Shannan Bolton

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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What does calling my cable company have to do with Medicaid? I had to call a certain notorious cable/internet provider recently. The one with customer service so bad that it was skewered in a classic South Park episode. I blocked out an hour and braced for my inevitable PCOM aneurysm rupture. Shockingly, it was a breeze. The rep was friendly, and my issue vanished in minutes—a far cry from their usual 'dial-one-to-scream-into-the-void' reputation. So, what changed? Competition happened. A decade ago, our choices for cable and internet were as limited as the soda options in a health spa. Now, thanks to a buffet of streaming services—even including live local TV—the old cable giants had to step up their game or step aside. Turns out, competition is more effective than caffeine at improving service quality. Why can't Medicaid beneficiaries get the same treatment? Currently, most Medicaid coverage is through Managed Care Organizations (MCOs), where the state pays a fixed monthly rate per patient. This model should spur cost-efficiency, but it often just limits the scope of care. Low payments to doctors, restricted access to necessary services—who does that help? Could strict government regulations guarantee better service? Maybe, but FA Hayek (and a basic reading of history) prove that bureaucracy alone can't engineer excellence. And choice for Medicaid patients? Virtually non-existent. Many areas offer just one MCO. If you're dissatisfied, too bad—there's no alternative. It's like being stuck with dial-up in the era of fiber optics. Long wait times for basic procedures, no freedom to seek better coverage... It's eerily reminiscent of the old cable monopoly days. In the private sector, at least there's a semblance of choice: HMOs, PPOs, HSAs... But for Medicaid recipients? Sorry, the state chooses for you. Hope you like it. Our Medicaid system desperately needs a dose of competition. Isn't it time we offer Medicaid patients the luxury of choice that drives quality up and costs down? https://t.co/C7XE6CpIIP Joe Grogan Lisa Grabert Joanne Spetz Cheerag Upadhyaya, MD, MBA, MSc, FAANS, FACS Brian R. Gantwerker, MD, FAANS, FACS Sanjay Dhall Larry Bucshon, M.D.

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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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In a move to streamline care, LA Care Health Plan which managed Medi-Cal and several other plans for low-income Californians is cutting back 24% of its prior authorization requirements. "This change aims to reduce administrative burdens and speed up patient access to necessary treatments," the article explains. This is good to see. Could significantly benefit patient care by removing unnecessary delays in treatment approvals. Devil is in the details but still good progress, particularly for the most vulnerable. Check out the article by Nona Tepper in Modern Healthcare at https://lnkd.in/evVP3eqP

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#HASC2024AM 12:45, Laviana: Hear how Zephyr Healthcare Advisors & Altius Healthcare helped a CA hospital address post-pandemic workforce issues and save $12 million yearly. Zephyr is now assisting a SoCal hospital with these challenges. #workforce #performanceimprovement

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Recent regulatory changes provide hospitals a unique opportunity to reassess their reimbursement practices and strategy, showing the value of completing three reporting types in tandem rather than one at a time. By understanding how reimbursement programs like Medicare DSH, Worksheet S-10 Uncompensated Care, and Medicare bad debts are related, hospitals can save time, alleviate strain on their IT departments, free up staff to focus on high-priority work, and potentially improve their financial health. Learn more in this Moss Adams article by Heather Keser, Jonathan Mason, Jesse Vo and Josh Stewart.

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🚨 Top 10 #PatientSafety Concerns for 2024. 📌 Have significant changes been made over the last decade? An important question is to reflect on what has been done, what we are doing, and what remains to be done.

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CMS just issued the RADV audit target list for Payment Year 2018 (with premium claw backs). 60 MA plans selected for audit, instead of the usual 30. CMS claims that claw backs will begin in mid-2026. Plans need to act immediately to: Consider self-identifying encounter data submissions pursuant to the Overpayment Rule. It's better to refund money to CMS rather than allowing those errors to be used as extrapolated claw backs for all enrollees. MA plans may want to conduct a mock-RADV audit on 2018 encounter data submissions to inform the 2026 bid development process. A mock-RADV would limit the refund of identified overpayments just to those records included in the mock-RADV audit.  If the Payment Year 2018 goes off as CMS has indicated, premium claw backs will occur in 2026. And if the PY 2018 claw backs occur, then there is PY 2019 and subsequent years for the plans to deal with. CMS has accelerated its RADV process beyond the “tortoise” pace that had been apparent. This means that all MA contracts (not just the 2018 audit targets) need to dramatically improve both data integrity and data accuracy of their encounter data submissions.

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September is National Suicide Prevention Month. Thank you Katrina Domingo, PsyD for nominating subject matter expert, Terra Morais, Psy.D., provide insightful tips for suicide prevention. Dr. Morais has worked for Kaiser Permanente for 9 years, and has been manager of its Psychiatric Consultation Service for 2 years. She has specialized training in the treatment of psychiatric emergencies in children and teenagers. We all have times when we feel sad or overwhelmed. For some people, these feelings can become so strong that they have thoughts of ending their life. Suicide is a leading cause of death in the United States and has been on the rise across all groups for years, but we can take steps to help prevent it.   SELF If you are having serious thoughts that you or your loved ones would be better off if you were dead, the most important action you can take is getting immediate help. You can call or text 988 to talk to someone who knows how to keep you safe. If you notice yourself having these thoughts occasionally, or find yourself feeling hopeless, here are some steps to help prevent those thoughts from getting worse: 1. Tell someone you trust how you are feeling. This can be scary, but it the people who care about us want to help us feel better and can be devastated by the thought that they could have helped if only they had known how their loved one was feeling. 2. Prioritize your sleep and reducing stress in any way you can. Lack of sleep contributes to problems with mood, thinking, and emotional regulation. 3. Make a plan to do something enjoyable with a loved one and ask them to help you stick to it. Research has shown that social connections and responsibilities are highly protective factors in preventing suicide deaths. OTHERS Here are some warning signs that someone may be having thoughts of suicide: https://lnkd.in/dyz2BZsd If you notice worrying changes in someone you know, here are a few ways to help: 1. Ask them if they have been feeling like hurting or killing themselves. Sometimes people worry that asking will “put the idea in someone’s head,” but in fact people struggling with thoughts of suicide are usually relieved that they can talk about it. 2. When someone tells you about their thoughts of suicide, listen without judgment or argument and ask if they want assistance reaching out for help. You can call or text 988 with them or make sure they have the number.   RESOURCES The National Suicide Prevention Lifeline (24/7 toll-free suicide prevention service): Dial 988, https://988lifeline.org/   Suicide Prevention Hotline in Spanish: 1-888-628-9454, https://988lifeline.org/   LGBT Youth Suicide Hotline: 1-866-488-7386, or text START to 678-678, https://lnkd.in/d656hGQy   The Crisis Text Line: Text "HOME" to 741741 for free, 24/7 crisis support #suicideprevention #suicidepreventionawarenessmonth #TPMG #DSA #health #wellness #leadership #tips #support

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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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So this gem 💎 by Susan Walberg JD arrived in the mail.... If you are a decision maker at a health tech companies or care provider who has to navigate regulatory and legal requirements related to healthcare and technology 😫 this is a fantastic resource that is super user friendly! 😅 Key elements include:  -HIPAA and The Cures Act -Fraud and Abuse -The FDA and Safety Standards -FTC Laws and Enforcement -Compliance Guidance for Building a Telehealth Practice "Whether you are the CEO of a healthtech start-up, a physician building a telehealth practice, a compliance officer, or a developer working on the next great AI tool, this book is a must-read." If you want a copy, link is in the comments. #Healthcare #Technology #Law #Compliance #healthcareinnovation

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Introducing CDIQ Consulting - Education Empowering Healthcare Our services empower allied healthcare professionals and the organizations they serve to achieve excellence in patient care and operational performance. We specialize in transforming clinical documentation integrity (CDI) into actionable strategies that enhance severity reporting, risk adjustment, and quality metrics. Under the leadership of Tarman Aziz, MD, CCDS, our CEO, and Anna Rusinowski, our COO, we deliver innovative solutions grounded in expertise and a commitment to elevating healthcare standards. Together, they guide a team dedicated to operationalizing intelligent insights into documentation accuracy, financial outcomes, quality metrics, and career excellence. Our Physician Advisor Solutions focus on training Documentation Champions to more comprehensively prevent DRG downgrade denials, mentoring custom strategies that sustainably improve provider assessment documentation. The Comprehensive CDI Apprenticeship Program builds future CDI specialists using real-world practical training, preparing them for faster onboarding to readily exceed management expectations. HIM and CDI leaders leverage our CDI training modules to enrich their programs with enhanced team productivity and query scope. We design middle revenue cycle consulting initiatives featuring both efficient assessments and immediate solutions strengthened by policy creation to optimize CMI and risk adjustment metrics. For professionals pursuing CCDS certification, our CCDS Exam Preparation course offers a custom curriculum to each enrollee, based on a diagnostic assessment. Our hourly and subscription-based Professional Coaching sessions deliver personalized support to foster leadership skills, professional growth, and adaptability to industry trends. Discover how we can transform your plans into positive outcomes! Empower your success by visiting cdiqconsulting.com today. #EducationEmpoweringHealthcare #ClinicalDocumentation #CDI #RiskAdjustment #HealthcareConsulting #CDIQ

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Enhanced Care Management (ECM) is a whole-person healthcare approach that improves care coordination and outcomes for California’s most vulnerable populations. This statewide benefit addresses the complex needs of high-risk members, from those experiencing homelessness to individuals with #MentalHealth and substance use disorders. Read the full CareThreads blog to learn how ECM provides dedicated care managers and leverages tools for efficient service delivery, ensuring timely interventions and better health outcomes for Californians: https://okt.to/n6Gx5N

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California is making impressive progress implementing the DxF! So far: 📝 98% of required health plans have signed 🏥83% of required General Acute Care Hospitals have signed 🧑‍⚕️83% of required Skilled Nursing Facilities have signed

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The Association of Healthcare Value Analysis Professionals (AHVAP) celebrates Elizabeth Eisenberg, MSN, RN, CVAHP from Scripps Health for commitment to excellence in the specialty of healthcare value analysis! Liz has signified this commitment by signing the official Association of Healthcare Value Analysis Professionals (AHVAP) healthcare value analysis pledge. To learn more about the Association of Healthcare Value Analysis Professionals (AHVAP) Commitment pledge: https://lnkd.in/gqEWPBue. #AHVAP #valuebasedcare #excellenceincare #valueanalysis

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