Lacey Sapkiewicz

As announced in the CMS Proposed Rule for CY 2025 Outpatient Prospective Payment System released in July 2024, the ON-Q device is proposed for approval under the NOPAIN Act and to receive a unique code eligible for separate payment effective January 2025. This would mark the first time that the ON-Q® device would qualify for separate payment. Learn about NOPAIN: https://ow.ly/T9NQ30sHjnm #PainManagement #NOPAINAct

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OIG ALERT: A new HCC review results in an extrapolated $4.7M penalty AND a new targeted condition. Let’s digest! Hope the holidays treated everyone well. It has been an amazing year so thank you for your support. A reported released Monday shows the OIG audit results for UCare Minnesota for 2017 and 2018 dates of service. Like prior targeted reviews, this review focused on 10 conditions that often have high levels of unsupported conditions on claims. In fact, 86% of conditions reviewed lacked supporting documentation. A few key findings: -The report found that 254 of the 294 conditions reviews lacked documentation support for the diagnosis placed on the claim. -These unsupported conditions accounted for $869k in unsupported payments. However, due to extrapolation, the OIG has requested $4.7M in repayments. The OIG originally found $5.7M of risk from high risk diagnoses. -A NEW category has been highlighted by the OIG. This is the first review that I have seen Ovarian cancer called out. The OIG highlighted this HCC as being at risk when a diagnosis is only on one claim and there is no evidence of treatment within 6 months before or after the date the code is on a claim. -Sepsis and Pressure Ulcers (both new in 2024 reports) were seen. The trend continues that the failure rate on these is much less than cancer and other acute episodes. Know your data. If you need help, I am happy to discuss it with you. Remember to educate providers, evaluate conditions captured once a year, and understand where technology you use may expose you to risk. https://lnkd.in/e2kSzZa6

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Have you registered for our HFMA Region 7 Midwest Conference? Here are a few reasons why you don't want to miss this event: Unparalleled Networking Opportunities: The conference will bring together a diverse group of healthcare leaders from across the Midwest. This presents an excellent opportunity for you to connect with like-minded professionals, exchange ideas, and build valuable relationships that can benefit your career and organization. Engaging Educational Sessions: The conference agenda is packed with thought-provoking sessions and panel discussions led by industry experts. You will have the chance to gain insights into the latest trends, best practices, and innovative solutions shaping the healthcare landscape. These sessions will provide you with actionable knowledge that you can apply to your own organization. Collaborative Learning Environment: The conference fosters a collaborative learning environment, encouraging open dialogue and the exchange of ideas. You will have the chance to engage in discussions, and learn from the experiences of your peers. This collaborative atmosphere will inspire new perspectives and innovative approaches to the challenges facing the healthcare industry. This Week's Featured Session: Medicare Advantage Plans: How CMS Final Rules Are Making An Impact Speakers: Terrence Cunningham, Director of Administrative Simplification Policy American Hospital Association Session Description: In this session, Terrence Cunningham from the American Hospital Association will provide an overview of the CY2024 and CY2025 Medicare Advantage rules, including an analysis of the potential impact of key provisions contained within the regulations.   https://cvent.me/W8wlZZ

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Join Eric Lucas, Jonathan Mason & Georgia Green, MS, CHFP for a webcast on 8/27 - Medicare Regulatory Update: 2025 IPPS Final Rule. We’ll discuss the latest updates for hospitals and cover topics including an evaluation of the IPPS final rule key areas, reimbursement shifts and data trends identified in the IPPS final rule data, and next steps and factors to consider because of the final changes, including the mandatory TEAM model. #healthcare #hospitals

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The PDP market is something that we at Healthsperien LLC have been closely watching and advocating around. The demo and the $15 premium waiver are laudable adjustments to a marketplace that is facing a perfect storm of financial pressures. However, more work has to be done around other aspects of the Part D program - namely Star Ratings - as applied to particular subsets of the Part D program. Specifically, those benchmark plans with high % of LIS beneficiaries (~20% based on the data we've looked at). Those plans have extreme difficulty satisfying minimum Stars thresholds and while financial amelioration is necessary, it is not sufficient for an all around response to the woes of that particular market subset.

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Proof of Purpose; PDPs kept afloat Good for Manufacturers, too? The intricacies of IRA Part D benefit redesign dramatically reshape the OOP for millions of beneficiaries, reducing financial toxicity and raising utilization (I will post to past non adherence figures in comments) Unlike MA PDPs, freestanding PDPs can’t shuttle money over from the medical benefit to moderate premium increases, so some speculated that PDPs would fail. I commented several times that given this administrations view of the private market exemplified by MA that was highly unlikely. And after all PDPs are holding up half the benefit. CMS moves forward. “CMS is also announcing a voluntary demonstration program for standalone prescription drug plans (PDPs). The Part D Premium Stabilization Demonstration is designed to test whether additional policy changes stabilize year-over-year changes in premiums for participating standalone PDPs, leading to more predictable options for beneficiaries during the initial implementation of the IRA’s) benefit improvements, creating more gradual enrollment changes… Under the voluntary demonstration, there will be a reduction in the base beneficiary premium of $15 for all participating PDPs, combined with a year-over-year plan premium increase limit of $35 and narrowed risk corridors..” Thanks Tom Thoughts on implications, such as spillover from reducing headwinds, moderating adoption of narrower formularies and networks? If so possible plus for Phrma —not to mention if it slows down MA train with attendant Part B drug prior auths. #PartD #PDPs

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Check out this quick and insightful review of the latest updates from CMS, brought to you by the #Michigan Health & #Hospital Association (MHA)! 🚑📊 The proposed #Medicare 2025 Outpatient Prospective Payment System rule includes a net 2.3% increase, new service additions, the adoption of three measures related to health equity and more: https://lnkd.in/gS8rTHEr #HealthcareUpdates #CMS #Medicare2025 #MHA #OPPS

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Healthcare organizations that have strong lateral communications can “turn on a dime,” adapting quickly when new challenges or opportunities emerge. Learn more about how you can leverage lateral communication for better team cohesion and patient experiences. https://bit.ly/4fyWCa4 #OrganizationalEfficiency #HealthcareLeadership #CommunicationStrategy

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Through an independent review organization and patient feedback, the Ohio Department of Medicaid provides a managed care plan report card each year. The 2024 report card was just released rating each of the seven Medicaid managed care plans. See how Ohio Medicaid’s health insurance plans compare in key performance areas: https://lnkd.in/gXRtKKMn #OhioMedicine #Physicians #Ohio

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A new report from the Chicago-based consulting and advisory firm Kaufman Hall, a Vizient company, is highlighting the significant financial pressures that hospitals and health systems are facing nationwide, as last year saw a record number of hospital divestitures, as hospitals and health systems were forced to sell off assets, as they entered into mergers and acquisitions.

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💡Interesting recent stat from Beckers! A consistent (3% to 5%) margin of revenue opportunity is lost due to the complexity of documenting and coding for complex inpatient cases. This uncaptured revenue is significant to a hospital's bottom line, with a 5% loss in a mid-size hospital potentially equaling $22 million to $38 million in lost revenue annually‼️ MDaudit can help with our Hospital and Coder audit workflows. Check out this short demo!

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Recent regulatory changes provide hospitals a unique opportunity to reassess their reimbursement practices and strategy, showing the value of completing three reporting types in tandem rather than one at a time. By understanding how reimbursement programs like Medicare DSH, Worksheet S-10 Uncompensated Care, and Medicare bad debts are related, hospitals can save time, alleviate strain on their IT departments, free up staff to focus on high-priority work, and potentially improve their financial health. Learn more in this Moss Adams article by Heather Keser, Jonathan Mason, Jesse Vo and Josh Stewart.

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CarePoint Health System's most recent bankruptcy reflects years of financial struggles, legal disputes, and attempts to salvage its healthcare operations. Ironically, it was formed in 2013 when three hospitals—Bayonne Medical Center (BMC), Hoboken University Medical Center (HUMC), and Christ Hospital— were purchased out of bankruptcy. Financial strain and management controversies plagued the network, particularly after reports surfaced in 2019 that former CEO Vivek Garipalli and other leaders funneled millions through shell companies, casting a shadow over CarePoint’s financial integrity. In recent years, CarePoint’s financial troubles deepened, with operating losses reaching 14% and significant debt accumulation, prompting the state to appoint a fiscal monitor. CarePoint repeatedly requested state subsidies to maintain operations, cut employee hours, and faced over $11 million in lawsuits from unpaid vendors. An intense rivalry with Secaucus-based Hudson Regional Hospital and its owner, Yan Moshe further complicated CarePoint’s stability. Moshe acquired the land beneath BMC in 2019, spurring legal battles over property control. Bayonne’s city council attempted to safeguard BMC’s future as a hospital through zoning protections, leading to a prolonged court dispute that recently concluded with a ruling in favor of preserving the hospital's function. Despite their adversarial history, CarePoint and HRH recently forged a tentative partnership to create a unified healthcare network, a deal brokered by Jersey City Mayor Steven Fulop. However, just weeks after this announcement, newly appointed CarePoint CEO Dr. Jawad Shah abruptly resigned, leaving CarePoint without a clear leader and triggering renewed uncertainty. Following Shah’s departure, HRH promptly offered $25 million in interim funding to help CarePoint avoid liquidation. HRH proposed to integrate HUMC, Christ Hospital, and BMC into its network, which includes its existing facility in Secaucus, with hopes of forming a stable, regional healthcare system. The Hudson County community and union representatives have since called for a state investigation into CarePoint’s financial management. To keep this story very "New Jersey" its also worth noting that HRH’s recent public image suffered a blow due to the arrest of its marketing director, Reuven Alonalayoff, who was found with an arsenal of weapons and ammunition in an unlocked hospital office. This prolonged crisis raises a pressing question for New Jersey’s state leadership: why wasn’t more done to prevent this unfolding catastrophe? For years, warning signs were not only apparent—they were glaring. Mismanagement, spiraling debt, and questionable practices were well-documented. As a critical safety-net system, CarePoint’s facilities serve some of the most vulnerable populations in Hudson County. When we have a crisis in leadership, patients and communities suffer. Full stop. Kevin Lyonsjeff lestonJohn TozziAnna Mathews

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Purchased services are vital to healthcare, but they can also become financial drains if not managed properly. A mature purchased services strategy includes insight into all expenses, reduction in unnecessary variation, and prioritized patient care, outcomes, and experience. By focusing on these areas, health systems can lower costs, improve clinical care, and enhance patient experiences. Learn more in Advantus Health Partners article about how to create a mature purchased services strategy: https://lnkd.in/g4UwCjCW #HealthcareSupplyChain #ValueBasedCare #SupplyChainManagement

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Michigan Health Information Network has launched a pilot project that enables real-time health data exchange between emergency medical services and hospitals.

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USA Health is expanding its women’s services division with the addition of Michael Fesenmeier, M.D. He spent two decades in private practice in Ohio before moving back to the Gulf Coast to join the region's only academic health system. https://ow.ly/xA2x50UbmUk

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Imagine Simone Biles trying to win Olympic gold medal while being interrupted constantly by: -Insurance-"we are unable to process this claim, because extra, unnecessary, meaningless paperwork is needed" -Post-authorization, Post Surgery Claim Review (PSCR), prior authorization, peer-to-peer review, HIPAA, etc.; “you have to do RVUs, EMR, eRX, PQRS, MIPS, arbitrary expensive training exercises, etc. or they’ll penalize you"  #EMR #EHR #DeathByaThousandCuts #BoilingFrog #PostAuthorization #PSCR #PriorAuthorization #DelayandDeny #clawback #recoupment #HealthcareAdvocacy #Healthcare #HealthcareHeroes #HealthcareProfessionals #Nurses #Doctors #NursesOnLinkedin #Nursing #HealthcareOnLinkedin #AMA #ANA -Taxing our morals-third parties intruding on patient doctor bond, restrictions, regulations, interference, etc.; insurance companies employ more physicians than anyone else in US #MoralTrauma #Moralinjustice #MoralAssault #Moralinjury #BurnOut #SimoneBiles #Olympics All rights and credits are reserved to the respective owner(s). Credit: The New Feminist

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