Jeff Hatfield

Health insurers continue to leverage transformative and generative Artificial Intelligence (AI) technology to improve the customer experience, expand access to care and lower costs. Learn about how Florida Blue us using AI in a very responsible and intentional way so our members can get the help they need in a secure, faster, personalized and more seamless way. https://lnkd.in/eS9gkX7z

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NEWS ALERT- CMS has finally released the 2023 MSSP results. The results provide tremendous insight on the ACO landscape, risk adjustment, and value based care. Here are some numbers: Thanks for reading. Help us get the word out by smashing the like button, sharing the post, or commenting. Key stats -453 ACOs with data released -69% of ACOs achieved shared savings -$3.08 billion dollars in shared savings payments to organizations -The top 10 organizations with the most savings racked up $631M, or 20% of all savings. -Average risk score for the top 10 organizations with the largest savings in pure dollars (not adjusted for ACO size) was 1.137 -Average risk score for the top 10 organizations with the largest savings per beneficiary was 1.379 -75% of organizations with a risk score above 1.00 had shared savings. Only 65% of organizations with a risk score below 1.00 had shared savings. -78% of the largest 100 ACOs by size had savings while only 64% of the 100 smallest ACOs had savings. CMS noted "ACOs led by primary care clinicians had significantly higher net per capita savings than ACOs with a smaller proportion of primary care clinicians. These results continue to underscore how important primary care is to the success of the Shared Savings Program." This makes sense because primary care is such a critical driver in overall patient care success and in accurately reflecting risk scores. There is a LOT more to dig into. My main takeaways are: 1) Primary care participation is a driver of success 2) Risk scores are a critical component of success and organizations in risk should have outpatient CDI programs and strong compliance programs 3) Larger organizations may have more resources and infrastructure to build scale for success Let's talk more about this. What do you see in the data? What is your experience with your ACO? https://lnkd.in/erjc-peV

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As policymakers consider changes to the Medicare Advantage (MA) program, it's essential to acknowledge the diversity of D-SNP and MA-PD plans. A one-size-fits-all approach may fail to address the unique needs of these plans and lead to unintended consequences for Medicare beneficiaries. Thoughtful and tailored policy decisions can help ensure that all beneficiaries receive the care and support they desire and deserve. Our new Association for Community Affiliated Plans (ACAP) report shares specific policy recommendations and options for consideration: https://bit.ly/4dHIpWj #MedicareAdvantage #DSNP 

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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.

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Accelerating MMIS Implementation with Newgen Software: GHIT Digital POV The Medicaid Management Information System (MMIS) is a vital platform that automates and manages the Medicaid program lifecycle. It ensures smooth administration of Medicaid services, from claims processing and beneficiary eligibility to provider management and compliance reporting. MMIS integrates business workflows with advanced technology to improve operational efficiency, maintain compliance with Centers for Medicare & Medicaid Services (CMS) regulations, and deliver better outcomes for Medicaid beneficiaries. Challenges in MMIS Implementation - While the vision for MMIS is clear, execution faces hurdles: - Complex Business Rules: Customization for state-specific Medicaid programs. - Regulatory Overload: Adapting to evolving CMS requirements and audits. - Legacy System Integration: Ensuring interoperability with outdated platforms. - Scalability: Managing the increasing volume of claims and beneficiaries. GHIT Digital, in partnership with Newgen Software, addresses these challenges with the NewgenOne Platform. This AI-powered, Low-Code, and Modular platform is perfectly aligned with the modern MMIS architecture and provides the tools necessary for efficient implementation and long-term success. Call to Action For Medicaid agencies, Managed Care Organizations (MCOs), and other stakeholders, GHIT Digital and Newgen Software offer the expertise and technology to revolutionize MMIS implementation. Connect with Monika Vashishtha, President of GHIT Digital, to schedule a personalized demo of the NewgenOne Platform and see how it can transform your MMIS deployment. MonMass, Inc. (the legal name of GHIT Digital) will work on your strategic IT Projects or Consulting requirements (NAICS codes 541511 / 541512 / 541330 / 541618). Feel free to call at 646.734.6482 or write to me at [email protected] for no obligation discovery conversation. You are welcome to share your RFPs/RPQs for us to review and respond on time. Click the Pic below to read the rest of the POV.. https://lnkd.in/eniSWN-e

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I’d highly recommend those interested in direct contracting take the time to sign up for this webinar next week. Steve Wiggins is a legendary disrupter in healthcare and I’m certain that you’ll find value in what he is creating. #directcontracting #paymentreform #caretransformation #valuebasedhealthcare #healthinnovation #healthcare #healthleadership

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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!

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Join Dr. Shardul Mehta at the RISE 23rd Risk Adjustment Forum for insights on ACO updates. Discover why data is crucial for ACO success and how a robust population health platform can elevate coding accuracy and documentation. Wednesday, May 22nd, 2024, 9-9:45 AM. Don't miss out!  #Persivia #Healthcare #ACOs #DataManagement #Ai #Populationhealthmanagement #rise #RAF #23rdriskadjustment

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The highest increase since 2012 highlights the pressing need for further action to curb increases in medical cost trend. Insurers should prepare for tougher contract negotiations as providers strive to enhance their financial standing and offset stagnant Medicare and Medicaid reimbursement rates.

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🚨 Healthcare RCM is at a crossroads. Are we addressing the elephant in the room—fragmentation? 🚨 Fragmented revenue cycle processes are driving up costs, delaying reimbursements, and frustrating patients. But there’s hope. Unified, AI-driven solutions like our comprehensive team of RCM AI Agents are slashing preventable claim denials by 75% and delivering 5x ROI payback. Ready to take control? Start here: - Understand fragmentation’s financial impact - Leverage AI for seamless RCM integration - Achieve measurable ROI and operational efficiency It’s time to move toward smarter, patient-centered RCM. Learn more at https://lnkd.in/enZ5Qduh 🚀

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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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From modernizing codesets and #USCDI v4, to ePrior Auth and bulk #FHIR data, the #HTI-2 rule builds on #ONC’s prior efforts to improve processes across #payer, #provider, #publichealth, and more. While the use cases are wide ranging, the entire industry benefits from improved #quality and access to #healthdata. Great news for Tenasol, as we process #clinicaldata of all shapes and sizes, so we are excited to see ONC’s continued efforts to raise the bar for #healthIT and #interoperability.

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The 2024 CMS Priori Authorization rule was passed to reduce burden for providers, members and Payers for data exchange and approval process, however work must be done for payers and providers. Some provisions and policy adoption are required (January 2026) and data exchange integration by January 2027. This article provides an overview of the policy, provisions and requirements, as well as some guidance to build your strategy to meet the requirements. https://lnkd.in/gp32MjUN

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The time is now for new business models for virtual care to integrate more fully with existing care or to focus on unmet needs like chronic condition management….

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Tough RCM Questions with Michael Quinn from Inovalon - Healthcare IT Today #ToughRCMQuestions with Michael Quinn from Inovalon In a recent interview, Michael Quinn from Inovalon addressed several challenging questions related to revenue cycle management (#RCM) in healthcare. Here are the key takeaways from the discussion: #ImportanceofDataIntegration Quinn emphasized the importance of data integration in RCM processes. He highlighted how integrating data from various sources can streamline operations and improve revenue collection. #RoleofPredictiveAnalytics Predictive analytics play a crucial role in optimizing revenue cycle performance. Quinn discussed how leveraging predictive analytics can help healthcare organizations identify trends, forecast revenue, and make informed decisions. #ChallengesinRCM Quinn acknowledged the challenges faced by healthcare organizations in RCM, such as ai.mediformatica.com #health #inovalon #healthcare #michaelquinn #this #about #healthit #healthcareit #healthcareittoday #interview #management #revenue #digitalhealth #healthtech #healthcaretechnology @MediFormatica (https://buff.ly/4dun2rV)

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Read the case study to find out how Guthrie Clinic is transforming and modernizing their revenue cycle, resulting in improved financial outcomes and patient experience: https://optum.co/o76mwo #Optum #Healthplans #Providers #Revenuecycle #Guthrieclinic

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As healthcare providers transition to value-based care, the significance of CDI cannot be overstated. Effective CDI capabilities and resources are crucial for ensuring medical record accuracy, completeness, and consistency, resulting in optimal reimbursement and enhanced compliance.    At AGS Health, we’ve made substantial investments in clinical technology and resources to help ease the CDI burdens on your valuable clinical resources. We’ll handle the documentation so your clinicians can focus on care delivery. 

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