Todd Guren

Interoperability standards continue to shape the #healthcare industry from #CMS regulations to #HEDIS reporting. To set themselves up for continued success, payers must anticipate the coming shifts, and stay ahead of the ever-evolving landscape. 💭 A recent byline in DOTmed.com, Inc from our client Cotiviti dives into the necessary steps payers must take to ensure these standards are met for seamless #dataexchange: https://lnkd.in/ghGB_txj #interoperability #datasharing #FHIR 

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Four things you'll learn in our August 14th, 12:00 PM live webinar with Intermountain Health's Mona Baset, MBA, MA, CHCIO, CDH-E & Endeavor Health's Jim Economou: 1. How Intermountain Health increased NPS by 130% YoY while cutting call abandonment rates by 85%. 2. Why Endeavor Health prioritizes average speed to answer. 3. Why digital healthcare experiences still lag behind other industries. 4. Newly released findings from a survey of 1,500 US patients. Don't miss out! Save your seat here https://bit.ly/3StXTFK #patientaccess #livewebinar #healthit

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How does a $497k chart audit risk turn into a recommended $6.8M recoupment? Impact extrapolation, that is how. The rule now allowing the OIG to recommend larger recoupments are now in effect. This is the first of two audits published today. It isn't too often that the OIG publishes not one, but two, findings reports in a day. Let's dig into the first one. The article linked below is tied to a 2017 and 2018 date of service audit of high risk diagnosis codes by the OIG. Beginning with 2018 dates of service the OIG is able to recommend that dollar impacts reflect the extrapolated error rates from their reviews. This is highly controversial because of financial magnitude and the approach to extrapolation. This marks one of the first ones that I have seen. In this audit the OIG reviewed 240 conditions from the years in question. There are 8 conditions that were reviewed during the audit. They were stroke, heart attack, embolism, sepsis, lung cancer, breast cancer, colon cancer, and prostate cancer. What jumps out to me in this review is the sepsis category. This is the first time I have seen sepsis as a high risk diagnosis. In fact, sepsis and pressure ulcers are in the other review (which I will post shortly). The story continues to be the same. Acute conditions being captured when they often represent historical conditions. In fact for the cancers, strokes, and heart attacks a whopping 93.3% (168 of 180) were found to not be valid. This is in line with prior reviews. Organizations, both payers and providers, must have processes in place to identify and review these. For the sepsis patients, 30% were rejected. While higher than desired, this is significantly lower than other targeted conditions the OIG historically reviews. The call to action for organizations is simple: 1) Know your data- know what patients you have, what conditions they have, and what you are billing for your patients. 2) Increase scrutiny on high risk conditions- if a patient has a stroke, heart attack, or cancer that is captured by a PCP or captured only once in a calendar year it is worth a second review. 3) Educate providers- it is critical to educate providers on the difference between active conditions and historical conditions. There is often no ill intent by providers rather it is matter of coding appropriateness. Leverage your experts to help them know the rules. Enjoy your Wednesday! https://lnkd.in/eX7tjgyB

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Is #ValueBasedCare reaching a tipping point? Early results from Blue Shield of California suggest we're on the verge of a health care transformation, with 56% of health care costs now in a VBC model. And the model is working! This year alone, Blue Shield of California’s Primary Care Reimagined strategy has produced “a 7.4% reduction in overall cost of health care,” says Krishna Ramachandran, senior vice president for health transformation and provider adoption. Read more at: https://bit.ly/3BIaCz9

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⚡️Breaking News in the Health Insurance Industry ⚡️ 4 nonprofit health systems have launched new health plan, Longitude Health Comments from our CEO James (Jim) Rodriguez, FACHE: Ok health insurance carriers…pay attention! Four (count them, FOUR) health systems have banded together to offer a new health plan called Longitude Health. The four owners, investors, operators are Baylor Scott & White Health, Memorial Hermann Health System, Novant Health and Providence. It appears that these delivery systems decided to take the plunge because of the carrier turmoil in their respective regions. For example, in Central Texas there are now only 2 major small group carriers with any real gravitas. They are United Healthcare and Blue Cross Blue Shield with Baylor Scott & White health plan trying to make inroads. And while the literature is shouting that rate increases for 2025 are going to be in the mid-single-digits we are seeing double digits across the board. This new entre may not bode well for the majors. To read the full article by Modern Healthcare, visit the link below. https://lnkd.in/g3EPYn5Y #healthcare #health #healthcoverage #insurance #uninsured #premiumassistance #subsidy #texas  

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One of the most interesting learnings we took away from the recent MESC conference is the critical role third-party liability plays in the Medicaid ecosystem. Too often, other health insurance options are underutilized, driving up costs for Medicaid programs. Josh Schultz shares more from the session ⬇️ https://bit.ly/4d259Al #Healthcare #Medicaid #HealthTech

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