Shane Cerone

🌟 Whether you’ve determined now is the time for you to begin the process toward FACHE or you’re still deciding, the next stop on your journey is our FACHE Overview Webinar. This webinar is free for you to attend but it requires registration. Learn more and save your place here: https://bit.ly/3MkxxT8

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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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Track your growth with custom reports for your Practice. Watch a demo -> #patientsafety #patientcare #physicians nexusclinical.com

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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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🚀 Transform Your Hospital with the CDI MasterClass! 🚀 Are you ready to elevate your hospital's Clinical Documentation Integrity (CDI) practices? Join the ultimate resource for adult acute inpatient care teams, including physicians, CDI specialists, coders, and all stakeholders! ☀️ What We Offer: Unlock a year-long subscription to 50 engaging 30-minute on-demand webinars, rolled out every week! These sessions are designed to ensure that all team members are on the same page while revolutionizing your approach to CDI. Regardless of your shift, take a moment to enhance your skills and knowledge -- just log in and learn at your convenience throughout the contract year! 🏥 Why Choose the CDI MasterClass? The CDI MasterClass program is tailored not only for CDI specialists but also for all stakeholders involved in the process, including medical staff, coders, the CDI team, quality assurance, utlization/case management, appeals/denials management, risk management and compliance. The success of a CDI program relies on collaboration and cohesive efforts among all these groups, as operating in silos rarely leads to effective outcomes. Our comprehensive curriculum empowers your teams to adopt a proactive approach to CDI, leading to: - Improved patient care - Optimized coding accuracy - Enhanced net financial outcomes for your organization 👌🏽 Don’t Miss This Opportunity! Transform your hospital's operations and elevate your CDI practices. Encourage your hospital or health system to sign up today! The path to financial success lies in effective and resilient revenue optimization.  How can you achieve revenue optimization? By accurately capturing the patient's story through concise documentation and precise coding. The key is to enhance revenue with integrity while reducing denials through authentic storytelling. A proactive approach is essential to mitigating risks associated with malpractice and payment denials. ℹ️ Ready to Learn More? For more information about our CDI MasterClass program and to receive a copy of the curriculum principles, email us at [email protected]. Take the first step towards a successful and cohesive CDI strategy! Join us today and make a lasting impact on your healthcare team’s performance! AHIMA American College of Physician Advisors (ACPA) American Medical Association American Hospital Association Healthcare Financial Management Association (HFMA) Health Care Compliance Association (HCCA) American College of Healthcare Executives

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Sullivan senior consultant Shawn Craddock, DNP, RN, CNOR, NE-BC, discusses procedural sedation and analgesia considerations for ASC leaders and the effect on patients in this article from OR Manager. Hear from Shawn about balancing anesthesia practices based on therapeutic effects, patient safety, practitioners' skills and credentials, and cost-effectiveness. Read more from OR Manager here.

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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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The latest National Hospital Flash Report highlights a concerning trend - the gap between high and low performing healthcare organizations is widening. Lower performing organizations often struggle to invest in key areas like strategic initiatives, employee retention, and facility enhancements. Is your organization looking to elevate its performance and drive positive change? Altius Healthcare Consulting Group offers leadership development, workforce optimization, and change management support to help you achieve your goals. Don't risk falling behind - take action today to propel your hospital or healthcare system to new heights of success. Reach out with a quick phone call or message to get started on your journey towards excellence. #HealthcareConsulting #LeadershipDevelopment #WorkforceOptimization #ChangeManagement https://lnkd.in/eZzvA2Ch

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9 Strategies for Diagnosing and Treating Cash Flow Problems Check out the latest Practice Management Institute / The Michigan Society of Hematology and Oncology article in the July issue of Oncology Practice Management magazine! The article, written by industry expert and PMI faculty member Jamie Claypool CMPE,CPC,CPMA, CMCA-EM, is worth the read!   “In the 30 years of my physician practice consulting career, I have learned a number of ways to diagnose and treat cash-flow problems. Some problems were easy to diagnose and others a bit more difficult, with many “differential diagnoses” along the way. While providing practice assessments to my clients, I developed various strategies that I consider productive. People in revenue cycle management may find some of the techniques I am suggesting part of their everyday routines. However, if you are a practice owner, an office manager who is not a professional financial manager, or a veteran billing and practice management staff member, you may be helped by these strategies.” Read the full article here #PMIPARTNERSHIPS

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KH's most recent Flash Report unveils promising signs of financial performance, with a notable slowing of margin decline. The widening gap between lower and higher performing organizations highlights the focus on long-term investment and innovation in high-performing orgs. Lower performing organizations must focus on enhancing efficiencies and reworking key elements like their operating model and portfolio management. Explore the insights in the report here: [National Hospital Flash Report May 2024 Metrics](https://lnkd.in/ggUcyDPh). For resources to boost performance, visit us at https://lnkd.in/enBa3Tp

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This should be a major RED FLAG 🚩 for all providers! However, it also creates a significant leverage point for providers who know how to use it at the negotiating table. Payers need broad networks to maintain MA market share and profits. Providers can use that to their advantage at the bargaining table…payers need you more than you need them when it comes to MA. Remember, seniors don’t change doctors, and if forced to decide between keeping an insurer or their provider, 99.9% will change insurers….ask any broker! Learn how to leverage MA with Payers to increase reimbursements. 👉 https://lnkd.in/gRB3rMw3 #EllsworthConsulting #HealthcareInnovation #ConsultingServices #HealthcareLeadership #PayerNegotiations #HealthcareConsulting

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🎯 Unlocking Healthcare Efficiency with Risk Adjustment 🎯 Thrilled to share my latest article, “Risk Adjustment: Reducing Inefficiencies and Waste,” featured in the third quarter 2024 issue of St. Louis Metropolitan Medicine. In today's healthcare landscape, understanding risk adjustment is more crucial than ever for driving real change in value-based care delivery. 🔍 Key insights include: - How risk adjustment can streamline processes and reduce waste. - The role it plays in enhancing patient care and outcomes. - Practical strategies for implementation in your organization. 💡 I’d love to hear your thoughts! How is your organization leveraging risk adjustment? Let’s continue to innovate and push the boundaries of what’s possible in healthcare. 👉 Check out the full article here: https://lnkd.in/gyQWdRuE A big thank you to St. Louis Metropolitan Medicine and Jim Braibish for the platform to share these ideas. Let’s keep the conversation going and drive forward with impactful solutions! If you find value in this, please share with your network. Together, we can make a difference. 🌍 #HealthcareInnovation #RiskAdjustment #ValueBasedCare #HealthcareEfficiency #Leadership #Innovation

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There is a lot of excitement in Washington (& around the country) around new healthcare policy possibilities. Of course we are ready with our own wishlist of changes and updates at the federal level to enhance access to trusted medical care and drive down the bloated healthcare industrial complex. Here's a snapshot: Expand Tax Benefits: Make all health plan payments, including individual contributions to DPC, tax-deductible. Enable HSAs for all Americans without requiring high-deductible health plans. Empower Physicians: Simplify Medicare opt-outs and give states authority over Association Health Plans (AHPs) to promote autonomy and flexibility. Enhance Transparency: Mandate public disclosure of insurer-negotiated rates to level the playing field for patients and independent practices. Address Workforce Shortages: Increase residency funding and loan forgiveness for independent physicians to sustain innovative care models like DPC. Support Medicaid Reform: Enable Medicaid voucher programs, similar to EBT or SNAP to allow recipients to pay directly for healthcare and DPC memberships, reducing reliance on costly emergency services. Caution: The government can't get in the middle of the financial or care transaction. 🔑 Leveraging tools like budget reconciliation and agency rulemaking, we can achieve these transformative changes to create a patient-centered, efficient healthcare system. #HealthcareInnovation #DirectPrimaryCare #PolicyReform #DPC #TaxBenefits #Transparency #PhysicianAutonomy https://lnkd.in/gSmndNXG

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The path to high performant specialty care starts with the referral—ensuring the patient sees the right doctor, at the right time, the first time, and every time. What I’ve been most impressed with in my early days on the Conduce Health team is the ability to accurately and consistently make this possible and personalized at the patient level. Interested in learning more? Let’s connect!

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More and more, marketing/communications/digital executives are focused on the patient experience. Please read the summary of a personal health journey from my valued colleague, Jeff Peters. Given his decades of experience in healthcare, Jeff knew what to do. Others?

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