Medicare Advantage Audit Ready with AI
Adding generative AI and other AI tools to coding and chart review practices streamlines a complex process and better positions plans for risk adjustment audits.
Making the Most of Structured Data
As the industry strives for data use that is standardized, consistent, and fluid, payers that automate data flow, in the long run, will be able to discern the risk of each member and prioritize their needs to drive member services for outcomes-based care delivery.
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How PDPM Optimization Improves Facility Financial Performance
Transitioning to PDPM models significantly shifted the healthcare industry. By replacing the RUG system, healthcare providers cut waste and more accurately reflect the care each patient received.
Top 5 Medicare Advantage plan changes coming for 2022
The greatest uncertainty is members' health status, which could impact MA organizations’ bidding submission process for 2022. Fortunately, fully vaccinated members are likely to resume in-person care this year, which means MA plans can expect a more consistent and reliable stream of data to form financial projections.
What health plans must know about telehealth’s immediate impact on risk adjustment
When CMS approved telehealth as a means for health plans to gather risk adjustment data it made the right move, as it is critical for Medicare Advantage (MA) plans to stay on track with risk adjustment.
Appeals court upholds ACA risk adjustment
The appeals court overturned a New Mexico court’s ruling that the risk adjustment approach was “arbitrary and capricious.”
Sutter Health settles Medicare Advantage upcoding case for $30 million
Sutter Health was allegedly involved in a practice called upcoding, which refers to the submission of incorrect or exaggerated information about the health status of a beneficiary in order to receive a higher payout from CMS.
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Why Your Patients Are Leaving and How to Stop It
Patient expectations continue to evolve, and healthcare practices that fail to adapt risk more than just revenue—they risk losing trust.
Report: Three-fourths of Medicare Advantage denials overturned on appeal
The report from the Inspector General comes amid increasing scrutiny of Medicare Advantage organizations for potentially overcharging the government for services.