Jeffrey Heaton

Ventricle Health chose Humbi because “Humbi ... provided us with decades of high-level experience. They lead a team of actuaries and data scientists that we have complete confidence in.” https://lnkd.in/eH-V-M-9 #DataAnalysisHealthcare #ActuariaConsultinglServices #ActuarialIntelligence #Ventricle #VentricleHealth

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Price transparency MRF callout to be aware of. In the files, you could see for inpatient services MS-DRG's and/or APR-DRG's. These are different billing methodologies to be aware of when comparing network rates by NPI. See breakdown below. Diagnosis Related Groups (DRGs) are a patient classification system that relates the type of patients a hospital treats with the costs incurred by the care. Medicare Severity-Diagnosis Related Groups (MS-DRGs) classify a Medicare patient’s hospital stay into various groups to facilitate payment. These are typically used on the commercial side as well for inpatient services.   APR-DRGs are more comprehensive and include four levels of severity of illness or risk of mortality for each case. These are used on the commercial insurance side if MS-DRG are not chosen. Similar to MS-DRGs, an APR-DRG payment is calculated using an assigned numerical weight that is multiplied by an individual fixed dollar amount. APR-DRGs, however, consider severity of illness and risk of mortality instead of only a complication or comorbidity. More than one significant diagnosis, procedures, age, discharge disposition, and sex can add to the APR’s clinical severity. There are four levels of severity of illness or risk of mortality are: minor, moderate, major or severe.   APR-DRGs and MS-DRGs are both systems of classifying hospital cases based on diagnosis and procedure, and expand upon the basic DRG list by Medicare. #pricetransparency #employeebenefits #costcontainment

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For those looking for an update on Change Healthcare, this is a great article to read. A few things that stick out to me: - They confirm that patient data was part of the data stolen (duh) - They confirm it will be possibly "months" before the forensic analysis is complete to determine who has officially been impacted by the breach, but in the interim offer credit monitoring to those who believe they have been (sounds a bit vague) - Importantly for my healthcare clients: "the company has also offered to make notifications and conduct required administrative steps on behalf of providers and customers" - so notification will be centralized and streamlined through Change and NOT through each individual provider (phew!) - Most services are back to "near normal" levels Stay tuned - this is going to be a case study for years to come. #cyberrisk #changehealthcare #cyberinsurance

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If you're attending the 38th Annual Farm Bureau Actuarial Conference in Park City, Utah next week, be sure not to miss the session by Guidewire's Christopher Cooksey, "Generative AI market/opportunities and governance needed." #GuidewirePredict #insurance #innovation #insuranceinnovation #insurtech #insurancetechnology #pandcinsurance #propertyandcasualtyinsurance #generativeartificialintelligence #generativeAI #GenAI #analytics #data #predictiveanalytics

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The GAO report summarizes key themes in state regulations of pharmacy benefit managers, offering guidance for compliance in an evolving legal landscape. https://wix.to/I3ycCOe #healthcare #healthcarenews #regulations

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Let’s talk about “Value Based and Risk Adjustment Models”. How Medicaid segment applied a Risk Adjustment Model using CDPS methodology “What is a risk adjustment model? It’s a statistical tool used in healthcare to forecast and assess the potential healthcare expenses associated with beneficiaries.”

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CMS conducts Risk Adjustment Data Validation (RADV) audits to ensure payment accuracy for Medicare Advantage Organizations (MAOs). With the authority to extrapolate findings, CMS focuses on high-risk contracts, emphasizing the importance of compliance. #HealthLaw #Medicare

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What share of #opioids prescribed in #workerscomp is prescribed to #injured workers FIVE years or more after their injury? Revealed opioid #utilization and prescribing trends identify another feature of state #medicalpixels. Join me next Thursday, September 19 at 2:00 pm Eastern to find out more. #workerscompensation #NCCI

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In this #CCA health series webinar, presenters provide an overview of two Actuarial Standards of Practice applicable to general actuarial practice – ASOP 56 Modeling and ASOP 12 Risk Classification. Learn more: https://lnkd.in/gemYpWPA Speakers:  David Tuomala | Optum Brian Mullen | American Family Insurance R. Jason Reed | UnitedHealth Group Susan Pantely | Milliman #actuary #actuaries #healthcareactuaries #webinar

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When you work with Humbi AI, you’re not just getting access to data—you’re getting a partner who is as invested in your success as you are. https://lnkd.in/dYnPUGQC #HealthcareDataAnalysts #HealthcareActuarial #ActuarialIntelligence

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New Tshirt idea: "HEALTH ACTUARIES do it with diseases." So Health Actuaries, now that I have your attention, this article by Greg Fann is a must read. And the conversation is a must have. We've lost sight of what risk adjustment is. In this article, Greg brings us back to the fundamentals. Rating risks appropriately: In a world where any rating variables are fair game, the company that best uses all of them wins. Risk adjustment: Bridges the gap created when carriers are not allowed to use certain variables. Fundamental premise: The rates should dictate the rules of risk adjustment. But in today's rate review world, the risk adjustment is often dictating the rates. Can we figure out a solution? Are there any working groups that are addressing it? If there are, my bad, exams (ha, ha) have been blocking my view. https://lnkd.in/gF_pmGca

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Great post from Chris Deacon regarding PPO Networks. It further proves what many of us have known for a while, that networks are not the answer. They've been converted from a "Savings" tool to a "Profit" tool for the Big Health insurance companies and health systems. As pointed out, cash prices can be significantly less than network prices, 30%-70% less. Further proof that networks aren't the answer is the last 30+ years of continuous premium increases, on average approximately 7%-8%. BTW – using the rule of 72, at an annual increase of 8%, premiums double every 9 years. Another way of putting this is that your 2025 premiums will be double what they were in 2016 if you averaged an 8% annual renewal increase, or $500 in 2016 = $1,000 in 2025.

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Chris Deacon is absolutley right, Networks are becoming outdated. As she points out, cash prices can be as much as 40% less than network prices. Weren't Networks supposed to deliver better prices? Yes, however, over the last 30+ years they be transformed toprofit centers. Their hidden negotiated fees manipulated to benefit carriers and healthcare systems instead of members and patients. Their are employers across the country that have already figured this out with the help of advisors committed to helping their clients rather than the carriers. Advisors that align their clients' best interests with theirs. Yes, this is happening. The question is how long will employers that have embraced the legacy status quo BUCA health plans continue to support the carriers and healthcare systems instead of their own companies and employees? The new ERISA fiduciary standards for health plan sponsors, part of the CAA of 2021, may have a hand in expediting this transition. Just ask Johnson & Johnson, Wells Fargo, and Grainger.

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Artificial intelligence has the potential to revolutionize disease diagnosis and prediction, but it comes with a critical responsibility: ensuring it serves everyone fairly. Check out this insightful Q&A to learn more about the intersection of AI, healthcare, and equity.#AI #HealthcareInnovation #HealthEquity

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Discover how Humbi’s Medicare Advantage Strategy Builder delivers competitive insights and drives better outcomesfor health plans, providers, and pharmaceutical companies. https://lnkd.in/eVGNm7SM #HealthcareDataAnalysts #HealthcareActuarial #ActuarialIntelligence

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Price Transparency Jan 2021: Hospital Price Transparency Rule was passed which requires hospitals to publish their contracted rates for procedures and services online. July 2021: Transparency in Coverage Rule was passed which requires insurers to disclose their contracted rates for procedures and services online. Over the last 18 months, I've been focused on this price transparency movement plus quality to bring this data forth to employers, hospitals, stop loss entities, independent TPA’s, and policy makers. Most, if not all, of these verticals have a high interest in this data to make better informed decisions. Times are changing. Two months ago, I had the absolute pleasure of meeting one of the individuals who was responsible for the Hospital Price Transparency Rule. It was my fan boy moment ;) Since then, we continue to converse on the future ahead. What's the reason for this post? This individual has spent his whole career in this space and 3 years dedicated to this rule. Since then, he has not fully seen the fruits of this rule. While he knows a lot more work needs to be done, he was excited to hear the momentum happening in the industry. Going up against the status quo can be challenging, but when you know this is making a difference in the lens of affordability and accessibility for all Americans, it aligns to a bigger purpose than any one individual. Doing the right thing is never the wrong thing. Keep going. #pricetransparency

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"Artificial intelligence (AI) technology is moving quickly, with lots of different terminology emerging and a nearly equal amount of misunderstanding. Some forms of AI, such as computer vision, are already being used effectively to automate certain processes. Others, such as artificial general intelligence, are years from becoming productive tools. As more organizations inside and outside of insurance explore AI to improve their operational efficiency, it is important to keep in mind risks that accompany this remarkable innovation." AI is an interesting new technology hitting every industry today. However, I think that a personal touch will be forever needed, especially in the insurance industry. How has AI impacted your industry today? https://lnkd.in/eejXQ7Z5

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