Tenzin Takza, MBA

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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This commentary from Sachin H. Jain, MD, MBA is extremely timely and aptly captures the shifting landscape within #MedicareAdvantage. It underscores that providers who can establish meaningful, real-world partnerships with at-risk #primarycare practices—especially those targeting high-cost areas like #emergencyroom and hospital utilization—will be crucial in driving down both costs and unnecessary utilization. GuideWell Emergency Doctors is a prime example of how such partnerships can maintain high-quality patient care even as the focus shifts from revenue maximization to #valuebasedcare. In this environment, efficiency and effectiveness are no longer optional; they’re essential to staying competitive amidst these widespread industry changes. ▶️READ NOW: https://lnkd.in/ehMsYejG

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📈 CVS Health just released their Q3 earnings this morning and the market seems to love that they beat on top line revenue despite being aware of the elevated medical benefits ratio. MBR rose to 95.2% from 85.7% in Q3 of last year (WOW). 🚀 Despite the high MBR, the stock is up 7% in premarket as expectations were low headed into the earnings call. I will take a deeper dive in my substack over the weekend but below are the CVS Health Q3 Earnings Highlights: 👑 New Leadership: Steve Nelson former UnitedHealth Group executive, now leads Aetna, aiming to address financial challenges in CVS’s insurance unit. Prem Shah, Chief Pharmacy Officer, has also been promoted to President. 💰Financial Performance: • Adjusted Q3 profit was $1.09 per share, a drop from $2.21 per share last year. • The company took a $1.1 billion charge related to anticipated losses in its insurance business for Q4. 📈💰Revenue Growth: Revenue in the healthcare benefits unit rose by 25.5% to $33 billion, supported by Medicare and commercial insurance growth Aetna, a CVS Health Company •. Health Services down to 44 billion in the quarter which is down from 49 billion in Q3 of 2023 due to the loss of the Centene Corporation PBM contract at Caremark. 🙌 Strategic Focus: Glenview Capital met with the leadership team a month ago demanding leadership changes leading to the departure of CEO Karen Lynch. Overall changes are expected to drive CVS’s cost management efforts and bolster Aetna, a CVS Health Company as they weather the storm in Medicare Advantage while integrating some of their recent M&A assets. #healthcare https://lnkd.in/gUXieZm6

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Basic “explainer” on Risk Adjustment and a RAF conundrum. This article from The Commonwealth Fund does a good job of providing the basics of risk adjustment. It also calls out one of the major contributors to patient outcomes that isn’t captured in traditional risk models, the Social Determinants of Health (SDoH). They do a great job on this, so I won’t summarize it here. However, I think there is another factor that isn’t captured that I wanted to discuss and would appreciate some different perspectives. I’d love to get some thoughts on the following. Maybe I am simply being pedantic. The issue not mentioned in the article that I think current methodologies of risk adjustment miss is duration and management of disease. A patient with a new diagnosis of diabetes, for example, now has an elevated risk of numerous complications over their lifetime. However, that risk in year 1 after the initial diagnosis is much lower than the risk at year 10. Current risk models don’t take that escalating risk into consideration, keeping the risk adjustment fixed regardless of duration of underlying diagnosis. In addition, there are few scenarios that will impact me differently as the provider: 1) Management of this patient’s diabetes has been poor for the prior 9 years and now my group “inherits” this patient at year 10. 2) My team has helped this patient manage their diabetes very well for the past 9 years. 3) For the past 9 years, this patient’s prior group had managed their diabetes well but they have now switched into my group. As noted above, in scenario 1, that “new” diagnosis of diabetes severely underestimates this patient’s risk of needing expensive resources this upcoming year. I will be adversely impacted from something that is clinically obvious (duration of a disease increases risks) but which is not captured in the current data. To go one step farther, in frameworks 2 and 3, there is a gap between what the patient’s risk would have been without 9 years of great care and what it likely is now. However, there is no recognition of this work. That is to say, if the patient switched to a group that did a terrible job of managing diabetes, they’d receive the same risk adjustment in year 10 as my group would receive after all of our time, effort and resources had been dedicated to keeping this patient healthy. If the patient’s healthcare needs in year 10 are low because of our efforts, shouldn’t we receive more credit than a group that simply gets attribution? And, what about the prior group? How are (were?) their efforts recognized? Please share your thoughts in the comments.

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An Outpatient Clinical Documentation Improvement (CDI) program offers substantial advantages to healthcare organizations by elevating patient care and operational efficiency. By integrating risk stratification with chronic conditions, enhancing quality measures, addressing social determinants of health, and establishing a collaborative team empowered by technology, such strategic initiatives result in improved patient outcomes and streamlined operations.

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Completely agree - as in many areas, AI/NLP is well-placed to augment, not replace, human experts. If you're not using AI/NLP in some ways you are fast being left behind, and likely wasting a lot of time on things that can be automated. But if you're jumping head-first into AI-only, you're likely going to hit your head on the bottom of the pool, metaphorically speaking, and it's gonna hurt... In RA, for example, NLP is extremely helpful for surfacing codes, for both editions and deletes, but isn't ready to replace coders completely, and may never fully get there.

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📰 My latest Substack article, diving into Centene's impressive Q2 2024 earnings report. 📈 Despite challenging headwinds, Centene Corporation, under the leadership of Sarah London, has delivered one of its best quarters yet. Here are some key highlights: 💎 Revenue Growth: 5.2% increase through the first half of 2024 to over 80 billion. 💎 EPS Growth: 15% rise compared to Q2 2023, with EPS at $2.42, up from $2.10. 💎 Stock Performance: Almost 9% rally on Friday driven by strong EPS growth and a 34% surge in the ACA/Marketplace membership.. Sarah London's strategic shift away from vertical integration is proving to be a winning move, focusing on core strengths while divesting non-core assets. Here are some major takeaways from the earnings call: 🏥 Medicaid - Addressed acuity misalignment, Centene sees a brighter second half of 2024 as their PMPM rates will move upward. - Significant wins in Florida, Kansas, and Michigan. - Exciting LTSS launch in Arizona, with Oklahoma, Delaware, and North Carolina in launch mode. 👨‍⚕️ ACA/Marketplace - The Ambetter brand is shining as Centene is the largest domestic ACA/Markeplace provider with membership growth of 34%. - Premium subsidies are driving this explosive growth, with total enrollment now at 4.4 million beneficiaries - Premiums revenue hit $8.5 billion in Q2, a 49% increase quarter-over-quarter. 👵 Medicare (Wellcare) - Rebuilding the brand with an eye on growth in 2025/2026. - Focus on the dual-eligible market as a potential growth area. - STAR ratings improvements with the CMS adjustment but must feel good about their meta data for CAHPS/HEDIS -Strong PDP business positioning post-IRA as they feel good about their 2025 bids 💰 Investments/Divestments - Continued share repurchases with $851 million in Q2. - Divesting in non-core businesses like Magellan Rx, PantherRx , Apixio, etc. are now paying off for the company This quarter truly showcased Centene's execution on their longer term strategy. Impressive cause when everyone zigged....They zagged. Full article below: #Healthcare #Medicaid #ACA #Marketplace #Medicare #Centene #Earnings

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Discover how balancing business and consumer demands can lead to a more proactive, sustainable and efficient organization. Learn from the experts at Optum Advisory and transform your revenue cycle today: https://optum.co/3ghjna #Healthcare #RevenueCycle #OptumAdvisory

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How does a $497k chart audit risk turn into a recommended $6.8M recoupment? Impact extrapolation, that is how. The rule now allowing the OIG to recommend larger recoupments are now in effect. This is the first of two audits published today. It isn't too often that the OIG publishes not one, but two, findings reports in a day. Let's dig into the first one. The article linked below is tied to a 2017 and 2018 date of service audit of high risk diagnosis codes by the OIG. Beginning with 2018 dates of service the OIG is able to recommend that dollar impacts reflect the extrapolated error rates from their reviews. This is highly controversial because of financial magnitude and the approach to extrapolation. This marks one of the first ones that I have seen. In this audit the OIG reviewed 240 conditions from the years in question. There are 8 conditions that were reviewed during the audit. They were stroke, heart attack, embolism, sepsis, lung cancer, breast cancer, colon cancer, and prostate cancer. What jumps out to me in this review is the sepsis category. This is the first time I have seen sepsis as a high risk diagnosis. In fact, sepsis and pressure ulcers are in the other review (which I will post shortly). The story continues to be the same. Acute conditions being captured when they often represent historical conditions. In fact for the cancers, strokes, and heart attacks a whopping 93.3% (168 of 180) were found to not be valid. This is in line with prior reviews. Organizations, both payers and providers, must have processes in place to identify and review these. For the sepsis patients, 30% were rejected. While higher than desired, this is significantly lower than other targeted conditions the OIG historically reviews. The call to action for organizations is simple: 1) Know your data- know what patients you have, what conditions they have, and what you are billing for your patients. 2) Increase scrutiny on high risk conditions- if a patient has a stroke, heart attack, or cancer that is captured by a PCP or captured only once in a calendar year it is worth a second review. 3) Educate providers- it is critical to educate providers on the difference between active conditions and historical conditions. There is often no ill intent by providers rather it is matter of coding appropriateness. Leverage your experts to help them know the rules. Enjoy your Wednesday! https://lnkd.in/eX7tjgyB

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Recently, a group of specialists talked about the 2025 Medicare Advantage Final Rule on RISE Radio. Here's a quick summary of the topics covered. https://lnkd.in/gZfXn5ZT #medicalbilling #medicalcoding #riskadjustment #healthcareinnovation #healthtech #medicare #healthcaretech #aco #medicareadvantage #healthcareit #riskadjustment #valuebasedcare #healthcaredata #healthcareanalytics #clinicalinformatics #hcc #artificialintelligence #machinelearning #medicareinsurance #naturallanguageprocessing #nlp #foreseemedical #hccriskadjustmentcoding

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Use patient segmentation to identify highest predicted utilization and risk for Medicaid. Humana Health Informatics applies the ACG® System for recommended actions. See how in this success guide: https://lnkd.in/eg6ta2us #ssnchealth #HopkinsACG #Medicaid #patientcare #valuebasedcare

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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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The healthcare landscape is undergoing a seismic shift, driven by vertical consolidation led by insurance giants. A recent perspective in the New England Journal of Medicine highlights this trend and its far-reaching implications for patients, physicians, and the entire healthcare system. Key points to consider: 🏢 Vertical Consolidation: Major insurers like UnitedHealth Group, Humana, and CVS are rapidly acquiring physician practices and care-delivery companies. This has resulted in over 50% of Medicare beneficiaries now enrolled in Medicare Advantage plans. 💰 Financial Scale: The government will pay approximately $500 billion to insurance companies in 2024 alone to administer Medicare Advantage programs. 🚑 Patient Impact: This consolidation poses significant risks to patient care. Insurers can deny coverage or discourage use of necessary services, steer patients toward their own services (potentially disrupting longstanding care relationships), and replace physicians with lower-cost clinicians. 📈 Cost Inflation: In Medicare Advantage, abuse of risk adjustment accounts for $54 billion in overspending per year compared to traditional Medicare. 👨‍⚕️ Physician Autonomy: Corporate ownership promises to unburden physicians from administrative tasks, but it may be a Faustian bargain. Insurers can dictate staffing, scheduling, and patient visit durations, potentially compromising care quality. America's complex health care system in an "object in motion" with sizeable inertia- without intervention, it will continue on its current path. The status quo has a predictable outcome: a healthcare system increasingly controlled by a handful of insurance conglomerates, potentially at the expense of patient care and physician autonomy. Changing course will require intentionality and energy. The article suggests several policy approaches: 1. 🔍 Strengthening antitrust scrutiny 2. 🚫 Limiting vertical integration of insurance companies 3. 📜 Revitalizing corporate practice of medicine laws 4. 📊 Enhancing medical loss ratio regulations and closing loopholes As healthcare professionals, policymakers, and concerned citizens, we must actively engage advocate for reform. The future of our healthcare system - and the quality of care available to patients when they need it most - depends on the actions we take today. What are your thoughts on this trend? How can we work to ensure a healthcare system that prioritizes patient care and physician autonomy over share holders? #HealthcarePolicy #MedicareAdvantage #VerticalIntegration #HealthcareReform

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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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😳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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