Pavan Patel, MHA, CRCR

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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Calculating Return on Investment for CDI Most CDI Programs measure CDI performance and success through traditional Key Performance Indicators consisting of: Number of charts reviewed Number of queries issued Query response rate Query agreement rate CC/MCC capture Coder CDI DRG agreement rate CMI increase SOI/ROM scores I submit to all CDI professionals and CFOs that these KPIs do not measure real CDI program performance. These KPIs are based on task-based activities centered on the query process and reimbursement. Every program like CDI must generate revenue for the hospital. What matters most is net patient revenue, revenue the CFO requires to pay vendors, make payroll, invest in physical plant, and find financial reserves, etc. Consider the following: Just because a physician documents a diagnosis does not mean it will be allowed by the payer. Just because the hospital bills a particular DRG does not mean the payer will pay the same DRG. CMI is a gross number not reflective of reality. CDI must be evaluated based on net patient revenue & denials avoidance. Medical necessity/clinical validation denials & level of care downgrades usually occur due to insufficient documentation. Increasing denials is a strong indication a CDI program is not performing well. A good place to pop the hood & take a look in CDI is table E4 of the 2023 CERT Improper Payment Report. How are denials for these specific DRGs at your facility? #mesasuringCDIperformance, #CDIsham, #ROI, ERNIE DE LOS SANTOS

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Would your healthcare organization benefit from a more streamlined RFP process? Well, our tool is not just for data analysis. Valify also provides a centralized platform for managing proposals. It's a lesser-known feature, but it saves our members hundreds of hours of administrative labor and ensures that they get the best value from their suppliers. Want to learn more about simplifying your RFP process? Send me a DM and let's chat!

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Read this special report that provides a detailed review & validation process for the appropriate use of discharge status code 06 and Condition Codes 42 & 43 in claims involving home health services post-hospital discharge. Download your copy now: https://gag.gl/kkTLyy #TransferDRG #ConditionCodes

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"We'll first have a refresher on the format, the structure, the alphabetic index, & the tables of ICD-10 PCS. Then we'll jump into a deep dive step-by-step procedure coding review. So, this area should help provide clarification on those common errors identified in audits." - Victoria Hernandez, BESLER Sr. Coding Analyst. Listen to this NEW The Hospital Finance Podcast: https://gag.gl/ZTq1kb #HospitalFinancePodcast

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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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It’s not enough to be great at billing, optimization of revenue cycle best practices are a necessity in realizing great healthcare financial health. Leveling up strategies heavily revolve around: ✅ Proactive patient collection strategies. 30% of healthcare revenue comes from patient cost sharing. Nobody can afford inefficient and costly patient collections strategies. Up front, with accuracy and transparency, is always best. ✅ Improve registration and eligibility checks. Automate, automate, automate. And then do it every visit, every service rendered. ✅ Develop patient friendly payment plans and options. Even grocery stores are now taking after pay programs. People want options and some people really need them. ✅ Maximize EMR and PM capabilities. If your systems aren’t working for you - and on the constant edge of innovation - they’re working against you. Getting paid quickly and accurately is the mission of any great revenue cycle operation. When you focus on strategies around accomplishing this, you become a well oiled machine. #revenuecyclamagement #operationalexcellence #healthcarefinance

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Table of Contents 1. Introduction 2. Why This Matters Now 3. Understanding the New Incentives - Quality Metrics Integration - Financial Incentives 4. Impact on Medicare Advantage Plans - Opportunities - Implementation Challenges 5. Best Practices for Implementation - Member Engagement - Provider Collaboration - Technology Integration 6. Looking Ahead 7. Call to Action 8. Final Thoughts Introduction The Centers for Medicare & Medicaid Services (CMS) has taken a significant step forward in promoting person-centered care with new regulations that incentivize Medicare Advantage plans to engage members in advance care planning. This move represents a pivotal shift in how we approach end-of-life care discussions in the healthcare system. Why This Matters Now The timing of this regulatory change couldn't be more critical. As our Medicare population continues to grow and age, the need for clear, documented healthcare preferences becomes increasingly important. Consider these statistics: - Only 1 in 3 American adults has an advance directive - 80% of people say they want to die at home, yet 60% die in acute care settings - Nearly 40% of family members experience significant depression after making decisions for relatives without advance directives Understanding the New Incentives Continued… https://lnkd.in/eUpnAmWJ

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I have spoken to representatives from hospital regions that have invested in PACS and the associated PACS VNA. When I ask if they have considered what happens after the contract ends, they tell me they paid upfront for the right to migrate out of the PACS/VNA. 𝗕𝘂𝘁 𝘄𝗵𝘆 𝘀𝗵𝗼𝘂𝗹𝗱 𝘁𝗵𝗶𝘀 𝗯𝗲 𝗻𝗲𝗰𝗲𝘀𝘀𝗮𝗿𝘆? Shouldn’t a true VNA provide customers with all the tools they need to access and migrate out of the solution whenever they choose?   When selecting a Vendor Neutral Archive (VNA), it’s crucial to ask yourself the right questions to ensure you’re making the best choice for your healthcare system. Consider these key points:   𝗧𝗿𝗮𝗻𝘀𝗽𝗮𝗿𝗲𝗻𝗰𝘆: Are the costs fully transparent? Hidden costs can lead to mistrust. With a true vendor-neutral VNA like Acuo, you get clear and upfront pricing.   𝗤𝘂𝗮𝗹𝗶𝘁𝘆: Is the VNA of high quality? High-quality VNAs, such as Acuo, come with advanced technology, ensuring robust performance and reliability.   𝗦𝘂𝘀𝘁𝗮𝗶𝗻𝗮𝗯𝗶𝗹𝗶𝘁𝘆: Is the business model sustainable? Acuo VNA is designed for long-term support and regular updates, ensuring consistent performance.   𝗛𝗶𝗱𝗱𝗲𝗻 𝗖𝗼𝘀𝘁𝘀:Are there unexpected costs for upgrades or maintenance? Acuo VNA’s transparent pricing model avoids hidden costs, so you know exactly what you’re paying for.   𝗩𝗮𝗹𝘂𝗲 𝗣𝗿𝗼𝗽𝗼𝘀𝗶𝘁𝗶𝗼𝗻: What are the benefits of the VNA? Acuo VNA offers unmatched flexibility and integration capabilities with its vendor-neutral approach.   𝗖𝘂𝘀𝘁𝗼𝗺𝗲𝗿 𝗦𝘂𝗽𝗽𝗼𝗿𝘁: Is reliable support available? Hyland ensures you have accessible assistance whenever needed.   𝗙𝘂𝘁𝘂𝗿𝗲-𝗣𝗿𝗼𝗼𝗳𝗶𝗻𝗴: Is the VNA future-proof? Acuo VNA is designed to stay at the cutting edge of technology with regular updates.   𝗠𝗶𝗴𝗿𝗮𝘁𝗶𝗼𝗻 𝗖𝗵𝗮𝗹𝗹𝗲𝗻𝗴𝗲𝘀:  How does the VNA handle data migrations? Acuo VNA simplifies the migration process, ensuring seamless integration and continuity of care.   𝗗𝗮𝘁𝗮 𝗢𝘄𝗻𝗲𝗿𝘀𝗵𝗶𝗽: Do you own your data without extra costs? With Acuo VNA, there is no lock-in. You retain full ownership of your data, ensuring free access and migration. Choosing Acuo VNA means opting for a solution that is not tied to any PACS vendor, providing you with the flexibility, transparency, and quality essential for a sustainable and efficient healthcare system. https://lnkd.in/dcHZy4hg Alexander Ryan Christopher Brice Jamey Baszuk Dan Sperring Sthephanie Colmenares Garcia Peter Lager Ian Robinson #Healthcare #VNA #MedicalTechnology #DataTransparency #CustomerSupport #FutureProofing

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The Centers for Medicare & Medicaid Services (CMS) recently finalized a rule increasing the Medicare inpatient prospective payment system rates by 2.9% for FY2025. This rate adjustment, slightly higher than the initially proposed 2.6%, is based on a hospital market basket increase of 3.4%, offset by a 0.5% productivity cut. While the adjustment will increase payments by $2.9 billion and add $300 million for new medical technologies, rural hospitals may face significant financial challenges. Without legislative intervention to extend the Medicare-dependent hospital and enhanced low-volume adjustment programs, rural health payments could decrease by $400 million. Additionally, disproportionate share hospital payments are expected to fall by $200 million due to a reduced uninsured rate. The American Hospital Association has expressed concerns that these updates will exacerbate financial pressures, particularly in rural and underserved areas. Molly Smith, Vice President for  Public Policy, criticized the 30% increase in the long-term care hospital outlier threshold, which has risen 180% since FY2021, placing financial burdens on hospitals treating the sickest patients. Critics argue that the rate increases fail to cover rising costs of care, including inflation and labor expenses, leaving providers struggling to stabilize operating margins and maintain healthcare access for underserved populations. Our Revenue Cycle Management (RCM) team can assist by optimizing reimbursement strategies, ensuring accurate billing, and enhancing revenue capture. We support rural and underserved hospitals in navigating CMS changes, reducing financial strain, and improving cash flow, ultimately helping them maintain access to care and achieve financial stability. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner HealthLeaders

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➡️The Importance of Credentialing and Enrollment for Practice Growth 📌Credentialing and enrollment are critical processes for any healthcare practice. They ensure that healthcare providers meet the necessary qualifications and standards to deliver care and receive reimbursement from insurance companies. Here are some key points highlighting their importance: ⚡Access to a Broader Patient Base: Credentialing with insurance companies allows providers to be listed as in-network, making their services accessible to a larger number of patients who prefer or are required to use in-network providers. ⚡Financial Stability and Growth: Enrolling with various insurance plans ensures a steady flow of patients and revenue. It prevents loss of potential income from patients who cannot afford out-of-network costs. ⚡Enhanced Reputation and Trust: Credentialing demonstrates that a provider meets the stringent standards set by insurers and regulatory bodies, thereby enhancing the trust and confidence of patients and other stakeholders. ⚡Compliance with Legal and Regulatory Requirements: Proper credentialing and enrollment ensure that a practice complies with all necessary regulations, avoiding potential legal issues and penalties. ⚡Improved Operational Efficiency: Streamlined credentialing and enrollment processes reduce administrative burdens, allowing healthcare providers to focus more on patient care rather than paperwork. At CARE RCM SERVICES we understand the complexities of credentialing and enrollment. Our expert team ensures error-free, timely credentialing, enabling your practice to grow and thrive. Let us handle the paperwork while you focus on providing exceptional care to your patients. For more information or assistance with your credentialing and enrollment needs, please contact us today! #credentialing

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Understanding CMS-0057-F Compliance: A Guide for Health Plan Executives Executive Summary The CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) is poised to transform healthcare payer operations by mandating streamlined, interoperable processes for prior authorizations and enhanced data exchange capabilities. For health plan executives, this represents both a compliance challenge and an opportunity to improve operational efficiency, provider relationships, and patient outcomes. This guide details the key compliance requirements, phased implementation timelines, and critical strategic steps needed to achieve compliance while minimizing disruptions and maximizing value. Key Compliance Requirements Electronic Prior Authorization CMS-0057-F mandates the implementation of electronic prior authorization processes via FHIR-based APIs to reduce administrative burden. Payers must integrate these APIs with provider EHR systems to enable seamless data exchange and support automated decision-making for certain requests. To enhance efficiency and member experience, urgent prior authorization requests must be completed within 72 hours, and standard requests within seven days, setting a new industry benchmark for responsiveness. API Implementation Requirements Payers are required to deploy multiple APIs—enhanced Patient Access, Provider Access, Payer-to-Payer, and Prior Authorization APIs. All APIs must align with FHIR Release 4.0.1 standards, ensuring interoperability and compliance with CMS guidelines. These APIs aim to standardize data sharing across stakeholders, offering real-time, accurate information exchange and laying the groundwork for scalable, interconnected healthcare ecosystems. Data Exchange Standards Compliance extends beyond APIs to include the use of standardized FHIR resources and support for bulk data exchange capabilities. Payers must adopt APIs that integrate prior authorization requirements, documentation, and decision processes to facilitate uniform workflows. Additionally, real-time data sharing capabilities must be implemented to provide instant insights to providers, ensuring that information is accessible and actionable when needed. Implementation Timeline Phase 1: January 1, 2026 The initial phase emphasizes foundational API implementation, including the Provider Access API, enhanced Patient Access API, and Prior Authorization API. Payers are also expected to initiate the tracking of response time metrics for prior authorizations, establishing early benchmarks for performance measurement. Phase 2: January 1, 2027 The second phase requires the deployment of the Payer-to-Payer API to ensure continuity of care across plans and full integration of electronic prior authorization systems. By this deadline, all compliance requirements must be operational, with provider systems fully integrated to deliver real-time, automated workflows. Technical Requirements API Standards Continued… (link in bio)

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The 2024 HealthLeaders Exchange RevTech Exchange in Nashville highlighted eight essential tips for effective revenue cycle management (RCM) technology. First, continuous training is critical due to AI-driven changes; RCM staff must evolve from manual tasks to monitoring automated processes. Leaders must address AI-related job concerns and help staff adapt to their new roles. Technology alone isn’t a solution; it’s a tool requiring effective utilization to improve revenue cycle performance, as seen in WVU Medicine's predictive denial tool that lacked actionable value. Second, health systems must proactively address root causes of common RCM pain points, such as denials and prior authorizations. Third, cross-department collaboration, particularly with IT and clinicians, is essential; RCM staff should understand clinical workflows and find clinician champions to improve technology alignment. Fourth, securing a clear ROI is crucial to justify AI investments, and fifth, balancing new and established tech requires strategic decisions on in-house versus outsourced solutions. Sixth, learning from other industries like retail and banking can bring fresh perspectives to RCM, fostering innovation and adaptability across healthcare systems. Our RCM team supports effective revenue cycle technology management by offering tailored training on evolving tech, fostering cross-department collaboration, and addressing root causes in areas like denials. We help healthcare entities maximize ROI, balance new and established tech, and adapt successful strategies from other industries for seamless integration. #HomeHealthServices #HospiceCare #FrontEndServices #BackOfficeSolutions #HealthcareManagement #RevenueCycleManagement #HealthcareCompliance #PatientSupport #CareCoordination #MedicalBilling #ClaimsManagement #PatientEngagement #HealthcareOutsourcing #MedicalCoding #ProviderSupport #CliniqonCare #HealthcareSolutions #PatientCareExcellence #HomeHealthRCM #HospiceBilling

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Most Health Systems and Large Physician groups have no idea how much $$$ may be available to them through Kodiak Solutions Unclaimed Property Asset Recovery service. This has been one of the easiest sources of quick cash for our clients with the least amount of resources required. - Are you aware Unclaimed Property is a major revenue source for states? - Are you aware most health systems are required to file in 30-40 states due to patient and vendor relationships? - Are you aware states have engaged companies to actively get the unclaimed property $$$ they are owed and assess fines for noncompliance? - Are you aware many organizations are overreporting and missing exemption opportunities? We handle 97% of the asset recovery and have $$$ in 30-90 days. Our service is turnkey and we will keep you in compliance. There's a reason we have never lost an unclaimed property client and why over 2000 organizations use us to remove this reporting headache. Interested in learning more? DM me and happy to talk.

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💡💡Great insights from our #MDaudit #2023Benchmarkingreport Case accuracy in professional and hospital billing present significant revenue opportunities.... With national staffing shortages impacting the field of healthcare; technology, automation, and analytics have become important catalysts for billing compliance departments as leaders look to increase productivity despite fewer staff members. Operational efficiency and coding accuracy become key drivers for financial effectiveness. Billing compliance teams are doubling down on auditing coders and tracking case accuracy rates for E&M and procedure services across professional and hospital billing. As you will see in subsequent pages, a single percentage increase in accuracy rates will mean cleaner claims during initial submission and in turn millions of dollars in reimbursement in a timely manner. 1. Case accuracy describes the accuracy of the total claims being audited 2. Code accuracy describes the accuracy of codes (E&M, CPT/HCPCS or DRG) in the claims being audited

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Are you confident your organization can handle the next cyberattack? LBMC ensures your patient services and key Revenue Cycle Management functions stay uninterrupted with our thorough, all-encompassing approach. Let’s chat about how we can help – reach out to us today! #revenuecyclemanagement #RCM #healthcare #cyberattack

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Tension between payers and providers in healthcare arises because health systems' revenues are the payers' expenses, creating a natural conflict. Steve Rowe from 3Pillar Global explains this tension and offers solutions for improvement. He emphasizes the importance of efficiency to benefit both parties, highlighting inefficiencies as costly for both payers and providers. Rowe suggests that streamlined processes, like faster reimbursements in exchange for lower rates and network participation, can create win-win situations. For payers, platform modernization is crucial; legacy systems are costly and inefficient. For example, Rowe describes a situation where a payer’s call center agent had to navigate five screens to answer a question. 3Pillar’s member-centric chatbot streamlined this process, reducing call volumes and costs while enhancing member satisfaction. On the provider side, understanding payer algorithms can help avoid claim denials by integrating financial considerations at the point of care. Rowe advocates for modern technology, including AI, to improve user experiences across the healthcare sector. Our RCM team assists by streamlining billing processes, leveraging advanced technology to reduce inefficiencies, and improving claim accuracy to prevent denials. We focus on aligning financial strategies at the point of care and negotiating better reimbursement terms, ensuring smoother interactions between payers and providers for enhanced revenue cycles. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Healthcare IT Today

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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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Artificial intelligence and automation are revolutionizing middle revenue cycle management in healthcare. Discover how these innovations are enhancing revenue integrity and improving patient journeys. Check out the article here: https://optum.co/qp0nb7. #AI #automation #healthcare #revenuecyclemanagement

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