Jose Ivan Delgado, Ph.D.

Hundreds of nursing homes in Florida have been forced to shut their doors over the past five years because of the soaring cost of commercial property insurance in the state. In the five-year period ending in 2023, an average of 146 nursing homes or assisted-living facilities in Florida have closed each year, according to the state’s Agency for Health Care Administration. During that same five-year period, commercial property insurance premiums rose 125% in Florida.

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Both political parties are more open to Medicare Advantage (MA) reform than in previous election cycles, a shift former federal officials warned should be a warning call for the health insurance industry to refocus its messaging and advocacy efforts surrounding the plans. Scrutiny is ramping up among Democrats concerned MA is not a good deal for taxpayers and within a group of more populist Republicans, whereas there used to be more bipartisan agreement on the program’s importance. #medicareadvantage #MAreform

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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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Understanding the Complex World of Therapy Services: Documentation, CPT Coding, NCCI Edits, and Billing This seminar will teach participants the required components of documentation, what interventions are included within each CPT code and how to correctly bill to Medicare and all other insurance carriers as they relate to outpatient therapy services.

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STOP THE MEDICARE PHYSICIAN FEE SCHEDULE CUT! CONTACT YOUR LEGISLATORS TODAY! Tell your Senators and Representative to support the Medicare Patient Access and Practice Stabilization Act (H.R. 10073) and include its provisions in the year-end spending package! The CY2025 Medicare Physician Fee Schedule (MPFS) final rule published on November 7 cuts Medicare physician payments by 2.8%, the fifth straight year physicians are slated for an additional payment reduction. The only way to stop the cut is to have Congress pass a legislative fix before the end of the year. Congress returned to Washington on November 12. Time is running out – there are precious few legislative days left before the end of the year for Congress to address the cut during the “lame duck” session. After years of consecutive physician payment cuts, it is clear the Medicare physician payment model is hopelessly broken. Thankfully, Congress has started to take this threat to the future of physician practices and their patients seriously. In the House, Representatives Greg Murphy, MD (R-NC), and Jimmy Panetta (D-CA) introduced HR 10073, the Medicare Patient Access and Practice Stabilization Act of 2024. The legislation ensures that physicians are not cut in 2025 and provides a temporary payment update reflective of the rising costs of running a practice. This bipartisan bill stops the latest round of payment cuts stemming from statutorily mandated budget neutrality reductions and provides physicians with a 12-month payment increase that is equal to one half of the Medicare Economic Index (MEI). Because of the short time frame, it is imperative that you call your senators and representatives while they are in Washington, D.C., and urge them to include this legislation in any year-end legislative package. Please log on to the ASCRS Legislative Alert Center on the ASCRS website to contact your legislators using the provided template and talking points. You may use our Legislative Alert system to call or email your legislators’ Washington, D.C., offices. Please do so as soon as possible and ask them to stop the Medicare physician pay cut.  When you call, please ask to speak with the staff person who handles healthcare issues. If you are unable to reach them, it is fine to leave your message with the person answering the phones or on the voice mail of the healthcare staff. Congressional offices keep track of the calls received by their office and will share your message with the appropriate staff. We encourage you to edit portions of the provided message to add personal information about your practice. Please make sure to include examples of how these reductions and the absence of an inflation update will impact your patients and your practice. Thank you for taking action!  

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If you can’t get to your doctor, Florida Blue members can receive virtual care from Teladoc: 1-800-TELADOC (835-2362). Member cost share is based on individual benefits and may be as little at $0* for fast virtual care.  myBlue Connected Care members and Sanitas patients should continue to use their mySanitas app for their virtual visits, if possible.  Not a member? If your community has been affected by the storm, call 1-855-225-5032 for virtual care at no cost from Teladoc.   *$0 cost share does not apply to Health Savings Account (HSA) plans. HSA plans pay deductible + coinsurance. Please refer to your health policy for specific benefits for virtual visits.

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On Veteran's Day we honor the brave men and women who have served our country with honor. Thank you for your service. More than 700,000 veterans call Florida home. Older veterans many not know that a Florida Blue Medicare Advantage plan can complement your VA benefits, providing additional coverage and flexibility. Read the blog post here to find out the three reasons why you should consider a Medicare Advantage plan. https://lnkd.in/en-fhZD7

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🚀 Introducing LTCInsight 360: Revolutionizing Compliance Management 🚀 Are you tired of drowning in paperwork and spending endless hours on compliance tasks? Say hello to LTCInsight360—the game-changing solution that will transform the way you manage compliance in your organization. 🔍 What is LTCInsight360? LTCInsight360 is not just another software platform—it's a comprehensive compliance management system designed to simplify your workload and enhance efficiency. Powered by advanced AI technology developed by RxPulseSolutions, LTCInsight360 is your all-in-one solution for navigating the complex landscape of compliance effortlessly. ⚙️ Key Features: AI-Powered Plan of Correction: Say goodbye to manual correction processes. Our revolutionary AI technology analyzes data and generates customized plans of correction in minutes, saving you valuable time and resources. Customizable Audit Templates: Tailor audits to your specific needs with our easy-to-use template builder. Effortlessly create, edit, and manage audit templates to ensure compliance across all areas of your organization. Automated Document Creation: Generate training documents and review policies and procedures with unparalleled ease. Our AI technology simplifies document creation, allowing you to focus on what matters most—delivering exceptional care. 🌟 Why Choose LTCInsight360? Efficiency: Streamline your compliance processes and eliminate manual tasks. Accuracy: Rely on AI-driven insights to ensure compliance and mitigate risks effectively. Time-Saving: Free up valuable time to focus on providing quality care to your residents. Innovation: Stay ahead of the curve with the latest advancements in compliance management technology. 📢 Join Us as an Early Adopter! Be among the first to experience the future of compliance management. We're currently accepting early adopters to join our journey towards revolutionizing the industry. Don't miss this opportunity—reach out today to secure your spot on the list and unlock the full potential of LTCInsight360! Ready to take compliance management to new heights? Get in touch with us today and embark on a journey towards effortless compliance with LTCInsight360. Your future starts now. #ComplianceManagement #AIinHealthcare #HealthcareTechnology #LongTermCare #EfficiencyInHealthcare #InnovationInCompliance #HealthcareCompliance #FutureOfCare #DigitalTransformation #EarlyAdopters

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Annual Medicare enrollment is upon us! It extends from 10/15/24-12/7/24. This is the time when beneficiaries can review and make changes to their plans. There are two major Medicare options to consider: Medicare (fee for service) and Medicare Advantage plans. Medicare is administered by the government and Medicare Advantage is administered by a commercial insurance company. There are pros and cons to each of these options. Pros of Original Medicare: -Flexibility: You can see any doctor or specialist who accepts Medicare, anywhere in the U.S. -No Network Restrictions: No need to worry about being "in-network" or "out-of-network." -Simpler to Use: There are fewer rules about referrals, pre-authorizations, or finding a provider. -Medigap Available: You can purchase supplemental coverage (Medigap) to help with out-of-pocket costs like deductibles and coinsurance. Cons of Original Medicare: -No Prescription Coverage: You’ll need a separate Part D plan for prescription drugs, which can increase costs. -Higher Out-of-Pocket Costs: There’s no annual out-of-pocket maximum, so costs can add up, especially for serious health conditions. -No Additional Benefits: Original Medicare doesn’t cover dental, vision, hearing, or wellness programs without supplemental policies. Medicare Advantage (Part C) Medicare Advantage plans are offered by private insurers and provide Part A and Part B benefits. Most include prescription drug coverage (Part D), along with extras like vision, dental, and hearing services. Pros of Medicare Advantage: -All-in-One Plans: These plans bundle hospital, medical, and often prescription drug coverage into one package, making it easier to manage. -Lower Out-of-Pocket Maximums: Unlike Original Medicare, Medicare Advantage plans have an annual cap on out-of-pocket spending, providing more financial protection. -Additional Benefits: Many plans offer extras such as dental, vision, hearing, gym memberships, and wellness programs. -Coordinated Care: Some plans, like HMOs, focus on care coordination, which can be a benefit for those with complex health needs. Cons of Medicare Advantage: -Restricted Networks: Many Medicare Advantage plans (especially HMOs) require you to use a network of doctors and hospitals, which can limit your provider options. -Referral Requirements: Some plans require referrals for specialists and may need prior authorizations for treatments, which can add complexity. -Limited Availability by Region: Coverage and plan options vary based on where you live, and not all areas have many choices for Medicare Advantage plans. -Possible Extra Costs: Some Medicare Advantage plans have additional premiums on top of your Part B premium.

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Open Enrollment is officially in full swing for Medicare and the Marketplace! Wondering how to promote that you offer healthcare planning, which includes end of year insurance reviews to your prospect and client base? Take a (literal) page out of Bailard, Inc.’s book. As soon as you walk in their office, they make it clear that reviewing your health insurance annually is a critical part of financial planning. Bravo Lena McQuillen and the Bailard team on this awesome marketing technique that clearly lays out the value of healthcare planning and how the offering is available at the firm!

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Private insurance companies paid US hospitals 254% of Medicare rates regardless of the quality of care. Ouch. Premiums go up and so do shareholder profits. #PrivateInsurance #Hospitals #Medicare #Premiums #Profits https://ow.ly/1avv50RFGYG

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Private insurance companies paid US hospitals 254% of Medicare rates regardless of the quality of care. Ouch. Premiums go up and so do shareholder profits. #PrivateInsurance #Hospitals #Medicare #Premiums #Profits https://ow.ly/1avv50RFGYG

The Office of Inspector General (OIG) conducted an audit of Humana Health Plan, focusing on high-risk diagnosis codes submitted to CMS under Medicare Advantage. The findings revealed that Humana received overpayments totaling $13.1 million for 2017 and 2018 due to errors in diagnosis codes. The OIG recommends that Humana refund $6.8 million, address compliance issues, and improve its policies to prevent future errors. Despite Humana's disagreement with some audit methods, OIG stresses the need for compliance to enhance healthcare resources management. #HealthcareCompliance #MedicareAudit #Humana #OIGReport #HealthcareManagement #MedicalCoding #HealthcareIntegrity #RiskAdjustment #CMS #HealthcareRegulations

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