Ted Fligor

Exciting times at 4C Digital Health! Wilmington, Delaware - 4C Digital Health (4C), the preeminent organization delivering independent financial oversight and control solutions for self-funded employee health plans, recently announced the strategic expansion of its services into the Commonwealth of Kentucky. In late 2023, 4C successfully competed for an initial award issued by Kentucky’s Department of Employee Insurance, and Kentucky has since extended the initial contract to allow 4C to continue its important work on behalf of the Commonwealth, its employees, and its taxpayers. The Kentucky Employee Health Plan (KEHP) serves more than 288,000 members, which amounts to 1 in 16 Kentuckians. In addition, KEHP spends over $1.8 billion dollars in total healthcare benefits on behalf of its members per year and covers over 8.2 million claims per year. KEHP objectives include “improving employee health and well-being” and “providing state-of-the-art benefits while maintaining reasonable premiums.” Recognizing its important fiduciary responsibilities to its employees and its state health plan, the Commonwealth of Kentucky enacted Senate Bill 42 (2023) introduced by Senator Stephen Meredith for the purpose of ensuring that critical health plan dollars are being spent properly on behalf of state employees. The legislation requires that 4C analyze 100% of medical claims submitted for payment to KEHP; identify erroneous overpayments; and identify inappropriate or erroneous fees imposed by KEHP’s third-party administrator. Ron Templeton CEO of 4C Digital Health stated: “4C Digital Health is grateful to the Commonwealth of Kentucky for recognizing the fiduciary responsibility that state and local governments have to their employee health plans and for the opportunity to provide our services in support of this mission. We appreciate Kentucky’s goal of using 4C’s expertise and innovative solutions to improve healthcare outcomes and reduce healthcare costs for the Commonwealth, its employees, and its taxpayers.” About 4C Digital Health: 4C Digital Health (https://lnkd.in/eB-fJg4X) is a healthcare data analytics company that was founded for the purpose of developing a disruptive technology targeted at bringing transparency and honesty to the healthcare marketplace.

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Program Audit season is over. Join our webinar to hear all about what CMS is focusing on. If you haven’t done a mock audit now is a great time to do one and incorporate our lessons learned.

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Getting bigger through consolidation to eliminate competition and increase market share is an old-school philosophy and ultimately losing business strategy. Innovating to compete in a different healthcare economy is the way forward. https://lnkd.in/gYkNQeYP

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My takeaways from the Reuters Events Healthcare #digitalhealth24 in San Diego this week. Please pardon any discrepancies 😀 or confusion this morning - Alaska Airlines delayed me for four hours so I could re-live my college days and get to bed at 1:50 am. Here are some highlights: - AI has a lot of potential in health systems, but ethical concerns and risks are top of mind and being wrestled with daily. - Change management is the biggest challenge, not the technology itself. - Tech leaders understand the importance of focusing on problems rather than solutions. Will this mindset spread throughout the industry? - Endeavor Health is a great example of a smart health system with a clear progression from research to enterprise-wide execution. Thanks Justin R. Brueck - The role and definition of the consumer in healthcare is still a topic of debate, especially when it comes to healthcare and services they would rather not spend time or money receiving. No one identifies as a patient! #digitalhealth #healthcare #AI #healthsystems #consumerhealth #healthcareinnovation #changemanagement HCT Consulting Group

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#HippocraticAI agents collected measurement at 73% higher rate than human agents leading to better reimbursements for all the answered calls for the #RPM clients #generativeAI #superstaffing can help the entire Healthcare ecosystem

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🤔 What do you know about healthcare administration? 🤔 #claimsadjudication #thirdpartyadministration #specialtyinsurance... :) Andrew Munroe, Senior Vice President of Operations, Pharma, and Payor Partners at NexgenRx Inc. joined us on the latest episode of the Health Tech Horizons Podcast to share industry insights, and the latest trends shaping the future of healthcare administration. Join us as we explore the intersection of insurance related technology, innovation, and healthcare with NexgenRx Inc. and Andrew Munroe. ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ 📲 CHECK OUT the VIDEO 📺 ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ ⚡ ⚡

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Today, CareBrains, a division of ClickMedix, announced they, as a partner organization, have been selected by the Centers for Medicare & Medicaid Services (CMS) to participate in a new Medicare alternative payment model designed to support people living with dementia and their caregivers. Under CMS’ Guiding an Improved Dementia Experience (GUIDE) Model, CareBrains and its coalition partners will be one of  ~400 participants building Dementia Care Programs across the country, working to increase care coordination and improve access to services and supports, including respite care, for people living with dementia and their caregivers. “CMS is excited to partner with selected participants under the GUIDE Model,” said CMS Administrator Chiquita Brooks-LaSure. “GUIDE is a new approach to how Medicare will pay for the care of people living with dementia. The GUIDE participants are envisioning new ways to support not only people living with dementia, but also to reduce strain on the people who care for them, so that more Americans can remain in their homes and communities, rather than in institutions.” Launched on July 1, 2024, the GUIDE Model will test a new payment approach for key supportive services furnished to people living with dementia, including: comprehensive, person-centered assessments and care plans; care coordination; 24/7 access to an interdisciplinary care team member or help line; and certain respite services to support caregivers. People with dementia and their caregivers will have the assistance and support of a Care Navigator to help them access clinical and non-clinical services such as meals and transportation through community-based organizations. “We are thrilled to work with CMS in this innovative new program which allows us and our partner organizations to create a dementia care ecosystem,” said Jodi Lyons, Chief Care Officer of CareBrains. “CMS’s support allows us to build upon and exponentially expand our dementia care experience and expertise.” CareBrains’ participation in the GUIDE Model will help people living with dementia and their caregivers have access to education and support, such as training programs on best practices for caring for a loved one living with dementia. The GUIDE Model also provides respite services for certain people, enabling caregivers to take temporary breaks from their caregiving responsibilities. Respite is being tested under the GUIDE Model to assess its effect on helping caregivers continue to care for their loved ones at home, preventing or delaying the need for facility care. This model delivers on a promise in the Biden Administration’s Executive Order on Increasing Access to High-Quality Care and Supporting Caregivers and aligns with the National Plan to Address Alzheimer’s Disease. For more information on CMS’ GUIDE Model, please visit: https://lnkd.in/eRt-UDTM.

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On September 13, lawmakers introduced the No Surprises Enforcement Act, a bill aimed at penalizing health insurers who fail to comply with #NSA payment obligations. This move comes in response to data from Medicare showing over 16,000 complaints, including insurers delaying payments and failing to issue required #reimbursements or #denials within 30 days. The legislation increases penalties on insurers that do not pay after losing disputes. It proposes fines three times the difference between the insurer’s initial payment and the IDR ruling per claim, along with compounding interest. This bill has my support. Strengthened enforcement is necessary to prevent insurers from exploiting the system and jeopardizing the financial sustainability of healthcare practices, especially smaller, community-based providers. For more information, visit https://zurl.co/1RkN #healthinsurance

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Healthcare has a history of borrowing from the airline industry...Universal Protocol, anyone? We are doing it again...this time with CLEAR technologies. Patients at Wellstar Health System in Georgia will be able to fasttrack registration and sign in. We always talk about the future of healthtech- The Future is Now ✨ More and more hospitals will be adopting this technology, and perhaps telehealth companies in order to avoid the patient identity issue that some companies like Cerebral have been fines for in the past after having poor patient outcomes due to identity verification. How are you optimizing your workflows to speed up registration? #registration #airlinehospitals #healthcareinnovation #hospitalleaders Article in comments ⏬

📈 Is Your Clinic Burdened by Documentation Demands? Running a clinic means balancing patient care, documentation, and revenue—but it often feels like a juggling act. Missed revenue opportunities, compliance headaches, and burnout are common struggles for healthcare providers everywhere. Imagine if you could: 🕒 Spend more time with patients instead of paperwork 📊 Increase revenue by up to 30% while reducing errors 🔒 Achieve 100% compliance with full data security, thanks to our Zero Data Leakage Policy At Mscribed, we’ve helped clinics boost patient capacity by 33%, reduce documentation errors by 99%, and ensure seamless revenue cycles. Our medically trained scribes handle documentation in real-time, so you can focus on delivering quality care without the added stress. ➡️ Let’s chat about how we can help your clinic thrive with less admin hassle and more patient-focused care. Your practice deserves to operate at its best! #ClinicEfficiency #PatientCare #MedicalDocumentation #RevenueGrowth #HealthcareCompliance #HealthcareInnovation #StreamlinedWorkflows

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When I think of value based care and game changing analytics for payers and providers, I think of Clarify Health Solutions. A month ago, I interviewed Terry Boch, CEO at Clarify Health on the podcast and recently at #HIMSS24 had the chance to spend time with Dr. Neechi Mosha, MD, the Senior Vice President of Growth, and John Barzydlo, the Vice President of Customer Success. These interviews didn’t happen because of luck or by chance… Clarify Health Solutions has been very intentional about their messaging in the market.  During the at #HIMSS24 they shared an exciting new data partnership, their Best in KLAS award, and ways they’re helping their customers with price transparency regulation for the upcoming July requirement for hospitals to have their pricing in machine readable files. When looking to make an impact in the marketplace, you have to leverage every opportunity and tool that best aligns with your company culture and budget.  Clarify does 3 of these things very well: 1️⃣ Owned media - Many updates through email, podcasts and partnerships. 2️⃣ Earned media - Validation of their platform with customer testimonials, 3rd party validation networks, press releases, and stories. 3️⃣ Paid media - leveraging industry conferences and opportunities to accelerate their reach. In today’s noisy healthcare marketplace, it is not enough to have great technology that adds value and meets HIPAA, FDA, CMS, CDC etc. requirements.  You have to share stories, then have others share their stories about you, and finally amplify reach and pull back time through highly targeted vehicles and platforms. I give Clarify Health Solutions kudos for having both a stellar product and a team while doing a fantastic job of sharing it with the market. Listen to the entire episode to learn more and be a part of the transformation here: https://lnkd.in/eTYxn6fv #outcomesrocket #podcast #HealthcareInnovation #DataAnalytics #HealthcareTransformation

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As you know I've been on the road with TRAVIS ANSEL recently, sharing our "Key Market and Provider Metrics to Drive Service Line Growth" presentation with healthcare leaders. If you missed it, or you want a refresher, here's the video and slides with all of the insights we shared! HSG Advisors https://lnkd.in/gUBbgKUy #healthcareconsulting #presentation #healthcareleaders #hospital #healthsystem #claimsdataanalytics #healthcaredata

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Key Metrics a Virtual Hospital Manager Should Monitor In the rapidly evolving landscape of healthcare, virtual hospitals are at the forefront of leveraging technology to provide accessible and high-quality care. For a virtual hospital manager, monitoring key metrics is crucial to ensure smooth operations and optimize resource allocation. Appointment and Patient Flow Management Completed Appointments: Track successfully completed appointments. Cancelled Appointments: Monitor cancellation rates. Pending Appointments: Keep an eye on appointments awaiting confirmation. Geographic Distribution Patient Distribution Map: Visualize patient numbers from different regions. Service Coverage Areas: Identify high-demand regions. Service Performance Average Service Time: Measure service completion times. Patient Satisfaction Scores: Analyze feedback to improve services. Resource Utilization Staff Workload: Track patient numbers seen by healthcare professionals. Equipment Status: Monitor availability and functionality of medical devices. Emergency Management Emergency Calls: Track number and nature of emergency calls. Response Times: Measure emergency response times. System Health and Security Server Performance: Monitor IT system health. Data Security: Track security incidents. Financial Performance Revenue and Expenditures: Monitor income and operational costs. Insurance Claims: Track processed claims and billing accuracy. AI and IoT Integration Diagnostic Accuracy: Measure AI-based diagnostic tools' accuracy. Remote Monitoring: Ensure IoT devices are properly connected. By prioritizing these metrics, virtual hospital managers can create a responsive, patient-centered healthcare environment that meets the needs of a diverse and dispersed patient population.SEHA AL RAHBA HOSPITALSanalBeePudena Health Consulting Co.Mustafa Köroğlu

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It’s great to see that we covered more US citizens but the overall financial trend is obviously unsustainable. We’ve got to figure out ways to bend this cost curve to something that works over the long haul.

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Radiologists are achieving payments 500% above the Qualified Payment Amount (QPA) in surprise billing disputes, thanks to the No Surprises Act. This figure is staggering and highlights an important reality: many providers might not realize the tremendous potential of this opportunity. When the No Surprises Act (NSA) was enacted in 2022, the rates at which providers were reimbursed took a major hit, often cut in half. Payors exploited the QPA to justify lower payments, essentially giving themselves the green light to underpay claims. If a provider disagreed with the payment, they had to navigate the cumbersome claims process to recover what they deserved. But here’s the good news: By participating in the IDR process, radiologists are claiming up to 5 times their initial payments. This result is a powerful incentive for payers to engage in a meaningful negotiation and ensure fair compensation. Providers should leverage the NSA to their advantage - and capture every dollar they’re owed.

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As the demand for emergency care and hospital beds increase, ensuring health systems have enough space to support care will require a multipronged approach. Here are potential capacity solutions from all angles.

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