Kevin Klauer, DO, EJD

Health insurance companies Medicare Advantage plans subsidy and premium based EBITDA and Profits can only be guaranteed and expanded by taking from the physicians who manufacture preventive, medical, surgical and palliative outcomes with their patients and also taking from the hospitals in which clinical outcomes are manufactured and produced. #quadrupleaim, #medicare #medicareadvantage #healthcarecosts

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Starting April 1, 2025, Rural Health Clinics (RHCs) can include CPT Category II codes on Medicare claims. This advancement enhances quality reporting and aligns with value-based care initiatives, as these codes offer detailed insights into patient care. Previously, such submissions led to claim rejections; now, they aim to improve reporting accuracy without altering payment policies. Integrating these codes into the revenue cycle offers several benefits: 1. Accelerated Claims Processing: Detailed documentation reduces the need for additional payer audits, leading to quicker payments and less administrative burden. 2. Improved Quality Metrics: Tracking performance in areas like diabetes management aligns with programs such as Medicare’s Quality Payment Program, potentially resulting in higher reimbursements or bonuses. 3. Error Reduction: Precise coding minimizes errors in claims submissions, decreasing rework and payment delays. 4. Enhanced Negotiation Leverage: Demonstrating high-quality care through data enables better terms with private insurers, leading to higher payment rates or inclusion in premium networks. 5. Alignment with Value-Based Care: Participation in value-based contracts, where outcomes and quality metrics drive revenue, can unlock shared savings and incentive payments. While CPT Category II codes themselves are not reimbursable, their strategic use supports faster payments, fewer denials, and operational efficiency, positively impacting cash flow and the revenue cycle. #Medicare2025 #RuralHealthCare #CPTCodes #QualityReporting #HealthcareUpdates #ValueBasedCare #HealthTech #RHCUpdates #MedicalCoding #HealthPolicy #RevenueCycle #HealthcareInnovation #PatientCareQuality #HealthCareReform https://lnkd.in/etXFK3UG

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Do you want to see who knows what we need to do and what is most important to fix health care? Listen to Sue Veer addressing this Committee. Hear from those who have a heart for serving most Americans most behind and are willing to sacrifice to address the next generation always ignored - and then we wonder why outcomes get worse. She was discussing 340B in about them most balanced and informative way possible. She noted how the CHC used 340 B "supports health care services that would otherwise be unavailable in many of the communities that we serve... the one that is near and dear to my heart are those early childhood services that are otherwise unfunded because we are building the health of the future generation" - Early Childhood Services - Sue Veer - More than a Hero - A leader for our nation and absolutely on target with her heart and her service and her testimony $600,000 margin lost and 0.6 FTE of labor to comply with 340 B - loss of nearly $700,000 in delivery capacity for those most in need! Did you hear this Congress, CMS, and others how you cut the lifeblood and distract the delivery team members time and time again over the past 40 years of design changes. Stop killing hospitals, practices, and delivery team members where most Americans are most behind. Start paying attention to Sue Veer and many others like her who can teach you how your designs fail and how they can work - for future generations. You do not fun health care where needed. You have forced a patchwork. Please don't kill the patches and pieces before you actually implement a plan for sufficient basic health access for 95% of the nation, not just 50 - 60%. Listen to the heart of health care delivery. Listen to those that you must fully fund who are the only ones that can be most and best for most Americans most behind.

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Full Medicaid expansion needed to retain Georgia’s physicians Georgia was ranked 5th worst place to practice in a recent Medscape article (“Best and Worst Places to Practice 2024”), using five criteria: physician compensation, cost of living, malpractice premiums, the health of the state’s residents, and physician burnout levels. As current and future physicians and health advocates, this column will add context by detailing our experiences practicing in Georgia. It is no surprise that three of the five worst-ranked states for practicing are among those that have not expanded Medicaid. In Georgia, refusal to expand Medicaid means that nearly 12 percent of residents (well over a million people) are uninsured, significantly limiting their access to healthcare. Only in Texas is coverage worse. Due solely to political concerns, Georgia chose to submit a Medicaid waiver and develop its own Medicaid expansion program, Pathways to Coverage. The governor’s office projected that the program would cover an additional 100,000 Georgians in its first year. But it has been an utter failure, with fewer than 3,500 covered at a cost to taxpayers of $26 million. Full Medicaid expansion would have added over 350,000 Georgians while cutting state spending by $710 million. These three states that refused to expand Medicaid are not surprisingly red. It is also unsurprising that the states with the greatest percentage of unhealthy residents are red. Hopefully, Georgia who thought they had a better way of expanding access to care with their own plan that squandered $26 million to cover 3,500 residents will realize that retaining physicians requires a more sensible approach to expanding access to care. #expandinghealthacess, #accesstocare, #limitingcoveragetoresidents https://lnkd.in/eefqH-9Y

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The CMS Primary Care Flex model is significantly more involved that any of the CMS' other ACO programs. Risk adjustment continues to be a key component to receiving PPCP enhancement payments. The level to which risk adjustment effects enhancement payments varies significantly depending on where your enhancement payments fall based on the other components of the model. Towards the high end of enhancement payments, risk adjustment might not affect your payments at all (enhancement payments are capped at the high end). Even reduced risk scores sometimes have to be large before generating impact. For this simulated ACO, risk scores needed to fall 25% before affecting the enhancement payment. For another simulation with a lower base enhancement payment risk scores had a more significant effect. As shown in the chart, minor percent changes in risk score had 10%-50% impacts on enhancement payments. These were on a much smaller based, but still significant to overall revenue within PC Flex. It will be important for ACOs participating in Flex to understand where they reside within the payment structure to understand the multiple factors that affect total revenue within the program.

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The Medicare Advantage star ratings system is designed to evaluate the quality of Medicare Advantage plans. These ratings range from 1 to 5 stars, with 5 being the highest, and are based on several factors, including customer service, member satisfaction, and health outcomes. Higher star ratings lead to better reimbursement rates from CMS and can help attract more enrollees. UnitedHealthcare’s lawsuit claims that its downgrade was based on a single customer interaction, which could negatively affect its reimbursement and market competitiveness during the open enrollment period https://lnkd.in/erKQy7Ge #MedicareAdvantage #StarRatings #UnitedHealthcare #CMS #HealthcareLawsuit #HealthInsurance #MedicareNews #OpenEnrollment #HealthcareUpdates #MedicareAdvantagePlans #InsuranceRatings #HealthcareFinance #PatientCare #MedicareReform

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UnitedHealthcare Has Faced Scrutiny Over Denying Claims and Payments For Physician Recommended Care. The company has been accused of using computer algorithms to deny diagnostics and treatments.

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There is no transparency or accountability regarding the number or clinical or workflow consequences of health insurer prior authorization rationing of physician recommended care. What’s interesting about his graph which shows an approximation of physician recommended care which the health insurers deny or delay is that We have no idea what’s right or wrong regarding who benefits or who’s is harmed from rationing physician recommended care. Are the insurers who ration 7% of physicians care recommendations improving healthcare access, outcomes or costs vs the company that denies 1/3 of physicians care recommendations? Is one company causing increased morbidity and mortality and bankruptcies along with increased physician workflow vs another company? Only the insurers know and they won’t share that data. There is no transparency or accountability regarding the number or clinical or workflow consequences of health insurer prior authorization rationing of physician recommended care.

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Great article from American College of Emergency Physicians and refreshing to see ED physicians writing about the need to remedy ambulance patient offload delays. The authors offer sensible commentary and suggestions, including: - Yes, patients who arrive by ambulance can be placed in the waiting room; - Hospitals can move patients waiting for inpatient beds to upstairs hallways and not ED hallways; - Assign a hospital practitioner to screen low-acuity patients and order appropriate routine tests. - And this nugget: "a hospital that is so overwhelmed that it must hold ambulances for hours...should be activating its disaster plan." As I've said often, EMS serves the community, not the hospital, so I applaud the authors for including the phrase "release EMS personnel back to the community" in their article. However, even though I applaud these authors, I must take some issue with the word "release," for it implies that EMS staff are not free to leave an ED unless ED staff permit them to. When clinically appropriate, it is legally and operationally valid for EMS clinicians to tell hospital staff "the patient is stable and we're returning to service" and leave the hospital even without being "released" by ED staff. EMS staff aren't hospital staff (as the authors correctly note), so they are not the hospital's to command. And federal law (EMTALA) clearly imposes the legal duty of care on the hospital once the patient is on their property. Finally, for what it's worth, data tell us that a large percentage of the patients brought by ambulance do not clinically require constant monitoring by EMS personnel while awaiting hospital care and would derive no clinical benefit from being watched by EMS clinicians during the EMS-ED handoff interval. Again, kudos to ACEP and to these authors for their helpful contribution to this conversation. #pww #emslaw #emtala #apot

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On October 8th, U.S. News & World Report released its annual rankings of Children's Hospitals, called "Best Children's Hospitals". It is a 174-page report describing the methodology and data tables which I scanned through. Appendix C-10 has the data on Pediatric Pulmonology which I took a deep dive into. In the attached carousel, I have recreated two datasets that matter. If I were to shop around for a hospital for my care, what really matters to me is the outcome data for a particular condition I am seeking care for and not the reputation score. However what separates the top-ranked "Best Children's Hospitals" is their reputation scores, not the outcome scores for selected conditions as in asthma here. It's a different matter whether the outcome scores used in the rankings are good measures. We will discuss them in another post. What are your thoughts? Feel free to like, share, and comment. #healthcare #hospitals #physician

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Join Eric Lucas, Jonathan Mason & Georgia Green, MS, CHFP for a webcast on 8/27 - Medicare Regulatory Update: 2025 IPPS Final Rule. We’ll discuss the latest updates for hospitals and cover topics including an evaluation of the IPPS final rule key areas, reimbursement shifts and data trends identified in the IPPS final rule data, and next steps and factors to consider because of the final changes, including the mandatory TEAM model. #healthcare #hospitals

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🔩 Q: What is a Bolt on healthcare benefit? ✅ A: Great question! Self-funded ERISA-governed plans may add on OPTIONAL services to provide more options for members and potentially save more time and money for both plans and members. We call these "bolt-on benefits" in the industry. Here are some examples, and even focused examples on #prescriptiondrugs and #pharmacy: 💊 -On site or near site clinics - that can provide quick appointments for members to get in to the doc or provider when their primary care providers are not available. At these clinics, members can obtain many drugs at these on site or near site clinics at a discount or even free to get them started and up to 100% of the drugs could be charged back to the plan. 💊 -Canadian drug importation programs - patients are allowed legally to personally import drugs with several stipulations (not biologicals, not controlled substances). I will reserve my personal opinions on these Canadian programs for now, but just know that they can be another option for members. 💊 -Cash pay on prescriptions and applying the cost to deductibles and OOPs - especially for the 1/3 of plans that are High Deductible Health Plans (HDHPs) - your plan, if you have a savvy consultant or broker, can set up a program to allow those with HDHPs to apply their receipts to their deductibles and out of pocket accumulators at the beginning of the plan year when patients have to pay out of pocket. You MUST ask your broker, however, if they can set up this option for your plan with the medical carrier, and show a clear pathway at open enrollment for members on where they may turn in their receipts to apply to their deductibles. 💉 Example: 1/1/25 is right around the corner and 70% of plans' accumulators will reset. With the Team Cuban Card, for example, people may pay cash of $748+ cash price with Yusimry, an adalimumab biosimilar, (https://lnkd.in/g5gJz_Mf) or they can purchase a more expensive option on their drug formulary. Why not take advantage of better cash pricing and rewarding the member for finding it and applying it to the deductible? 🛑 Now that the breach of fiduciary lawsuits have arrived, considering bolt on benefits is/are another critical component for plans to explore. If you offer your members options, you're demonstrating that one way your plan is meeting their fiduciary obligations. Maybe all these won't work for your plan.....but you miss 100% of the shots you never take. #pharmacybenefits #pharmacy

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There is one issue that unites us: Physicians and their staff must get paid for doing hours of work to overcome insurer prior authorization rationing of our recommended patient care. Please support Resolution 814 at the upcoming interim November 2024 AMA meeting in Orlando. Resolution 814 was introduced to the upcoming interim November 2024 AMA meeting in Orlando with my amendment that reads as follows: RESOLVED, that our American Medical Association initiates prior authorization legislation aimed at Medicare Advantage plans, state Medicaid programs as well as commercial payers, via model legislation, that allows for fair reimbursement for physician’s time and that of their office staff when dealing with prior authorization. (Directive to Take Action) RESOLVED, that our American Medical Association report at the Annual 2025 Meeting and annually after that, until the goal of the resolution is fully achieved, on the progress of implementation of this resolution. (Directive to Take Action) You can also comment on this resolution as an AMA member or delegate until Friday Oct 25th 5 pm: https://lnkd.in/eBWRtBgw

Join Eric Lucas, Jonathan Mason & Georgia Green, MS, CHFP for a webcast on 8/27 - Medicare Regulatory Update: 2025 IPPS Final Rule. We’ll discuss the latest updates for hospitals and cover topics including an evaluation of the IPPS final rule key areas, reimbursement shifts and data trends identified in the IPPS final rule data, and next steps and factors to consider because of the final changes, including the mandatory TEAM model. #healthcare #hospitals

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𝗪𝗲 𝗻𝗲𝗲𝗱 𝘁𝗼 𝘂𝘀𝗲 𝗱𝗮𝘁𝗮 𝘁𝗼 𝗱𝗿𝗶𝘃𝗲 𝗯𝗲𝘁𝘁𝗲𝗿 𝗱𝗲𝗰𝗶𝘀𝗶𝗼𝗻𝘀. There is a strong negative correlation between 365-day readmission rates and the average length of hospital stays for COPD (R = -0.68). Decisions to rush COPD discharges can backfire: Shorter hospital stays are linked to higher readmission rates and poorer long-term outcomes. Cutting hospital stays below five days may save costs short-term but risks driving up readmissions and total costs, highlighting the need for comprehensive in-hospital care and psychological support for COPD patients before patients are being discharged. In general, longer hospital stays reflect lower readmission rates. Countries that report fewer than five days spent in hospital due to COPD report average 𝗿𝗲𝗮𝗱𝗺𝗶𝘀𝘀𝗶𝗼𝗻 𝗿𝗮𝘁𝗲𝘀 𝘁𝗵𝗮𝘁 𝗮𝗿𝗲 𝗻𝗲𝗮𝗿𝗹𝘆 𝟭.𝟱 𝘁𝗶𝗺𝗲𝘀 𝗵𝗶𝗴𝗵𝗲𝗿 than the average readmission rate of countries recorded in the COPD Index. People admitted to hospitals with COPD often have multiple problems and could benefit from longer hospital stays to enable multidisciplinary interventions. 🌐 𝑬𝙭𝒂𝙢𝒊𝙣𝒆 𝒕𝙝𝒆 𝒈𝙡𝒐𝙗𝒂𝙡 𝙞𝒎𝙥𝒂𝙘𝒕 𝒐𝙛 𝘾𝑶𝙋𝑫 𝒂𝙣𝒅 𝒍𝙚𝒂𝙧𝒏 𝒘𝙝𝒂𝙩 𝙩𝒉𝙚 𝙡𝒆𝙖𝒅𝙚𝒓𝙨 𝙞𝒏 𝒕𝙝𝒆 𝒇𝙞𝒈𝙝𝒕 𝒂𝙜𝒂𝙞𝒏𝙨𝒕 𝑪𝙊𝑷𝘿 𝙜𝒆𝙩𝒔 𝒓𝙞𝒈𝙝𝒕:  https://lnkd.in/da6Aj7dJ 𝗪𝗲𝗱𝗻𝗲𝘀𝗱𝗮𝘆 𝟮𝟬𝘁𝗵 𝗡𝗼𝘃𝗲𝗺𝗯𝗲𝗿 𝗶𝘀 𝗪𝗢𝗥𝗟𝗗 𝗖𝗢𝗣𝗗 𝗗𝗔𝗬 Make a note to try out the COPD Index before then Copenhagen Institute for Futures Studies Respiratory Health Initiative

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With the news of a potential shortage of IV fluids due to the damage of a manufacturing facility in North Carolina, dental and oral surgery practices may be looking for ways to conserve their supply. ⚠ Please remember that sharing or splitting bags of IV fluids between patients is inappropriate, even if you change out the IV tubing. ⚠ Not only did I hear clinicians recommend this practice during the last shortage in 2017, but I also had to counsel dentists who attempted to implement it in their practices. We must prioritize patient safety and avoid such measures, even when supplies are limited. ------ Hi! I'm Katie, Chief Nursing Officer of Soteria Clinical Solutions. I provide expert nursing leadership to office-based healthcare practices to support patient safety 🩺, improve outcomes 📈, ensure regulatory compliance ✅, and enhance clinical oversight 🔍. Ready to elevate your practice? Let's connect and explore how I can support your team 💬. #oralsurgery #patientsafety #dentistry #sedation #nursingleadership

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I would venture to say that our Clinical Documentation Integrity (CDI) team at Pediatric Resource Group (PRG) has more collective years of pediatric CDI experience than all other CDI consulting firms combined. 110 years amongst us and we are not done growing our team. If we include my physician advisor consultants that support peds CDI, the years of experience goes beyond 150. It's not just experience. Our team is full of national CDI leaders who speak at conferences regularly as well as CDI and coding leaders at major children's hospitals. We bring that expertise to our clients to assess, develop or optimize pediatric and neonatal CDI programs around the country. Peds is different from a care, culture, and reimbursement perspective. Your CDI consulting partner needs to understand all the nuances associated with this unique patient population. Hospital leaders, let's connect to see how PRG can help you optimize or cover peds/NICU CDI. CDI consultants, let's partner on peds clients. Amy Bush, BS, RN, MJ, CCDS, CCS, Kristen Johnston Jorde Spitler MHA BSN RN CCDS, Ashley Ezell, Kristin K., Kesia St Romain, Amy Philen, BSN, RN, CCDS, Jeff Morris, BSN, RN, CCDS, CCS, Jessica Audino-Iwuji #pediatricCDI #clinicaldocumentation #peds

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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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