Charity Bogumill

🚨 Coming Soon: How healthcare payers can navigate CMS-0057 & TEFCA 🚨 Are you ready for the upcoming FHIR API mandates? Our latest article breaks down what healthcare payers need to know about CMS-0057, TEFCA, and the critical deadlines ahead. Don’t get caught in the 2025 implementation crunch—learn how to leverage this digital transformation for a strategic advantage. Stay tuned!

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Stay alert, #MA friends! #CMS Administrator Brooks-Lasure told a crowd at an AHA event yesterday the agency is taking on Prior Authorization in #MedicareAdvantage next. Now that their focus on Sales and Marketing is codified, CMS is paying close attention to the stories and complaints they receive about Prior Auth, researching them, and asking for data through RFIs to ensure their conclusions and decisions are data-driven and effective. Word on the street is that politicians on both sides are rallying harder around Prior Auth reform than many other topics as they, and their own families, experience denials, delays and other barriers to care caused by PA. If we've learned one thing in DC, the more personal it feels to decision makers, the more likely we'll see action. Pro Tip: CMS also reminded plans they can change their policies without waiting on agency action. #LeadersDontWait on regulations to make change happen! #NotBusinessAsUsual

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🏥 Healthcare Leaders: Advance Your Data Capabilities for Better Outcomes Learn how effective data governance can significantly enhance healthcare delivery and patient safety. Our webinar will equip you with the frameworks and examples needed to manage your data better. 👨‍🔬 Join Us on May 21st and elevate patient care through data! https://ow.ly/gb8C50RAkLS

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Upon reviewing feedback on the proposed TEAM approach related to patient risk adjustment, CMMI has finalized and added many new variables at the episode level within TEAM to adjust the target pricing accordingly and minimize the risk of mandated participation and losses. Here is the comprehensive list of variables. Hospitals should begin to evaluate and educate their physicians today so that they can appropriately capture the patient acuity. Check it out!

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NCQA has extended the deadline for HEDIS MY 2023 submission to June 28, 2024. In alliance with CMS, NCQA is offering an extended window to submit HEDIS MY 2023 results through the Interactive Data Submissions System (IDSS). This extension recognizes the disruption of the Change Healthcare cyberattack on quality reporting efforts. All organizations that report HEDIS to NCQA may submit data by 5:00 p.m. (ET) June 28. All submissions must be marked final, and attestations must be signed by this time. No additional extensions, late submissions or resubmissions will be considered. NCQA recommends that organizations that report HEDIS through the IDSS, due to state or other contractual requirements, confirm that their agency allows them to exercise this extension.   NCQA strongly recommends that organizations maintain their existing HEDIS MY 2023 operational timeline for submission if no relief is needed. The June 1 plan lock deadline is still encouraged, but it should be applied for all submissions approximately 2 weeks before the final submission deadline to allow auditors time to review the final data.  #HEDIS

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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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