to enhancing patient care through interoperable APIs, the landscape is evolving. 🌐 Dive into the full blog for insights and strategies: https://lnkd.in/esSv36ds #HealthAxis #HealthcareInnovation #CMS #CMSFinalRule #PriorAuthorization #HealthAxis #AxisCore #Automation #ClaimsProcessing #ClaimsManagement #HealthcarePayers #ThirdPartyAdministrator #HealthcareOperations #HealthPlanConsulting #Consulting #Medicare #Medicaid #Healthcare #HealthcareTechnology #HealthcareTech #HealthcareInnovations

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https://lnkd.in/eyTV68Z3 this article highlights EMR adoption however it doesn't mention some additional key players like Athena for example. the key takeaway is the all EMRa come with pros and cons and to get the most value requires improving staff knowledge or the toolset and processes. often custom reporting is required for a clean Revenue Cycle function. I've worked for many clients who used only a fraction of their EMRs capabilities often because they were not aware of them and didn't know the right questions to ask to pull that knowledge from the EMRs customer success teams. having a trusted partner that understands your processes and can help align clinical and back office operations with data, reporting and increasing AI applications is critical to leverage such toolsets properly. Leaders should not consider these tools plug and play. maybe one day...

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Excited to be part of this launch and the ability to share our solution with payers and providers to use themselves. For all of my payer friends, if you have internal teams completing payment integrity reviews, just starting on the journey to create an internal team, or even thinking about the possibility - let's chat! ProperPay and our team of experts are here to help support you no matter where you are in your journey. As a business and technology company, we believe in strategic partnership and a holistic approach - technology transformation, data management, process optimization, and strengthening payer/provider relationships. Best of all - we love your feedback! Reach out today to schedule a demo and tell us what you think. #paymentintegrity #revenuecyclemanagement #AIinpaymentintegrity #ProperPay

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Can generative AI revolutionize RCM? Generative AI has made impressive strides in healthcare, from diagnosing complex cases to aiding in drug research. However, its potential for transforming revenue cycle management is often overlooked. Where generative AI might be helpful? ✔️Generating appeals for claim denials ✔️Streamlining prior authorizations & documentation ✔️Data-powered decision making ✔️Strategic financial planning through predictive analytics However, there are areas where generative AI may fall short. ❗️Limitations of Generative AI: ❗️Understanding nuanced communication ❗️Dependence on data ❗️Tackling intricate claim denials While generative AI might not be an answer to all revenue cycle challenges, it holds promise in reducing administrative burdens and improving workflows. What do you think? Kenny Dewan Monika Roots, MD, FAPA Scott Penn #RevenueCycle #RevenueCycleChallenges #GenerativeAI #RCM #RevenueCycleManagement

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Here is a summary of CCHP's latest update on Out-of-State Telehealth Provider Policies: Provider licensure exceptions for telehealth across state lines remain a key issue, with frequent inquiries from providers and patients. Providers often seek a list of states allowing out-of-state care via telehealth. Generally, telehealth is governed by the patient's state, requiring providers to hold an in-state license or approval, with some limited exceptions. Limited licensure exceptions vary widely by state and profession, making a comprehensive list difficult. Common exceptions include provider-to-provider consultations, continuity of care, infrequent interactions, emergencies, and specialized care. Currently, 29 states have such exceptions, with 9 states also having a telehealth registration process. Telehealth registration processes exist in 21 states, aiming to ensure oversight of out-of-state providers, often with restrictions on in-person care. Interstate licensure compacts also facilitate out-of-state telehealth, with only 5 jurisdictions not participating in any compact. There are twelve compacts, each varying by provider type, aiming to streamline multi-state practice. Providers should always check with state licensure boards for compliance, as state policies and insurer coverage requirements vary. As of June 25, 2024, CCHP's data shows: - 29 states with limited licensure exceptions - 21 jurisdictions with telehealth registration processes - 9 states with both exceptions and registration - 12 jurisdictions with no specific exceptions or registration, 9 of which are compact members - 5 jurisdictions with no compacts - 3 jurisdictions with no exceptions, registration, or compact https://lnkd.in/gspndAWG

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This is an old news item, but still very relevant I think. I have noticed a lot of 'isolated incidents' happening around the country as a result of sub-optimal EPR implementations. This time last year, there was a news article that the U.S. Department of Veterans Affairs had got so fed up with its under-performing #EPR, that it had renegotiated its contract with the vendor to include penalties related to performance management, specifically reliability, responsiveness and interoperability. (I wonder if the new contract is publicly available Neil Evans, MD ?) While this is a $10Bn contract, UK trusts looking to contract with an EPR vendor should still try to include penalties for under performance, and most importantly, safety issues. Especially those that directly affect patients such as the one at Durham (https://lnkd.in/eyQePGip). https://lnkd.in/e6GC4HhC #patientsafety #digitalhealth #EHR #electronichealthrecord #EMR #clinicalsafety #humanfactors #implementationsafety Sam Shah Shane Tickell Simon Swift Adrian Byrne FBCS CHCIO Dr Temi Akitikori Dilshan Arawwawala Jenny Sutcliffe Stuart Harrison CEng FIET MIEEE Apira Ltd Alan Brown Mohammad Al-Ubaydli Masood Ahmed Dr Patrick Lester, PhD 🩺 Dr Gyles Morrison MBBS MSc Dr Penny Kechagioglou Helen Hughes Jonathan Hazan Kiran D Shetty Lisa Goldstone Patient Safety Learning

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70% of hospitals participate in healthcare interoperability. Healthcare #interoperability is growing across hospitals, but gaps remain, especially in data exchange with long-term care and behavioral health providers. CapMinds offered health information exchange(#hie) and health interoperability (#fhir, #hl7, #mirthconnect) to its various clients across the specilaity including #behavioralhealth #mentalhealth

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In light of today’s widespread network outages impacting services from airlines to healthcare systems, it’s clear that reliable access to critical documentation and clinical pathways is more essential than ever. 🚨‼️ Taylor Healthcare helps hospitals during unplanned outages, like today, to minimize the impact of direct patient care. Trust Taylor Healthcare to keep you connected when it matters most. Learn more at the link. #Microsoft #NetworkOutage #TaylorHealthcare

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Dr. Donald Rucker, Chief Strategy Officer at 1upHealth, Inc., and Jocelyn Keegan, Program Manager for the HL7 Da Vinci Project, presented at the 2024 WEDI Spring Conference on FHIR Implementation Guides for CDex and PDex. Data and Data Liquidity are Extremely Important "It’s in this current state of play – where the goals of improving care quality while decreasing care cost are paramount – that data has become the currency of care. To be successful, we need to be able to exchange clinical data and payer data, combine it, and compute it. We must continue to move away from manual, analog processes and digitally transform, just as almost all other industries have." https://lnkd.in/eafqMr6C

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Exciting news from Epic Systems and Microsoft! They have announced that they are integrating generative AI technology into Epic's EHR for the first time! According to Seth Hain, Senior VP of R&D at Epic, this integration has the potential to increase productivity for physicians & staff. The integration will allow health systems using Epic's EHR system to run generative AI solutions through Microsoft's OpenAI Azure Service. The first use case will be through Epic's In Basket communication software system. Here clinicians can use generative AI to create a draft response when communicating asynchronously with patients. This has already been rolled out to a limited number of users at UW Health and UC San Diego Health, with Stanford Health Care expected to follow soon. The second use case will allow providers to use generative AI to source recommendations from Epic's Slicer Dicer data visualization tool. While there is excitement around its potential benefits, there are also concerns about its influence on clinical diagnosis and decision-making. However, this move could provide a welcome respite to physicians suffering from burnout due excessive administrative burden. What do you think about the integration of generative AI into healthcare? Share your thoughts in the comments below. #EpicSystems #Microsoft #GenerativeAI #EHRIntegration #Productivity #HealthcareTechnology #OpenAIAzureService #InBasket #ClinicalCommunication #UWHealth #UCSanDiegoHealth #StanfordHealthCare #SlicerDicer Oron Afek Braedan Russell Justin L. Neece Tom Liddell Christopher Blackerby

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What if you could alleviate provider burnout while enhancing patient-provider interactions? In this Healthcare IT Today article, TouchWorks EHR EVP Ben Scharfe CPA, CA discusses how #ambientlistening technology can do both. Read about his insights on this next step in the #healthcare #AI evolution here: https://hubs.li/Q02SpqZM0

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🔥 It's ok to ask for help in IT🔥 Maintaining and enhancing the technology that healthcare organizations rely on is no small feat. With diverse tech systems in play, it's unrealistic to expect any single IT manager to be a master of them all. That's where the expertise of an Oracle Health EHR consultant becomes indispensable. Our latest blog post delves into the vital responsibilities and transformative impact these consultants have on advancing healthcare systems with cutting-edge technology. Don't miss out on understanding the pivotal role they play in modern healthcare here: https://lnkd.in/e_Aj6AJr #OracleHealth #EHRConsultant #HealthcareTechnology #HealthTech #DigitalHealth #HealthcareInnovation

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📢 Medicare Telehealth Waivers: What's Next? As the end of the year approaches, Congress is still deciding whether to extend, modify, or let the temporary Medicare telehealth waivers expire. A new study in Health Affairs examined 2022 Medicare claims, revealing significant insights into who could be most impacted by changes to telehealth policy. 🔹 Key Findings: - Female physicians, PCPs, psychiatrists, and urban providers are among the highest users of telehealth. - Psychiatrists are particularly impacted—23% deliver nearly all services via telehealth. - Interestingly, urban areas see more telehealth use than rural areas, challenging the assumption that telehealth primarily serves rural populations. HR 7623, the Telehealth Modernization Act of 2024, may extend these waivers by two years. This decision will have a considerable impact on how mental and behavioral health services are delivered moving forward. Let’s see what happens next for telehealth! 🩺✨

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The devil is in the details. Learn why record retrievals for HEDIS and Risk can be challenging and how Inovalon solutions help

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We’re excited to share Optum Rx is the first to develop a new capability that helps address a major provider pain point: prior authorizations. Prior authorization is an important checkpoint helping patients receive coverage for safe, effective care supported by the most up-to-date clinical guidelines. But the process can add manual, time-consuming tasks to providers’ already heavy workloads. Together with our partners, Surescripts and Cleveland Clinic, we developed Optum Rx PreCheck Prior Authorization, an innovative solution that helps automate the prior authorization process for select drugs, including GLP-1s – from 8.5 hours to under 30 seconds. Learn more about Optum’s commitment to providing a better provider and patient experience: http://spr.ly/6045S4vph

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