Jonathan Immordino

CMS has announced a new structure in audits around Medicare Advantage Risk Adjustment. A quick breakdown of the changes: - Previously, around 60 plans were audited each year. Now, all approximately 550 eligible MA plans will be audited annually. - In the past, there were 35 records per plan. Currently, there will be 35 to 200 records per plan, depending on size. - Earlier, about 40 coders reviewed records. By September 2025, approximately 2,000 coders will be involved. - Previously lagging behind on audits, CMS aims to complete all audits from 2018 to 2024 by early 2026. If you are not ready you are already behind. #MedicareAdvantage #RADV #Compliance

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CMS’s final Medicare Advantage rates for 2026 came out yesterday, landing at a notably higher average increase (5.06%) than initially proposed. As always, the devil is in the details—particularly the significant upward revision of the effective growth rate, now at over 9%, balanced against continued adjustments in risk model normalization and Star Ratings pressures. For Clover, this announcement is reassuring, but not game-changing. Unlike many MA plans whose profitability hinges tightly on annual rate fluctuations, our model has always been designed differently. Our core thesis isn’t just about capturing incremental payments—it's about leveraging our technology-driven model to fundamentally improve care delivery, outcomes, and economics in ways less sensitive to policy shifts. This doesn't mean we’re indifferent to policy (far from it!), but it underscores a key distinction in how we’ve structured our business. The rate environment is always important, but our differentiation comes from deeper operational strengths: wide networks, minimal reliance on traditional risk-sharing or premium delegation, and substantial clinical and financial outcomes powered directly by Clover Assistant. For the broader MA space, this higher-than-expected rate increase may provide short-term relief and optimism. However, this is a somewhat logical fallacy - I view it instead as reinforcing the cycle many plans are caught in—reliance on favorable policy shifts rather than fundamental innovation. This is why people follow the rate so incredibly closely and use it as a bell-weather for the industry. The years where the rates are on the higher side should not be seen as a relief but instead a sign that industry medical costs are rising (not a good thing) and it's time to invest to bring costs down. Yet many will simply ride the wave. When rates inevitably tighten, those who didn't build real differentiation will face tougher waters, something we’ve seen play out very recently. In short: yesterday’s CMS announcement is good news for everyone—but a useful reminder that sustainable long-term growth in Medicare Advantage requires more than riding the annual rate. It demands investing in true differentiation, creating tangible value for members, providers, and the broader healthcare ecosystem. #MedicareAdvantage #medicarerates #CMS #ValueBasedCare #HealthcareInnovation

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📉 Staffing gaps are hitting healthcare finance hard—44% of healthcare executives identified staffing as a top priority, while 73% are actively focused on improving retention. FinThrive’s latest playbook is your roadmap to resilience. 🔍 Inside the guide: - Industry insights into staffing challenges - Retention strategies to keep your top talent - Tech solutions that ease the burden and boost efficiency 📥 Ready to future-proof your team? Get your free copy of the The Modern Approach to Managing Healthcare Staffing Gaps today: https://hubs.li/Q03NLR-Y0

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Big News from CMS: A major shake-up in Medicare Advantage oversight. Last night, CMS announced a bold and aggressive new audit strategy: -         Every Medicare Advantage (MA) plan will now be audited every year -         Larger claim sample sizes will be reviewed -         Resources are being deployed to clear the audit backlog from 2018– 2024 https://lnkd.in/etxdSKrG Now is the time for providers, coders, and billing partners to tighten documentation, review risk coding accuracy, and be audit-ready. If you work with MA plans — this isn’t a warning, it’s a new normal. #CMS #MedicareAdvantage #RiskAdjustment #MedicalBilling #HealthcareCompliance #ProviderEducation #ValueBasedCare #WCHCredentialing 

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DocuComp LLC is pleased to announce our partnership with Bulwark Health. Bulwark Health is a healthcare technology firm that leverages Clinical-AI technology (ARC+) to assist hospitals with denial mitigation and pre-bill audit management solutions. When combined with DocuComp’s CDI MasterClass program, this partnership offers a win-win solution for acute care hospitals. In addition, Bulwark Health has the following goals: 1. Achieve Revenue Cycle Integrity 2. Ensure Accurate Risk Adjustment 3. Mitigate Outpatient & DRG Denials 4. Increase CDI & Coding Auditor Efficacy 5. Decrease Operational Costs For more information about Bulwark Health, please visit their website: www.bulwarkhealth.com. For more information about our CDI MasterClass program, click on the link: docucompllc.com, or email us at cdimasterclass@docucompllc.com. #CDIMasterClass

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Attention CFOs and Revenue Cycle Directors/VPs If you receive a message from a CDI consulting company pitching their CDI software or CDI programs with numbers such as the following, do yourself a favor: ask questions, clarify claims, and do not believe whatever you hear from the salesperson trying to close a deal and earn his/her commission. This from a CDI consulting company pitching its consulting services- "Within 90 days, revenue increased by 15.5%, and CMI rose 17.5% (from 1.47 to 1.78), reflecting more accurate patient acuity capture. Enhanced documentation also led to higher reimbursements, improved quality scores, and stronger reputational ratings." Questions to clarify: 1- Is this sustainable, durable patient revenue or revenue on the books, which constitutes merely "feel good money?" You cannot pay bills with feel-good money 2- CMI Increase- you cannot pay this year's bills with next year's CMI 3- Patient acuity- How is this measured and calculated? If calculated based on DRG relative weights, this is not a valid and reliable number since payers tend to challenge diagnoses secured by a query based on clinical validation. The same goes for SOI/ROM reporting with the disallowance of a CC/MCC 4- Higher reimbursement, once again, are we referring to feel-good money or sustainable, durable revenue that drops to the bottom lines 5- Inquire about medical necessity denials, clinical validation denials, and DRG downgrades. To what extent did the numbers decrease? If these numbers did not decrease from baseline before implementing the consultant's engagement, then the project was not likely successful Take-home message! Ask the right questions and do not believe what the CDI consulting companies tell you. They have a vested interest in selling their services and expensive CDI software, and generally are the only party to come out ahead! #neverbelievewhatyouaretold, #beinquisitive, #itsoundstoogoodtobetrue

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RCM complexity isn’t going away. Legacy systems, staffing gaps, and payer disputes aren’t anomalies – they’re trends. Mid-size hospitals deserve a partner with proven speed and scale. TruBridge delivered on both for Three Rivers Health. They recovered millions. They cleaned GAAP cash metrics. They prepared for growth. See what modern RCM can actually deliver by downloading the case study: https://bit.ly/4lrkEG4

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Is your business a "lifestyle business" or a "value growth business"? The distinction is crucial, especially when it comes to tax planning. As Fractional CFO Steve Richards points out, shifting your mindset can significantly impact long-term growth and business valuation. Learn how to embrace a growth mindset and strategically plan your taxes in our latest blog post: https://hubs.la/Q03dXMst0 Discover how a strategic CFO can be your "tax strategy evangelist". #TaxPlanning #BusinessGrowth #CFO #FinancialStrategy #FocusCFO

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Unpopular opinion: Not all claim errors are equally important. Fixing a $20 error doesn’t have the same impact as catching a $200,000 overpayment. COOs need smart QA, not more QA. Prioritizing high-risk claims first is the real key to reducing financial exposure.

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Clifton J. Porter II referenced the Medicare Payment Advisory Commission a post today. In the parlance of our times, it triggered me, and the reality should alarm the entire industry - starting with beneficiaries and their families. MedPAC has no meaningful grasp of SNFonomics or the damage it inflicts on the SNF-economy. They once provided useful insight as SNFs transitioned to PPS. I’ve followed their work closely ever since, and it pains me to watch their SNF commentary degrade into satire. Their standard response to serious structural deficiencies is to recommend “future studies” on trends that are already harming providers. They espouse CMMI APMs but ignore the largest transfer of funds from one provider class (SNFs) to another (health systems). They lament the lack of MA data, yet never once recommended that CMS replace Title V - a maternity benefit - with MA on the cost report. It’s finally happening, but I shouldn’t have been the one screaming about it – isn’t that MedPAC’s job? Medicare does not exist in a vacuum; SNFs don't operate within vacuums. SNFonomics is the study of fragmented yet interconnected variables - and MedPAC ignores nearly all of them. It’s like playing Jenga while insisting only one block matters. Their margin and efficiency classifications are mathematical absurdities. They rely on Medicare cost reports whose accuracy has atrophied to arbitrariness. If MedPAC understood the system, they would not treat siloed data domains as self-contained truths or ignore how Medicare policy filters through state-specific Medicaid rules. They can’t connect the dots, and there are dozens of critical issues they routinely ignore. Their SNF commentary does more harm than good - it's enough already. The industry deserves transparency into how MedPAC reconciles its conclusions. Until then, its SNF recommendations will accelerate closures – to which they'll no doubt suggest more “future studies” to identify root causes of the obvious. Ok, I’m approaching rant-mode, and my New Year’s resolution was to stop ranting. I’m requesting a structured, transparent Q&A with MedPAC – I’ll assemble a small, generally sane group of stakeholders and we'll talk it out. After 30 years, it’s time to pressure-test their assumptions before they calcify into policy. If you’re wondering what this is all about – MedPAC just recommended a 4% (about $60k/SNF/year) reduction in SNF rates because profit margins – which cannot be quantified that way, are too high. The MA argument wont resonate with them – MedPAC claims that the fact SNFs continue to admit MA residents at lower rates proves FFS rates are too high. That logic defies logic. It won’t reform anything, and it pales in comparison to the real problem rotting the SNF-economy: https://lnkd.in/eeTDx_gt. It's time to retire MedPAC. MACPAC is far more consequential – but that’s a story for another time. https://lnkd.in/eePytpN4

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