Troy Brumfield

In this blog post written for Health Tech Idaho by Jason Hudson, Rourke Yeakley, MD and I break down in simple, easy to understand principles of why we need to switch away from historical #feeforservice healthcare billing and care delivery. Enjoy!

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California becomes the latest state to attempt the fool’s errand of telling #healthcare interested parties to restrain their margins (#hospitals, #physicians, #pharma, #homehealth, device makers, etc) in the interest of the #TripleAim or else! Wish state legislators the best of luck as policymakers attempt to tame the state’s half Trillion dollar healthcare economy. Never forget Uwe’s Cosmic Rule of Healthcare: “every dollar of healthcare spending = someone else’s dollar of healthcare revenue”. The effort “will require a sustained wrestling match with a sprawling, often dysfunctional health system and powerful industry players who have lots of experience fighting one another and the state.” I’ll say! Heard predicted at a healthcare conference many years ago by Senator Ron Wyden of Oregon “True meaningful #healthcarereform will never happen at the state level”. Add California to the growing list of states to prove him correct. #healthcarecosts #healthcarevalue #valuebasedhealthcare #patientcenteredcare #PrimaryCare #HealthEquity

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Putting $350m at risk is kind of a big deal. BSCA Calpers coup - VBC 2.0 "variation" perhaps? Especially when it's to pay for your administrative services and yet your incentive is aligned to care delivery. The deal between CalPERS, Blue Shield of California and Included Health is more interesting than I thought and maybe it's just because my head is ususally more in payment transformation and VBC in every segment BUT self-insured. Anyways, Matthew Holt got me thinking with his comment that perhaps Blue Shield is not at all ready for primetime of value based care and so it prompted me to dig deeper. What I found fascinated me. Although I still am not addressing the issue of readiness (that's for another day). Follow along with my first ever carousel and take a peek. It's no Eric Bricker, MD video but I combined the facts I found via the interwebs but especiallly a STAT article plus a SLEW of MY OWN ASSUMPTIONS based on my years in the industry so take them with a grain of salt. As all consultants say "it's directional". Basically most health plans need 10-15% of total premium to do all the health plan things and have some margin if they are lucky and then whoever takes risk on the medical spend has to manage the rest be that the insurer or the health plan. Well in the case of the Calpers deal they got creative, even though Calpers is on the hook for the medical spend since they are self insured, they were tired of Elevance Health collecting their healthplan admin fees while they were left holding the proverbial bag. So, they got Blue Shield and Included to put 75% of their admin fees at risk (that's $350m) with measures they have to meet for quality and care cost to earn those dollars. When I made some assumptions and did the calcs, that means they have to try to help Calpers shave 13% of their medical spend off in order to get their admin fees. Great idea if you ask me and I'd love for BP2 Health to be part of making this a success Paul Markovich and Owen Tripp. I'm sure this has been happening for a while in the self-insured space and I'm somehow just now coming out from beneath the rock. In case others are as well, I thought I'd share. Colby Schaeffer Eric Bricker, MD Preston Alexander

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Pain score and pain relief documentation are critical for prior authorizations because they offer objective evidence of the patient's condition and the treatment's effectiveness. Pain Physicians: How do you ensure that this information is accurately and consistently recorded? https://lnkd.in/dbr-bnZT

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Final Step 8: Adding Immediate Value. We guide you in implementing value-added services and operations that not only prevent revenue loss but also propel your practice to new financial heights using the findings from the practice evaluation in step 4. Transform your practice's financial health. Join us today for a free consultation to discuss our proven 8-step process for buyers at https://lnkd.in/gN-q7PRf or click the link in bio. #DentalPracticeBuyer #ASDA #NewDentist #DentalCoachUSA

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Care is moving home... USC Schaeffer Center study published in JAMA detailing the benefits of hospital at home. Benefits include: Patient Preference: Many patients prefer receiving care at home due to the comfort and familiarity of their environment, which can positively impact their recovery experience. Safety and Confidence: The majority of surveyed individuals feel safe managing medications and care at home, indicating trust in home-based healthcare services. Faster Recovery: A significant portion of respondents believe that recovery is quicker at home, potentially reducing the overall burden on healthcare facilities. Cost Efficiency: Hospital-at-home care can lower costs by reducing the need for hospital stays, which often include higher overhead and resource expenses. Policy Support: Temporary programs allowing hospital-at-home care during the pandemic have been extended, reflecting positive policy momentum and recognition of its benefits. At Corstrata, we have been providing wound and ostomy specialized virtual consultations for hospital systems that have implemented hospital at home services for over two years. These multidisciplinary, collaborative consultations increase access to scarce WOC Nurse resources- improving care at a lower cost. https://lnkd.in/eMr4AWk7 #hospitalathome #clinicaloutcomes #valuebasedcare #Corstrata #woundcare #ostomy #WOCN

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Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

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As the days grow longer and the sun shines brighter, it's time to embrace your own journey to recovery. At Passages Malibu, we understand the pain and struggles of addiction. Our holistic, non-12-step treatment center offers a unique and personalized approach to healing, targeting the root causes of addiction—not just the symptoms. Imagine starting your path to sobriety in the serene beauty of Malibu, with luxurious accommodations and a dedicated team supporting you 24/7. Our integrated therapies and one-on-one counseling ensure a high success rate and long-term sobriety. This Summer Solstice, let the light of a new beginning guide you. Don't wait any longer—take the first step towards a healthier, happier life. Contact us today to learn how our top-rated services, accepted by most insurance plans, can help you reclaim your life. 🌞 Embrace change. 🌿 Heal holistically. 🌊 Experience Passages Malibu. Call (866) 361-5809 today. #PassagesMalibu #LuxuryRehab #AddictionRecovery #SubstanceAbuseHelp #Non12Step #MalibuHealing #Alcoholism #Alcoholic #PersonalizedRecovery #HolisticHealing #ExclusiveRehab #TransformativeCare #SummerSolstice

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Exciting news for physician practices! DiaSante Health, LLC is changing the game with cutting-edge virtual healthcare solutions tailored specifically for your practice. DiaSante's Remote Patient Monitoring (RPM) and Chronic Care Management (CCM) services empower physicians to thrive in today's healthcare landscape. Utilizing wearable devices, RPM enables early detection and personalized interventions, while CCM services offer regular check-ins on high-risk patients—extending your care without increasing staff workload. The results speak for themselves: practices using DiaSante have reported significant increases in net revenue and reductions in ER visits among RPM program participants. These solutions revolutionize healthcare delivery, allowing physicians to deliver superior care, boost revenue, and enhance patient satisfaction. In a world where value-based care reigns supreme, DiaSante's solutions are custom-built to support physicians in delivering quality care while ensuring financial stability. As patients live longer with multiple chronic conditions, the need for personalized care has never been greater. Ready to transform your practice with DiaSante? Reach out to me via LinkedIn or email at jim@pittmarketingllc.com to arrange a demonstration or learn more from our experts on how DiaSante can revolutionize your practice. #DiaSante #RemotePatientMonitoring #ChronicCareManagement #HealthcareTransformation #PhysicianPractice #PatientOutcomes #PracticeGrowth #RPM #CCM #ValueBasedCare #ImprovingOutcomes

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On my free listserv https://lnkd.in/gYHg8z5A I've had since 1996, a member posted that UHC was denying for timely filing - and asked about the suspension of timely filing due to the UHC/Change Healthcare breach. I replied: Insurance companies have been lying to medical providers for many years and the problem is that more than 99% of medical providers, their managers, and their billers believe the lies.  Please don’t take offense as you’re in great company, but the problem is that they probably have you convinced, like everyone else, that the timely filing limit is what THEY tell you it is. Everyone Believes Their Lies!   What is the TRUTH?   1. The timely filing if it was truly enforceable is only what the patient’s insurance plan says it is, regardless of anything your doctor may have signed.  So – what does that policy say?  98% of people have no idea as they never look at the policy the patient has.   So – the carrier can say “you have a 120 day limit but the patient’s policy usually says 1 year.  The patient’s policy ALWAYS supersedes the lies told by the carrier or the timely filing period the agreement has. We prove this with the laws in our full day seminar. 2. Next – for something that almost no one in the medical field knows – including 99% of healthcare attorneys,   Karlene and I show folks in our full day classes exactly where the government says that timely filing periods are not enforceable with commercial insurance plans. Yes – ANY timely filing period. No – I’m not giving that away for free in this post – as you need to attend the full day seminar we’re teaching in 13 different cities this year.      3. We also show you how to appeal claims from 6 years ago and win simply because a requirement is not met before the timely appeal period BEGINS.  Remember – the timely appeal period doesn’t begin until a specific thing is accomplished or performed and if that is not performed, the timely filing period does not start.   That is something else we teach in our full day classes along with other tidbits that will shock most people.     Anyway – yes – you can win on those UHC timely filing denials almost every time – even the UHC Medicare claims as Medicare Part C plans lie to you about timely filing also. The next one is in Schaumburg Illinois at the end of this month (24th) and it’s almost full. I think we have 23 or 24 people registered for it already. San Diego in August is filling up quickly too.   Don

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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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Explore the world of medical practice valuations with Clevehouse Advisors! Our latest blog post has everything you need to know. 🔗 https://lnkd.in/gmpfaJBj Check it out now! 💡 #MedicalBusiness #FinancialInsights #ClevehouseAdvisors

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"Do these financial incentives lead to more innovation in the Medicare Advantage plans?" This is a quote from our latest guest, Peet van Biljon, and the existential question for Stars. In this snippet from our latest episode of Rising Stars, Peet Van Biljon and Nate Lucena join Rex Wallace and me to explore the impact of innovation on the Stars program. This episode had so much depth that we had to turn it into a 2-parter, so stay tuned for more snippets from this episode and soon, part 2 will be released. You can watch the full episode here: https://lnkd.in/gzUFHFeg 

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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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The First Episode was released on YouTube @TheRightCredNtwk and on Spotify. Thank you, Yesenia, for being my first guest. This educational tool for medical services professionals is just the beginning. Tune in and stay tuned. Episode 2 is coming out soon. #credentialing #Medicare #Enrollment #Medicareenrollment #medicalservicesprofessionals #MSPs #Podcast #SCOPE #patientsafety    

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Across the healthcare industry, inpatient denial claims are skyrocketing - and inflation is decimating providers’ financial stability. According to a recent report from Becker’s Hospital Review, the final denial rate on inpatient claims increased by a staggering 51% between 2021 and 2023 alone. This surge in denials is concerning for several reasons. Not only does it drain $1.2 billion in revenue that hospitals and health systems rely on to provide care to their communities, but it also means that hospitals are spending more money and resources to appeal these denials. The increase in initial denials on inpatient claims for prior authorization and precertification errors is particularly alarming. These errors rose by 26% from 2021 to 2023, adding to the financial burden faced by healthcare providers. As providers navigate these challenges, companies like No Surprise Bill must advocate for a fairer system that prioritizes patient care over profits. I encourage you to read the full report for more insights into this critical issue - click the link in the comments below to learn more.

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Transparent pricing allows you to avoid overpaying, make informed decisions, and compare prices. More importantly, transparent pricing builds trust by showing a company's dedication to honesty and integrity. Trust is crucial in healthcare as we "first, do no harm" when caring for patients. I am thrilled that LookDeep Health offers transparent pricing to our customers recognizing the importance of trust and relationships in healthcare. #trust #healthcare #AI

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Hang your head KFF on Managed Care Margin Story Winner of the misuse of stats award for July KFF says “the end of 2023, gross margins per enrollee ranged from $753 in the Medicaid managed care market to $1,982 in the Medicare Advantage market. Gross margins per enrollee in the group and individual markets were $910 and $1,048, respectively, roughly half the level observed among Medicare Advantage plans on average.” What’s the CMS OACT $ per enrollee: Medicaid is $6,838, say gross margin is 11 Medicare is $15,689, say gross is 12 Private is $7,247 say gross 14 Now what I just did was wrong as MA spends less than Medicare FFS and there are other factors that should be accounted for in any analysis. But at least I didn’t compare three v different population bases and conclude one was twice as high. In comparison the last Walmart gross margin was 24 percent. KFF had a tough contender in the Peterson medical debt study (stock/flow, poorly targeted) #MA #KFF https://lnkd.in/eSN_hRfX

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In policy analysis, differentiating between intended versus actual impact often guides the process. Why would hospitals not favor such policy? “Under TEAM, selected acute care hospitals would be responsible for coordinating and improving care for Medicare patients undergoing certain surgical procedures. This includes ensuring that patients receive high-quality care during and after surgery, and referring them to primary care services to support long-term health outcomes. Hospitals would also be accountable for the cost and quality of care from surgery through the first 30 days after the patient leaves the hospital. The model would be performance-based, with CMS evaluating hospitals by comparing their actual Medicare spending to a target price. CMS would also evaluate quality measures such as hospital readmission, patient safety, and patient-reported outcomes. The model would apply to hospitals paid under the Hospital Inpatient Prospective Payment System (IPPS), and the performance period would run from January 1, 2026 to December 31, 2030. Surgical procedures that would initiate an episode include: lower extremity joint replacement, surgical hip femur fracture treatment, spinal fusion, coronary artery bypass graft, and major bowel procedure”.

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