The Centers for Medicare and Medicaid Services (CMS) recently announced plans to ramp up its risk adjustment data validation (RADV) audit program in 2020 based on a recent study by the Office of Inspector General (OIG), which found potential issues related to Medicare Advantage Organizations (MAOs) using chart reviews to inappropriately increase risk adjusted payments. …
Concurrent Review for Risk Adjustment – Why “Cleaning As You Go” Works in Healthcare, Too
Posted in Payer SolutionsIf you’ve ever worked in a restaurant or commercial kitchen – you know one of the golden rules is to “Clean as You Go.” Employing a “Clean As You Go” policy is lauded not only for its efficiency, but also for its ability to reduce the risk of problems associated with health, safety and hygiene …
Value-Based Care – It Starts and Ends With Documentation
Posted in Value-Based CareWe’ve all heard the adage – when it comes to healthcare, if it wasn’t documented, it wasn’t done. This couldn’t be more true when it comes to value-based care – particularly as it relates to the Centers for Medicare & Medicaid Services risk adjustment program. This innovative program offers higher payments to providers who deliver …
Revenue Cycle Management- An Interdisciplinary Approach
Posted in Revenue Cycle Management (RCM)In healthcare, providers at the bedside know the care team goes far beyond the nurse and doctor. Delivering the highest quality care requires an interdisciplinary model where experts are called on as needed, information is shared, collaboration and continuous performance improvement are part of the process. Much like a patient’s care team, there are many …
Rev Up Your Revenue Cycle with AI
Posted in Health Information Management (HIM), Healthcare TechnologyWith profit margins shrinking and the cost of health care going nowhere but up, operational leaders and consultants throughout the healthcare industry are looking in every nook and cranny to either find ways to cut costs or generate more revenue. With the ongoing need for costly equipment, an expert workforce and the state-of-the-art facilities needed …
It’s Working – CMS Report Concludes the Effectiveness of Risk Adjustment
Posted in Healthcare Technology, Payer SolutionsIn late June, the Centers for Medicare & Medicaid Services released data demonstrating that its Risk Adjustment Program – developed as part of the Affordable Care Act just five years ago – is working just as planned. What was the plan? To prevent payers from developing plans intended to attract healthier patients and to incentivize …
The #1 Most Critical Driver in the Successful Adoption of Shared Risk Programs
Posted in Healthcare Technology, Payer SolutionsThe unavoidable shift toward value-based and two-sided risk payment models is here to stay – and while the benefits are countless, the journey thus far has been slow and somewhat painful for payers, providers and healthcare organizations alike. Healthcare is one of the slowest industries to effectively adopt technology and the reasons for this are …
Strategies for Mastering Two-Sided Risk
Posted in Payer SolutionsPopulation health and the transition to two-sided risk is no easy feat – it’s a monumental shift in the way providers, payers and hospitals think about the delivery of health care. And, while, we all know it’s coming – knowing how to get there and doing it successfully is the real challenge. While most accountable …
Accurate RAF Scores Could Mean Billions in Savings for Medicare
Posted in Payer SolutionsA recent study published by the Kaiser Family Foundation sheds light on a complex issue – how to determine the real or predicted cost of care for Medicare Advantage plan members when establishing RAF scores is based on the inexact science of provider documentation. The study released this spring indicated that those who were enrolled …