Howard Closs

📉 Elevance Health 3Q Earnings Recap: What Went Wrong? On October 17, Elevance Health reported its Q3 earnings, and the market reaction was swift—a 15% drop. The major culprit? A soaring Medical Loss Ratio (MLR) of 89.5%, up by 270 basis points from Q3 2023. The primary driver: Medicaid reimbursement misalignment, which has burdened payors across the board. The mismanagement of Medicaid redeterminations led to a per-member cost spike, which wasn’t matched by state reimbursement increases, pushing Wall Street into a broad sell-off of the “Big Six Payors.” 📉 Despite these challenges, Elevance’s revenue still grew by 5%, reaching $44.7B. Their membership remains steady at 45.8 million, with ACA and commercial gains offsetting Medicaid losses. Key Takeaways from the Earnings Call and 10-Q: • Medicare Advantage: Conservative bids for open enrollment amid CMS rate cuts. While Elevance improved Medicare Star ratings on 60% of measures, one of their 4-star plans narrowly missed CMS’s cut-off, costing them. • Medicaid: CFO Mark Kaye noted cost-per-member increases as high as 3-5x in some states, driven by a shift to sicker populations post-redeterminations. With half of the state rate adjustments set for January, there’s hope that reimbursement alignment will improve. • Carelon’s Growth: Low 20% growth anticipated as Carelon expands its specialty drug offerings, with recent acquisitions of BioPlus, Paragon, and Kroger Specialty. Their latest acquisition of Carebridge further solidifies Carelon’s role in Elevance’s growth strategy. The specialty drug assets will be driving new value for larger employers they seem to attract. • AI Investments: Elevance is pursuing AI to streamline internal operations and enhance member experiences. This investment is set to mature through 2025, aiming to improve productivity and personalization. While Wall Street’s reaction may seem like an overreaction, the strategic groundwork Elevance has laid—especially in Carelon and specialty pharmacy—positions them for a potential rebound. Expect Carelon to become a key revenue driver as Elevance navigates the current Medicaid headwinds. For a deeper dive into the Elevance Health earnings for Q3 feel free to read and subscribe to my substack! #Healthcare

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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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Provider Data Management (PDM) is super important for both Payers & Health Plans (P1) & Providers & Hospital Systems (P2) - Why? An interesting article. Perfect 👍 & to-the point. Click the Link below 👇 Summary Mobilizing Big Data To Support Healthcare Providers Even at the best of times, managing provider data can be a complicated business. Say that each provider has around 140 data points. A practice with 10 providers and 20 health plan contracts might have to manage around 28,000 data points each quarter. Across the US, such information is gathered from over a million providers and from more than 6,000 hospitals and clinics. Health plans further transfer provider claims data to multiple downstream applications and provider systems. Talk to us on LowCode & AI Powered Newgen PLM / PDM Software Manish Jaiswal 646.644.3049 https://lnkd.in/ezwmRrKb

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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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Interested in the CMS Medicare Shared Savings Program (MSSP), but not sure where to start? Check out this Sg2 expert blog post on how MSSP provides a structure for intentional strategic exploration and learnings, even for systems not fully committed to value-based care.

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These new rules are undeniably patient- and healthcare worker-friendly. For the first time, Medicaid participants will enjoy predictability around costs in terms of time and money. https://bit.ly/44jM1ei  Healthcare Finance News #healthcare #Medicaid

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OIG ALERT: Diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023. Before we dive in here I want to say that I have seen HRAs used appropriately and inappropriately during my time in this space. There can be great value for patients, particularly those with limited access to care and or those reluctant to visit their primary care provider. However there is tremendous risk to the system if these visits are a fragmented approach to care and or not aligned with care planning. What the OIG has identified represents the risks and shows care continuity breakdowns. Ultimately organizations and payers must know their vendor partners because there are some really good ones in this space. Earlier this week the OIG released a really interesting look into Health Risk Assessment, or HRAs. These HRAs are often performed in the home by payers or vendor partners. These should be in depth reviews of the patient and include a host of assessments that often are hard to complete in a condensed visit to a provider office. What the OIG found was that 7.5B or about 2% of all Medicare revenue was tied to conditions captured only during these visits. Is that bad? I don’t know. If these are new conditions and then ultimately incorporated into a broader care plan that improves outcomes then they are a great thing. If they are captured, never shared with the care team, and ultimately used to solely drive revenue with little focus on outcomes then it is bad. I suspect there is a mix of both. If I was at the OIG I would want to take a multi-year look at what was captured year over year only in a HRA as a next step. The report recommends CMS take the following actions. CMS subsequently agreed with recommendation number three but not numbers one and two. 1) Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments. 2) Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews. 3) Determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies. I am doing some advanced analytics on information in the report for future posts but this is a nice easy read for folks. https://lnkd.in/ehNzzSWu

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The Medicare Advantage landscape is in a state of flux, and the implications for coding operations are profound. The increasing scrutiny on claims, coupled with the rising volume of medical records, is creating a perfect storm for our teams. We’re seeing a dramatic uptick in audits, denials, and charge capture issues. This requires a laser-like focus on accuracy, compliance, and productivity. To address these challenges, we're investing heavily in advanced coding software, robust training programs, and stringent quality control measures. Simultaneously, the growing complexity of medical documentation and the evolving coding guidelines are testing our team's expertise. We're expanding our coder skill sets through continuous education and certification programs to ensure we stay ahead of the curve. Balancing increased workload with maintaining high-quality standards is a constant challenge. We’re optimizing our processes, leveraging automation wherever possible, and exploring flexible staffing models to ensure we can meet the demands of our clients. It’s a dynamic environment, but it also presents opportunities for growth. By demonstrating our ability to navigate these complexities, we can solidify our position as a trusted partner to healthcare providers and payers alike. #MedicareAdvantage #medicalcoding #healthcareoperations #coding #healthcareindustry

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More and more providers are wising up and learning they make more money being out of network with Medicare DisAdvantage plans. In fact, there is NO downside to being OON. You still file the claims as normal. They still have to allow one year timely filing. They have to pay 100% of the MPFS. You don’t have to fight to keep them from stealing the 2% sequester. They have to cover everything Part B covers (except hospice). Preauthorization is no longer required (you dont have a contract where you agreed to preauth). https://lnkd.in/g2iuCzU4 Why is it taking so many clinics, hospitals and providers to see that the MisManaged Medicare hurts patients, providers and our US economy (Part C patients cost HHS 16% more than I cost them, as I have Part B) https://lnkd.in/gPtmUB3Z Wake up people!

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I continue to be concerned with the amount of investment insurers are making in providers. So far there is no evidence that this reduces costs or improves outcomes so call me skeptical about Elevance invest $4B. Even worse this is a joint venture with Private Equity who are notorious for prioritizing profits over patients. Lastly, this is a "risk" arrangement where there is downside risk for providers and they appear to be focused on chronic patients. More perpetuation of the "sick-care" model? I would suggest the Fed's need to take a look at this deal, but it appears that is already happening. It's not a great sign about the trajectory of healthcare when the FTC, DOJ, and HHS have to develop a portal dedicated to healthcare Mergers & Acquisitions, but at least someone is taking notice. https://lnkd.in/geXpKTrU

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Let's discuss the escalating payer-provider tug-of-war now mediated by AI in healthcare interactions. Our own Amit Phull dove into the impact of AI in revenue cycle management, claims processes, and patient experiences within the healthcare industry. Is it time to unleash your army of algorithms? Let's navigate through the AI arms race and its implications together! 💡 🏥 Providers are turning to AI to predict and reply to denials, whereas payers are countering with AI to detect upcoding, raising vital questions about the evolving landscape of healthcare interactions and the patient journey. It's time to empower patients to navigate the maze of chatbots and automated systems for clarity regarding their coverage without needing a PhD in machine learning. Let's ensure that patient-centricity remains at the core of the AI transformation journey! While AI promises to reduce costly claims denials and improve efficiency, we must address concerns about potential cost escalations and the necessity for new regulatory frameworks, such as AI-specific CPT codes. The future of AI in healthcare depends on effective rulemaking—let's shape it together! 🤝 At the end of the day, AI is a tool shaped by human rules. Let's harness the power of AI while ensuring that it enriches, not overwhelms, the healthcare journey. 🦾 Let's work together to create a future where AI drives positive patient outcomes without transforming healthcare into a scene from The Terminator! ⚕️ #HealthcareAI #DigitalHealth #PatientCentricity #AIInHealthcare #HealthcareInnovation #HealthTech #PatientExperience #AIRegulations #DigitalTransformation #HealthcareLeaders #AIImplements #HealthcareJourney 🏥 https://lnkd.in/e49XMAnE

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In a world where visibility is power, it's heartbreaking to see leaders forced into the shadows. In a world where transparency and connection are more important than ever, it's disheartening to see industries and individuals forced to hide their identities for safety. The recent removal of executive photos from CVS Health and UnitedHealthcare's websites amid a tragic manhunt is a stark reminder of the challenges we face. This situation underscores a troubling reality: the need for safety and privacy often clashes with the ideals of openness and accessibility. It's a sad commentary on our times that leaders must conceal their identities to protect themselves. LinkedIn was created to foster professional connections, build trust, and showcase the faces behind the names. It's a platform where we celebrate our achievements, share our expertise, and connect with like-minded professionals. But what happens when the very essence of this platform—visibility and connection—becomes a risk? As we navigate these complex times, let's remember the importance of creating a safe and supportive environment for all. Let's advocate for a world where leaders can be visible without fear, where transparency doesn't come at the cost of safety. It's time to reflect on how we can balance the need for security with the values of openness and connection that LinkedIn embodies. Let's work together to ensure that our professional networks remain a place of trust, support, and genuine connection. How can we, as a community, ensure that our professional networks remain safe and supportive while maintaining the transparency and connection that LinkedIn stands for? https://lnkd.in/eKxYGFb2 #UnitedHealthCare #LinkedIn #Leadership #BeKind

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In win for #healthinsurers and #members, CMS will recalculate 2024 Medicare Advantage star ratings. After recent wins in court, Federal judges told Medicare to recalculate star ratings for SCAN’s plans and one Elevance plan. The new CMS guidance would recalculate quality ratings industrywide, likely increasing bonus payments for many insurers. As health insurers assessed poor financial performance and lower star ratings, member benefits were in the crosshairs. While this won't save all those extra benefits members have come to enjoy, they will hopefully save some of the most critical. Want to learn more about the latest trends in #MedicareAdvantage? Forrester clients can check out our published and upcoming research, including a data deep dive on individuals aging into and enrolled in #Medicare and Medicare Advantage (link in comments). #starratings #qualityratings #CMS #healthcare #memberexperience

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Join the conversation with our very experienced and knowledgeable panelists. Link to register is in the comments. Look forward to talking about this topic. #evidencecare #medicare #2MDNrule

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What are the most significant obstacles to using electronic health records (EHRs)? Klas Research asked 33,000 clinicians across over 300 healthcare organizations this question and compiled their answers in the 'EHR Interoperability 2024' report. When asked specifically about their experiences with patient data from external organizations, 47% mentioned the lack of proper integrations to access EHRs. At Tiga Healthcare Technologies, we utilize our expertise to develop healthcare IT products that enhance efficiency and lead to better treatment outcomes. Our Healthcare Interoperability product family, which includes Health Information Exchange (HIE) Viewer, Terminology Server, FHIR Stack and Enterprise Master Patient Data Index (EMPI), is designed to meet clinicians' most urgent needs around integration and data accessibility. This way, we offer successful solutions against health data inefficiencies affecting nearly half of the physicians and clinicians surveyed in the Klas report. Let's shape the future together with the power of interoperability, as always! Further insights from the ‘EHR Interoperability 2024’ report: https://lnkd.in/dvxJSJHN  #Tiga #HealthcareIT #PharmaIT #EHR #Interoperability 

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EHRs have transformed healthcare, but challenges like interoperability, security, and costs hinder widespread adoption. In my latest article for Medgate Today. I delve into these issues and explore strategies to overcome them. From understanding the nuances between EHRs and EMRs to highlighting the importance of data standardization, the article provides insights into building a robust digital health ecosystem. Let’s embrace these changes to create a more efficient, patient-centered healthcare system. Check out the article to gain a holistic perspective on advancing digital health records and driving innovation in healthcare. TrioTree Technologies Pvt Ltd #Healthcare #EHR #DigitalHealth #MedgateToday #HealthTech #TrioTree

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According to Becker’s Healthcare: The country's largest payers reported year-over-year increases in medical cost ratios, with the exception of Elevance Health, which decreased 0.1%. This is great news considering the trajectory of expanding healthcare costs in our nation.

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UHG'S IMPACT ON HEALTHCARE COSTS & PATIENT CARE On the first of May, the CEO of United Health, Andrew Witty, gave testimony in a deposition to the US Senate Finance Committee regarding the Change Healthcare data breach that has affected everyone. After watching the entire hearing and reading the transcript, I am of the belief that the Senate do not fully understand what UHC (or UHG now) is doing and how it affects not only the cost of healthcare but also how it is affecting patient care. We (Don Self, Karlene Dittrich and Chris Champman) need YOUR help as we are gathering data to present to the U.S. Senate (as well as the House). In fact, we cannot do it without your help. The May 1st hearing is available at: https://lnkd.in/g_CaZ-vy In his testimony, he made statements about the loans that UHG us giving to providers as well as how UHG is not taking advantage of the situation and doing everything they can to help the providers. There were no statements by Mr. Witty about actions pertaining to refund demands, recoupments/offsets or other tactics that are withholding reimbursement or trying to get payments back. However, we are hearing of large amounts of refund demands (or overpayment letters), recoupments (or offsets), and statistical or extrapolation letters being sent to provider organizations. We are offering this opportunity in a, short survey to compile a report from healthcare providers and organizations to share with the Senate Finance Committee. We have seen several providers get refund demands by UHG for over $100,000. One was more than $315,000 for a Pediatric office in South Texas and another was more than $400,000 in Oregon and there are countless others. If you get these from UHG (or anyone else), reach out to us as we can usually make them GO AWAY! Help us educate the Congress on this. They need to know the TRUTH! If your organization is being negatively impacted by these non-compliant and improper attempts to recoup from you and would like to help us share such recent recovery attempts by UHC or its affiliates with the Senate Finance Committee, please do the survey at https://lnkd.in/gzR_RPE7 You don’t have to send us a copy. Also, this survey and your responses will be considered confidential and only shared with us and the committee. Also, please provide your contact information and location (or locations if multiple) that are being impacted. If you are uncomfortable with providing organization or contact information, please at least include the locations so that we can provide the committee with a reliable geographically accurate aggregated report. If the committee wants to see examples, we can get them in touch with you if your contact information and organization is also supplied. Don Self, CPC, CMCS, CECS Don Self & Associates, Inc

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