Beth Carlson

AI’s Impact on CDI A recent ACDIS Survey of ACDIS members gauging impact of AI on CDI processes and the CDI profession revealed some interesting points and sentiments towards AI. The most common impacts from the implementation of CDI technology are increases in remote work and in productivity (cited by 67% each), followed by identifying “low-hanging fruit” queries (65%) and improving documentation issues with high-volume DRG groups (54%). Additional responses appear in Table 4 below. Remote work is not conducive to effectively providing sustainable measurable physician documentation educational training. One-on-One training or small group training is most effective in ultimately changing overall physician behavioral patterns of documentation. Often, the best form of training is small bit size nuggets provided in a quick conversation specific to a case on the floor. Productivity is not a valid and reliable measure of CDI performance. The mere fact that the CDIS reviewed a record does not necessarily equate to achieved improvement/integrity of the record. Identifying low hanging fruit diagnoses through queries implies CDI has room for improvement in physician documentation education through reinforcement that improves physician's muscle memory of better documentation practices. Electronic querying serves to mechanize the query process and is no substitute for physician documentation training and knowledge sharing. Physicians do not want more queries, they prefer to document right the first time versus more repetitive transactional reactive queries. AI definitely can assist and serve as an effective tool in CDI activity. However, it must be considered as a tool and not a crutch. There simply is no substitute for good old fashioned CDI boots on the ground, helping physicians achieve clinical documentation excellence through documentation training with reinforcement and guidance. AI is the panacea for improving documentation. #AI, #documentationimprovment, #notapanacea

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Healthcare systems must recognize the importance of both HHS-HCC and CMS-HCC risk adjustment models. While the CMS-HCC model remains crucial for Medicare Advantage plans, the HHS-HCC model provides essential insights for managing risks in the broader ACA market. Understanding and integrating both models ensures that healthcare systems can deliver high-quality care, maintain financial stability, and comply with regulatory requirements across different patient populations. By doing so, they can better navigate the complexities of modern healthcare delivery and funding, directly impacting our quality of care. Healthcare systems benefit from integrating knowledge of both models to: 1. Enhance Comprehensive Care: By addressing the needs of diverse populations. 2. Improve Accuracy: In risk assessment and resource allocation. 3. Ensure Compliance: With federal regulations and market requirements. 4. Promote Equity: In healthcare access and funding.

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Join us for a crucial session where we delve into the Health Equity Index. Learn how it's calculated and its significant impact on quality and Star metrics for Medicare Advantage plans. View the SOA Health Meeting agenda here: https://optumin.co/ssw6cc #Optum #SOA #HealthEquity #Medicare #Payer

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💡Interesting recent stat from Beckers! A consistent (3% to 5%) margin of revenue opportunity is lost due to the complexity of documenting and coding for complex inpatient cases. This uncaptured revenue is significant to a hospital's bottom line, with a 5% loss in a mid-size hospital potentially equaling $22 million to $38 million in lost revenue annually‼️ MDaudit can help with our Hospital and Coder audit workflows. Check out this short demo!

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NEWS ALERT- CMS has finally released the 2023 MSSP results. The results provide tremendous insight on the ACO landscape, risk adjustment, and value based care. Here are some numbers: Thanks for reading. Help us get the word out by smashing the like button, sharing the post, or commenting. Key stats -453 ACOs with data released -69% of ACOs achieved shared savings -$3.08 billion dollars in shared savings payments to organizations -The top 10 organizations with the most savings racked up $631M, or 20% of all savings. -Average risk score for the top 10 organizations with the largest savings in pure dollars (not adjusted for ACO size) was 1.137 -Average risk score for the top 10 organizations with the largest savings per beneficiary was 1.379 -75% of organizations with a risk score above 1.00 had shared savings. Only 65% of organizations with a risk score below 1.00 had shared savings. -78% of the largest 100 ACOs by size had savings while only 64% of the 100 smallest ACOs had savings. CMS noted "ACOs led by primary care clinicians had significantly higher net per capita savings than ACOs with a smaller proportion of primary care clinicians. These results continue to underscore how important primary care is to the success of the Shared Savings Program." This makes sense because primary care is such a critical driver in overall patient care success and in accurately reflecting risk scores. There is a LOT more to dig into. My main takeaways are: 1) Primary care participation is a driver of success 2) Risk scores are a critical component of success and organizations in risk should have outpatient CDI programs and strong compliance programs 3) Larger organizations may have more resources and infrastructure to build scale for success Let's talk more about this. What do you see in the data? What is your experience with your ACO? https://lnkd.in/erjc-peV

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🔥Really big news out of Centers for Medicare & Medicaid Services right now with their plan for payments from the government to MA plans expected to increase on average by 4.33%, or over $21 billion, from 2025 to 2026, as proposed. 📰 The news is much needed as Medicare Advantage has faced two years of flat reimbursement growth from CMS that has Humana down 43% in the last year along with CVS Health down 44% that leaned into MA last year. 💵 Humana is up big (4.5%) in after hours trading along with UnitedHealth Group up 2.5% as they UNH is the largest Medicare Advantage provider with over 7.8 million lives (3 million pdp) while Humana is second with 6.2 million lives (2.3 million pdp/8.5 million total). CVS Health is up 2% in after hours trading as well which is a nice shift for them. ⬇️ Medicare Advantage was one of the hottest lines of business in healthcare but over the past 6 quarters seniors have experienced high utilization post COVID, reimbursement was starting to slow as there was a 5.0% increase in 2023, 3.32% in 2024, and 3.7% for 2025. This 4.33% increase is a big unexpected tailwind for Medicare Advantage providers. UnitedHealth Group, Humana, CVS Health, Elevance Health, Kaiser Permanente and Centene Corporation are the largest providers of Medicare Advantage in the US so this will be good news headed into the weekend! Nice little shot in the arm for HCSC which is expected to close on the 600,000 member Medicare Advantage business from The Cigna Group in Q1! Interested to hear comments this week J.P. Morgan Healthcare Conference in San Francisco #healthcare https://lnkd.in/g2qZTaxM

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Are these costly coding errors the result of bad coding, bad documentation or an over-aggressive approach to risk adjustment coding? In the end, the reason doesn't really matter - what matters is that provider organizations and payers understand incorrect coding that is not sufficiently backed up by clinical documentation will land them in a difficult spot! Consultants who truly understand HCC models and technology specifically geared to recognize risk adjustable coding opportunities and risks can help! #Edifecs #riskadjustment #Norwood

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Cost analysis in isolation lacks depth. Consider comparing costs - or cash shortfalls - from multiple angles: -Procedure codes -CPT codes -Payers -Aged A/R A record of CARCs and RARCs can be used to map shortfalls and denials, getting you closer to the root causes. This is what my team calls an RCM Health Check and I’m covering the concept in a webinar this Thursday. Join me here: https://lnkd.in/epuhRSn7 

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The Centers for Medicare & Medicaid Services (CMS) has proposed a rule to make Medicare Advantage (MA) plans' prior authorization rules and coverage criteria publicly accessible. This move aims to reduce inappropriate denials, improve patient access to care, and increase appeal opportunities. Currently, only 4% of denied claims are appealed, yet 80% of appealed denials are overturned. The proposal would require plans to publicly clarify coverage criteria and inform enrollees about their appeal rights. Additionally, CMS seeks to enhance Medicare Advantage provider directories by integrating them into Medicare Plan Finder, simplifying provider comparisons across plans. This would empower seniors to make better-informed healthcare decisions. The rule has garnered support, including from Sen. Ron Wyden, who praised its potential to address prior authorization misuse, eliminate "ghost networks," and curb broker exploitation. Public comments are open until January 27, 2025, after which its future depends on policy decisions by the next administration. Our home health and hospice clients will benefit from enhanced transparency in Medicare Advantage rules, ensuring timely access to care and reducing authorization-related delays. Clearer appeal rights and streamlined provider directories empower clients to secure appropriate reimbursements, optimize workflows, and focus on delivering quality care without administrative burdens. Cliniqon is committed to delivering Guaranteed Quality, Ensured Compliance, and Unparalleled Outcomes in Home Health and Hospice agencies. #HomeHealthServices #HospiceCare #FrontEndServices #BackOfficeSolutions #HealthcareManagement #RevenueCycleManagement #HealthcareCompliance #PatientSupport #CareCoordination #MedicalBilling #ClaimsManagement #PatientEngagement #HealthcareOutsourcing #MedicalCoding #ProviderSupport #CliniqonCare #HealthcareSolutions #PatientCareExcellence #HomeHealthRCM #HospiceBilling MedPage Today

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OIG ALERT: The first OIG report since February came out on Friday. Not shocking but the findings continue to be consistent with previous reports. If you need help assessing your risk, let me know. The report that came out Friday looked at 2016 and 2017 claims that Independent Health Association submitted to CMS for risk adjustment. The OIG focused on 8 target areas seen to have consistently high false positive rates. In this case they found that 230 of the 247 conditions reviewed, or 93%, did not have documentation to support the conditions submitted. The total takeback for this $646k for the two years. However, if the results were extrapolated, as can be done beginning in 2018, the takeback would have been 10X larger at $7M. The areas reviewed included: -Acute Stroke: 100% incorrectly captured -Acute Heart Attack: 97% incorrectly captured -Embolism: 90% incorrectly captured -Lung Cancer: 100% incorrectly captured -Breast Cancer: 100% incorrectly captured -Colon Cancer: 97% incorrectly captured -Prostate Cancer: 93% incorrectly captured -Miskeyed Diagnoses: 73% incorrectly captured For my followers by now this shouldn't be an earth shattering report. One of our 45 best practices for a strong risk adjustment program is to have stops in place to prevent these claims from going out the door without a review. Stay tuned for more updates and summary stats that aggregate the findings from these OIG reviews. https://lnkd.in/ec2R9C-G

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A new report from Azara Healthcare and Sage Growth Partners shows a lack of trust between providers and health plans in value-based care (VBC). Despite this, both agree on the importance of data exchange and integration for VBC success. Providers and health plans face different challenges, with providers citing lack of buy-in and staff, and health plans pointing to provider engagement and market issues. There's a perceived imbalance in VBC benefits, with providers feeling they gain less compared to health plans. Despite these challenges, both parties recognize the need for better data infrastructure and patient/member engagement. The report suggests that transparent data exchange could be a key to improving collaboration and trust in VBC. Our RCM team can assist by facilitating effective data exchange and integration, ensuring clean and consolidated clinical data, and supporting unified care management and coordination solutions. This can help bridge the trust gap between providers and health plans, enhancing the implementation of value-based care and improving patient outcomes. We are the One! #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner HealthLeaders

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Want $59M worth of reasons to ensure accurate HCC capture? Read this report. While the penalty was only $165k, had extrapolation started in 2017 (the time period of this review) the penalty could have been massive. For the first time in a while the OIG released a review of randomly selected patients that they completed a review on. While the OIG has been focusing efforts on the targeted review, with the onset of extrapolating impact beginning for 2018 dates of service, I believe these are going to become the new trend. A few notes on the review: -200 patients reviewed -For those 200 patients, 688 conditions were submitted for risk adjustment -The OIG validated 580 HCCs of the original 688 submitted. This means 15.7% were not supported. -The OIG found 22 net new HCCs not previously submitted -The total impact for the net 86 conditions removed (688 submitted - 580 validated + 22 found) was $165,312 -The extrapolated impact is $59M I will be digging deeper into the report itself (listed in the comments) but this should be a huge eye opener for organizations focused on risk adjustment. By all means organizations need to do everything they can to get credit for what they deserve; however, it is vital to ensure appropriate checks and balances in place. It should be noted that the MA plan in question refutes some of the findings and the methodology. I expect the intensity of these disagreements will be expanding in the coming months as the extrapolated impacts from reviews for 2018 and beyond begin. https://lnkd.in/eJtszMxa

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OIG ALERT: Diagnoses reported only on enrollees’ HRAs and HRA-linked chart reviews, and not on any other 2022 service records, resulted in an estimated $7.5 billion in MA risk-adjusted payments for 2023. Before we dive in here I want to say that I have seen HRAs used appropriately and inappropriately during my time in this space. There can be great value for patients, particularly those with limited access to care and or those reluctant to visit their primary care provider. However there is tremendous risk to the system if these visits are a fragmented approach to care and or not aligned with care planning. What the OIG has identified represents the risks and shows care continuity breakdowns. Ultimately organizations and payers must know their vendor partners because there are some really good ones in this space. Earlier this week the OIG released a really interesting look into Health Risk Assessment, or HRAs. These HRAs are often performed in the home by payers or vendor partners. These should be in depth reviews of the patient and include a host of assessments that often are hard to complete in a condensed visit to a provider office. What the OIG found was that 7.5B or about 2% of all Medicare revenue was tied to conditions captured only during these visits. Is that bad? I don’t know. If these are new conditions and then ultimately incorporated into a broader care plan that improves outcomes then they are a great thing. If they are captured, never shared with the care team, and ultimately used to solely drive revenue with little focus on outcomes then it is bad. I suspect there is a mix of both. If I was at the OIG I would want to take a multi-year look at what was captured year over year only in a HRA as a next step. The report recommends CMS take the following actions. CMS subsequently agreed with recommendation number three but not numbers one and two. 1) Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments. 2) Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews. 3) Determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies. I am doing some advanced analytics on information in the report for future posts but this is a nice easy read for folks. https://lnkd.in/ehNzzSWu

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Looks great for RCM and related industries! It’s concerning yet unsurprising that US healthcare spending is projected to rise to $4.8 trillion in 2023, This trend of healthcare costs outpacing GDP growth highlights the increasing financial burden on both individuals and the economy. It underscores the need for sustainable healthcare reforms that can balance cost, access, and quality. https://lnkd.in/gNsdd7_A

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Sharing key takeaways on the CMS Hospital Inpatient Quality Reporting program for FY2025. - Seven new measures are added (which are welcome, with the caveat of let's see how they work out) -> Patient Safety Structural Measure beginning CY 2025 with payment determination in FY 2027 -> Age Friendly Hospital CY 2025/FY 2027 -> Catheter-Associated Urinary Tract Infection Standardized Infection Ratio Stratified for Oncology Locations (CAUTI- Onc) CY 2026/FY 2028 -> Central Line-Associated Bloodstream Infection Standardized Infection Ratio Stratified for Oncology Locations (CLABSI-Onc) CY 2026/FY 2028 -> Hospital Harm – Falls with Injury (eCQM) CY 2026/FY 2028 -> Hospital Harm – Postoperative Respiratory Failure (eCQM) CY 2026/FY 2028 -> Thirty-day Risk-Standardized Death Rate Among Surgical Inpatients with Complications July 1, 2023–June 30, 2025/ FY 2027 - Five existing measures are removed (which is a breath of fresh air) - the unpopular PSI-04, and measures related to 30-day episode payments for acute myocardial infarction, pneumonia, total hip/ knee arthroplasty, heart failure - Two existing measures are modified (Global malnutrition composite score expanded from seniors over 65 to anyone older than 18 - this is very positive; and Refined HCAHPS measure - will post details on this next week.)

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The 2025 Inpatient Prospective Payment System (IPPS) final rule is out. These rules are always long and this one is no exception, but here’s some interesting bits I pulled out for CDI and coding professionals. Acute care hospitals will receive a 2.9% payment bump. Adoption of portions of the new mandatory alternative payment model, TEAM (Transforming Episode Accountability Model). See p. 21 of the final rule below for details. New CC designation of seven ICD-10-CM codes that describe inadequate housing and housing instability. These fall in the Z59 series. Four new MCCs, including: ·     I26.03 Cement embolism of pulmonary artery with acute cor pulmonale ·     I26.04 Fat embolism of pulmonary artery with acute cor pulmonale ·     I26.95 Cement embolism of pulmonary artery without acute cor pulmonale ·     I26.96 Fat embolism of pulmonary artery without acute cor pulmonale 104 new CCs, too many to list here but primarily codes related to lymphoma types (C81-C88 series), anorexia and bulimia (F50 series), epilepsy, GI repairs, and of course the inadequate housing codes above. Your friend is Table 6J.1. 18 deleted CCs, mostly non-specific codes that are now included in the new CC list Seven new quality measures, deletion of five quality measures, and modification of two measures in the Hospital Inpatient Quality Reporting Program. Note that these measures can be impacted by more than just clinical care; accurate diagnosis and procedure coding can move patients in and out of them. Seven new measures: ·     Hospital Harm – Falls with Injury eCQM, with inclusion in the eCQM measure set ·     Hospital Harm – Postoperative Respiratory Failure eCQM, with inclusion in the eCQM measure set ·     Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications ·     Patient Safety Structural Measure ·     Age Friendly Structural Measure ·     Catheter-Associated Urinary Tract Infection Standardized Infection Ratio measure stratified for oncology locations ·     CLABSI Standardized Infection Ratio measure Modified measures:   ·     Global Malnutrition Composite Score eCQM (now includes patients ages 18 to 64 to the current cohort of patients 65 years or older) ·     Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey Deleted measures. These include Hospital-level, Risk-Standardized Payment Associated with a 30-Day Episode of Care for: ·     Acute Myocardial Infarction ·     Heart Failure ·     Pneumonia ·     Elective Primary Total Hip Arthroplasty and/or Total Knee Arthroplasty CMS is also removing PSI-04, Death Among Surgical Inpatients with Serious Treatable Complications measure, replacing with the new Thirty-day Risk-Standardized Death Rate among Surgical Inpatients with Complications measure. The Hospital-Acquired Condition (HAC) Reduction Program and Hospital Readmissions Reduction Program remain unchanged; minor tweaks were made to the Hospital Value-Based Purchasing (VBP) Program.

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Last year’s #Medicaid unwinding—which caused 16 million people (about the population of New York) to lose access to #healthcare coverage—has led the Centers for Medicare & Medicaid Services to issue a final rule to standardize the Medicaid enrollment and renewal process. This rule will make it easier for eligible individuals to maintain their coverage and provides additional consumer protections originally made possible by the Affordable Care Act. It’s encouraging to see adjustments being made to avoid another instance of children and adults unnecessarily losing #AccessToCare.

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