The Terry Group’s Post

Over 100 hospitals, health systems, and providers have jointly advocated for enhanced Centers for Medicare & Medicaid Services oversight regarding Medicare Advantage (MA) denials. Premier Inc., a leading healthcare services company, spearheaded the initiative, urging CMS Administrator Chiquita Brooks-LaSure to mandate thorough data collection on MA claim denials and enforce compliance with Medicare coverage guidelines.   Premier's survey findings underscored the severity of the issue, revealing that while 15% of claims to private payers are denied, Medicare Advantage claims face a slightly higher denial rate of 15.7%. Moreover, hospitals incur an average administrative cost of $47.77 per appeal for denied Medicare Advantage claims.   In their letter to CMS, the healthcare entities emphasized the importance of monitoring MA plans' expenditure on direct patient care to ensure alignment with beneficiaries' entitlements. Notable healthcare providers, including CommonSpirit Health, Ascension, and AdventHealth, joined the call for CMS action.   Our RCM team plays a vital role in supporting hospitals by analyzing denial patterns, identifying underlying causes, and implementing effective strategies to minimize denials. Leveraging our expertise in Medicare Advantage regulations, we facilitate efficient appeals processes and advocate for fair reimbursement, ultimately striving to alleviate financial burdens on hospitals and uphold patient care standards.   We are the One!   #revenuecycle #revenuecyclemanagement #priorauthorization #medicalbilling #medicalcoding #healthcare #healthcaretechnology #accountsreceivables #denialmanagement #consulting #management #implementationpartner Becker's Healthcare

The ACO Primary Care Flex Model aims to ease financial burdens for low revenue ACOs while encouraging tailored patient care and a focus on health equity, CMS said. One-time advanced shared savings payments of $250,000 are meant to help providers with the costs of forming an ACO, as well as administrative costs tied to program participation, according to a news release. The monthly, prospective payments would replace Medicare fee-for-service pay for primary care. #valuebasedcare https://lnkd.in/gZiTK8iX

🚨 Big News in Healthcare Payment Reform! 🚨 Senators Sheldon Whitehouse (D-RI) and Dr. Bill Cassidy (R-LA) have introduced the Pay PCPs Act to revamp how primary care providers are compensated under Medicare. This legislation aims to address the primary care physician shortage, enhance patient outcomes, and reduce healthcare costs. Key points include: - Hybrid payment models rewarding quality care. - Reduced cost-sharing for Medicare beneficiaries. - Establishing a technical advisory committee for accurate fee schedules. Let's drive the change towards a healthier future! 🌟

Understanding MA plans’ regulatory obligations and your enforcement options is critical. We help negotiate contract terms that align with plans’ commitments to CMS giving providers a direct and clear means to enforce payment rules.

It continues to be encouraging to see the commitment that the Centers for Medicare & Medicaid Services has toward expanding and enriching pathways for more #Medicare patients to receive care in an accountable relationship. This Health Affairs Forefront article authored by CMMI and CMS leadership summarizes those efforts and highlights the proposed change in the 2025 Physician Fee Schedule introducing Advanced Primary Care Management billing codes to help support primary care practices that are delivering more robust care management and advanced primary care services to Medicare patients. As with RPM and CCM codes I expect that a small subset of practices will engage in these billing codes initially, but for those who are well setup to do so it provides a more sustainable funding mechanism to bring more dollars into Primary Care and help to create a hybrid financial model between FFS and Full Capitation. I’m curious what others think about these proposed codes https://lnkd.in/eurGqvPW

A significant portion of healthcare spending is allocated to patients in their last year of life. Specifically, studies indicate that approximately 25% of Medicare expenditures are spent on beneficiaries during their final year. This statistic highlights the substantial financial resources directed towards end-of-life care, reflecting the intensity of medical services utilized during this period. Moreover, it has been noted that 62% of individuals in the top 5% of healthcare spenders are often those who are nearing the end of life, further emphasizing the concentration of healthcare costs in this demographic. This trend is consistent across various healthcare systems, where end-of-life care tends to consume a disproportionate share of overall health budgets.

Health Affairs provides the authors (Centers for Medicare & Medicaid Services leaders) an opportunity to summarize their portfolio approach to achieving the stated goal - having 100% of Medicare beneficiaries in an accountable provider relationship by 2030. This is a helpful for those of you looking at the #valuebasedcare national landscape over the next three to five years, especially if you are supporting or selling into providers and provider organizations.

A new report from MedPage Today reveals a significant increase in prior authorizations within Medicare Advantage plans, closely mirroring the rise in Medicare Advantage enrollment. As more seniors opt for these plans, healthcare providers are feeling the unfortunate impact of added administrative hurdles. Prior authorizations play a critical role in ensuring that patients receive appropriate and cost-effective care. With healthcare constantly changing, it's important for providers and patients alike to stay informed about these trends and develop strategies to streamline the prior authorization process. #healthcare #medicareadvantage #priorauthorization

Medicare Advantage plans have financial incentives to manage and coordinate their enrollees’ health care. Plans may, in turn, pass along these incentives to their enrollees’ providers, particularly primary care physicians. If plans provide resources to primary care physicians to help them manage patient care more effectively and efficiently, all patients seen by a practice might benefit, including those in traditional #Medicare. But if plans add onerous requirements that make it more difficult to provide care, there could be adverse effects for patients and physicians alike. In a new study, The Commonwealth Fund’s Arnav Shah and Gretchen Jacobson examine results from a survey of primary care physicians and data from Medicare claims to identify differences in care delivery, care coordination, and administrative burden between physicians treating predominantly #MedicareAdvantage patients and those treating mostly traditional Medicare patients. The findings tell a complex story, one with important implications for patient care, primary care practices, and Medicare policy.

Opportunities to Improve PCP Care Coordination for both Medicare Advantage and Traditional Medicare Patients The Commonwealth Fund published research findings this week comparing care coordination among Medicare Advantage patients compared to traditional Medicare patients. They found few differences in care management for patients with chronic conditions, including treatment plans and written instructions to patients on managing their own care at home. These research findings point to an opportunity for plans to provide resources to PCPs to manage their patients more efficiently. Specifically, plans should enable efficiencies to contact patients between visits to monitor their conditions. Vironix offers exactly that efficiency with our AI-enabled virtual care management services. Our software provides patients, caregivers, and care teams with real-time updates on patient vitals . Our care teams communicate with both patients and their physician’s teams to avoid condition deterioration, hospitalizations, and emergency room visits. Our care management services provide efficiencies to avoid staff and caregiver burnout. Contact us at support@vironix.ai for more information. #medicareadvantage #remotepatientmonitoring, #healthcareai #healthcareinnovation #remotepatientmonitoring #remotehealthcare Sumanth Swaminathan Botros T.s Ram Reddy Sriram Ramanathan Jatin Rajput Christopher Chew Nicholas Wysham Chris Landon Mahesh Visvanathan Emily Twanmo, MBA, MHS Andrew Paolillo Jeff Hanson, MPH Shadin Hilton MS, MBA, RNC, PMP, CPHQ https://lnkd.in/gCdvpPet