Chris Cowart

Exciting times at 4C Digital Health! Wilmington, Delaware - 4C Digital Health (4C), the preeminent organization delivering independent financial oversight and control solutions for self-funded employee health plans, recently announced the strategic expansion of its services into the Commonwealth of Kentucky. In late 2023, 4C successfully competed for an initial award issued by Kentucky’s Department of Employee Insurance, and Kentucky has since extended the initial contract to allow 4C to continue its important work on behalf of the Commonwealth, its employees, and its taxpayers. The Kentucky Employee Health Plan (KEHP) serves more than 288,000 members, which amounts to 1 in 16 Kentuckians. In addition, KEHP spends over $1.8 billion dollars in total healthcare benefits on behalf of its members per year and covers over 8.2 million claims per year. KEHP objectives include “improving employee health and well-being” and “providing state-of-the-art benefits while maintaining reasonable premiums.” Recognizing its important fiduciary responsibilities to its employees and its state health plan, the Commonwealth of Kentucky enacted Senate Bill 42 (2023) introduced by Senator Stephen Meredith for the purpose of ensuring that critical health plan dollars are being spent properly on behalf of state employees. The legislation requires that 4C analyze 100% of medical claims submitted for payment to KEHP; identify erroneous overpayments; and identify inappropriate or erroneous fees imposed by KEHP’s third-party administrator. Ron Templeton CEO of 4C Digital Health stated: “4C Digital Health is grateful to the Commonwealth of Kentucky for recognizing the fiduciary responsibility that state and local governments have to their employee health plans and for the opportunity to provide our services in support of this mission. We appreciate Kentucky’s goal of using 4C’s expertise and innovative solutions to improve healthcare outcomes and reduce healthcare costs for the Commonwealth, its employees, and its taxpayers.” About 4C Digital Health: 4C Digital Health (https://lnkd.in/eB-fJg4X) is a healthcare data analytics company that was founded for the purpose of developing a disruptive technology targeted at bringing transparency and honesty to the healthcare marketplace.

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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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https://lnkd.in/eRqVTSr2 About 74% of hospitals and health systems are actively automating some portion of their revenue cycle operations, with an additional 46% of these organizations reporting using some form of AI. #revenuemanagement #automation #AI

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Why do hybrid outsourcing models in RCM sound great in theory, but in reality, fall short? Because end-to-end processes demand consistency, control, and expertise—not a patchwork approach. Here’s the truth: outsourcing isn’t about losing control. It’s about gaining focus. When done right, outsourcing transforms your team’s role from chasing claims to driving patient satisfaction and strategic growth. The key is knowing how to make the leap: ✔️ Start with a partner who aligns with your goals. ✔️ Plan for change with transparency and purpose. ✔️ Repurpose staff to focus on high-impact tasks. Outsourcing doesn’t have to be scary—it’s an opportunity to thrive. I plan to cover this topic in a couple weeks with Stuart Newsome, CPCO, wanted to share some initial thoughts for now.

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As announced in the CMS Proposed Rule for CY 2025 Outpatient Prospective Payment System released in July 2024, the ON-Q device is proposed for approval under the NOPAIN Act and to receive a unique code eligible for separate payment effective January 2025. This would mark the first time that the ON-Q® device would qualify for separate payment. Learn about NOPAIN: https://ow.ly/T9NQ30sHjnm #PainManagement #NOPAINAct

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In #NEMT, transportation vendors are often blamed for discharge bottlenecks due to their performance. While on-time performance is a critical factor, it's not the only one. For example, giving ample notice to EMS vendors vs just ordering a BLS for "right now" is essential. Unless there is a truck in the parking lot, it's impossible for the crew to be there right away. Health systems who understand this, optimize internal workflows, and collaborate with EMS vendors to collect data on what is reasonable for the market are the ones who will see real results in transportation program improvement. #rideeconomics #healthcareinnovation

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I hole heartedly agree Benjamin Schwartz, MD, MBA. Anywhere else in an economic system, innovators who can deliver a better product at lower costs are almost always rewarded with greater market share, and frequently set the direction for the future of a product or industry. Not so in healthcare. I think that Terry Adirim, MD, MPH, MBA (below) hit the nail on the head when she references for-profit health insurers in the mix. Although policies have been enacted with the idea of providing better healthcare at lower costs, they have always given the job of administering those policies to a middleman (insurance companies) whose motives are at odds with the objective they claim to be administering. Profit! Innovation is not in the best interest of the payer. They profit through the inefficiency of the system. Until this lack of alignment between quality patient care at low costs and for-profit health care plans is addressed, process innovation and improvement will only be able to nibble at the edges.

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This is a fantastic article showcasing revenue data across the country by region. Very interesting! If you happen to be in one of the areas where your net revenue is declining on average, please contact me. We can help reduce your administrative spend! #savistarcm #savista #revenuecyclemanagement #hospitalreimbursement #physiciansreimbursement

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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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Radiologists are achieving payments 500% above the Qualified Payment Amount (QPA) in surprise billing disputes, thanks to the No Surprises Act. This figure is staggering and highlights an important reality: many providers might not realize the tremendous potential of this opportunity. When the No Surprises Act (NSA) was enacted in 2022, the rates at which providers were reimbursed took a major hit, often cut in half. Payors exploited the QPA to justify lower payments, essentially giving themselves the green light to underpay claims. If a provider disagreed with the payment, they had to navigate the cumbersome claims process to recover what they deserved. But here’s the good news: By participating in the IDR process, radiologists are claiming up to 5 times their initial payments. This result is a powerful incentive for payers to engage in a meaningful negotiation and ensure fair compensation. Providers should leverage the NSA to their advantage - and capture every dollar they’re owed.

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Deadline reminder- April 30, 2025 is the last day to submit supplemental information to the EDGE server ensure accurate ACA patient complexity. If you need help reviewing records now is the time to plan! Are you focusing on accurate risk adjustment for your ACA population as much as you are for the CMS population? If you aren't you are likely missing out on revenue and/or creating unnecessary compliance risks. As the year winds to a close it marks the ACA chart review season launching in full force. What does this mean for you and what should you be doing? 1) Identify all of your patients that are in your ACA risk population. 2) Gather information about their visits including who they saw and what conditions were captured. 3) Review patients for both missed opportunity (i.e. documented conditions that were not placed on claims) and for compliance risks (billed conditions lacking support) 4) Collaborate with your payers to submit supplemental files by the April deadline If that is all a foreign language to you then we can help. We can partner with you to drive a complete and accurate risk score. Our team of consultants and coding experts have decades of experience in this space. The window for the ACA is short so don't miss out on ensuring your risk score is appropriate. https://lnkd.in/gnvB4eJp

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Receiving patient feedback is one of many functions a practice needs. What I love about our platform at Calvient is just how robust it is to solve a variety of functions, in one easy-to-use-platform.

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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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Healthcare sales is basically change management... Regardless of how "good" your solution or product is, adopting it requires your customers to do things differently... Maybe it's something small like using device A instead of device B... But, more often than not, switching to your device or solution requires a non-insignificant change to your customer's process... And that's one of the biggest things you need to address during latter-stage sales conversations... I say "latter stage" because unless you're selling something that's a total commodity, like bathroom tissue, your healthcare sales cycle will likely span several weeks-months and involve at least 3-4 different conversations... Early on, fancy marketing and customer testimonials do enough to get those initial conversations rolling... But, when it comes down to brass tax —actually changing or switching to your solutions— you need to tackle the nitty gritty of the actual "change" placed before the customer... If you don't address the change issue, it will majorly slow down the sale (at best) or tank the sale altogether... How do you know if this is a problem? -Your prospective customer seems all excited about your product/service during your first couple of calls -Then they pose a couple questions about "implementation"; maybe they ask about timelines, maybe they ask about the process, etc. -They begin waffling; maybe they're noncommittal about a go-live date, or maybe they -They may even simply ghost you; they become non responsive to emails, phone calls, and follow-ups They may say something about price or financials or "office politics"... But the reality is the reason they are having second thoughts... And the reason they're having second thoughts is because they either 1) don't believe your solution will truly solve their problem (can't help you here) OR 2) they believe that the inconvenience or challenges associated with switching to your solution are easily managed... They may think your solution is valuable and viable, but they may think that the switch is too difficult... If you don't address this late in the sales cycle, you're going to experience that late-stage sales stall... Once the prospective customer sees and understands the value of your solution, you must immediately begin to address the "change"... -Talk about your onboarding process -Describe how you alleviate common challenges or barriers -Discuss how you handle onboarding with client organizations similar to this customer You want the prospective customer to think, "these folks know what they're doing, and they've done this 1,000 times before"... Do what you can to take away the "unknowns" that may be bouncing around the prospect's head, specifically when it comes to the onboarding and implementation, and you'll likely see shorter sales cycles and fewer prospects that "go dark"... What do you think? #healthcare #healthcaresales #healthcarebusiness #healthcaremarketing #healthcaretech

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With years of proven evidence, iFR helps physicians make informed decisions. Decisions that help determine not just whether to treat, but where to treat, ensuring precise, patient-focused care. Learn more. https://lnkd.in/ggKNcWK2

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**CMS 2025 Final Rule & Key Implications** -Payment Rates: A 2.93% reduction for 2025 (conversion factor: $32.25). Your focus on efficient care delivery and accurate coding is essential to offset reductions. -KX Modifier: Therapy thresholds increased to $2,410 for PT/SLP and $3,000 for OT, making documentation critical to avoiding denials. -Telehealth Adjustments: Congress may determine whether current flexibilities continue. New allowances include audio-only telehealth and expanded billing for caregiver training services (CTS). -Therapy Assistant Supervision: General supervision replaces direct supervision in outpatient settings, offering greater flexibility and improving access to care. -Therapy Plan Certification: Physician orders can now act as signatures, reducing delays in therapy initiation and administrative burdens. Check out the HealthPRO Heritage comprehensive overview of the latest changes and their potential impact on your organization by reading our detailed summary of the Final Rule updates. #CMSFinalRuleUpdates

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**Join UnisLink AMA Webinar Series!** Dive deep with industry icons Patti Peets and James Muir in UnisLink's first "Ask Me Anything" webinar. Get your RCM questions answered and gain insights on improving efficiency, industry trends, and real-world solutions.💰💵🤑💲 **Sign up now!** #Healthcare #RCM #Webinar #UnisLink #IndustryExperts #AMA

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Good strategy! Focus internally on Margin Improvement, what data do you need to make informed decisions?

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