Value-based care
CMS Failure to Rescue quality measure financial impact hitting soon
By Brian Murphy A reminder: The new CMS Failure to Rescue (FTR) quality measure is going to hit hospital pocketbooks—possibly your own—on October 1. Key details of the new CMS FTR measure (FY 2025 IPPS Update) Definition: The percentage of surgical inpatients who experience a complication and subsequently die within 30 days of their initial…
Read MoreCMS 2027 Medicare Advantage final rate announcement: What changed, what it means
Regardless of how you feel about Medicare Advantage (MA), CMS is doubling down on the embattled program with the 2027 MA and Part D Rate Announcement. CMS reversed course on the advance notice and removed a proposed risk model recalibration which would have resulted in a payment cut for most MA plans. Instead, MA plans…
Read MoreA must watch: New CMS video signals new metric for Medicare Advantage
By Jason Jobes The 2027 Medicare Advantage final rate notice is out—and the buzz is everywhere. Let me just say I rarely pause to watch a video, much less one that is 20 minutes. This one is a MUST watch if you are in risk adjustment. Last week “Health Tech Nerds” hosted an interview with…
Read MoreGrassley Report of UnitedHealth Group takes aim at these 20 diagnoses: Here’s why
By Brian Murphy The Grassley Report examining the risk adjustment practices of UnitedHealth Group (UHG) is much more than just a one-time media splash. The report is 105 pages long and contains a wealth of information and insight into how UHG does its work. This includes the criteria it uses to report diagnoses to…
Read MoreMedicare Advantage plans: Should healthcare organizations care about payer audits, fines? Hint: Yes
You are a CDI Director at a large integrated healthcare system, with oversight of staff working in acute care hospitals and clinics. You have patients with Aetna and Kaiser Permanente. Then the news hits: Kaiser agrees to pay $556M to settle false claims act (FCA) allegations for inflated risk adjustment coding. Aetna, $117M for similar…
Read MoreFinancial success of Comprehensive Care for Joint Replacement (CJR) model paved way for TEAM
By Brian Murphy The Comprehensive Care for Joint Replacement (CJR) model is over, and it generated savings to Medicare. How much? We await the grand total, as final performance year financial results are expected later this year. But the latest, just released data (see attached graphic) shows that the CJR generated a whopping $112.7…
Read MoreYou need to have it both ways: Audits must target missed coding opportunities and invalid conditions in risk adjustment
By Brian Murphy Among the alleged behaviors that led to Kaiser’s eventual $556M payout to settle false claims act allegations was its aggressive effort to only add diagnosis codes (up to a year or more after the encounter) and never remove them. This is called a one-way audit, and the Department of Justice does not…
Read MoreRisk Adjustment Reality Check: What’s Working—and What Isn’t
Listen to the podcast. This year has been something of a reckoning for Medicare Advantage. Senator Grassley’s scathing report of UHG’s risk adjustment practices, and the Kaiser $556 million settlement to resolve False Claims Act allegations of upcoding, opened eyes, and got many in the industry talking. I wanted to get someone on the show with opinions, unafraid to speak their mind and share their perspective. I’ve found that person. Betty Stump is Senior Solution Consultant…
Read MoreNorwood publishes analysis of CMS 2027 Advance Notice
Download the guide here. Medicare Advantage just shifted again — and 2027 is already reshaping your 2026 strategy. If you think the 2027 Advance Notice is just another routine CMS update… think again. Inside this guide, we break down: 📉 A projected $1.2M funding reduction per 10,000 MA lives 📊 $2.3M impact tied to coefficient…
Read MoreA reckoning for Medicare Advantage: Inside the Kaiser case with Mary Inman and Liz Soltan
Listen to the episode here. Medicare Advantage is undergoing a reckoning … and that reckoning is coming from within. In January Kaiser Permanente affiliates agreed to pay $556 million to resolve allegations that it violated the False Claims Act by submitting invalid diagnosis codes for their MA Plan enrollees in order to receive higher payments…
Read More