Timothy Rauschenbach

CVS Health, Humana, and Centene are among the payers with the highest medical cost ratios in the first quarter of 2024. According to the latest report by Becker's Payer, payers with larger Medicare populations are struggling the most. Here's how the payers compared in Q1 2024: CVS Health  Q1 2024: 90.4%  Q1 2023: 84.6% Humana Q1 2024: 88.9%  Q1 2023: 85.9%    Centene  Q1 2024: 87.1%  Q1 2023: 87%    Elevance Health Q1 2024: 85.6%  Q1 2023: 85.8%    UnitedHealth Group Q1 2024: 84.3%  Q1 2023: 82.2%    Cigna Group  Q1 2024: 79.9% Q1 2023: 81.3% Compared to the previous year, CVS Health and Humana saw an increase in their medical cost ratios, while UnitedHealth Group had a slight increase. On the other hand, Cigna Group saw a decrease in their medical cost ratio. To learn more about the rankings, check out the source: https://lnkd.in/e9cQU9Hu

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🚨 Medicare Star Rating Changes🚨 Big changes are coming to Medicare Advantage Star Ratings, and they could impact your future plans! The CMS is recalculating star ratings, and the implications are HUGE. 📊✨ Wondering what this means for you? We’ve got you covered. From adjustments in measure weights to the introduction of new measures, this comprehensive guide breaks down everything you need to know. 🔍 Click below to read the full article and get all the insider details. #Healthcare #MedicareAdvantage #StarRatings #CMS #HealthcareInnovation #StayInformed #ProTips

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* 8 million patients visit emergency departments annually * 90% of U.S. emergency departments report overcrowding * The median ER wait time is 2 hours, 40 minutes * 97% of emergency physicians report boarding times exceeding 1 day Just a few of the concerning statistics highlighted in the latest Medicus whitepaper. The implications to these staffing challenges are troubling for healthcare leaders and all of us that have the unfortunate need to visit an emergency department. Download to learn more and how the Medicus team can help.

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Update to MA 2025 Final release ( more details are still required). The final (4/23/24) introduces changes to the regulations concerning agents, brokers, and Third-Party Marketing Organizations (TPMOs) in several areas: Unified Compensation Framework: The new regulations implement a unified compensation structure for agents and brokers across all plans. A single compensation rate is set for all plans, updated annually, which also includes a revision of the scope of items and services within agent and broker compensation. Separate payments for administrative services by agents and brokers are eliminated (administrative is defined but more details coming). Oversight and Compliance: Enhanced oversight measures are introduced to ensure that agents, brokers, and TPMOs (includes FMO’s) comply with the updated compensation structures and marketing rules. TPMO Marketing and Data Privacy: TPMOs are now subject to stricter marketing and communication rules. The final rule prohibits TPMOs from selling or sharing personal beneficiary data collected during marketing activities without explicit beneficiary consent. A new one-to-one consent structure is required, where TPMOs must obtain explicit consent from the beneficiary for each TPMO that will receive their data, ensuring more transparent and controlled use of beneficiary information. Prohibitions on Overrides: The regulations explicitly prohibit compensation structures that include additional payments known as "overrides" for TPMOs, which could influence the marketing and enrollment practices in favor of higher-paying plans. As we all know this will need further evaluation but recordings; trainings; portals etc will all be included in the total capped enrollment comp. #MAfinal2025 #medicareadvantage

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Well worth a read if you are in heathcare.

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The #healthcare industry faces a critical challenge: 67% of critical-care nurses may leave their roles within three years. For payer and provider organizations, addressing staff shortages and retention is crucial.   #Digitization is key. #AI and #cloud computing can streamline processes, simplify workflows, and reduce manual tasks - empowering healthcare professionals to focus on what truly matters: patient care.   Explore our latest white paper to see how technology can transform healthcare for a more resilient future: https://bit.ly/4fglkf7 Anita Mahon

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One key way to build trust is through clear and concise messaging that addresses what the patient needs and conforms to the patient's preferences. Follow RevSpring Healthcare for insight and perspective.

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Comeback story is set: Major Payers are struggling due to higher medical spend but are actively taking steps to manage costs (especially in the Medicare market). The second half of the year going into 2025 is going to highlight which health plans are nimble enough to take action against these headwinds. Article link: https://lnkd.in/eDWBNdT7

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𝗜𝘀 𝘆𝗼𝘂𝗿 𝗠𝗲𝗱𝗶𝗰𝗮𝗹 𝗣𝗿𝗮𝗰𝘁𝗶𝗰𝗲 𝗨𝗻𝘀𝘂𝘀𝘁𝗮𝗶𝗻𝗮𝗯𝗹𝗲 𝘄𝗶𝘁𝗵 𝗹𝗼𝘄 𝗠𝗲𝗱𝗶𝗰𝗮𝗿𝗲 𝗮𝗻𝗱 𝗠𝗲𝗱𝗶𝗰𝗮𝗶𝗱 𝗣𝗵𝘆𝘀𝗶𝗰𝗶𝗮𝗻 𝗣𝗮𝘆𝗺𝗲𝗻𝘁𝘀? The American Medical Association (AMA) recently highlighted a critical issue impacting small community medical practices: the unsustainable nature of low Medicare and Medicaid physician payments. Many of these practices, particularly in rural and underserved areas, are facing severe financial strain due to reimbursement rates that fail to cover rising costs and inflation. The AMA is advocating for reforms to address these disparities, including uncoupling payment schedules from Medicare benchmarks and ensuring payment levels reflect the full cost of care. 𝗛𝗼𝘄 𝗣𝗿𝗶𝗺𝗮𝗿𝘆 𝗕𝗣𝗢 𝗖𝗮𝗻 𝗛𝗲𝗹𝗽 Primary Business Process Outsourcing (BPO) services can play a pivotal role in supporting these small practices by: 𝟭. 𝗥𝗲𝗱𝘂𝗰𝗶𝗻𝗴 𝗢𝗽𝗲𝗿𝗮𝘁𝗶𝗼𝗻𝗮𝗹 𝗖𝗼𝘀𝘁𝘀: Outsourcing administrative tasks, billing, and patient communications can significantly cut overhead expenses, allowing practices to allocate resources more effectively. 𝟮. 𝗘𝗻𝗵𝗮𝗻𝗰𝗶𝗻𝗴 𝗘𝗳𝗳𝗶𝗰𝗶𝗲𝗻𝗰𝘆: Streamlined processes and expert management of non-clinical functions can improve practice efficiency, enabling physicians to focus more on patient care. 𝟯. 𝗡𝗮𝘃𝗶𝗴𝗮𝘁𝗶𝗻𝗴 𝗥𝗲𝗴𝘂𝗹𝗮𝘁𝗼𝗿𝘆 𝗖𝗵𝗮𝗻𝗴𝗲𝘀: BPO providers can assist practices in staying compliant with evolving healthcare regulations and payment structures, reducing the administrative burden on small practice staff. 𝟰. 𝗦𝘂𝗽𝗽𝗼𝗿𝘁𝗶𝗻𝗴 𝗩𝗮𝗹𝘂𝗲-𝗕𝗮𝘀𝗲𝗱 𝗖𝗮𝗿𝗲: By leveraging advanced analytics and technological expertise, BPO services can help small practices succeed in value-based purchasing arrangements, which require significant financial and operational investment. By partnering with a reliable BPO provider, community practices can enhance their operational resilience, ensuring they continue to provide vital healthcare services despite challenging payment environments. For more detailed insights, read the full article on HealthExec. https://lnkd.in/gvXWQb78

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CMS Preparing to Close Program that Addressed Medicare Funding Issues Resulting from Change Healthcare Cyber-Attack On June 17, 2024, the CMS announced that payments under the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption (CHOPD) will conclude on July 12, 2024. CHOPD accelerated payments have been issued to over 4,200 Part A providers, such as hospitals, totaling more than $2.55 billion. CMS also issued 4,722 CHOPD advance payments, totaling more than $717.18 million, to Part B suppliers, including doctors, non-physician practitioners, and durable medical equipment suppliers. Providers of services and suppliers are now successfully billing Medicare, and to date, CMS has already recovered over 96% of the CHOPD payments. After July 12, 2024, CMS will no longer accept new applications for CHOPD accelerated or advance payments. Any providers of services or suppliers that are having difficulty billing or receiving payment should contact Change Healthcare, owned by UnitedHealth Group, by visiting https://lnkd.in/ePxwAT2r  and/or their Medicare Administrative Contractor (MAC). To find your MACs contact information, please visit  https://lnkd.in/exSbpg9v. All new CHOPD program applications must be submitted from eligible providers and suppliers prior to that date. CMS will continue to monitor for other effects of the cyberattack on Medicare providers of services and suppliers and will continue to engage industry partners to address any remaining issues or concerns. CMS encourages all providers of services and suppliers, technology vendors, and other members of the health care ecosystem to double down on cybersecurity, with urgency. Please visit the HPH Cyber Performance Goals website at  https://lnkd.in/eWwhgDU3  for more details on steps to stay protected.

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Today on The Daily Grind tune in to a replay featuring Alex Foster, MPA, CPMM, Senior Regional Facilities Manager at CVS Health! Tune in as Alex joined Bill to discuss the challenges and complexities of Vendor Management, shares common pain points of managing a diverse portfolio, how to manage multiple CMMS programs and more. Watch now! #ConnexFM #VendorManagement #FacilitiesManagement

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Are These 10 Pain Points Holding Your Medical Clinic Back? 😩 By partnering with a trusted medical BPO provider, you can unlock a world of possibilities, addressing pain points such as: 1. High administrative costs 💥Outsource administrative tasks like billing, coding, and data entry to reduce overhead 💥Leverage economies of scale and access to lower-cost labor through BPO 💥Automate processes and optimize workflows with BPO expertise 2.Revenue cycle management challenges 💥Partner with BPO for end-to-end revenue cycle management services 💥Improve coding accuracy and compliance for better reimbursements 💥Streamline billing processes and follow-up on denied claims 3. Staffing shortages and high turnover 💥Access a flexible, scalable workforce through BPO 💥Offer better work-life balance by outsourcing non-core tasks 💥Tap into BPO's pool of specialized healthcare professionals 4. Regulatory compliance and risk management 💥Work with BPO providers specializing in healthcare compliance 💥Leverage BPO expertise in HIPAA compliance and data protection 💥Stay updated on changing regulations and industry best practices 5. Patient satisfaction and experience 💥Streamline administrative processes for smoother patient interactions 💥Leverage BPO for efficient appointment scheduling and reminders 💥Improve overall operational efficiency for better patient experience 6. Managing growth and scaling operations 💥Scale BPO services up or down based on changing demand 💥Expand into new locations or service lines without adding overhead 💥Maintain consistent service quality across multiple clinics 7. Increased competition and market pressure 💥Focus on core competencies by outsourcing non-core functions 💥Improve cost-efficiency and service quality through BPO partnership 💥Leverage BPO expertise to optimize operations and stay competitive 8. Physician burnout and work-life balance 💥Reduce administrative burden on physicians by outsourcing tasks 💥Enable physicians to focus on direct patient care 💥Improve work-life balance and job satisfaction 9. Inaccurate medical coding and billing 💥Partner with BPO providers specializing in medical coding and billing 💥Ensure accurate coding for proper reimbursements 💥Implement robust quality checks and audits 10. High denial and rejection rates for claims 💥Leverage BPO expertise in denial management and appeals 💥Improve coding accuracy and documentation for clean claims 💥Streamline follow-up processes for denied claims If you're ready to explore how medical BPO solutions can transform your clinic's operations, let's connect! I'd be happy to share insights and best practices on leveraging this powerful strategy. Drop a comment below or message me directly.

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 IT solutions that work together are critical in converting chaos to connection, from pre-care all the way through a patient’s final payment.

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In today’s healthcare environment, organizations are facing unprecedented challenges. For provider organizations, workforce shortages, rising operational costs, and the need to implement new technologies while maintaining patient-centered care are critical hurdles. For insurance companies, regulatory pressures, shifting member expectations, and the need to manage costs while improving outcomes are ongoing concerns. And healthcare navigation companies are navigating the complexities of integrating innovative solutions to help patients and providers streamline care, while also dealing with the constant evolution of healthcare policies and reimbursement models. As someone with executive-level experience across these sectors, I understand the pressures organizations are under and the importance of developing adaptive strategies that balance innovation with operational efficiency. Whether it's leading through times of change as an executive leader or providing consulting expertise on high-priority initiatives, I can offer solutions that deliver real impact. If your organization is seeking an executive or needs an experienced consultant to navigate these challenges, let's connect and explore how I can help. [email protected] 717-439-6170 or message me via LinkedIn

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Prior authorization is a hot topic for everyone involved in healthcare—from patients to plans to providers. All want to get the process right. A new article by my Sagility colleagues offers three ways that prior authorizations can change healthcare for the better. Read the article and let me know what you think! Thanks! https://lnkd.in/d7qiEKU5 #Healthcare #PriorAuthorization #Payer #Provider

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The landscape of #healthcare financial management is evolving rapidly, with changes in the last 5 years outpacing the previous two decades. John Talaga, EVP of Healthcare at Flywire, shares insights on the momentum building around patient collection methods and the shift toward integrated financial solutions. Discover what needs to change and why in this article from Healthcare IT Today: https://lnkd.in/dpbRPjEQ

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Health care providers should understand the current and future use of Medicare Advantage in their respective locations. Learn more about the growth of this program and how it may impact your organization. https://hubs.li/Q02CV5f-0

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A new state law mandated a specific, detailed process for #Medicare and #Medicaid payers. One coordinated care organization didn’t have the knowledge or resources to ensure #compliance. They needed an active partner. EXL brought domain expertise, a flexible approach, and a skillful team who designed a solution that prevented the organization from losing any recoveries. Find out how in our case study.

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