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This change emphasizes transparency and timely communication of decisions to enrollees, fostering better protection and equity.

One significant issue highlighted is the misrepresentation of care quality, which creates a false impression of superior performance by MA plans compared to traditional Medicare.

This distinction isn’t just about payment—it directly ties into quality reporting and metrics, such as hospital readmissions, which only involve patients classified as Inpatient.

These new CoPs reflect the CMS commitment to addressing the maternal health crisis through enhanced quality and safety standards for OB services.

This new rule will have a significant impact on protecting a subset of beneficiaries from coverage denials due to hospital reclassifications.

Don’t continue to pick up Q codes just because they have risk adjustment implications.

This practice and strict policy run the risk of hospitals defaulting to a conservative stance to place observation orders when there is any uncertainty about the patient’s status, because of the anticipation of a potential UHC denial.

CMS hosted virtual listening sessions to gather feedback from patients and caregivers involved in AHCAH. The responses were generally positive, with patients appreciating the convenience and personal nature of home-based care.

It would be optimal for everyone to have an advocate as they try to navigate the morass which is our healthcare system.

My philosophy is that a correct and complete set of discharge diagnoses can be used to reconstruct the entire patient encounter.

Technology firms such as Iodine are making significant strides in bridging UR and CDI, enhancing transparency and efficiency in collaborative learning.

The Age-Friendly Hospital measure aims to ensure transparency and consistency in hospital reporting, allowing CMS to monitor and improve the quality of care delivered to older adults across the healthcare system.

It will be a massive undertaking to determine how these questions will be provided to patients and how appropriate follow-up will be conducted when a patient responds positively to one of these questions.

This policy is designed to reduce unnecessary readmissions, which Aetna views as a risk to patient safety and a burden on healthcare resources.

Dying is not the only consequence of sepsis. Besides the fact that sepsis survivors are at higher risk for another bout of sepsis from a subsequent infection (and for readmission), there are potential sequelae of sepsis, especially if a patient was in an intensive care unit.

The expansion of SDoH screening to the outpatient setting aims to align and enhance the delivery of holistic care, ensuring that patients receive the necessary referrals and support to address critical needs in the five Health Related Social Needs domains, which include food insecurity, housing instability, transportation, utility challenges, and interpersonal safety.

CMS will now reimburse for inadequate housing and housing instability as indicators of increased resource utilization in the acute inpatient hospital setting.

The typical chief complaint was shortness of breath, which can herald pneumonia…or an exacerbation of COPD or heart failure.

Using “chronic AF” for all AF could be interpreted as fraud or abuse, an attempt to capture a CC when it isn’t warranted.

In a move to support individuals at high risk of suicide or overdose, the Centers for Medicare & Medicaid Services (CMS) is proposing changes in the payment structure and services to expand telehealth options for care management and the inclusion of SDoH risk factors in outpatient treatment programs.

The problem that we have with sepsis right now is that all the attempts to codify and operationalize it left out the most important characteristic. The patient is sick.

When considering social admissions made primarily for non-medical reasons, such as convenience or social support, the differences between using an ABN and a preadmission HINN become particularly relevant.

It is difficult to understand, with today’s staffing limitations and lack of hospital beds, how it can be considered perfectly acceptable for patients to sit in the hospital an additional 7-9 days while they wait for an outside evaluation.

Application of the Two-Midnight Rule for hospitalizations covered by Medicare Advantage plans has not resulted in fewer denials