Matt Whitnack

What is the bottom line if you have financial responsibility for a provider group? Your competitors have the ability to know your contracted rates for everything you do. That's the bad news. The good news is that you can know theirs to help you in your next negotiation.

7

GASTROENTEROLOGY QUARTERLY UPDATES - 3rd Quarter - Live Webinar - July 10, 2024 - 1 hr web - 10am PT - 1 ceu from AAPC. SPECIAL DISCOUNT ADDITIONAL ATTENDEES - sign up first person at regular price - each add'l attendee(s) goes for $99 a person (includes their own connection, materials & ceu's) - limited spaces available at this rate, so signed up soon! Here's link to download registration and fax to (415)892-1271 or register online at McVey Seminars website - https://lnkd.in/g4SAuyic WANT AN AMAZING DISCOUNT? (for a short time this below discount has an extra $50 off for this week only - so take advantage of double savings for a limited time) TO GET THE NEXT 4 GI QUARTERLIES AT THE LOW PRICE OF $735.00 (BRINGS THE COST FROM $230.00 EACH TO $183.75> here's link to do all 4 sessions for 2024/2025 - https://lnkd.in/gNXFUe8 / #gastroenterology #gastroenterologist #gastrointestinal #gastro #gidoc #healthcare #medicalbilling #medicalcoding #medicalbillingandcoding #coding #billing

1

More interesting #news today on #carecoordination and transitions of care, this time specific to bundled payments for hospitals and the #TEAM model. #CMS #Healthcare #reimbursement

2

A recent report from the Office of Inspector General (OIG) has sparked discussions about the effectiveness and utilization of HRAs. However, a closer look reveals that the findings may not fully capture the potential benefits these arrangements offer to both beneficiaries and health plans. HRAs can play a crucial role in enhancing care coordination and empowering members to manage their health costs effectively. They provide tailored financial support, making healthcare more accessible and improving overall member satisfaction. It's important to note that not all diagnoses identified through an HRA or chart review are considered for risk adjustment payments. For instance, if an individual has multiple diagnoses within the same Hierarchical Condition Category (HCC), only the most severe condition is counted, which can impact the financial support available for their care. As we navigate the evolving landscape of Medicare Advantage, let’s advocate for informed policies that recognize the comprehensive needs of our seniors and enhance the role of HRAs in their care journey! 💙 #MedicareAdvantage #HRAs #HealthcareInnovation #PolicyAdvocacy https://lnkd.in/erwBaK9q

2

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.

15

3 Comments

At Reveleer, we understand that accurate data is the cornerstone of value-based care. The recent article by Eric Demers on the impact of inaccurate provider data highlights a pervasive challenge across the healthcare landscape -- fragmented, siloed, and outdated information obstructs care organizations from delivering the best patient care.    That’s why we’re using AI-driven automation to solve this problem — among others — to improve care quality, operational efficiency and optimize financial performance for value-based care payers and providers. And with our recent acquisition of Curation Health - a Reveleer company, we’re even better positioned to make value-based care more effective for everyone. It’s time to bridge the gap in provider data management—because value-based care only works when everyone has the right information at their fingertips.   #ValueBasedCare #DataIntegrity #Reveleer #HealthcareLeadership     https://lnkd.in/gjqixvPR

61

1 Comment

News, mostly AI-related: 1. On the Medicaid front, bad news for Georgia's rollout, which includes a work requirement: https://lnkd.in/gg4i9uSg This gets at a fundamental misunderstanding some conservatives have about public benefits; namely, that there are a number of lazy people who will take advantage if they're not forced to work. Not that it's easy to qualify and maintain Medicaid in other states, but the harder you make it, the lower the uptake. From a purely financial perspective, ensuring that poor people have coverage and access to healthcare lets you treat things preventively and head off more costly measures later on when it's too late (for example, treating advanced diabetes or hypertension because people didn't get screenings or managed their blood sugar or sodium intake/take their meds). Not to mention that everyone deserves access to healthcare, regardless of whether they can pay for it or not or are employed. The easier you make it (fewer qualifications, less hoops to jump through to get and maintain coverage), the more people will use a benefit. And in the case of Medicaid expansion, the federal government picks up most of the tab, so it's a particularly good deal for states. 2. Demo reel from Sora for GenAI video: https://lnkd.in/g8DawWgz A few things here are impressive -- frame-to-frame consistency for both the characters and the motion is solid; a lot of these images are complicated (person riding a creature or creature riding a bike) and the camera movement is also sophisticated; and it does a nice job of mimicking old black and white film. 3. Invisible watermarking for audio and image files. https://www.garandor.com/ Interesting take on protecting IP from unauthorized training; they even have a version that applies adversarial protection if your content is used in Gen AI. It'd be funny to see new foundation or frontier models get unknowingly screwy because they scraped content that had adversarial watermarking.

2

https://lnkd.in/epcXuFNy The Centers for Medicare & Medicaid Services (CMS) approved an amendment to Vermont’s section 1115 demonstration, “Global Commitment to Health.” Approval gives the state authority to provide health-related social needs (HRSN) services and infrastructure support, close the Substance Used Disorder (SUD) Community Intervention and Treatment (CIT) coverage gap by expanding eligibility for the CIT expansion group for eligible beneficiaries up to and including 225 percent of the federal poverty level (FPL), expand Developmental Disabilities Services benefits, and support transition of most Community Rehabilitation and Treatment (CRT) and Mental Health Under 22 services currently covered under the demonstration to the Medicaid state plan.

1

🔥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

37

In case you missed yesterday’s exciting news, Arcadia acquired CareJourney. Aaron Weitzman of Axios wrote about why this deal matters: Insufficient data analytics capabilities are one challenge in the shift to value-based care. However, the industry is moving towards a long-awaited, more open, interoperable ecosystem that requires Arcadia’s data engineering know-how and CareJourney’s strength in data science to navigate.   My colleague Aneesh Chopra (now Chief Strategy Officer for Arcadia) put it simply: “We can basically build the data platforms that organizations need to thrive as they make this transition to VBC from FFS.”   Read more: https://lnkd.in/eEbaB-cw  

130

1 Comment

Let's look at the top professional negotiated rates for a Screening Colonoscopy with BCBS of North Carolina. Do you know where your rates fall? Let's talk.

7

As 2024 concludes, healthcare leaders have gained critical insights amidst rapid advancements and challenges. Here's a glimpse of the year's key lessons: 🔍 Data as a Strategic Ally: Harnessing real-time analytics transforms operations and patient care. 💻 Telehealth’s New Era: Virtual care isn't just an option—it's expected. 🩺 Workforce Resilience: Supporting staff well-being is pivotal for quality care. 💡 Personalized Patient-Centered Care: Building trust through tailored approaches ensures loyalty and satisfaction. 📜 Adapting to Regulations: Proactive compliance safeguards growth and quality. 🚀 Tech Integration: Innovations like AI show promise but demand careful execution. 💰 Value-Based Care's Rise: Aligning rewards with patient outcomes reshapes operations. As we step into 2025, the focus remains on resilience, innovation, and care. These takeaways set the stage for a robust and adaptable future. What 2024 lessons resonate most with your healthcare journey? Let’s connect and discuss! #HealthcareLeadership #InnovationInCare #2024Lessons #FutureOfHealthcare

1

1 Comment

There's still time to sign up for Plug In to Technology! I was able to work with Christopher Copsey on his Connections article (just published today! link below) around creating affinity scores, so I know this presentation, and the others will be fantastic. This is your opportunity to learn how to harness the power of technology in the nonprofit sector, including AI and its impact on fundraising and prospect identification. Plus, uncover the secrets of successful CRM conversions, change management and consolidation, concluding with the essential skill of building metrics for your CRM. As prospect development delves further into how technology can help our organizations succeed, Plug In to Technology will surely help you become a more rounded member of your team! https://lnkd.in/grASQdgM

6

It’s great to see that we covered more US citizens but the overall financial trend is obviously unsustainable. We’ve got to figure out ways to bend this cost curve to something that works over the long haul.

5

CMS’ “Year 2” IRA Guidance Concedes Agency Patient Engagement Has Been a Bust A number of patient groups have quietly expressed frustration with #CMS’ “listening sessions” on the #InflationReductionAct “fair price” negotiations. If you read CMS’ “year 2” guidance carefully, it effectively admits the patient complaints are real and legitimate. The Complaints: Patient groups sat on the sidelines in the litigation challenging the constitutionality of the IRA, at least in part, because they believed that they could shape IRA implementation through agency engagement. But some groups are now expressing frustration. They expected CMS to explain how it was approaching negotiation and the underlying evaluation of the selected drugs. With that context, they expected to be able to provide meaningful feedback to CMS’ plans and preliminary assessments. According to the groups I have spoken to, that is not how things have gone. CMS is tight-lipped—in “listen only” mode. Unclear what CMS is considering and how it sees the “value” question, “patient interaction” on the IRA has devolved into CMS and patient groups staring at each other blankly. Confirmation: When you read the “year 2” guidance, it confirms the patient complaints. Deploying diplomatic “regulatory speak”, CMS says it “intends to improve upon the design of the patient-focused listening sessions”. Note the reference to “listening sessions”—confirming the agency has been in “listen only” mode. CMS admits the need for change, saying it “is soliciting comments from interested parties on event format, scope, and logistics”; it then indicates it “is considering events where there is discussion among speakers and in which CMS may ask clarifying questions”. But even this proposal isn’t getting to the core of the problem—patient groups shouldn’t have to be expert mind readers regarding CMS’ intent based on a few interspersed “clarifying questions”. CMS offers some other alternatives, too: “CMS is also weighing different event formats, such as round table sessions on broader topics with a mix of speaker types (e.g., patients, providers, and health data experts) or focus groups on targeted topics with one speaker type (e.g., patients or caregivers)”. But all that doesn’t commit CMS to doing any speaking. Just that others—patients, providers, and “experts” will be asked to speak. Patient groups can’t react in, or to, a vacuum. No Time: The guidance concedes that they can’t fix the problem for “year 1”. After all, July 31, 2024 is the deadline for manufacturers of selected drug to accept or reject CMS's final MFP offer. Indeed, CMS acknowledges that its proposed changes in patient engagement will be effective only “for…price…year 2027”. So, in another words, at least for “year 1”, we are going to get “fair prices” that don’t reflect meaningful patient input. #drugdevelopment #drugpricing #Medicare #managedcare #rarediseases #patientsfirst #lifesciences

8

9 Comments

Last week, I had the pleasure of presenting ‘Transforming Payer Operations with AI-Powered Process Intelligence’ with Dr. Rodney B. Woods, former Chief Clinical Engineer and VP at BlueCross Blue Shield of Tennessee. Together, we put forward the case for process intelligence and how it can be deployed to tackle the multi-various challenges for US healthcare payers in 2024 and beyond. Here’s a tear sheet with the key highlights:   🔺Top priorities in the healthcare payer landscape: ↳ Member experience ↳ Human capital effectiveness ↳ Admin cost optimization ↳ Regulatory requirements complexity   🔺 Key business challenges facing payers in 2024/5: ↳ Discrete automations ↳ Legacy application landscape ↳ Human centric operations ↳ M&A induced complexity ↳ Fragmented technology landscape   🔺 Existing common solutions to these challenges: ↳ Member experience - journey optimization & process standardization ↳ Human capital effectiveness - enhanced compensation and benefits ↳ Admin cost optimization - outsourcing/offshoring + Lean Management & Six Sigma ↳ Regulatory requirements complexity - compliance software & services   So how can payers address these inter-related, multi-dimensional challenges?   🔸 How Skan is addressing the root causes of critical payer operations: ↳ Operations black box - understanding what humans are doing and the telemetry of work ↳ Understanding process gaps between blueprint and what actually happens ↳ Multi-dimensionality of intersection between people, technology and processes, which are like a Rubik’s Cube   🔸 How Skan’s Digital Twin architecture provides real-time continuous telemetry: ↳ Sensors - to understand human-centric operations ↳ Gateway - AI stitches together end-to-end processes to generate data-driven insights ↳ Analytics - intelligence to inform transformation decision-making ↳ All of the above with zero integrations, no APIs or logs, and a ‘privacy first’ architecture   🔸 Based on the information Skan collects, clients have a 360 view, for… ↳ Workforce intelligence - to optimize utilization and productivity ↳ Process discovery - analyzing process health via time-based factors and cost ↳ Automation - discover opportunities to introduce AI   So from a payer perspective, they can expect to see recognizable returns from embracing process intelligence.   🔹 Process intelligence can transform healthcare payer operations: ↳ Reveal inefficiencies and enhance member experience ↳ Ensure compliance and reduce costs ↳ Unlock data-driven decision-making ↳ Achieve organizational agility   These bullets represent a highly-condensed snapshot of our presentation, so please head over to event download page for more in-depth explanations, case studies and advice for how to proceed with confidence. 🔗 https://lnkd.in/eFk-cpHq #healthcare #processintelligence #healthcaretransformation #payers

30

1 Comment

💨 After a flurry of new customer announcements to end 2024 strong, we’re not slowing down. This week Duke Health and Abridge announced our partnership to improve clinician efficiency and patient care. Abridge will be available to Duke’s 5,000 clinicians in 150 patient care centers across North Carolina—in all care settings, specialties, and languages. Duke and Abridge will also work together on AI research and development. At Abridge, we have developed a unique partnership model where we truly collaborate with health systems to implement our AI clinical conversation platform to meet their particular needs. It starts with establishing relationships with technologists and end-users at each system, developing strong feedback loops where we listen to our partners and make the changes they need to our product and practice. Throughout our engagements, we provide strong data streams and evidence to support our collective learnings, creating a virtuous cyle of communication as we progress. The key to delivering outstanding results starts at the foundation of the relationship. 💪 Read more about our partnership with Duke —> https://lnkd.in/eh62a_RV And if you want to learn more about what makes partnering with Abridge different, Becker's Healthcare is hosting a webinar on the topic next week —> https://lnkd.in/eRyXEn-W

110

3 Comments