Value-based care
Two reasons why the 2027 OPPS proposed rule hurts your hospital
By Brian Murphy The 2027 OPPS (outpatient) proposed rule landed just prior to the July 4 holiday weekend. CMS’ timing is conspicuous, presumably to dodge the tomatoes hurled at it from the likes of the American Hospital Association. Not a whole lot of great news in here for healthcare orgs; here are two and…
Read MoreDo hospital ratings matter? Here’s what your peers say
By Brian Murphy Hospital ratings: Does anyone care? Healthgrades earlier this year announced its top 50, top 100, and top 250 hospitals awards. Links below; do you see your home state or hospital represented? Some heavy hitters made the Top 50 Hospitals list (though none from my home state of MA, which is traditionally…
Read MoreMedicare Annual Wellness Visits (AWVs) a fantastic risk adjustment tool–but don’t sleep on FFS
If you work in outpatient CDI you might have already reached the conclusion that the Medicare Annual Wellness Visit (AMW) is your friend. You’d be right. The AWV is first and foremost a tool for preventive screening and health. But it’s also a powerful tool in the arsenal of mid-revenue cycle work. For Medicare Advantage…
Read MoreCMS 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…
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