Roger N Fowler, MD, FAAFP

Elevating Chronic Care Management through Nurse Care Managers As healthcare continues to pivot towards value-based care models, the role of #NurseCareManagers (#NCMs) in Chronic Care Management (#CCM) has never been more pivotal. NCMs are at the forefront of identifying eligible patients, developing personalized #careplans, and ensuring seamless #carecoordination. But how does this translate into better Quality Payment Program (#QPP) scores and increased incentive payments? First, by identifying patients eligible for CCM, NCMs ensure that those with multiple #chronicconditions receive continuous, comprehensive care. They not only enroll patients but also provide them with the necessary education about the benefits of such programs, leading to higher patient engagement and satisfaction. Secondly, care coordination is the heart of CCM. NCMs work tirelessly to connect the dots between various healthcare providers, ensuring that the patient's care plan is executed flawlessly. This includes managing medication, scheduling follow-ups, and monitoring the patient's health status. The seamless execution of these plans leads to improved patient outcomes and reduced hospital readmissions, which are critical metrics in determining QPP scores. Lastly, meticulous documentation and correct coding of CCM services by NCMs ensure that providers are reimbursed accurately for the care provided. This not only supports the financial health of the practice but also reflects the quality of care in QPP scores. In essence, NCMs are invaluable in navigating the complexities of chronic care, enhancing patient health outcomes, and steering healthcare practices towards higher QPP scores and increased incentives. Let's acknowledge and support the integral role of NCMs in elevating #chroniccaremanagement. #nursesofLinkedIn #innovation #nurseleaders #patientcenteredcare #valuebasedcare #CMS

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Many thoughts as Medicare Advantage continues to come under scrutiny. - MA has features of a value-based program, but most of the current "value" is being delivered through diagnosis capture and complexity payments. Ironically, much like FFS, it pays more to keep people sick (or make them look sick). Don't think that's anyone's definition of value. - To be fair, most doctors (especially specialists) don't do a great job of capturing diagnosis and patient complexity beyond their immediate area of expertise. (We're especially bad at this in MSK). We should have accurate representation of a patient's health in the medical record. Complexity and co-morbidities affect treatments and outcomes. We don't yet have a good way to account for this complexity -- and it's becoming clear the MA system isn't it. - EMRs make all of this worse. It's both too easy and too hard to record, change, or resolve diagnoses. EMRs should facilitate accurate complexity capture and treatment personalization. The goal shouldn't be to increase billing, it should be to increase sophistication and precision. - As MA scrutiny grows, the business model of many alternative care models (especially in primary care) will be challenged (potentially dealing another blow to retail healthcare). - CVS' purchase of Signify health is put into full context by this article. - It boggles the mind that CMS can develop and administer a program that nets billions for inscos (at the expense of taxpayers) while reducing physician reimbursement yearly and rolling out ineffective VBC programs for providers. CMMI should have an open-door policy for anyone delivering care and working on true value-based models. Ears, eyes, and minds should be wide open. h/t Mahek Shah MD, MBA Moby Parsons, MD #medicine #healthcare #vbc #valuebasedcare #health

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By: Don Self, CMCS, CPC, CASA          Karlene Dittrich, CBCS, CPC, CPMA, CECCS         Chris Chapman, CPC, CPMA     Is Your Practice Or Organization Receiving Negative Financially Impacted UHC Responses? , Please  Read Below and Complete Our Short Survey.  The aggregated survey results will be posted on Don's list serve   After listening to the Senate Finance Committee hearing May 1st with testimony by Andrew Witty, CEO of UHG, it was clear that the US Senate & House members DO NOT HAVE A FACTUAL UNDERSTANDING OF UNDISCLOSED ACTS BEING TAKEN BY UHC.   We believe some statements by Mr. Witty to be misleading in nature, especially when considering facts posing financial risk to healthcare organizations.  Mr. Witty said that UHG is doing everything to help physicians, clinics and hospitals and that at no point has UHG or its companies  tried to take advantage of its own cyber attack. He stated that claims are processing implying claims payments are being made but failed to disclose  the relevant denial tactics being applied to the processed claims.  However, we have already observed since the Feb 21 attack, an increase in clients reaching out to us due to "post-payment" medical record requests, refund demands & recoupments/offsets and extrapolation attempts from UHC being received by clinics across the USA, that appear to FAIL to meet compliance with applicable state and federal laws. This is HUGE & the committee seems unaware of such detrimental undisclosed financial acts being intentionally exercised by UHC.  As advocates, we would like to show Congressional members proof in numbers of what is really happening, however WE NEED YOUR HELP to report the magnitude of UHC's attempts to recoup or "claw-back" money (patient benefits) previously paid on claims.   If you received one or more Refund Demand/Overpayment notices, recoupment(s) or offset(s), extrapolation notifications  or "post payment" medical record requests, please help us inform the Senate Finance Committee what is really going on by filling out the short survey in the link below.  The data needs to be close estimates. We are not asking for any PHI, or copies of documents or evidence, yet  Your responses will be confidential and only shared with  us & the committee (without the name of your organization).  Also, please provide us contact information & impacted locations in case we need to reach back out to you.  Please at least include the city/states so that we can provide the Senate Committee with geographically accurate reports.  If the Senate Committee wants to see actual examples or evidence, we will reach out to you with info you can get in touch with them directly.   Short and Optional Survey  https://lnkd.in/gGKhKr2A     The May 1st  recording is available at: https://lnkd.in/g_CaZ-vy    

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Re: RPM services (99453-99458): Wellmed denies they are a Medicare Advantage plan and claim to be a claims processing arm of UHC, so you need to file any appeals with UHC.  We believe Wellmed has not been paying for RPM with any doctor in the country (Even though UHC-Medicare does), so we recommend all clients retrieve ALL RPM devices held by Wellmed patients and explain to them that the insurance plan they chose doesn’t cover it, while all other MAOs do cover it as does Part B and many commercial plans.   We are asking every clinic getting denials from Wellmed to file an appeal with UHC  to:   Dirk McMahan, President UHC Medicare-Wellmed 9900 Bren Road E. Minnetonka MN 55343   CFR 422.100(a) says an MA organization offering an MA plan must provide enrollees in that plan with coverage of all Medicare covered benefits except Hospice services. It's the law, folks.   When UHC denies the appeal – go ahead at that time and file a grievance via fax to CMS Regional at   443 – 330-8886 EACH TIME. Imagine the trouble WELLMED will have if a hundred offices in the country did this.   Grievance: Wellmed Part C MAO:   Patient Name:     ________   HIC #                     _________        Date of Service:                     __/___/___   CPT code (s):   EOB or Remittance Advice # _________________   Date of Remittance Advice:   ___/___/___   Remark Code on denial:       __________   Appeal to UHC was filed on: ___/____/___      UHC denied the appeal on ___/___/___   Medicare Part B has been paying on RPM since 2019 and Wellmed routinely denies this as being non covered, in spite of: “CFR §422.100  (a) Please help this patient get coverage for the services that we determined as their medical provider they should be receiving so they are not being penalized for electing to use a MAO:   Your name:                   ___________________   Phone Number:            _____________________________  Email: ________________________________   Clinic Name:                 ______________________________________   Provider Name:            ______________________________________   Provider Number:         ______________________________________      When you hear from CMS (no matter what they say), PLEASE reach out to us @ donself@donself.com as I need to know what they say. If CMS does not act on this, then we will be filing a grievance with the Office of Inspector General in Washington DC for the CMS employee that is NOT doing their job.     

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Steward Health Care seeks bankruptcy protections This was inevitable with the health system's debt load and leverage of the organization After months of uncertainty about its future, the nation’s largest private, for-profit hospital chain has filed for bankruptcy in Texas. Dallas-based Steward Health Care filed for Chapter 11 bankruptcy Monday, saying it will move to restructure its debt under court supervision and keep running its hospitals across the U.S. — including eight in Massachusetts — as it does so. Steward, in its statement, blamed government reimbursement rates, increasing labor costs, and inflation for its financial difficulties, as well as lingering impacts from the COVID-19 pandemic. "Steward Health Care has done everything in its power to operate successfully in a highly challenging health care environment," said Steward's CEO Ralph de la Torre. Can Ralph de la Torre be believed? His health system was mired in debt, was behind in rent payments to MPT, its landlord, stiffed staffing companies, and countless vendors, yet kept his lavage lifestyle including two expensive yachts, and paid himself well Flanked by health care officials, union leaders and the state's attorney general Monday morning, Massachusetts Gov. Maura Healey placed the blame for Steward's bankruptcy squarely on the shoulders of company leaders. "This situation stems from and is rooted in greed, mismanagement and lack of transparency on the part of Steward leadership in Dallas, Texas," Healey said. #anotherforprofithospitalbitesthedust, ##privatequitygrabsitsmoney, #privatequityextractsprofits, #profitsfirst, #dumpstewart https://lnkd.in/eqc3nhVs

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Another important position statement from Association of Healthcare Value Analysis Professionals (AHVAP). As value analysis evolves, it is vitally important to ensure that those who are entrusted with the process understand what is expected of them in terms of professionalism. Please feel free to share this important document.

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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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Worried about implementing a new call system? Learn more on how easy Clarus technology is for providers, patients and staff!

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In March, CMS announced a new voluntary model, the Accountable Care Organization (ACO) Primary Care Flex Model (ACO PC Flex Model), that will test primary care capitation in CMS’s permanent ACO program, the Medicare Shared Savings Program (MSSP).    In our featured Health Affairs article, we share more about the model, the restrictions on participation and how these factors may impact the ACO market.    Looking for targeted performance improvement to promote clinical, financial and operational excellence in your health system? Check out Premier Inc.’s PINC AI™ Value Based Care Collaborative. Read the full feature: https://lnkd.in/eqk8qsqc

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I'm working with Lyssa Limbrecht-Moss from Optimal 340B and we've determined we don't need any files from the CP to do an audit. We just take one audit download of all NDCs from the TPA and one EMR download from the hospital and we can audit every NDC and dispense for ALL of a hospitals CP for $1,000 total (plus one 3K implementation fee).  Audit is just verifying valid patient status, eligible NPI and location.  No Medicaid check because the TPA isn't accumulating anything when the payor is Medicaid. Doesn't matter if chain pharmacies or all different because we don't get any data from CP directly.  And requires zero implementation or connection to CP. Be SURE (and cost effective) with 340Bsure

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In the 2025 IPPS proposed rule, CMS is proposing to adopt seven new quality measures. Specifically, CMS is proposing to adopt two new eCQMs, one claims-based measure, two structural measures, and two healthcare-associated infection (HAI) measures. Read more about it here. https://lnkd.in/eJnEwURD

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Impact of Policy Changes on SNF Billing Let's know about how recent policy changes affect Skilled Nursing Facility (SNF) billing: 🔹Understand new reimbursement rules. 🔹Adapt to updated documentation requirements. 🔹Navigate changes in Medicare/Medicaid guidelines. 🔹Prepare for potential shifts in billing procedures. Ready to navigate these changes effectively? Let's discuss how they impact SNF billing practices today! Know more: https://bit.ly/452uyGo For more insights, Contact 24/7 Medical Billing Services for a free consultation at  888-502-0537 / info@247medicalbillingservices.com. #SNFBilling #HealthcarePolicy #MedicalBilling #MedicareBilling #HealthcareRegulations #SNFReimbursement #HealthcareFinance #BillingCompliance #MedicalBilling #LongTermCare #SkilledNursingFacilities #BillingUpdates #ReimbursementRates #SkilledNursingFacilityBilling #247MedicalBillingServices

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Is your practice still manually entering information into prior auth forms and portals and faxing your referring providers for missing information? If so, come by and say hello to Lamar Health at booth 428. We automate prior auths from intake right through fill, integrated directly into your system.

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A recent Better Medicare Alliance survey found that Medicare Advantage (MA) beneficiaries in rural areas save more on health care costs and are more likely to use preventative care services, such as mammograms and annual check-ups, than their Medicare fee-for-service (FFS) counterparts.   In particular, the analysis, which was conducted by ATI Advisory, noted the average Medicare FFS enrollee spends 49% more on premiums and out-of-pocket costs compared to MA beneficiaries. This study is significant as the number of MA enrollees in rural areas has quadrupled since 2010. Today, 40% of all eligible Medicare beneficiaries in rural counties are in MA plans. For more information about the report, visit: https://lnkd.in/gEXZcrsy #medicare #medicareadvantage #seniorcare #healthcare

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Exciting news! Susan Maupin and I will be presenting an ACHCU webinar on Hospital Outpatient Strategies on May 23rd. Stay updated on the latest hospital outpatient strategies and related regulatory updates by registering now! Don't miss out on this opportunity to gain valuable insights. #ACHCUwebinar #hospitaloutpatientstrategy #healthcareupdate

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Learn how to write a patient care report that meets industry standards. Craft an effective PCR narrative with this helpful checklist and examples. ⬇

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Give a listen! 🎙️ National Standards Group (NSG) Director, Michael Cimmino, talks on how HIPAA relates to Administrative Simplification and how NSG is addressing administrative burdens in the healthcare system. #HIPAA #HIM #Healthcare #HealthIT #HealthInformation #HealthInformatics #NSG #CMS

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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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