Hal Leftwich

Medicare Stars Analysis: Table of Contents and Executive Summary Table of Contents Introduction - Program Overview - Purpose of Analysis Part I: Highest-Weighted Measures Analysis - Member Experience Measures (5x) - Clinical Outcome Measures (4x) Part II: Strategic Implementation Guide 1. CAHPS Measure Enhancement Strategies - Getting Needed Care & Appointments - Customer Service Enhancement 2. Clinical Outcome Measure Strategies - Blood Pressure Control - Diabetes Care - Readmission Prevention 3. Implementation Framework - Success Metrics and Monitoring - Resource Allocation - Timeline and Milestones Conclusion - Key Success Factors - Final Recommendations Executive Summary This comprehensive analysis addresses the critical components of the Medicare Stars program, focusing on measures that carry the highest weights and therefore present the greatest opportunity for impact on overall ratings and revenue. Key Highlights 1. Measure Prioritization - Identifies seven 5x-weighted CAHPS measures focused on member experience - Outlines five 4x-weighted clinical outcome measures - Emphasizes the dual importance of member satisfaction and clinical quality 2. Strategic Approaches - Details operational improvements for access enhancement - Provides specific provider engagement strategies - Outlines technology integration opportunities - Addresses member engagement and support services 3. Implementation Framework - Presents structured timelines for various initiatives - Offers resource allocation guidance - Provides monitoring and measurement approaches - Includes corrective action protocols Critical Success Elements The analysis identifies several fundamental requirements for success: - Executive-level commitment and support - Robust data analytics capabilities - Strong provider partnerships - Effective member engagement programs - Continuous quality improvement processes Primary Strategic Recommendations 1. Member Experience Focus - Implement advanced access scheduling - Enhance customer service capabilities - Develop multi-channel support options - Create proactive member outreach programs 2. Clinical Quality Enhancement - Develop comprehensive disease registries - Implement remote monitoring capabilities - Create robust care management protocols - Establish community partnerships 3. Operational Excellence - Deploy predictive analytics - Implement real-time monitoring systems - Develop rapid-cycle improvement processes - Create comprehensive provider engagement programs Implementation Timeline Overview - Quarter 1: Assessment and Planning - Quarter 2: Priority Program Implementation - Quarter 3: Stakeholder Engagement - Quarter 4: Evaluation and Optimization Continued… https://lnkd.in/eqBZ6df2

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🚀 Transform Your Hospital with the CDI MasterClass! 🚀 Are you ready to elevate your hospital's Clinical Documentation Integrity (CDI) practices? Join the ultimate resource for adult acute inpatient care teams, including physicians, CDI specialists, coders, and all stakeholders! ☀️ What We Offer: Unlock a year-long subscription to 50 engaging 30-minute on-demand webinars, rolled out every week! These sessions are designed to ensure that all team members are on the same page while revolutionizing your approach to CDI. Regardless of your shift, take a moment to enhance your skills and knowledge -- just log in and learn at your convenience throughout the contract year! 🏥 Why Choose the CDI MasterClass? The CDI MasterClass program is tailored not only for CDI specialists but also for all stakeholders involved in the process, including medical staff, coders, the CDI team, quality assurance, utlization/case management, appeals/denials management, risk management and compliance. The success of a CDI program relies on collaboration and cohesive efforts among all these groups, as operating in silos rarely leads to effective outcomes. Our comprehensive curriculum empowers your teams to adopt a proactive approach to CDI, leading to: - Improved patient care - Optimized coding accuracy - Enhanced net financial outcomes for your organization 👌🏽 Don’t Miss This Opportunity! Transform your hospital's operations and elevate your CDI practices. Encourage your hospital or health system to sign up today! The path to financial success lies in effective and resilient revenue optimization.  How can you achieve revenue optimization? By accurately capturing the patient's story through concise documentation and precise coding. The key is to enhance revenue with integrity while reducing denials through authentic storytelling. A proactive approach is essential to mitigating risks associated with malpractice and payment denials. ℹ️ Ready to Learn More? For more information about our CDI MasterClass program and to receive a copy of the curriculum principles, email us at [email protected]. Take the first step towards a successful and cohesive CDI strategy! Join us today and make a lasting impact on your healthcare team’s performance! AHIMA American College of Physician Advisors (ACPA) American Medical Association American Hospital Association Healthcare Financial Management Association (HFMA) Health Care Compliance Association (HCCA) American College of Healthcare Executives

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Augusta Health President and CEO, Mary N. Mannix, FACHE, was featured on the American Hospital Association podcast! Topic: "Health care pressures are often magnified for rural caregivers, yet some are developing unique solutions for these turbulent times. In this conversation, Mary Mannix, CEO and president of Augusta Health, discusses the impact that cross-training has had on high-quality patient care in their community, and how the transition to an Accountable Care Organization (ACO) ensures patients are getting the right care at the right time." Click here to listen! https://lnkd.in/gqcAAzvh

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Another important position statement from Association of Healthcare Value Analysis Professionals (AHVAP). As value analysis evolves, it is vitally important to ensure that those who are entrusted with the process understand what is expected of them in terms of professionalism. Please feel free to share this important document.

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Fraudulent operators have misused millions of Medicare dollars in the hospice sector, posing a significant challenge to the industry. Providers and stakeholders are alarmed by the potential consequences on payment, access, sustainability, and utilization. Learn more about this critical issue at the link below: https://lnkd.in/gJ6HjbsX

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Tired of getting no support or transparency? Quality Life Services is still family owned and operated.

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The following item provides additional insight into physician consolidation

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Women Veterans have earned and deserve the best health care. Your VA women’s health care team is dedicated to supporting your whole health throughout every stage of your life. From primary and preventive care to specialty services, learn about VA’s comprehensive women Veteran’s health care services on pages four and five. The PACT Act continues to offer Veterans expanded VA health care eligibility. Read on page three how VA is making it even easier for millions more Veterans to enroll directly in VA health care without first applying for VA benefits. Many of us would benefit from sitting less and moving more. The good news is moving the body means more than traditional exercise. VA’s Whole Health approach is about doing physical activities that align with your needs and goals to live life to the fullest. If you are looking for more ways to move your body for energy and flexibility, check out page six. On page seven, try to solve the word scramble puzzle and get the recipe for a healthy summertime dessert that is easy to prepare. Be well and stay safe! #visn8 #vasunshinehealthcarenetwork

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Keep our rurals open but if you really want to help get the foreign equity owned GPO that sets the pricing for our hospitals BANNED from our state. Economies of scale are used by Vizient against Oklahoma rural hospitals. If you have 13 tiers, hidden tiers, and tier maxes…that’s not a contract, that a free for all nightmare of a scam we all fell for. Their awful written tiered agreements force our rurals to pay more for the exact same items that our large hospitals pay less for. Example box of gloves a large hospital system in the state will pay 6-8 bucks for a box of 250 exam gloves. That same box for a rural EMT? 24 bucks. There is no price transparency and you are forcing patients who live in rural areas to pay more because of the lack of infrastructure by the corporations serving them to effectively and economically get goods and services to these hospitals. And distributors who whine about the cost of delivering to rural hospitals all while posting BILLIONS in profit every quarter are the first on my 💩 list. Let’s keep our rurals open but let’s make them more profitable so that they can continue to add much needed services and gainfully employ more community members.

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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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In 27 states and Washington, D.C., NPs have Full Practice Authority, giving patients direct access to primary care providers. States with FPA consistently rank higher in health outcomes—because when NPs can practice fully, everyone benefits! #NPWeek2024 #FullPracticeAuthority

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Here are the files for the 2025 OPPS Proposed Rule HOPD: https://lnkd.in/g8mFHiUg; ASC: https://lnkd.in/gc2HdJsE

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Join Eric Lucas, Jonathan Mason & Georgia Green, MS, CHFP for a webcast on 8/27 - Medicare Regulatory Update: 2025 IPPS Final Rule. We’ll discuss the latest updates for hospitals and cover topics including an evaluation of the IPPS final rule key areas, reimbursement shifts and data trends identified in the IPPS final rule data, and next steps and factors to consider because of the final changes, including the mandatory TEAM model. #healthcare #hospitals

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It is with great pride I share that three of our Geisinger hospitals have been recognized for high performance in the 2024-2025 U.S. News & World Report “Best Hospitals” rankings. Geisinger Medical Center in Danville and Geisinger Wyoming Valley Medical Center in Plains Twp. were named among the Best Hospitals in Pennsylvania, with Geisinger Wyoming Valley recognized as No. 1 in the Scranton/Wilkes-Barre area. U.S. News evaluated nearly 5,000 hospitals across 15 specialties and 20 procedures and conditions; only 11% of evaluated hospitals earned a “Best Hospitals” ranking. The Geisinger hospitals recognized received high-performance rankings for a variety of specific procedures and conditions, including: • Geisinger Medical Center: Orthopedics; pulmonology and lung surgery; aortic valve surgery; heart bypass surgery; heart failure; colon cancer surgery; COPD; heart attack; kidney failure; leukemia, lymphoma and myeloma; lung cancer surgery; pneumonia; and stroke. • Besides its ranking as No.1 in the Scranton/Wilkes-Barre area, Geisinger Wyoming Valley Medical Center received high-performance rankings in pulmonology and lung surgery; urology; heart failure; colon cancer surgery; COPD; heart attack; hip replacement; knee replacement; lung cancer surgery; pneumonia; and stroke. • Geisinger Community Medical Center received high-performance rankings in heart failure; heart attack; knee replacement; pneumonia; and stroke. According to U.S. News, the “Best Hospitals” procedure and condition ratings focus on specific and more commonly required individual procedures and conditions, such as hip replacement and heart failure, rather than on broader specialties like orthopedics and cardiology. The goal is to evaluate how well hospitals perform in each procedure or condition – not just with the most challenging cases, as with the specialty rankings, but with the full range of patients. U.S. News estimates that nearly 2 million hospital inpatients a year face the prospect of surgery or special care that poses either unusual technical challenges or a significantly heightened risk of death or harm because of age, physical condition or existing conditions. These rankings are a tool that can help patients and their families find sources of skilled inpatient care. This recognition, along with the others I've shared over the last few years, emphasizes the quality and breadth of care available to our patients in central and northeastern Pennsylvania. When you need us, we'll be here, and you can rest assured you'll get the highest quality care available. Congratulations to the clinical and operational teams that made this happen! Megan Brosious Crystal Muthler, BSN, MHA, RN, NEA-BC Renee Blakiewicz RN BSN Navneet Dang MD MBA MS CPE FACP Michael Fitzpatrick Michael DiMare Nicholas Coleman, MBA

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