Hanan Weizman

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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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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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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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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Missed our webinar about the hype surrounding AI and outpatient infusion coding? Watch this snippet from the event to see how having an automated solution can simplify your coding so that you aren't leaving revenue on the table.

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The 2025 ACDIS Pocket Guide offers the latest information CDI professionals need to know https://hubs.la/Q02WVFdd0 including: 🔎Fiscal Year (FY) 2025 guidelines 🔎AHA 2024 Coding Clinic guidance 🔎New provider tips from James Manz, MD, CCDS-O of Mayo Clinic 🔎Updated critical thinking tips, treatment protocols, and diagnostic criteria 🔎The latest updates related to social determinants of health 🔎The inclusion of 75+ conditions 🔎And more!

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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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While the industry is experiencing a plethora of regulatory changes, mounting litigation, new and complex coding changes, it is vital that health plans and providers are armed with everything they need to survive. Hear your peers discuss real world solutions and practical options to optimize your comprehensive risk adjustment strategies. You won’t want to miss this event. You will gain best practices for strengthening your risk adjustment strategy plan. Hear how others in your position are navigating these risk adjustment complexities. Register today,

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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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Hey Y'all! To further a post from last week, here are the payors ranked by their Q2 profits. UnitedHealth Group tops the list with Q@ profits of $4.2 billion, which is actually down 23%. Let that sink in.... This highlights a glaring disparity in our health care system. While payors continue to see the huge profits (some in the billions) many health care practices and facilities are struggling to stay afloat amid declining reimbursement rates and rising operational costs. This imbalance is not just unsustainable; it’s detrimental to patient care and the overall health of our communities. It's clear that our health care payor system needs reform. Practices must be fairly compensated for the care they provide. We need to push for reimbursement structures that reflect the true cost of delivering high-quality care, rather than being squeezed by payers’ profit margins. We need greater transparency on how payors determine reimbursement rates and allocate funds, which can help practices negotiate their contracts. We need legislative reform to ensure that payors are held accountable, and practices receive the financial support they need to thrive. Things like legislation to increase state/federal oversight of payor practices to ensure that they adhere to fair pricing and reimbursement standards, which could include stricter regulations on how payors set their reimbursement rates and profit margins; laws that could establish minimum reimbursement levels for essential services, or cost of living pay scales; or legislation could cap profit margins of payors similar to that in other industries. I'm just spit balling here, but minds much smarter than mine can figure this out. I’m not against companies making a profit and I am against government overreach, but when big payors set unfair rules that force health care practices to comply out of fear of losing their patient base or financial stability, it's clear that we need legislation to ensure a level playing field. By advocating for changes, we can help create a more balanced and equitable health care system that supports both providers and patients. It’s time to make these payors operate fairly, supporting the providers who deliver essential care. I'll get off my soapbox now. Enjoy your Monday, y'all! Please share/repost if you feel others will benefit from this information. #HealthcareReform #PayorProfits #LegislativeReform #ReimbursementRates #HealthcareProfessionals #CHCS https://lnkd.in/ehQ6VJWV

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Join me at our live webinar on May 15 to learn more about the newly defined standard Part D benefit. 

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Read how hospital consolidation is reshaping healthcare, the tactics drugmakers use to block competition, why protecting Medicare Advantage is critical for seniors, and more in this week’s newsletter. https://lnkd.in/evkip5C7

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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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Don't let incomplete documentation put your organization at risk. At Coker, we specialize in guiding healthcare organizations through the complexities of documentation requirements. Our comprehensive compliance reviews and educational programs help you capture all required components, preventing costly errors and lowering your organization’s risk of an adverse payer audit. Partner with Coker to stay compliant and efficient! 👉 Learn more about Provider Coding Audit & Education 🔗 https://ow.ly/yxQJ50TiZIT

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The OIG conducted an audit of EmblemHealth’s 2015 Medicare Advantage (MA) risk adjustment submissions, focusing on Hierarchical Condition Categories (HCCs). Of 1,220 HCCs reviewed, 362 were found to lack sufficient documentation in medical records to support the submitted diagnosis codes, resulting in $551,917 in net overpayments. Additionally, 65 valid HCCs were identified but not submitted to CMS. It highlighted deficiencies for compliance with CMS requirements for accurate and complete diagnosis coding to support risk adjustment payments. CDI are reminded of the critical importance of ensuring diagnosis codes are fully supported by detailed and compliant clinical documentation, as errors can result in both underpayments and significant financial penalties. Recommendations include refining policies and auditing processes to improve the accuracy of HCC submissions.

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Implementing an electronic health record (EHR) or migrating to a new one is a complex process. It requires you to keep track of timelines and stay on budget – all while keeping clinicians happy and not interrupting patient care. In its latest report, Gartner® notes that when implementing a new EHR “healthcare provider CIOs can avoid setbacks and position for success by undertaking an organizational readiness assessment and mitigating risks during the strategy and planning phase.” Access the complimentary Gartner® report, Gauge Readiness and Mitigate Risk to Succeed in EHR Implementations, to learn more. Read the report: https://bit.ly/3KCgZVY #EHR #EHRmigration #EMR #EMRmigration #healthcare #interoperability #digitalhealthenablement

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#ICYMI: Last month, #FEHRM Data Integration Solutions Director Crystal Baum talked about #FederalEHR Advancements in Population Health at #DHITS. She detailed the federal EHR's implementation of population health applications like HealtheRegistries to identify gaps in patient care, HealtheAnalytics to provide aggregation of data to offer different levels of reporting, and HealthRecord to offer a complete view of the longitudinal record. Learn more at https://lnkd.in/eqGY-9qC. 

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Are you considering a new Practice Management (PM) System for your Physician Practice Group? Talk to us about a transition strategy that will maintain cash flow. Visit https://lnkd.in/ebwfTvc7 to learn more. #practicemanagement #physicianleadership #healthcareit #revenuecycle #systemsintegration #systemsmigration #remedics

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