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how to navigate RAPS-to-EDS revenue expectations

In the 2017 payment year, the 25 percent Encounter Data System (EDS) contribution and its impact on risk scores and asso...

white paper: thinking inside the box with a provider decision quadrant

Sophisticated data analytics can process billions of claim code line edits through the course of the day, helping payers...

infographic: what Aesop’s Fables can teach us about quality improvement

As we get closer to January, we know that you have a lot to keep track of for HEDIS® 2018. If you’re looking for some me...

technology, clinical power, and a unified health plan deliver better results, together

Those who seek to commit healthcare fraud and abuse are continually adapting. Often, they fly just under the radar, with...

trick or treat: solving the spooky RAPS/EDS transition challenge

Visiting a corn maze on Halloween can be fun, but trying to navigate the transition from RAPS to EDS has been more like ...

HEDIS® 2018: tech specs on deck

The National Committee for Quality Assurance (NCQA) has released its HEDIS® 2018 Technical Specifications Update, closel...

busted: top fraud and abuse busts of summer

From California to New York, fraud and abuse took no vacation over late spring and summer this year. The National Health...

HEDIS® lessons from the ant and the grasshopper

Remember Aesop’s Fables? They may be thousands of years old, but the moral of each tale is just as relevant today. One o...

improve medical record retrieval success by analyzing provider behavior patterns

Medical record retrieval is labor intensive, consumes time and resources, and requires great patience and persistence—bu...

infographic: analyzing 2017’s risk adjustment valuation to improve 2018’s processes

How is your health plan setting its target return on investment (ROI) per chart for your 2018 retrospective risk adjustm...

jumping the hurdles to value-based care

The transition from fee-for-service to value-based healthcare, where payers compensate providers based on the patient’s ...

five tips for getting your proactive HEDIS® runs to take off

How frequently does your quality improvement team plan to conduct prospective HEDIS® runs in the coming year? Here’s wha...

can healthcare fraud special investigators keep up the pace?

This week the U.S. Justice Department announced one of the biggest multi-agency healthcare fraud busts in history involv...

NCQA’s new timeline is out—are you ready for HEDIS® 2018?

Quality reporting is closely aligned with financial success for health plans across the country, amplifying the importan...

amid healthcare reform, ACA risk stabilization goes on

While the House and Senate attempt to re-write healthcare policy, the pressing problems that the Affordable Care Act (AC...

who canceled summer? why the HEDIS® 2018 season really starts now

Ah, summer. Time to relax, pat yourself on the back for a job well done for HEDIS® 2017, and think about something else ...

step up your game: how to improve risk adjustment coding accuracy

The Office of Inspector General (OIG) sets the bar for coding accuracy at 95 percent, but you can’t achieve that goal wi...

podcast: why value-based care requires “strength from all sides”

As the transition from fee-for-service to value-based care continues to disrupt the healthcare industry, payers and prov...

when waste becomes fraud: where do you draw the line?

Under HIPAA, healthcare fraud is defined as “knowingly, and willfully executing or attempting to execute a scheme … to d...

from the HEDIS® 2017 trenches: the final countdown

As HEDIS® season comes to an end, you always seem to have an infinite number of things to remember to ensure your submis...

busted: the top fraud and abuse busts in Q1 2017

Tens of billions of dollars are wasted each year thanks to fraudulent healthcare billing practices, according to the Nat...

from the HEDIS® 2017 trenches: for MRRV success, don’t overlook over-reading

Now that we have a second season with the new medical record review validation (MRRV) guidelines under our belts, were y...

improving healthcare quality: four proven health plan strategies that providers should ado...

The following article by Verscend President and CEO Dr. Emad Rizk was originally published by the HFM blog, a publicatio...

are you playing “whack-a-mole” with your performance improvement initiatives?

In the past, payers’ approach to data analytics was more tactical than strategic. Analytics were deployed in a siloed fa...

how does data analytics curb healthcare spending?

Despite the uncertainty surrounding what U.S. healthcare will look like five years from now—or maybe even five months fr...

from the HEDIS® 2017 trenches: the importance of an admin refresh

The HEDIS® 2017 season is more than halfway done. Are you on track for the reporting deadline? Our Verscend experts are ...

the 2018 final payment notice: the top four takeaways

After listening to public comments, the Centers for Medicare & Medicaid Services (CMS) has released its Final Notice for...

from the HEDIS® 2017 trenches: tracking your retrieval and abstraction efforts

The HEDIS® 2017 season is about halfway done. Are you on track for the reporting deadline? In the latest addition to our...

RISE to the occasion: quality, risk adjustment, payers, and providers converge

Although its Nashville location remains the same, the Annual RISE Summit continues to grow in size and importance each y...

busting myths about clinical claim review

We know that automated claim editing is unable to analyze many claims due to their clinical complexity, the most obvious...

watch: how big data and automation are disrupting healthcare

How is the shift to value-based care creating a “perfect storm” for payers and providers to leverage big data as technol...

the art and science of handling Medicare risk adjustment coding “gray areas”

While the Centers for Medicare & Medicaid Services (CMS) has guidelines in place for Medicare risk adjustment coding, th...

sharpening your view: using predictive modeling to identify potentially avoidable ED utili...

The rapid growth of retail clinics and urgent care centers presents an opportunity to deliver certain types of care in a...

from the HEDIS® 2017 trenches: optimizing your chases

The countdown to the HEDIS® 2017 reporting deadline is well underway. Are you on track? Our Verscend experts are here to...

the 2018 advance payment notice: what you need to know

Health plan executives across the country have a lot of planning to do now that the 2018 Advance Payment Notice for Medi...

how far can automated claim editing go? three fast facts you should know

There’s no question that automated claim editing is a crucial component of accurate and efficient claims payment. Using ...

what makes Verscend "Best in KLAS"?

Verscend this week received the 2017 Best in KLAS award for payer quality analytics and reporting solutions. This first-...

how population health analytics can help identify and address opioid abuse

Unfortunately, it is all too easy to find a news story about the devastating impact of opioid abuse as the epidemic cont...

from the HEDIS® 2017 trenches: digging into the data

The countdown to the HEDIS® 2017 reporting deadline has begun. Are you on track? Our Verscend experts are here to share ...

tips to drive your population health journey and avoid the potholes

Whether your provider organization is just getting started on its population health journey or looking for a change from...

the true costs of medical identity theft

$13,500. That is the average cost victims pay to resolve medical identity theft—when they can resolve it.   Medical iden...

how to support successful MRA through medical record retrieval

You have many choices to make when it comes to how your health plan will conduct Medicare Risk Adjustment (MRA). Among t...

tips to ensure your quality program actually improves quality

The increasingly strong link between quality outcomes and payment in healthcare increases the importance of closing gaps...

post-election recap: the future of healthcare reform

For most of the 2016 election cycle, the future of the Affordable Care Act (ACA) looked secure. But President-elect Dona...

best practices to ensure end-to-end payment accuracy in your organization

As many healthcare organizations know, the frequently changing and extremely complex healthcare landscape has unintentio...

CareOregon: how to achieve measurable quality improvement

Health plans across the country expend significant energy on annual HEDIS® quality reporting requirements. With quality ...

the evolution of DxCG: part two

Verscend is celebrating the 20th anniversary of DxCG, the leading risk adjustment and predictive modeling tool in the in...

streamlining medical record retrieval to ensure program efficiency

For health plans and other healthcare organizations, quality measurement, risk adjustment, and reporting requirements gr...

how risk adjustment and predictive models drive effective value-based care

Healthcare technology is constantly evolving and improving. Although risk adjustment and predictive models have long bee...

DxCG is a top performer in the new Society of Actuaries study

The Society of Actuaries (SOA) recently published “Accuracy of Claims-Based Risk Scoring Models,” a study of commercial ...

the keys to a successful quality improvement program

A core requirement for health plans across the country is measuring and reporting on quality metrics. However, directly ...

the evolution of DxCG: part one

Verscend is celebrating the 20th anniversary of DxCG, the leading risk adjustment and predictive modeling tool in the in...

are your improper payments hiding in plain sight?

After years of focusing efforts on speeding up automated claim processing, most payers’ claim review systems have uninte...

common FWA overpayments your automated claim editing system may miss

The cost of healthcare continues to dominate headlines as the Affordable Care Act (ACA) expands managed care, and thus p...

best practices to drive HEDIS® success in 2017

Quality reporting continues to be closely aligned with financial success for health plans across the country, amplifying...

planning ahead: tactics for success in commercial risk adjustment

The Centers for Medicare & Medicaid Services (CMS) released its 2015 Payment Transfer Report on June 30, 2016. Now that ...

5 tips from the trenches: best practices for HEDIS® 2017

Each year, plans face new challenges in their HEDIS® reporting as NCQA updates its reporting requirements to account for...

why "no assembly required" is a welcome phrase for fraud investigators and parents alike

If you’ve ever purchased a bunk bed, swing set, or bicycle for your child, you likely recall the hours it took to progre...

10 steps to enhance your medicare risk adjustment success

As its beneficiary population continues to expand, the Medicare program faces persistent pressure to do more with less. ...

taking action on maternity care variability

In April, Verscend’s Sam Stearns co-authored an article in Employee Benefit News titled, “5 ways employers can optimize ...

busted 2016: prominent healthcare fraud schemes

The National Health Care Anti-Fraud Association (NHCAA) estimates that tens of billions of dollars are lost each year to...

RISE interviews Verscend experts on the impact of the EDS transition

In its Summer 2016 newsletter, the Resource Initiative and Society for Education (RISE) features an interview with Versc...

how to fine tune your investigation approach

For health plans’ special investigative units (SIUs), the notion of wading through a pile of false leads before finding ...

decoding MACRA: implications and recommendations for provider organizations

There is one healthcare acronym that is currently impacting provider organizations across the country more than any othe...

for providers, successful accountable care can start with employees

Providers across the country are working to ensure that they are delivering high quality care that addresses the unique ...

5 tips for managing employee health

Top-rated employers use claims and other employee-related information as a foundation for managing employee health and p...

how CMS’ medicare advantage final rules could impact your plan

From methodology updates to a new way to segment eligible populations, 2017 offers up some impactful rule changes that c...

the financial impact of 2017 medicare advantage payment rules

In early April, the Centers for Medicare & Medicaid Services (CMS) released its Final Call Letter outlining payment meth...

8 tips for a seamless commercial risk adjustment program

With the implementation of its payment transfer model, The U.S. Department of Health & Human Services (HHS), in conjunct...

Dr. James Colbert featured in Health Affairs

In a recent Health Affairs blog post, Verscend’s Dr. James Colbert, along with co-author Dr. Ishani Ganguli, explore why...

fast-tracking FWA investigations with turnkey allegations

Healthcare fraud, waste, and abuse (FWA) investigators have a tough job. Keeping pace with the latest schemes, continuou...

8 tips for supporting your population health management programs

Provider organizations have almost too many options when it comes to finding population health management expertise and ...

highlights of CMS’ 2017 advance notice

Following the release of the Centers for Medicare & Medicaid Services’ (CMS’) proposed changes for 2017 Medicare Advanta...

ICD-10 and its impact on risk adjustment

Tackling the first year of risk adjustment since the ICD-10 transition took effect last fall, we’ve kept our ears to the...

Western Health Advantage leverages population health analytics to better serve patients

Accountable care organizations (ACOs) show promise yet, regardless of their configuration, they continue to struggle wit...

bundled payments gather momentum

One of the attributes of a sustainable value-based healthcare delivery system is payment based on the value of services ...

exploring new quality and payment initiatives

It’s no surprise that healthcare reform is greatly changing the playing field for providers. New reporting requirements ...

new factors impacting HEDIS® in 2016

While spring signals the re-emergence of warm weather, it also heralds a new HEDIS® season; many of our clients are busi...

evaluating risk with population health analytics

Healthcare reform is drastically changing the playing field for providers. Today, organizations are evolving to successf...

provider success in an ACO setting

Recently, the Center for Medicare and Medicaid Services (CMS) announced the addition of 141 new Medicare Accountable Car...

prepping for what’s next in risk adjustment

2016 is expected to present new risk adjustment reporting challenges for Medicare Advantage plans. We recently visited w...

why collaboration is the next frontier of fraud, waste, and abuse prevention

Andy Tolsma is a registered respiratory therapist with a degree in Health Services Administration. After 13 years of cli...

strengthening primary care and population health across accountable care

On November 11, 2015 I had the opportunity to participate in a panel discussion on how provider organizations are streng...

first look at CMS five-star: proposed changes for 2016

It seems that just as our market adjusts to the current set of performance measures, the Centers for Medicare & Medicaid...

supporting actionable FWA investigations with deep data

In the past ten years, healthcare technology has made significant advancements. Today, there are Electronic Medical Reco...

what is value-based insurance design?

While the U.S. healthcare system is known for its rapid access to specialty providers and patient-centered care, the cou...

post-acute care: strategies and analytics for ACO success

With a goal to create a more efficient healthcare system, accountable care organizations strive to identify opportunitie...

ask our experts: using data to drive value in population health

Dr. Colbert is a national expert on accountable care, population health, and value-based payment. He is the primary auth...

what you should know about physician online rating websites

Surveys have found that nearly half of all Americans who use the Internet search the web for information about doctors a...

how to play as a team to fight fraud

As this year’s NBA Finals made clear, even LeBron James can’t win the ultimate prize by himself. Similarly, a carrier ac...

top five HEDIS® strategies of successful plans

Getting ahead of an upcoming HEDIS season with careful planning can have a big impact on a health plan’s efficiency duri...

tackling cost drivers: how employers can stop rising medical costs

For employers, evaluating the overall risk of their workforce can help identify areas of healthcare waste. One such empl...

in the news: the importance of physician engagement

Physician engagement is one of the cornerstones of a sustainable value-based healthcare system. For those of us who were...

five tips for a successful HEDIS® season

With the 2016 HEDIS® season still a few months away, now is the best time for health plans to reflect on their submissio...

combating healthcare fraud through collaborative investigations

When reading through the headlines, it is hard to ignore the growing number of stories that highlight recent cases of he...

the other performance metric for your population health success

Appropriate measurement and action related to patients’ risk factors, likelihood to readmit, and current and future clin...

calculating risk scores for dual eligibles under the medicare risk adjustment model

While the Medicare Advantage risk adjustment model has been in place for several years now, health plans are just beginn...

five strategies for navigating value-based contracts

As the transformation to value-based healthcare continues, providers will assume greater risk on their path to accountab...

improving medical cost containment with pre-payment claim review

For many healthcare organizations, fighting fraud, waste, and abuse (FWA) can be a daunting task. Therefore, it’s best t...

the features of best-in-class medicare risk adjustment reporting

Health plans providing Medicare Part C (Medicare Advantage) coverage to beneficiaries are often under pressure to correc...

how population health analytics can help lower medical costs

For employers, ensuring a healthy workforce is key to reducing medical costs. Population health analytics can help emplo...

three ways payers can improve their fraud, waste, and abuse strategy

Fighting healthcare fraud, waste, and abuse (FWA) is not something that happens overnight. For many healthcare organizat...

how population health analytics help providers strengthen their infrastructure

Healthcare reform is drastically changing the playing field for providers. Today, organizations are evolving to successf...

interoperability: what it means for health information technology

Patients with chronic diseases commonly get care from multiple clinicians practicing in a wide variety of care settings,...

bracing for big change in risk adjustment

It seems that just as Medicare Advantage plans understand a standard set of reporting rules, CMS makes large changes to ...

the employer shift towards value-based healthcare

With the rollout of the Affordable Care Act (ACA) nearly complete, employers have the opportunity to build on the indust...

how to promote employee wellness with population health analytics

For employers, population health analytics can be used to help measure the success of employee wellness programs. One su...

how one employer used population health analytics to decrease costs

Employers are shaping new cost and quality improvement approaches by drawing on population health analytics to understan...

the key elements of successful integrated care delivery

Integrated care delivery is an emerging trend in healthcare. Under this model, healthcare organizations and providers wo...

three questions for the CMS star ratings expert

While reporting quality measures to CMS is not a new requirement for many health plans, the increasing value of higher S...

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