Greg Shockey

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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➡️ 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 register here: https://bit.ly/4fVBYRC

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Managed Care Negotiation Best Practices - 2025, Class 2. Negotiating Targets and Rebalancing •Know the facts, not the nonsense the insurance cartels and the academics/think tanks report. According to Millman, national commercial reimbursement rates for states range from 136% of Medicare to 266%. You are being underpaid if your rates are below the national average and/or below the average for your state. https://lnkd.in/gJn8xF6y •The average commercial inpatient reimbursement for each state ranges from 152% of Medicare to 261%, with a national average of 202% •The average commercial outpatient reimbursement for each state ranges from 137% of Medicare to 357%, with a national average of 252%. Note: these rates apply to ASCs as well •The average commercial professional reimbursement for each state ranges from 115% of Medicare to 252%, with a national average of 147% - Health systems need to do a better job negotiating professional rates for their affiliated physicians. •Again, the rates you NEED are based on your mix, i.e., Medicare, Medicaid, Commercial, and Self Pay, and the management effectiveness and efficiency of your organization – it is a straightforward calculation •Like hospitals, the insurance cartels must publish their rates. However, they have made it very difficult to analyze their files. If you want assistance with a local rate comparison, contact John and Pete at After Transparency https://lnkd.in/gHDVBEtS •You can’t fight gravity; GI, Orthopedics, Imaging, and several other procedure-based specialties are (and should be) moving to the outpatient setting. Counting on HOPD rates for these outpatient services is a fool’s errand. •Rebalance the commercial fee schedule so that service revenues migrating to the freestanding outpatient setting are priced below traditional HOPD rates but significantly higher than the commoditized rates being offered by the insurance cartels (i.e., At a minimum, target rates of at least 200% of the outpatient Medicare fee schedule) •The revenue reductions in the outpatient rates should be rebalanced to hospital-centric services such as neurosurgery, ED, and NICU. Ultimately, your organization must base its commercial pricing on:  Revenues-Expenses= Survival So it goes n8 Stay tuned for Class 3 - Preparing for the Unwillingness of the Insurance Cartels to Pay Physicians and Hospitals Fairly #hospitals #healthsystems #healthinsurance #healthinsurance

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Great free Seminar on #Medicare updates

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Perfect way to mange the revenue cycle

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Enhancing Quality Improvement in Hospitals with ORControl™ Quality Improvement (QI) in healthcare isn’t just about outcomes—it’s about creating smoother, safer, and more efficient processes. ORControl™ empowers hospitals with minute-by-minute coordination, optimized OR utilization, and instant day-of-surgery insights, helping clinical teams stay aligned and proactive. By addressing challenges as they happen, ORControl supports a more streamlined, patient-centered approach to perioperative operations and day-of-surgery workflows. Learn more about how ORControl is transforming QI initiatives and advancing healthcare standards in this article by Becker's Health. View full article below ⬇

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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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Is incomplete documentation costing your healthcare facility? With the CDI market hitting $1.4B, now's the time to optimize your documentation process! 📋 From physician education to advanced analytics, we'll help you capture the revenue you deserve. Ready to transform your clinical documentation? Visit revcureconsultants.com today! #revcure #cdianalytics #healthcarecoding #revenuemanagement #kansas

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🌟 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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☝ Don't Miss the Application Deadlines for the ACO Primary Care Flex Model! CMS is accepting applications for the ACOs Primary Care Flex Model until August 1, 2024. Interested organizations must apply as new or renewing ACOs to the Medicare Shared Savings Program (MSSP) by June 17, 2024. The ACO PC Flex Model will launch on January 1, 2025, and run for five years. Low-revenue ACOs participating in the Shared Savings Program can apply to the ACO PC Flex Model. This innovative model aims to increase the number of low-revenue ACOs and enhance primary care payment through a Prospective Primary Care Payment (PPCP) option, shifting payment from fee-for-service to a predictable, monthly payment. 💲 Enhance primary care payment and innovative care delivery  📉 Narrow Disparities in health care outcomes  🔻Reduce program expenditures while preserving the quality of care  💪 Strengthen participation incentives for new and low-revenue ACOs 💰 Base Rate and Payment Enhancements  💴 One-time Advanced Shared Savings Payment Health Equity Strategy to drive accountable care and advance health equity #ACOPrimaryCareFlexModel #HealthcareInnovation #PrimaryCare #AccountableCare #Medicare #HealthEquity #SustainableHealthcare #ValueBasedCare #VBC #RiskAdjustment #PPCP #SharedSavings #CMS https://lnkd.in/gmiKZsHM

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Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

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By automatically capturing patient care summaries directly to the EHR, Dragon Medical One is the speech recognition solution that fits your needs without fighting your workflow. Learn more at https://lnkd.in/e86xfcb7

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Health insurer Prior authorization is rationing.

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For part of your fiduciary duty, self-funded plans, you should be asking your carriers about #medicaldrug rebates, or under Medicare, these are considered "#PartB" drugs. These are not drugs you pick up at the corner drug store. These are the drugs that are infused as an outpatient at an infusion center, doctor's office, or even sometimes at home. Chemotherapy, drugs like infliximab, or any drug that you need to have infused are likely in the medical plan benefit, NOT the pharmacy plan or benefit. And, spoiler alert - they're often the most expensive drugs to hit plans....ever. ✅ The next time you're with your medical carrier, ask them about medical drug rebates. ✅ Then ask them about medical drug rebates as they apply to your plan, specifically. ✅ Last, ask them when you should be expecting a check on your medical drug rebates. If you get South Park blank stares, that means you're on to something. Keep asking....hold them accountable. There ARE medical drug rebates, and if your plan is paying for medical drugs, your plan should be getting drug rebates back. #pharmacy #medicaldrugs

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Purchased services are vital to healthcare, but they can also become financial drains if not managed properly. A mature purchased services strategy includes insight into all expenses, reduction in unnecessary variation, and prioritized patient care, outcomes, and experience. By focusing on these areas, health systems can lower costs, improve clinical care, and enhance patient experiences. Learn more in Advantus Health Partners article about how to create a mature purchased services strategy: https://lnkd.in/g4UwCjCW #HealthcareSupplyChain #ValueBasedCare #SupplyChainManagement

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EARN 7 AAPC CEUs and/or 6 AAFP CMEs for $49!! Vast changes are coming to Medicare Risk Adjustment. Is your team ready? Workshop Agenda: ­Discuss the importance of managing HCCs year over year. What resources are available from CMS to help? When is the Advanced Notice published? What are the components of a risk score? How will CMS calculate risk scores for 2025? Review NEW and updated HCCs. What documentation is needed to validate payment? Sharpen your Auditing Skills – Group review of clinical documentation and coding for HCCs. Take a deep dive into the grey areas and red flags of HCC coding and clinical documentation. See what your team should and should not be coding. Dates and Registration Links: Friday June 28 - https://lnkd.in/eNW7jDgw Friday, July 26 - https://lnkd.in/emS6nP9x Visit https://lnkd.in/esDVsekk to view all upcoming events.

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By: Don Self, CMCS, CPC, CASA          Karlene Dittrich, CBCS, CPC, CPMA, CECCS         Chris Chapman, CPC, CPMA     Is Your Practice Or Organization Receiving Negative Financially Impacted UHC Responses? , Please  Read Below and Complete Our Short Survey.  The aggregated survey results will be posted on Don's list serve   After listening to the Senate Finance Committee hearing May 1st with testimony by Andrew Witty, CEO of UHG, it was clear that the US Senate & House members DO NOT HAVE A FACTUAL UNDERSTANDING OF UNDISCLOSED ACTS BEING TAKEN BY UHC.   We believe some statements by Mr. Witty to be misleading in nature, especially when considering facts posing financial risk to healthcare organizations.  Mr. Witty said that UHG is doing everything to help physicians, clinics and hospitals and that at no point has UHG or its companies  tried to take advantage of its own cyber attack. He stated that claims are processing implying claims payments are being made but failed to disclose  the relevant denial tactics being applied to the processed claims.  However, we have already observed since the Feb 21 attack, an increase in clients reaching out to us due to "post-payment" medical record requests, refund demands & recoupments/offsets and extrapolation attempts from UHC being received by clinics across the USA, that appear to FAIL to meet compliance with applicable state and federal laws. This is HUGE & the committee seems unaware of such detrimental undisclosed financial acts being intentionally exercised by UHC.  As advocates, we would like to show Congressional members proof in numbers of what is really happening, however WE NEED YOUR HELP to report the magnitude of UHC's attempts to recoup or "claw-back" money (patient benefits) previously paid on claims.   If you received one or more Refund Demand/Overpayment notices, recoupment(s) or offset(s), extrapolation notifications  or "post payment" medical record requests, please help us inform the Senate Finance Committee what is really going on by filling out the short survey in the link below.  The data needs to be close estimates. We are not asking for any PHI, or copies of documents or evidence, yet  Your responses will be confidential and only shared with  us & the committee (without the name of your organization).  Also, please provide us contact information & impacted locations in case we need to reach back out to you.  Please at least include the city/states so that we can provide the Senate Committee with geographically accurate reports.  If the Senate Committee wants to see actual examples or evidence, we will reach out to you with info you can get in touch with them directly.   Short and Optional Survey  https://lnkd.in/gGKhKr2A     The May 1st  recording is available at: https://lnkd.in/g_CaZ-vy    

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Allowing Medicare to negotiate drug prices on behalf of older Americans remains broadly popular across partisans, though many voters are unaware of the new law and the billions of dollars it is expected to save in 2026, a new KFF Health Tracking Poll finds. A large majority (85%) of voters say they support allowing the federal government to negotiate the price of some prescription drugs for people with Medicare. This includes at least three quarters of Republican (77%), independent (89%) and Democratic (92%) voters. The Inflation Reduction Act of 2022 authorized such negotiations, and the Biden administration recently completed the first round of negotiations on 10 drugs, resulting in an estimated $1.5 billion in lower out-of-pocket costs for Medicare beneficiaries in 2026. #kff #medicare #prescriptiondrugs

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⚠️ Errors in healthcare data entry can have serious consequences. Relaymed automatically inputs POC test results from the device to your EHR, this means no more printed reports, and no need to decipher someone’s handwriting. 🚨If errors do slip through, Relaymed flags them, notifies your staff, and makes it easy to correct issues. 📽️ Learn more about how Relaymed can automate your workflow, streamline processes and enhance patient safety at https://bit.ly/4bQhQhb #healthtech #POCtesting #EHRintegration

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