Amber Sharp

Another educated opinion about the need for Prior-Authorization Reform A recent American Medical Association survey found that prior authorization is "wreaking havoc" on patient outcomes, physician burnout, and productivity. One thousand physicians — 400 in primary care and 600 specialists — were asked about prior authorization and its impact on patients, clinicians, and unnecessary spending. Impact on patients Ninety-four percent of respondents reported that prior authorizations created delays in care. Prior authorization sometimes leads to treatment abandonment, with 22% reporting it happens often. Twenty-four percent of physicians reported prior authorization led to adverse events: 19% reported it led to a patient's hospitalization, 13% reported it led to life-threatening events or required intervention to prevent permanent impairment or damage, and 7% reported that it led to a patient's disability, congenital disability or death. Most physicians (87%) reported that prior authorizations led to higher overall utilization, including ineffective initial treatment (69%) and additional office visits (68%). Immediate care or emergency department visits (42%) and hospitalizations (29%). Source: https://lnkd.in/e3mthCp3

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📢 Attention Texas skilled nursing providers! In case you couldn't make it to Friday's crucial webinar discussing the proposed Patient-Driven Payment Model (PDPM) for Long-Term Care Rate Setting Methodology for Texas, fret not! We've got you covered. The Texas Health and Human Services has graciously made the webinar recording and presentation copy available on its website. You can view it here: https://lnkd.in/g4Hjs7Ch Background: Rider 25 in the 2024-25 General Appropriations Act (GAA), House Bill 1, 88th Legislature, Regular Session, 2023, mandates the development and implementation of a Texas version of PDPM for Medicaid reimbursement in long-term stay nursing facilities. This initiative, led by the Texas Health and Human Services Commission (HHSC), is aimed at elevating the quality of care provided to residents. The proposed change is scheduled to take effect September 1st, 2025. Stay informed and be part of the positive change in long-term care! #TexasHealthcare #PDPM #LongTermCare #QualityCare https://lnkd.in/g4Hjs7Ch

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Unlock the future of hospice care with our Strategic IT Review! 🌟 Our comprehensive assessment identifies technology needs for your hospice in the short, medium, and long term, perfectly aligning with your strategic objectives. Plus, we provide an easy-to-understand technology roadmap to guide you every step of the way. #HospiceTech #ITStrategy #CentralTechnology 🖥️🛣️

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Exclusive Update on Medicare Coverage Determination for Special Stains and IHC Stains by Palmetto and WPS Effective July 14, 2024, two Medicare Administrative Contractors (MACs), Palmetto and WPS, have finalized their Local Coverage Determinations (LCDs) concerning medical necessity guidelines for special stains and immunohistochemical (IHC) stains. These determinations, LCD L36805 (WPS) and LCD L35922 (Palmetto), provide clear and stringent criteria under which Medicare will cover these stains. Key Points of the LCDs: *Conditions for Coverage: 1.Medical Necessity: The special stains and IHC stains must be medically necessary to ensure a complete and accurate diagnosis is reported to the treating physician. 2.Communication and Utilization: The results of the stains must be communicated to and used by the treating physician in the patient's treatment plan. 3.Documentation: The pathologist must document in the pathology report the rationale for performing the additional stains. *Prohibitions and Requirements: -A statement in the pathology report that merely says "IHC confirms the diagnosis" will not be considered sufficient for coverage. -The necessity of the stains must be justified with specific documentation within the surgical pathology report, detailing why the stains were performed and the results obtained. *Specifics of the LCD L36805 (WPS): -This policy emphasizes that reflex templates or pre-orders for special stains and IHC stains before reviewing the routine hematoxylin and eosin (H&E) stain by the pathologist are not considered reasonable and necessary. -Only the pathologist may determine the need for special stains after reviewing the routine H&E stain. -Exceptions include recognized standards of care in certain biopsies and the suspicion of infectious diseases. *Specifics of the LCD L35922 (Palmetto): -Like WPS, Palmetto’s policy requires detailed documentation of the medical necessity for special stains or IHC studies and their results in the pathology report. -The policy delineates scenarios where over-utilization or incorrect billing of these stains may occur, such as the use of pre-orders for special stains without prior review of the H&E stain. Implications for Pathologists and Healthcare Providers These determinations highlight the critical role of pathologists in ensuring that the use of special stains and IHC stains is both necessary and properly documented. Healthcare providers must ensure compliance with these guidelines to secure Medicare coverage for these diagnostic tests. Proper documentation and communication with treating physicians are paramount to adhere to these new standards. For further details, you can review the complete LCDs on the CMS website using the following LCD IDs: L36805 and L35922. #Medicare #Healthcare #Pathology #MedicalNecessity #IHCStains #SpecialStains #Palmetto #WPS

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🆕 Pediatric Resource for Working with Private Insurance! Pediatric Concurrent Care: Advocating for Private Insurance Coverage, a new toolkit for NHPCO members, will help inform providers about how to work with private insurance companies to advocate for coverage of concurrent care for pediatric patients. Through this toolkit, hospice staff will learn how to discuss the importance of concurrent care with insurers, how to set expectations with families, the language insurers may use, and examples of working with private insurance companies. Download the toolkit here: https://lnkd.in/gpCu_y4i

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What a great article highlighting the ways the Chronic Care Management (CCM) can bridge the operational gap and transform the way both patients and providers manage chronic conditions.   Through Texas Panhandle Clinical Partner's CCM & RPM services, we handle the heavy lifting of patient coordination and documentation so providers can focus on what they do best - caring for their patients. We make it easy to integrate CCM & RPM into provider practices, ensuring they meet Medicare’s requirements without the administrative hassle.   Key Benefits: - Regular check-ins with patients reduce emergency room visits and hospital admissions. - Enhance patient satisfaction with continuous support and management. - Increase practice revenue with Medicare's reimbursement of $62 per patient per month for just 20 minutes of non-face-to-face care.   Enhance patient care, improve health outcomes, and grow provider practices with our expert support. Contact April Reining at April.Reining@uhsinc.com to learn more and get started.   #HealthcareInnovation #ChronicCareManagement #PatientCare #HealthcareProviders 

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Medicare's rules for incident-to and split/shared services give your practice the opportunity to gain extra revenue for a non-physician practitioner's (NPP) work. But the chance to receive 100% of the physician payment when an NPP does all or some of the work for an encounter comes with the risk of significant pain if members of your practice, including physicians and NPPs, don't follow the rules. Details here: https://hubs.la/Q02wK7QN0

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Hospitals face financial strain as patients seek care elsewhere The traditional hospital business model is under threat as more patients choose outpatient clinics for convenience and lower costs. This shift threatens hospitals' financial stability, especially as some high-profit services move outpatient too. What are your thoughts on how hospitals can adapt and ensure continued access to quality healthcare? #healthcare #hospital #futureofwork

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Choosing a random EHR system and expecting that it’ll meet your practice needs doesn’t work, especially for specialty healthcare practices like behavioral health. Each specialty practice has its own workflow needs. So, while choosing the EHR system, you need to carefully research and analyze the marketplace to choose the right one that meets your behavioral health practice. If you are wondering where to get started, this blog post will be your guide. Read this blog post to learn the 10-point checklist for considering while choosing an EHR system for your behavioral health practice. https://lnkd.in/gGr9Aqw8 #ehr #behavioralhealth #practice #specialty #billing #patient

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New Online Course! CMS-HCC Risk Adjustment Model Version 28: Be Proactive What can you do to mitigate the impact of the Centers for Medicare & Medicaid Services (CMS) Hierarchical Condition Codes (CMS-HCC) risk adjustment model Version 28? This online course reveals a proactive approach to mitigating the potential negative impact of Version 28 through proper identification of diseases and conditions coupled with addressing, assessing, and properly treating those diseases. It follows clinical and coding guidelines to address diagnoses and conditions for which the risk adjustment factor has been eliminated or reduced. It does this through a disciplined approach of reviewing co-morbid conditions, alternative diagnoses, and improved specificity. In all cases, the primary purpose is to treat the patient's diagnoses and conditions to improve the quality of life for the patient. Learn more about this course at https://lnkd.in/eVmECiEs. #CMS #hcquality #patientcare

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Chronic care management offers life-saving services to those battling long-term disease. Yet CCM can also be a burden on healthcare organizations. Why? - Internal teams may struggle to meet the demands of a CCM program in conjunction with their other duties. - It may be expensive to recruit and train the necessary coordinators. Here's how outsourcing this service is operationally and financially preferable: https://lnkd.in/gsJkxw9E

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Learn how Texas Health Dallas, a hospital operated by Sg2 member Texas Health Resources, is focusing on both the patient experience and the customer experience. via HealthLeaders https://bit.ly/3Va3F0Y

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