Tiffany Long

🔥Really big news out of Centers for Medicare & Medicaid Services right now with their plan for payments from the government to MA plans expected to increase on average by 4.33%, or over $21 billion, from 2025 to 2026, as proposed. 📰 The news is much needed as Medicare Advantage has faced two years of flat reimbursement growth from CMS that has Humana down 43% in the last year along with CVS Health down 44% that leaned into MA last year. 💵 Humana is up big (4.5%) in after hours trading along with UnitedHealth Group up 2.5% as they UNH is the largest Medicare Advantage provider with over 7.8 million lives (3 million pdp) while Humana is second with 6.2 million lives (2.3 million pdp/8.5 million total). CVS Health is up 2% in after hours trading as well which is a nice shift for them. ⬇️ Medicare Advantage was one of the hottest lines of business in healthcare but over the past 6 quarters seniors have experienced high utilization post COVID, reimbursement was starting to slow as there was a 5.0% increase in 2023, 3.32% in 2024, and 3.7% for 2025. This 4.33% increase is a big unexpected tailwind for Medicare Advantage providers. UnitedHealth Group, Humana, CVS Health, Elevance Health, Kaiser Permanente and Centene Corporation are the largest providers of Medicare Advantage in the US so this will be good news headed into the weekend! Nice little shot in the arm for HCSC which is expected to close on the 600,000 member Medicare Advantage business from The Cigna Group in Q1! Interested to hear comments this week J.P. Morgan Healthcare Conference in San Francisco #healthcare https://lnkd.in/g2qZTaxM

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New CMS Rules Hope to Curb Consumer Fraud! KFF Health News reports, “Unauthorized switching of Affordable Care Act plans appears to have tapered off in recent weeks based on an almost one-third drop in casework associated with consumer complaints, say federal regulators.” CMS “credits steps taken to thwart enrollment and switching problems that triggered more than 274,000 complaints this year through August.” But “now, the annual ACA open enrollment period that began Nov. 1 poses a real-world test: Will the changes curb fraud by rogue agents or brokerages without unduly slowing the process of enrolling or reducing the total number of sign-ups for 2025 coverage?” The article says “the clampdown could add complexity to enrollment and slow the process.”

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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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In a recent article, The Philadelphia Inquirer reported that two Aledade, Inc. Accountable Care Organizations (ACOs) were the Philadelphia area's top performers in the Medicare Shared Savings Program in 2023. They achieved higher savings rates and shared savings totaling over $38 million compared to the other ten ACOs in the region. In addition, Aledade's Delaware and New Jersey ACOs, both with practices in the Philadelphia metro, earned shared savings of more than $14 million. https://ow.ly/hyw950UehHH

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In a recent article, The Philadelphia Inquirer reported that two Aledade, Inc. Accountable Care Organizations (ACOs) were the Philadelphia area's top performers in the Medicare Shared Savings Program in 2023. They achieved higher savings rates and shared savings totaling over $38 million compared to the other ten ACOs in the region. In addition, Aledade's Delaware and New Jersey ACOs, both with practices in the Philadelphia metro, earned shared savings of more than $14 million. https://ow.ly/81rq50UehII

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In a recent article, The Philadelphia Inquirer reported that two Aledade, Inc. Accountable Care Organizations (ACOs) were the Philadelphia area's top performers in the Medicare Shared Savings Program in 2023. They achieved higher savings rates and shared savings totaling over $38 million compared to the other ten ACOs in the region. In addition, Aledade's Delaware and New Jersey ACOs, both with practices in the Philadelphia metro, earned shared savings of more than $14 million. https://ow.ly/52as50UjCO9

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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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The Centers for Medicare & Medicaid Services (CMS) has proposed a rule to make Medicare Advantage (MA) plans' prior authorization rules and coverage criteria publicly accessible. This move aims to reduce inappropriate denials, improve patient access to care, and increase appeal opportunities. Currently, only 4% of denied claims are appealed, yet 80% of appealed denials are overturned. The proposal would require plans to publicly clarify coverage criteria and inform enrollees about their appeal rights. Additionally, CMS seeks to enhance Medicare Advantage provider directories by integrating them into Medicare Plan Finder, simplifying provider comparisons across plans. This would empower seniors to make better-informed healthcare decisions. The rule has garnered support, including from Sen. Ron Wyden, who praised its potential to address prior authorization misuse, eliminate "ghost networks," and curb broker exploitation. Public comments are open until January 27, 2025, after which its future depends on policy decisions by the next administration. Our home health and hospice clients will benefit from enhanced transparency in Medicare Advantage rules, ensuring timely access to care and reducing authorization-related delays. Clearer appeal rights and streamlined provider directories empower clients to secure appropriate reimbursements, optimize workflows, and focus on delivering quality care without administrative burdens. Cliniqon is committed to delivering Guaranteed Quality, Ensured Compliance, and Unparalleled Outcomes in Home Health and Hospice agencies. #HomeHealthServices #HospiceCare #FrontEndServices #BackOfficeSolutions #HealthcareManagement #RevenueCycleManagement #HealthcareCompliance #PatientSupport #CareCoordination #MedicalBilling #ClaimsManagement #PatientEngagement #HealthcareOutsourcing #MedicalCoding #ProviderSupport #CliniqonCare #HealthcareSolutions #PatientCareExcellence #HomeHealthRCM #HospiceBilling MedPage Today

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Healthcare leaders' transparency about directory inaccuracies marks a pivotal shift. Leaders from top healthcare organizations such as Blue Cross NC. / BlueCross BlueShield of Tennessee, Elevance Health, and UnitedHealth Group have acknowledged a critical issue: #providerdirectory inaccuracies. This admission marks a significant step towards resolving #dataaccuracy challenges underpinning crucial healthcare delivery aspects. In recognizing these inaccuracies, healthcare leaders are not only addressing immediate operational concerns but also laying the groundwork for broader improvements across the industry. 🎥 In our latest Madaket Minute, we explore how transparency drives progress and how progress shapes the future of healthcare. #HealthcareLeadership #ProviderDirectories #HealthcareTransparency #DataAccuracy #MadaketMinute

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I'm thrilled to share a recent article from the Spring 2024 Winship Magazine highlighting the incredible efforts of our team in addressing oncology drug shortages. This challenge is a critical aspect of patient care that often goes unnoticed but requires immense hard work, coordination, and planning. A huge shoutout to our exceptional pharmacy department, especially our pharmacy technicians, buyers, and inventory teams. Your dedication ensures that our patients have uninterrupted access to the vital medications they need for their unique cancer treatments. Kudos to our Medical Director, Dr. Jonathan Kaufman for his leadership and unwavering commitment to overcoming these challenges. Throughout this process the integration between our physician and pharmacy leadership has been outstanding. The relentless efforts behind the scenes by our Winship Cancer Institute of Emory University teams are pivotal in providing top-notch care to our patients. It's a humble reminder of the intricate work that goes into each patient's journey, making a significant difference in their fight against cancer. To everyone involved in making this possible—thank you for your remarkable work! Read the full article to learn more about how our teams are making strides in mitigating oncology drug shortages: https://lnkd.in/exrXHFQ9 #PatientCare #Oncology #PharmacyHeroes #TeamWork #CancerCare #EmoryHealthcare #Winship #Cancer #Healthcare #Drugshortages #shortages #Medicationshortages #LifeSciences

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🔎🔎🔎 Anyone else pour over the settlement terms or was that just me? 🔎🔎🔎 With the settlement now approved by the presiding judge in the case, providers who treated a Blues covered member between July 2008 and Oct. 4, 2024 have until March 4, 2025 to opt out or will be automatically included in the $2.8B settlement. 90% of the settlement is reserved for hospitals and facilities with the remainder set aside for professional claims. More than just the monetary settlement, the other wins create opportunities in #RCM operations: ✅ Blues plans will have to pay clean, fully insured BlueCard claims within 30 days and will owe 8% annual interest on any such claim that is not promptly paid. Timely Accounts Receivable follow up is more critical than ever with interest on the line. ✅ In the event a claim is denied or remains unsettled, the plans must provide additional information that guides the provider in correcting any issues. Cheers to no longer being told “we can’t instruct you on that” by Provider Relations. ✅ An eligibility response must be generated within 20 seconds of a real-time inquiry and generally by the morning of the next business day for batch transactions. Let’s hope this landmark settlement makes progress in the payer / provider participation strain. #healthcarefinance #medicalbilling #bluecrosssettlement

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Medicaid Health Plan RFP Wins – Q3 YTD Highlights! Several major Medicaid health plans continue to make significant moves in 2024, expanding their Medicaid footprint and securing key contracts. Here’s a quick breakdown of the wins and losses: ✅AmeriHealth Caritas & UnitedHealthcare – Mixed results, with both wins and losses across their footprint. ✅Aetna – Big win in Pennsylvania’s CHC contract, despite a mixed track record. ✅Blue Cross Blue Shield affiliates – Solid growth! Resecuring contracts while making new moves in Kansas (win) and Rhode Island. ✅Centene – 100% defense! Successfully retained all eight contracts. ✅CareSource – New state entry! Secured a highly anticipated win in Mississippi. ✅Elevance & Molina – Strong defenses, but efforts to grow into new states fell short. 2024 Medicaid contract awards include: CO, FL, IA, KS, MA, MI, MS, NH, PA, and TX (STAR CHIP). Stay tuned for RI and VA – both currently under protest. Awards do not include BH-only contracts, dental-only contracts, PBM-only contracts, nor single population contracts (Foster Care/Children in State Custody). #Medicaid #MCO #healthplans #Growth #ContractWins #Thrive

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OIG ALERT- Another targeted condition review, the 5th this year, was released this week. While the penalty is only $297k, the risk found was 51X the penalty. I repeat... 51 times. In addition to the settlement with a health plan announced by the DOJ yesterday, the OIG also posted its most recent targeted review of conditions for a Medicare Advantage plan. These targeted reviews focus on conditions the OIG has identified as having an extreme likelihood for overpayment. Nothing is necessarily new in this report, especially since the dates of service were 2015 and 2016 dates of service. The details: -9 different clinical conditions were reviewed for potential over-capture. All 9 of these have been on prior reports. However, this is the first time vascular claudication has shown up in a 2024 report. I suspect that is because the dates of service are older and not representative of an increased emphasis on the condition. -73% of conditions reviewed failed to have supporting documentation. This number is consistent with prior reviews by the OIG. -Interestingly, depression and vascular claudication were supported in 93% of the reviews. This is on the high end and also one of the reasons the OIG has decreased emphasis on these conditions. -90% of heart attack, stroke, and cancer patients reviewed failed to have supporting documentation. The OIG found that in total the overpayment was $297k. However, this is due to the sampling was limited by condition and extrapolated payment penalties were not allowed for these dates of service. Had they been, the penalty would likely have been 51X higher since the OIG identified $15.3M of risk for these conditions. I expect that now that extrapolation is allowed we can expect to see more OIG reviews with larger penalties. Additionally, with yesterday's DOJ settlement with Independent Health and in particular the $2M penalty to former DxID CEO, I expect 2025 will bring more review findings. If you aren't reviewing your risk then you are susceptible for takebacks. https://lnkd.in/e_Sae-79

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Key Strategic Insights = A Successful OP CDI Program The challenge of value-based care starts with a collaborative approach, when launching an Outpatient Clinical Documentation Integrity (OP CDI) program. Here are some key strategic insights to success: 1. Engage with Population Health Understand Pain Points: Begin by understanding the specific challenges faced. This fosters collaboration. Tailored Questions: Use customized questions to facilitate productive discussions and ensure alignment with needs. 2. Effective Software Implementation Manage Patient (Pt.) Volumes: Implement software solutions to efficiently handle pt. volumes. OP CDI Calculator: Utilize a calculator to determine Full-Time Equivalent (FTE) needs. Data Analytics and Reporting: Emphasize the importance of continuous improvement via data analytics. 3. Workflow Creation Establish Robust Workflows: Create strong workflows before integrating reviewers. 4. Collaboration & Communication Promote Strong Collaboration: Encourage robust communication between key stakeholders. Leverage Software: Use technology to reduce physician burnout & streamline communication. 5. Patient-Centered Approach Address social determinants of health (SDOH) & ensure accurate documentation of conditions and care plans. Patient Outcomes: Keep patient care at the center of all doc. & workflow processes. 6. Regulatory Compliance Adhere to Guidelines: Follow regulatory requirements such as CMS guidelines on Hierarchical Condition Categories (HCC) coding to avoid penalties and enhance credibility. 7. Measurable Outcomes Set Clear Goals: Aim for measurable outcomes like improved HCC recapture rates, enhanced RAF scores, better HEDIS measures, and addressing SDOH needs. 8. Stakeholder Engagement Involve All Stakeholders: Ensure that executives, clinicians, and other relevant parties are involved in planning and implementation process. Success Stories Recently, I helped several CDI directors validate their cases for OP CDI programs within Accountable Care Organizations (ACOs). By engaging with population health leadership, we identified key issues such as RAF gaps and HEDIS measures, and tailored processes to address them. For instance, a CDI director I guided successfully identified HCC and HEDIS recapture as their biggest pain points. With strategic solutions in place, they are now ready to implement the project for the 2025 budget yr., aiming to improve their HCC recapture rate by 20%, leveraging data analytics for outcomes and improvement needs. Benefits of Implementing These Strategies Align Risk Stratification: Properly align risk stratification with chronic conditions and healthcare needs. Quality Measures: Improve quality measures and address SDOH. Collaborative Team: Ensure success with a collaborative team supported by technology. Overall, these strategic actions will enhance patient care and operational efficiency. #Healthcare #Leadership #CDI #PatientCare #ValueBasedCare #HealthcareInnovation

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Did you know that in the proposed rule, starting July 1, 2025, agencies will be required to submit OASIS on all patients regardless of payer? There is a 6-month period where it's voluntary to do so, and then mandatory as of 7/1/25. Exceptions include patients under 18 and those receiving personal care, but all OASIS submissions will now impact your agency's outcomes. "This change includes shifting data collection to begin at the start of care (SOC) time point. The SOC assessment, the first for non-Medicare/non-Medicaid patients, can be submitted either on or after Jan. 1, 2025, during the voluntary period or on or after July 1, 2025, for the mandatory period." Have questions? Feel free to reach out to me! Stay informed to ensure compliance and effectively track your agency's outcomes. #Healthcare #OASIS #Compliance #bartlettstrategygroup https://lnkd.in/exWTxnwA

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