Christopher Draven

That’s a wrap on the 24th Risk Adjustment Forum! It was great seeing you all there. If you’d like to discuss your organization’s risk adjustment strategy further or we didn’t get a chance to connect, let’s set up a time. #DataLink #Events #RiskAdjustmentForum #Ri

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ON-DEMAND WEBINAR: Is your RCM partner up to today’s security challenges? If you’re unsure, it’s time to find out. Watch to uncover how recent cybersecurity events have refocused vendor-selection requirements and what to evaluate during review.  #Cybersecurity #RevenueCycleSecurity #RCMSecurity

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Eager to excel in culture for data analytics? Check out this video (https://gag.gl/pyIZs2) featuring Jeff Fuller, MS, FACHE from his latest talk on healthcare analytics and data governance to the Greater Kansas City HIMSS Chapter.

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HHS and CMS with some important updates around ACA compliance - check out the details outlined in the Edifecs post below. We take a closer look at the most relevant pieces of these three major updates.

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Healthcare systems must recognize the importance of both HHS-HCC and CMS-HCC risk adjustment models. While the CMS-HCC model remains crucial for Medicare Advantage plans, the HHS-HCC model provides essential insights for managing risks in the broader ACA market. Understanding and integrating both models ensures that healthcare systems can deliver high-quality care, maintain financial stability, and comply with regulatory requirements across different patient populations. By doing so, they can better navigate the complexities of modern healthcare delivery and funding, directly impacting our quality of care. Healthcare systems benefit from integrating knowledge of both models to: 1. Enhance Comprehensive Care: By addressing the needs of diverse populations. 2. Improve Accuracy: In risk assessment and resource allocation. 3. Ensure Compliance: With federal regulations and market requirements. 4. Promote Equity: In healthcare access and funding.

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Unpacking the CVS MA success #medicare #cvs Enrollment, Experience, Quality, Leverage, Simplification in 5 words. CVS Aetna has achieved significant success with Medicare Advantage through several key strategies: 1) Strong Enrollment Growth -- Enrollment Aetna has experienced industry-leading growth in Medicare Advantage enrollment: - They saw 15% growth during the annual enrollment period, reaching around 4 million total members. - Aetna attracted about one-third of the 1.7 million new Medicare Advantage beneficiaries in 2024. - They added 544,000 new members in 2024, bringing their total to 3.9 million beneficiaries. 2) Focus on Member Experience and Benefits -- Experience Aetna has prioritized offering compelling benefits and improving the member experience: - Every county where they offer a plan has options including $0 primary care with no monthly premium, $0 cost sharing for tier one drugs, and dental, vision and hearing benefits. - They improved by nearly one star in the Member Experience survey domain. - Aetna achieved 5 stars in Care Coordination and delivered 5-star performance for low member complaints and low disenrollment rates. 3) Quality Ratings -- Quality Aetna has maintained strong quality ratings from CMS: - 87% of Aetna Medicare Advantage members are in plans rated 4 stars or higher for 2024. - Their National PPO contract improved to an overall 4-star rating. - They achieved 5 stars in key measures like Breast Cancer Screening, Controlling Blood Pressure, Diabetes Eye Exam and Annual Flu Vaccine. 4) Leveraging CVS Health Assets -- Leverage Being part of CVS Health has allowed Aetna to offer unique capabilities: - They can provide access to MinuteClinics, CVS Pharmacy locations, Signify Health home visits, and Oak Street Health primary care clinics specializing in senior care. 5) Strategic Market Approach -- Simplification Aetna has taken a targeted approach to expansion: - They've focused on plan simplification and enhancing their value proposition for members. - The company has made strategic efforts to establish a strong presence in the Medicare Advantage sector. While Aetna has seen strong growth, it's worth noting that this rapid expansion has also led to some challenges, including rising medical costs that have impacted CVS Health's overall financial performance. However, the company is taking steps to address these issues and maintain its competitive position in the Medicare Advantage market.

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Found this article on enterprise risk management software in healthcare really insightful (but maybe I'm biased)! It's a great quick read for anyone in the industry looking to enhance compliance strategies. Highly recommend giving it a look! #HealthcareCompliance #RiskManagement #CompliancyGroup

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Completely agree Joshua Liu. Tech will not solve your problems for you if you don’t have a clear view of how the tech will fit into your environment, your needs and your goals - which are defined and driven by your people and processes. Need to start with “what is it that you are trying to achieve and why?” Then evaluate holistically considering the people, process and technology needed to achieve that goal. Your tech solutions may change dramatically once going through this approach.

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Go beyond the buzz of #AI in our latest article, where risk adjustment expert, Melissa James CPC, CPMA, CRC, unpacks what AI can and can't do in risk adjustment: https://ow.ly/TIM050TGKms #riskadjustment

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We hear “AI” and “machine learning” everywhere these days—but what do they actually mean?   My colleague Natalia Arzeno-Gonzalez puts it simply:   Machine learning models (MLMs) are all about math.   They identify patterns, make predictions, and uncover insights from data that humans can’t process alone.   Here’s the kicker: ML isn’t just a part of AI—it’s the foundation.   From predicting claim denials to improving workflows, MLMs are the engine behind smarter healthcare solutions.   Want to understand the basics? Natalia breaks it down in this clip: https://lnkd.in/eGk9bajf

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Provider dissatisfaction with #MedicareAdvantage plans is growing, threatening network adequacy. On the blog, #ECGMC’s Ed Moran, Chris Costa, and Joe Casini offer 3 considerations to help #payers improve provider relations. https://lnkd.in/gUxqjqAR

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Claims denials continue to torment providers, and the challenge is growing, according to a Sept. 24 report from Experian Health. With #MDaudit Revenue Integrity & Revenue Cycle solutions you can address 20% of your high-dollar claim denials that drive 80% of your revenue impact, and maximize reimbursement with AI-powered technology. #RevenueIntegrity #Denials https://lnkd.in/e_KRCGd7

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We just announced a sneak preview of the next big thing for our practice product: DSO Analytics  What is it you may ask? This is the first AI-powered analytics suite built specifically for DSO’s. It enables executives to transform mountains of data into actionable insights to improve their organization’s performance, from case acceptance and productivity rates to treatment planning efficiency. Leaders can get a comprehensive view of their entire organization or drill down to see the performance of a clinic or specific provider level to uncover opportunities for education to improve patient care. In short, it’s a game changer for DSO leaders.https://https://lnkd.in/eKP6QKJb

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The 2025 Vizient Trends Report is out! It highlights trends that will drive success: - Accelerating patient access - Leveraging pharmacy advancements - AI enhancements for decision-making - Optimizing Medicare Advantage strategies

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Next year, Epic will expand its AI capabilities, specifically by enhancing the process for appealing denied insurance claims. Speaking at last month’s HLTH USA conference, Epic executive Mike Pontillo said the EHR giant is looking at various areas to expand. “It’s about trying to figure out what are the use cases that'll free people up to practice at the highest level either for their license or their role,” he said. Our expert consultants help healthcare organizations get the most benefit out of their Epic investments. Find out more in the comments below. Read about Epic’s plans: https://lnkd.in/gwgkthr6 I #Epic #EHR #HealthTech #HealthcareInnovation #Interoperability #HealthData Modern Healthcare

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In today’s healthcare landscape, reducing insurance claim denials is critical for optimizing revenue and maintaining a smooth billing process. For podiatry practices, predictive analytics offers powerful solutions to identify high-risk claims, improve coding accuracy, and streamline the appeals process. By leveraging data-driven insights, podiatrists can proactively address denial patterns and ensure better claim acceptance rates. Learn how your practice can use predictive analytics to improve reimbursement and elevate patient care. #Podiatry #HealthcareInnovation #PredictiveAnalytics #RevenueCycleManagement #MedicalBilling #HealthcareTrends #PodiatryCare #ClaimDenials

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