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Medicare Advantage Plans Brace For Impact As CMS Unveils RADV Final Rule 2023

The Centers for Medicare & Medicaid Services stirs controversy with finalized RADV Final Rule policies that exclude FFS Adjuster for Data Extrapolation from 2018. After numerous delays over several years, CMS finally released the MA-RADV program’s final rule. These policies are critical for auditing and overseeing payments made to the Medicare Advantage program. Implementing this...
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CMS Proposed Rule 2023: Releases Advancing Interoperability and Improving Prior Authorization Processes, What it Means for Payers?

The Centers for Medicare and Medicaid Services (CMS) has proposed a new rule that aims to speed up the initial authorization process and improve interoperability in the US healthcare system. CMS Proposed Rule 2023 would require specific payers, including Medicare Advantage organizations, to use prior electronic authorization and to respond to requests within 72 hours...
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Next Big Healthcare Trends in 2023 to Follow

Technological advancements are transforming the landscape of health in the US. Technologies like AI, IoT, wearable devices, telemedicine, blockchain, etc., have opened a stack of opportunities for the healthcare industry to ensure smooth and best care delivery. The proper use of technology provides providers with quicker and more accurate diagnoses, enhancing patient care. Healthcare Professionals...
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The Need to Incorporate Equity Lens into Patient Care

Healthcare costs are already skyrocketing and creating a challenging crisis for the industry. The disparities in the U.S. healthcare system forge an unnecessary rise in costs that spreads over society, resulting in a financial crisis. The continuing upward trend in costs could lead to an even more significant number of unaffordable bills and deteriorating health...
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Getting you up-to-speed for the all-new Primary Care First Program

Primary Care First (PCF) is an innovative payment model created by the Centers for Medicare and Medicaid Services (CMS) to encourage the high performance and delivery of extraordinary primary care services. PCF members must provide data on specified quality metrics annually, including the quality indicator Advance Care Plan (ACP), which needs reporting from a Qualified...
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Leveraging Data to drive Risk Adjustment Accuracy

Risk adjustment has incentive insurance companies to provide memberships to patients who need it the most by “adjusting” the risk of enrolling chronically ill people along with healthier patients, ensuring that providers are adequately compensated according to each patient’s underlying health patterns, and the care provided. To ensure a mutually beneficial risk adjustment program, payers...
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Healthcare Organizations Call on CMS and HHS to Scrap the New ACO REACH Model

The Centers for Medicare & Medicaid Services (CMS) has stated that the global Direct Contracting Model will be replaced by the Accountable Care Organization Realizing Equity, Access, and Community Health ACO REACH Model in 2023. Furthermore, the regional Direct Contracting Model, which has been on hold since March 2021, will be phased out immediately. Based...
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In Terms of Care Delivery and Care Coordination, The ACO REACH Model will benefit both Recipients and Providers

Even though the Social Determinants of Health (SDoH) and health equity have received a great deal of interest from the healthcare industry in the recent years, the Biden administration is overhauling the contentious Direct Contracting Model to include additional conditions aimed at addressing the health equity model of accountable care and assuaging progressive legislators’ worries...
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ACO REACH Model’s Strategic Ramifications in the Healthcare Industry

The Centers for Medicare and Medicaid Services (CMS) Innovation Center is working on replacing its Global and Professional Direct Contracting model (GPDC), which will be phasing out at the end of 2022, with the highly-anticipated Accountable Care Organization Realizing Equity, Access, and Community Health model (ACO REACH), which will take effect on January 1, 2023....
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The Financial Benefits of the Primary Care First Model for Practices

Primary Care First (PCF) intends to increase primary care professionals’ self-governance by providing more operational adaptability and performance-based incentives, allowing them to customize care delivery depending on their specific patient groups and resources. The concept actively encourages providers to invest additional time with patients and offer coordinated, effective care by connecting health outcomes for patients...
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