Karen Decaran-Voigt

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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My Friday good news celebrates the heroes of value-based care: primary care physicians and teams. The most successful #Medicare ACOs, those delivering value for Medicare and Medicare beneficiaries and sharing in that value, are primary care-centric #ACOs. We know how they do it; the playbook often includes support from enablers like Aledade, Inc.. Dr. Menard and his colleagues didn't give up when success wasn't immediate. How do we grow more primary care-centric ACOs and generate more value for Medicare and more access and quality care for beneficiaries? There are some health system ACOs investing in primary care and integrated teams. But it might take more forceful nudges from Medicare to get big health systems participating in total cost-of-care risk models. Or, we might need payment policies to give primary care more independence to practice comprehensive care. Congress could also consider restructuring the APM bonus to reward primary care "centricity". #primarycare #valuebasedcare Primary Care Collaborative David Raths David Muhlestein AAFP Foundation Thomas Culhane, MD, MMM, MS Darrin Menard, M.D. Stacey Richter https://lnkd.in/dThMvJrQ

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😳Humana faces a significant challenge following the release of preliminary 2025 Medicare Advantage (MA) Star Ratings data from CMS. Only 25% of its MA members are now enrolled in plans rated 4 stars or higher, a steep decline from 94% in 2024. 👉🏻The drop was driven primarily by the performance of contract H5216, which covers nearly half of Humana’s MA members, including over 90% of its Group MA plans, and saw its rating fall from 4.5 to 3.5 stars. 💴This will impact quality bonus payments in 2026. Humana is actively appealing some results and working to improve operating discipline to regain its industry-leading position. 🧘Key initiatives will focus on member engagement, customer experience, and technology enhancements to drive long-term value. Medicare Advantage open enrollment kicks off 10/15 and goes until 12/7. STAR ratings expected to be released to the public around 10/10! 📉Down 22% in premarket! https://lnkd.in/gUTT84tR

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The CMS has implemented anti-fraud measures for ACA enrollments, including requiring three-way calls for brokers not affiliated with existing plans and suspending 850 agents suspected of unauthorized switching. While complaints have dropped 30% since these changes, concerns remain about rogue agents exploiting system vulnerabilities. Critics, including agent groups, argue that the measures complicate enrollment and lack due process, advocating for two-factor authentication instead. Unauthorized switches have led to issues like higher deductibles and unexpected tax bills, creating political challenges for the Biden administration during a period of record ACA enrollment.

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#CMS will require states and #Medicaid insurers to annually report how carriers spend state-directed payments to #providers, how their rates compare to #Medicare, and survey #ManagedCare enrollees about their experience with insurance companies. CMS also mandated states create “one-stop-shop” websites that allow enrollees to compare the quality ratings of #MedicaidManagedCare plans. Hmm. Medicaid continues to look more and more like #MedicareAdvantage with each new set of federal rules: more ongoing #HealthcareReform on the margins via national rule-making. #HealthcareTransformation #TripleAim #QuadrupleAim #PrimaryCare #SDOH #PopultionHealth #PublicPrivatePartnership #PublicPrivatePartnerships #DSNP #DualEligible #BehavioralHealth #MentalHealth #HealthEquity #FoodisMedicine #HealthcareQuality #HealthcareCosts #HHS

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Good insights from Modern Healthcare discussing the challenges facing insurers in the wake of Medicare Advantage pay cuts. This reduction may have a significant impact on the industry and has insurers "scrambling" to adjust their strategies, (not to mention the implications for providers, and beneficiaries). Insurers are considering various responses including premium increases, benefit reductions, and provider reimbursement cuts. Insurers need to adapt quickly and efficiently to face this challenge. Anyone involved in the healthcare industry should understand the importance of staying ahead of these challenges and finding innovative solutions to overcome them. Since there is a delicate balance between profitability and ensuring quality care for Medicare Advantage beneficiaries, it will be interesting to see how insurers will continue to provide high-quality care for MA members in the face of these obstacles.  #medicareadvantage #healthcare #beneficiaries

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🚀 Just Published: Scoring Goals in Healthcare - How Claims Data is the Playmaker We’ve Been Missing 🏥⚽ Claims data is a game-changer, turning overwhelming data into actionable insights that lead to better outcomes helping healthcare providers anticipate needs, close gaps in care, and ultimately score big for their patients. 🔗 https://okt.to/VkvMSY Whether you're a healthcare professional, data enthusiast, or just love a good soccer analogy, I hope you'll find this piece insightful. #HealthcareInnovation #ClaimsData #DataDrivenCare #HealthcareIT #PopulationHealth #Leadership #Soccer

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CMS Staffing Rule Key Points: https://lnkd.in/dgVZUxQa 1. HPRD for RNs is 0.55 and for Nurse Aides is 2.45 2. In addition, facilities must include an additional 0.48 HPRD using any combination of nursing staff, (LPNs/LVNs, RN's, NA's). 3. An RN will be required on site 24/7. 4. CMS now requires that a good faith effort be made to support hiring and recruitment, and stresses the need to have contingency planning in place. Apploi can help. :-) 5. The rule will be implemented in phases: Staffing Plan/Facility Assessment for all- 90 days Non-Rural Facilities: 24/7 RN & 3.48 HPRD- 2 years RN 0.55 HPRD & NA 2.45 HPRD- 3 years Rural Facilities: 24/7 RN & 3.48 HPRD- 3 years RN 0.55 HPRD & NA 2.45 HPRD- 5 years

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This is the “Stars For Dummies” piece you’ve been looking for. When some brokers say all plans are the same, on the surface, I can see why - benefit grids are boringly similar. But that’s where the comparisons take a dramatic shift. Quality of care is the key differentiator, and where higher-rated plans do their best work. How can lower rated plans have “richer” benefits than those rated higher (SCAN 4.5 Stars!)? Because we are here when actual healthcare is the patient’s (and broker’s) priority. We approve your referrals, pay claims, and work with our members to stay healthy and independent. Broker question - If your parents were looking for a health plan, do Stars influence your selling decision? Assuming your truthful answer is yes, then why do you sell the others? If higher quarterly grocery benefits is the answer, there are lots of things you should reconsider.

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Hyper #competitive #MedicareAdvantage marketplace: #Healthplans compete annually on #PopulationHealth, extra benefits, member experience including #quality, access & outcomes, member cost (premiums charged), all the while limiting the per capita cost of care charged to the US #taxpayer. Continues to garner #bipartisan Congressional support. Enrollment quadruples since 2007 to 34 million. Sorta ongoing #HealthcareReform by assimilation. Americans like choices not mandates. #HealthcareTransformation #TripleAim #QuadrupleAim #PublicPrivatePartnership #PublicPrivatePartnerships #CMS #SDoH #DualEligible #DSNP #BehavioralHealth #HealthcareQuality #HealthcareCosts #PrimaryCare

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There’s renewed optimism for the passage of the Improving Seniors’ Timely Access to Care Act, a bill aimed at simplifying how payers process healthcare utilization requests in Medicare Advantage plans. Recent updates have brought the bill closer to budget neutrality and would require Medicare Advantage plans to report their approval and denial rates, develop electronic prior authorization to streamline approvals and encourage adherence to evidence-based guidelines. Supported by hundreds of organizations, this bipartisan effort could significantly reduce delays in access to necessary healthcare services. Continue reading at https://loom.ly/UkTTZP8

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As the 2025 Medicare Advantage (MA) enrollment season approaches, experts note significant challenges and changes in the landscape. The CMS has adjusted its payment models, impacting how health plans are reimbursed based on patient health conditions. This has led to a noticeable decline in the number of available plans, with major insurers like CVS and Centene cutting over 60 plans each, resulting in fewer carriers and increased plan terminations. Despite these challenges, enrollment in Special Needs Plans (SNPs) has surged, more than doubling since 2019, driven by the growing demand for tailored care for vulnerable populations. SNPs now account for 20% of overall MA enrollment, highlighting a significant shift towards specialized care amid broader market fluctuations.

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715 pages of potential regulation. I bet everyone is dying to read this over the thanksgiving break. Here are two things I will be looking into a bit more. 1) Prior Authorization - CMS says, "CMS remains concerned about barriers accessing care and high burden on the system. For example, data reported to CMS by MA plans indicate that, on average, MA plans overturn 80% of their decisions to deny claims when those claims are appealed to the plan. These data also show that a low percentage of denied claims are appealed, meaning many more could potentially be overturned by the plan if they were appealed." I anticipate this to be a hot topic in 2025. As MA plans see margin pressures from utilization and the V28 model shift they will look to ways to control costs. One way to do this is to curb or slow utilization. CMS has voiced a concern but providers have as well. What I find fascinating is that there is a low level of prior auth appeals but a high overturn rate. To me that means either organizations know when something shouldn't have been requested so they give up or they simply give up based on the administrative burden. Alternatively, the high overturn rate tells me there is likely some unnecessary authorization hurdles to jump through. For costs to be controlled providers and payers need to come together to drive meaningful change. 2) Guardrails for Artificial Intelligence- The summary says "given the growing use of AI within the health care sector, such as, but not limited to, AI-based patient care decision-support tools, we believe it is necessary to ensure that the use of AI does not result in inequitable treatment, bias, or both, within the healthcare system, and instead is used to promote equitable access to care and person-centered care for all enrollees." This to me is going to be fascinating to watch unfold. I am a huge believer in what technology can do. I see a world where people can be empowered to achieve greater things by automating simple, repeatable, or low value tasks. We also place a premium on human capital and this frees up time. However we have also seen cases where AI has negatively impacted the industry- be it in denials, gross over capture of risk conditions, or the recent OIG publication about emergency department billing. There are a few other important items that I will be digging into. I want to look into the weight loss medication updates, the possible changes to medical loss ratio calculations for MSSPs, and overall access to care provisions. What jumps out to you? Anyone want to share their deep dive on a particular piece of the proposed regulation? https://lnkd.in/eVjKjzyw

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Excellent article by Nona Tepper at Modern Healthcare explaining how Medicare Advantage #starratings are calculated and how they impact member recruitment. While they're not perfect, Stars ratings provide a good quality indicator for those choosing a plan. Check out the article here. Nona Tepper Modern Healthcare

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The discussion around real-world, synthetic, and de-identified data in #HealthcareAnalytics highlights an essential truth: the data you use doesn’t just inform insights—it shapes the decisions that impact patient care and access. Each data type has unique strengths: real-world data provides depth and variability, while synthetic data offers scalability and privacy protections. However, the true power lies in integrating these sources with reimbursement and knowledgebase data. By combining these latter two data types, we can ensure that the best diagnostics are not only developed and validated but also reimbursed—making them accessible to patients who need them most. Adding real-world data further enhances this process to demonstrate clinical utility when new biomarkers are tested, paving the way for reimbursement frameworks to support the rapid translation of innovation to the practice of medicine. In healthcare, better decisions start with better data, applied strategically to advance #PrecisionMedicine and improve #PatientOutcomes.

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#CMS touts #MedicareAdvantage premium stability, #HealthPlan choice (typically most people have 34 plans to choose from), excellent monitored #provider network adequacy, aggressive #marketing oversight (1000 TV ads rejected) & #PartD copay improvements on a conference call. Expects total 2025 MA enrollment to exceed 35 million. #HealthcareReform #HealthcareTransformation #HealthEquity #PrimaryCare #HealthcareCosts #HealthcareQuality #PatientCenteredCare #PublicPrivatePartnership #PublicPrivatePartnerships

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The time is now: Why addressing your revenue cycle challenges is critical in 2025 for healthcare leaders. Take a look at our eguide in the link below.

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