Renuka Gupte PhD

Program Highlights Opportunities for Community Pharmacies to Deliver Screening, Education, and Referral Interventions: Aligning community pharmacy interventions with top-down findings, payers’ population health priorities, and identified unmet needs can help develop a sustainable pathway. #finance #pharmacy #lifesciences

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNxbn0

Machine learning algorithm succeeded in generating risk adjustment models and predicted healthcare spending better than the current HHS hierarchical condition category (HCC) model. #cms #hcc #riskadjustment #jama #medicalcoding #qualcodeinc Link: https://lnkd.in/eX2Y5wD8

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNlbq0

CMS recently finalized rules aiming to improve healthcare data exchange and streamline prior authorization processes. The rules apply to various payer types, including #Medicare Advantage, #Medicaid, and CHIP programs. Payers need to implement several new APIs to facilitate data sharing with patients, providers, and other payers. Key Requirements: - API Implementation: Payers must implement various APIs for data exchange, including: - Patient Access API: Allows patients to access their claims and clinical data through health apps. - Provider Access API: Allows providers to access patient claims and some clinical data. - Payer-to-Payer API: Facilitates data exchange with other payers for new enrollments and concurrent coverage. - Prior Authorization API: Enables electronic submission and decision-making for prior authorization requests. - Prior Authorization Deadlines: Respond to standard requests within 7 days and expedited requests within 72 hours. - Public Reporting: Share data on prior authorization approvals, denials, and appeals annually. Benefits for Payers: - Improved care coordination and management through better access to patient data. - Reduced administrative burden with streamlined data exchange and automated tasks. - Enhanced fraud detection and prevention with real-time data access and improved analysis. - Streamlined prior authorization processes with faster submissions and fewer denials. - Increased member satisfaction and retention through improved care and easier access to information. Challenges for Payers: - Technical challenges: Integration complexity, data standardization, security concerns, and limited resources. - Operational challenges: Workflow disruptions, data quality management, interoperability with non-compliant providers. - Financial challenges: Implementation and maintenance costs, potential revenue impacts. - Regulatory and legal challenges: Complex regulations, compliance requirements, and potential legal risks. - Additional challenges: Lack of industry-wide standards, limited provider readiness, and potential stakeholder resistance. Overall, the new CMS rules present both opportunities and challenges for payers. Implementing these requirements will require careful planning, investment, and collaboration with various stakeholders to ensure successful adoption and achieve the intended benefits. Learn more: https://hubs.ly/Q02lNxbp0

Gain valuable insights and #payer strategies featuring expert discussions on improving #STARratings, addressing health disparities, and innovating ahead of #CMS #HealthEquity Index implementation. Read our Expert Insight and watch the webinar: https://ow.ly/HMUq50RWIJF #QualityImprovement