Accurate coding in healthcare is critical, especially with the recent changes brought about by the RADV extrapolation rule. This regulation allows the Office of the Inspector General (OIG) to apply audit findings from a sample across an entire Medicare Advantage plan, significantly increasing the financial risks associated with coding errors. For example, a $500,000 penalty for mistakes in coding can now balloon to millions, making it essential for health plans to prioritize coding accuracy and compliance.

To navigate these challenges, the OIG has developed helpful resources that guide health plans in identifying high-risk diagnosis codes and highlighting common mistakes to avoid. Organizations can leverage this information to enhance their coding practices and protect themselves against potential audits.

Tune in to learn more about effective strategies and resources to improve coding accuracy and compliance in your organization.

About Our Guest
Kristi Reyes is the Director of Risk Adjustment Coding Operations. She leads a team of medical coders from various aspects of risk adjustment—including retrospective, prospective, CDI, QA, risk mitigation, and RADV. Kristi holds certifications in Certified Professional and Outpatient Coding, Risk Adjustment Coding, and Auditing.

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Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

This episode explores the challenges and opportunities plans face during the digital transition. The most common challenges are outdated systems, fragmented data sources, and managing data integration effectively. We discuss innovative strategies to reshape HEDIS reporting and analytics—from integrating diverse digital data into a unified platform to accelerating processing speeds for real-time insights. Plans can leverage these powerful analytical tools, flexible reporting, and actionable data to proactively identify care gaps, deploy intervention campaigns, streamline workflows, and ensure regulatory compliance. 

This episode equips health plan leaders with the strategies they need to stay competitive and fully embrace the latest industry strategies for HEDIS success. 

About Our Guest
Sharon Kurht is the Director of Quality. She has 14 years of experience in HEDIS, Medicare Stars, and Medicaid. Sharon is an RN who holds a doctorate in nursing from Northeastern University, where she is also a health informatics professor at the graduate level.

Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.

Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

The 2025 Medicare Advantage and Part D Star Ratings were released on October 10, 2024. This year brought significant shifts that will impact health plans across the industry. With new challenges in place and more stringent performance measures, it’s essential for health plans to understand how these changes have affected Star Ratings. The introduction of updated methodologies, such as the use of Electronic Clinical Data Systems (ECDS) for certain measures, and increased weight on critical performance areas, are just a few of the factors reshaping the ratings landscape.

Looking ahead, plans need to stay ahead of the curve as Star Year 2026 and beyond bring even more changes. New measures, adjusted weights, and upcoming initiatives like the Health Equity Index will play a major role in future performance. Discover key strategies to prepare your plan for these changes and ensure your Stars strategy is built for success.

For a deeper look at what’s ahead and expert insights on how to stay competitive, listen to the Bonus Podcast Episode: Star Ratings 2025 Industry Report.

Thank you to our sponsor, usthealthproof.com—unburdening the healthcare experience. 

Preparation and a vigilant organizational mindset are critical to reducing the financial and reputational risk of cybersecurity incidents.  Join CISO, Hans Guilbeaux for an in-depth discussion on ways health plans can ensure their vendors have implemented industry best practices and are prepared for incident response with detailed disaster recovery and business continuity processes.

About Our Guest:
Hans Guilbeaux is the UST HealthProof CISO and has over 25 years of experience in network and infrastructure engineering, security systems administration, network penetration, vulnerability assessment, IT auditing, incident response, and forensics investigation. Hans is a Certified Information Systems Security Professional (CISSP), and a Certified CSF Professional (CCSFP).

Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.

Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

Previously, Medicare Advantage For Health Plans podcast,  we're changing names in Season 3 to Current Trends For Payers podcast. In response to the growing needs of our audience, we’re expanding our topic coverage to include commercial, ACA, government-sponsored health plans, and more.

You’ll be hearing from experts across all aspects of the business and learning about cutting-edge strategies and tactics used by some of the nation’s most successful health plans.

Tune in monthly for exclusive insider insights and be the first to know when new episodes drop by subscribing to Apple, Spotify, and all major podcast apps.

Thank you to our sponsor @ usthealthproof.com. Follow on LinkedIn.

Retrospective risk adjustment involves several administratively heavy processes, from chart retrieval to coding to supplemental data and submissions. The ever-changing regulatory environment requires continual updates in processes and technology.

Join expert Greg Pastor to discover ways to streamline retrospective risk adjustment processes and develop a strategic, multi-faceted approach to addressing industry changes.

About Our Guest: 
Greg is the Managing Director of Risk Adjustment Operations, leading a team of over 350 risk adjustment professionals to drive client execution, customer value, and plan revenue optimization.

While prior authorization serves as vital checks and balances, ensuring clinical quality and preventing fraud, the administrative burden it imposes on providers and payers alike has led to an industry-wide reevaluation of certain codes and an increased push towards technology for auto-approvals and Gold Carding.

Now, it's up to payers to encourage provider adoption of the technology by offering platforms with user-friendly interfaces, intuitive design, and seamless workflows.

Streamlining prior authorization improves the overall experience for payers, providers, and members to ensure timely care and a more efficient healthcare system.

Tune in to discover: 

• Current shifts in the industry to reduce administrative burden while maintaining clinical quality and medical necessity 
• How plans are leveraging technology to gain insights and refine prior authorization processes
• What CMS is doing to ensure guidance and appropriate timeframes serve members' best interests

About Our Guest:
Chris Hugenberger has been in healthcare software for nearly 20 years, working on operations, implementations, and product development for both the provider and payer sides. He has niche expertise in utilization management and prior authorization software. 

As payers adopt artificial intelligence (AI) technologies in different aspects of healthcare operations, there is a need for AI governance and the careful vetting of vendor AI practices to safeguard patient welfare. 

AI solutions can offer valuable decision support to create efficiencies at scale, timeliness, and accuracy. However, AI solutions should not run autonomously, nor should the final result go unquestioned. It is essential that all stakeholders understand how AI solutions draw their conclusions, what data sources inform the models, and the potential sources of biases that can occur. This level of critical thinking via human oversight is the crux of responsible AI principles: transparency, accountability, and safety.

Tune in to this episode to hear the latest on: 

• Current challenges using AI for decision support
• Responsible AI principles 
• The vital information needed for all stakeholders
• Ways to implement best practice processes for AI oversight 
• The AI algorithm lawsuit that's shaking up the payer space 

About Our Guest:
Sam Keith is an expert in data science, marketing, and analytics. He has over 18 years of experience working in the technology product space, leading product development teams and initiatives to support consumer engagement, user experience, digital experience, and operations. Sam has worked in healthcare, higher education, pharmaceutical, and network security industries and is particularly interested in digital accessibility practices. 

As more and more provider organizations enter into risk-sharing agreements, provider engagement programs are experiencing a surge in participation. Provider engagement programs improve the collaborative relationship between plans and providers to keep documentation up-to-date for CMS submission. It's essential for plans to offer a variety of delivery methods to suit the provider's practice. Some practices enjoy an in-person, on-site method to receive personalized guidance for education and to maximize documentation opportunities, while other practices enjoy an EMR-integrated solution for a highly efficient digital workflow. Providers with an already established process for responding to queries may prefer a remote option via fax. The important aspect of a healthy provider engagement program is not necessarily the delivery method but rather the timely and continuous communication between plans and providers to close gaps on addressable conditions. 

Tune in to discover the best practices for running a successful provider engagement program. 

About Our Guest:
Michelle Calagaz is an expert in prospective risk adjustment programs specializing in provider engagement tactics. She has over 30 years of experience working in healthcare with a focus on Medicare Advantage initiatives and has an array of experience across risk adjustment, business operations, program implementation, product development, and client relations. 

NLP is an AI technology that is being used in healthcare IT for clinical documentation and medical coding. For medical coding, the program identifies diagnoses codes for HCC risk adjustable categories and flags it for a medical coder to review. 

In robust medical charts that span up to thousands of pages in length, this enables coders with an automated way to identify diagnoses codes for review, hence increases speed, efficiency, and output. Academic research has found NLP increases medical coding productivity by 15-20%. 

After the medical chart is reviewed by a medical coder, the chart goes through a pre-submission QA process for accuracy and compliance review. In some cases the chart will go through the NLP program for a second pass to identify additional insights and potential missed opportunities. 

Tune in to this episode to learn: 

• Additional opportunities and limitations of NLP 
• Why medical coders are needed now more than ever
• How organizational goals influence the way plans customize their NLP engine

About Our Guest:
Kristi Reyes is the Director of Risk Adjustment Coding Operations. She leads a team of 250 medical coders from various aspects of risk adjustment—including retrospective, prospective, CDI, QA, risk mitigation, and RADV. Kristi holds Certified Professional and Outpatient Coding, Risk Adjustment Coding, and Auditing certifications.