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

Posted by Sean Creighton and David Bartley on 3/21/17 10:56 AM

Although its Nashville location remains the same, the Annual RISE Summit continues to grow in size and importance each year. RISE, or the Resource Initiative and Society for Education, has been bringing its membership together for 11 years to address fundamental issues in risk adjustment, performance measurement and improvement, and payment integrity. The American Health Care Act, the GOP alternative to the Affordable Care Act, was a focal point for this year’s meeting with its release on the eve of the conference. However, RISE is well known for its best-practice sessions, and while the future continues to be debated, there is clearly plenty of work still getting done to move the industry closer to value-based healthcare delivery and payment even in the midst of uncertainty.

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busting myths about clinical claim review

Posted by Debi Behunin on 3/16/17 10:53 AM

We know that automated claim editing is unable to analyze many claims due to their clinical complexity, the most obvious examples being claims with modifiers 25 and 59. These simply pass through the system and get paid without any further intervention. That’s why clinical claim review—also known as clinical validation—is so valuable. Clinical validation is a process whereby a team of clinicians, nurses, and coding experts reviews potentially incorrect claims and makes a swift payment recommendation. Over the years we’ve heard questions and concerns from health plans about the value of clinical validation. Here are four common myths and our responses to set your mind at ease.

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watch: how big data and automation are disrupting healthcare

Posted by Verscend on 3/10/17 7:32 AM

How is the shift to value-based care creating a “perfect storm” for payers and providers to leverage big data as technology and automation evolve? And at the same time, how are these advances empowering healthcare consumers? Verscend’s own President and CEO Dr. Emad Rizk discussed these topics in depth recently at the 2017 Health Care Forecast Conference held at the Paul Merage School of Business at the University of California, Irvine.

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

Posted by Deb Bradley on 3/9/17 8:30 AM

While the Centers for Medicare & Medicaid Services (CMS) has guidelines in place for Medicare risk adjustment coding, that doesn’t mean that every Medicare Advantage plan will code the same way. In fact, there is room for many different approaches—and it’s up to each plan to decide what will lead to the best outcome. We caught up with Deb Bradley, Verscend’s senior vice president of clinical coding services, to talk about how health plans can seek a better return on investment in their Medicare risk adjustment programs.

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

Posted by Sam Stearns on 3/2/17 10:27 AM

The rapid growth of retail clinics and urgent care centers presents an opportunity to deliver certain types of care in a more appropriate setting than the emergency department (ED). In addition, several state Medicaid agencies, including California and Washington, have developed lists of non-emergency diagnoses for use in quality assessment and, in some cases, limiting payments to providers. As a result, payers are showing increasing interest in understanding the extent to which non-emergency conditions drive ED utilization.

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the 2018 advance payment notice: what you need to know

Posted by Sean Creighton on 2/14/17 6:55 AM

Health plan executives across the country have a lot of planning to do now that the 2018 Advance Payment Notice for Medicare Advantage (MA) and Part D plans has been released by the Centers for Medicare & Medicaid Services (CMS). The agency is now accepting public comments on the notice through March 3, 2017, before publishing the final version on April 3. We sat down with Verscend’s Sean Creighton, senior vice president of risk adjustment, to get a quick roundup of the key highlights.

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

Posted by Debi Behunin on 2/8/17 12:00 PM

There’s no question that automated claim editing is a crucial component of accurate and efficient claims payment. Using black-and-white sourced edits from the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association’s (AMA) CPT® book, as well as payer-sourced custom rules, these systems save plans a significant amount of money by keeping them from paying incorrect claims without human intervention.

But is having one automated claim editing system enough to ensure total claim accuracy, or are you leaving significant savings on the table without a secondary editor? And if you already have a secondary editor, is there a benefit to adding a tertiary editor? Here are three fast facts you should know about how far automated claims editors can go.

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what makes Verscend "Best in KLAS"?

Posted by David Bartley on 2/2/17 7:15 AM

Verscend this week received the 2017 Best in KLAS award for payer quality analytics and reporting solutions. This first-of-its-kind award pitted top solutions against each other, using KLAS Research’s well-established methodologies and exhaustive customer research to evaluate vendor and solution performance across multiple categories. Verscend scored an 84.7 out of 100 in the ranking, published today in the report, “2017 Best in KLAS: Software & Services.”

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how to support successful MRA through medical record retrieval

Posted by Howard Gross on 1/4/17 9:01 AM

You have many choices to make when it comes to how your health plan will conduct Medicare Risk Adjustment (MRA). Among the most critical choices is how you’ll retrieve your medical records for retrospective review and coding. How can you find the right partner to work with in order to ensure a successful MRA season? We recently sat down with our own medical record retrieval guru, Howard Gross, to help guide health plans in their decision-making process for pursuing medical record retrieval.

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post-election recap: the future of healthcare reform

Posted by Verscend on 12/14/16 10:38 AM

For most of the 2016 election cycle, the future of the Affordable Care Act (ACA) looked secure. But President-elect Donald Trump’s surprise victory, coupled with Republicans retaining their majority in both the House and Senate, has thrown the healthcare industry for a loop, with payers, providers, and participants alike all anxiously awaiting what may happen next. Could all the work that has happened to implement the ACA be reversed? One thing is for certain—everything is uncertain!

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