Stephan O'Neill

This is not a front-desk problem. This is not a physician problem. This is a governance failure. Many outpatient departments (OPDs) feel busy yet continue to lose value. The PDF explains why.

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The 2026 Physician Fee Schedule is out. https://lnkd.in/g5Szcfhg Here is what you need to know. - MSSP changes encourage faster risk taking and newer practices to join. CMS will limit one-sided risk to 5 years starting 2027 down from the previous 10 years for "low-revenue" ACOs. Practices that are in an ACO but undergo a change in ownership will be allowed to put the new entity into the ACO mid-year if it has no Medicare billing history. ACOs without 5,000 beneficiaries in benchmark year 1 and 2 will be allowed to join if that make 5,000 in benchmark year 3 with some limitations. - Physician payments will increase 3.83% for ACO practices meeting APM requirements due to 2.5% from the recent reconciliation bill plus some savings from reduced procedure reimbursement in the form of a higher efficiency adjustment proposed by CMS. - Skin substitutes proposed to be reclassified as incident-to supplies rather than biologicals. This is projected to reduce spending on them by 90%. Spending had exploded from $256 million in 2019 to over $10 billion in 2024. - A new, mandatory Ambulatory Speciality Model focused on heart failure and low back pain would start in 2027. Built on MIPS like measures of costs and quality it would put 9% of the spend in these areas into and incentive pool. CMS would retain 15% of that pool and then redistribute the rest to eligible providers based on performance two years after the performance period. Not mentioned are any future ideas updating the ACPT or administrative benchmarking in MSSP. This is an urgent area given the failure of ACPT to even be in the same ballpark as actual trend in 2024. While recent years have seen all the MSSP changes in the physician fee schedule, MSSP used to get its own regulations. I will continue to work with CMS on developing a next generation administrative benchmark that is grounded in regional factors, available prior to the start of the performance year and is self-correcting. All features of how MA rates are set now. While today, there is no need for administrative benchmark as CMS should just measure the trends of non-MSSP beneficiaries, both CMS and I look forward to a day when MSSP grows so much that is no longer the case. We can plant the tree in advance so we should start working on it. Below is my favorite chart tracking the real world effects of the big re-weighting of E&M that occurred in 2021.

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CPSI Is Sunsetting – Are You Ready? With CPSI sunsetting, many healthcare organizations are facing a major decision: What’s next for your EMR system? If you’ve relied on CPSI, you know how important the right EMR is to your clinical and operational success. As you plan your transition, it is critical to look beyond basic functionality and focus on capabilities that will make your transition successful. Your next EMR choice can either streamline your operations or create new headaches. Over the next few days, I’ll share key insights on what to look for and avoid when making the switch. Stay tuned! #HealthIT #EMR #RCM #HealthcareLeadership #DigitalTransformation

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CDI Code of Ethics I felt compelled to post a quick summary read of the ACDIS & AHMA CDI Code of Ethics, after hearing from some of my CDI colleagues describe the pressure placed on them to review records, issue more queries, capture more CC/MCCs, and generate more revenue. This pressure emanates from CFOs who have been convinced by prominent CDI consulting companies pushing their CDI consulting services and CDI software. Typical claims made by these firms include " we can get you x million dollars every year for the next three years, just sign this contract for x million dollars," or buy our software, "you will achieve 5:1 ROI starting on Day 1: An average of $2.5M in annual net new revenue per 10K patient discharges. CFOs are being misled to believe that CDI is in the business of bringing in more revenue through more queries. More queries without improvement in the quality of physician documentation generate more denials, period. Durable, sustainable net patient revenue is a byproduct of solid physician documentation that reflects the clinical truth-Cesar M Limjoco MD. CDI has, in many respects has lost its way, caught up in coding of CCs/MCCs as opposed to collaborating with physicians to enable and facilitate better documentation. In the process, the profession as a whole is deviating from the ACDIS CDI Code of Ethics 📘 ACDIS Code of Ethics — Core Principles & References 🧭 1. Integrity in Documentation Commitment to accurate, complete, and honest documentation that genuinely reflects clinical care. Prohibition against altering or suppressing information to manipulate outcomes . 👩‍⚕️ 2. Ethical Query Practice Queries must be neutral, non-leading, and based on clinical indicators. Forbidden: "leading" queries, introducing unsupported diagnoses, or querying when no clinical basis exists. . 💰 3. Avoiding Financial Manipulation No participation in practices that inappropriately increase payment, distort data, or misrepresent medical necessity. . 🎓 4. Ongoing Education & Expertise Maintain and enhance professional knowledge through continuing education, including coding standards and ethical guidelines . 👥 5. Team Collaboration Work collegially with providers, coders, and quality teams. Commit to interdisciplinary education to support accurate documentation and compliant CDI processes. . 🔐 6. Confidentiality & Compliance Strictly protect patient confidentiality and access only necessary health information. Report any unethical, non-compliant, or unlawful behavior through appropriate channels. . ⚖️ 7. Professional Conduct & Reporting Uphold the highest standards of integrity, honesty, and professionalism. Take action against unethical behavior, even among peers. . #CDI, #codeofethics, #moneytalkscodeofethicswalks, #misnomer, #hoodwinkedbyconsultingcompanies

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Connecting Care: The Future of Electronic Health Care Records (EHCRs) Electronic Health Care Records are becoming increasingly vital in modern healthcare, with implementations at various stages across many regions. The focus is now shifting towards connecting these records to provide a more comprehensive view of patient information. This endeavor, however, brings forth numerous challenges and questions, including understanding the current landscape, the maturity of existing systems, clinical needs, and the roles of standards and various initiatives. The maturity of shared care records varies significantly across regions, with some having sophisticated systems and others still in early stages. A key indicator of maturity is the extent of connectivity and the availability of crucial datasets like End of Life, Maternity, GP, Social Care and Acute. Establishing interoperability within regions presents the biggest challenge but also offers the greatest benefits, as most interactions occur within a region. The "last mile" of connecting datasets is a slow and complex process but is essential for future progress. It's important to recognize that many of the NHS England national systems will need to be replaced within the next 5 years. Therefore, the current vision looks ahead to 2035, anticipating a complete transformation of the systems used to deliver a single EHCR. This will be an evolutionary process rather than an abrupt overhaul. Standards are crucial for creating an open, vendor-agnostic sharing infrastructure. While basic technical standards like FHIR, OpenEHR and IHE are well-established, ensuring compatibility between datasets is equally important. National bodies play a key role in managing a portfolio of proven standards, including FHIR, IHE, OpenEHR, JSON, JWT/SSL/REST, and PRSB. A National Backbone is essential to connect care records, facilitate data retrieval, and enable standards conversion. This backbone doesn't necessarily need to be a large, centralised system; a devolved approach based on standards and APIs is feasible. An evolutionary approach, starting simple and growing based on use-cases, is advisable to minimise the complexity and cost of national projects. This will also enabling patient choice in sharing and professional and patient access via the NHS app. Key priorities for the future of EHCR include: "Levelling Up" EHCRs: Improving data quality and supporting less advanced regions to ensure universal connectivity. Data Standards: Developing detailed, use-case driven data standards to ensure usability of shared data. Advanced Shared Care Record Proof of Concepts: Trialling advanced sharing functionalities International Patient Summary. National Backbone: Incremental development of a minimalistic National Backbone to support core data sharing functions. In conclusion, the journey to a fully integrated system will be evolutionary, requiring sustained effort and collaboration across various stakeholders.

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CMS’ latest clarification on telehealth rules is an important reminder of how quickly the regulatory environment can shift, and how ready our systems need to be when it does. For healthcare leaders, the update reinforces a few priorities: • Maintain clear governance structures for virtual care workflows • Ensure documentation and billing processes stay aligned with federal guidance • Support clinicians with tools and training that keep the care experience consistent across in-person and virtual settings Telehealth continues to be a critical access point for many patients. Strong policy alignment helps organizations deliver that care safely and reliably. #HealthcareIT #Telehealth #Medicare

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This article is a good reminder that we can generate metrics all day long. But the key is metrics that indicate risk. While the title is for MSPs to have a risk conversation in reviews, the lessons are good for any controls ownes by anyone. One rule of thumb when I evaluate metrics is to see if there are tolerances (eg should I be worried or not?) and then if I’m worried is there an action to take that will reduce risk. Now a counter to this …. I admit there is utility to counting large numbers such as attacks blocked at the firewall for “wow” numbers that let others know the threat is alive and our tooling is doing great. https://lnkd.in/gyCisbvw

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🚧 What’s Holding Back Operational Clarity in Healthcare IT? In my experience, some of the biggest barriers to achieving operational clarity in healthcare IT come down to three core challenges: 🔹 Misaligned priorities 🔹 Fragmented systems 🔹 Communication gaps Healthcare organizations bring together diverse stakeholders clinicians, administrators, IT teams,vendors and payers each with different goals and ways of working. Without shared understanding and alignment, even the best IT projects can miss the mark on what really supports frontline care. System fragmentation is another major hurdle. When EHRs, CRMs,Central data KPIs repository, scheduling platforms, and even patient-facing technologies like portals, apps, and kiosks don’t talk to each other (or worse, present conflicting data), it becomes nearly impossible to achieve a single source of truth. That lack of cohesion makes it difficult to streamline workflows, measure outcomes, or deliver a seamless patient experience. Add to that the communication gap between clinical and technical teams, and you often end up with missed requirements, delayed implementations, and poor adoption. Solving this isn’t just about deploying better tools it’s about building trust, embedding collaboration, and aligning technology with real care delivery needs. 📌 Key barriers we often face: • Data silos and system fragmentation (including patient-facing tech) • Legacy infrastructure • Lack of standardized workflows • Resistance to change • Insufficient training and change management • Regulatory and data privacy constraints • Poor coordination between vendors affecting integration timelines Achieving clarity in healthcare IT isn’t a technology problem alone — it’s a people, process, and culture challenge. 💬 What barriers have you encountered in your organization, and how are you addressing them? #HealthcareIT #DigitalHealth #OperationalExcellence #HealthTech #Leadership #HospitalIT #PatientExperience #Interoperability #ChangeManagement #DataDrivenCare

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Hospitals are piloting multimodal generative AI that processes voice, text, imaging, and lab data together, streamlining documentation, triage, and coordination in real time. Early adopters report faster decision-making and reduced administrative load, turning AI into a practical, behind-the-scenes assistant. #AIinHealthcare #ClinicalEfficiency #DigitalHealth #HealthInnovation #CareDelivery https://lnkd.in/e7J4AP7E

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📘 CMS Releases Updated Technical User’s Guide for the Five-Star Quality Rating System — Why It Matters More Than Ever On July 14, CMS has released a major update to the Technical User’s Guide for the Nursing Home Five-Star Rating System, following the June 18, 2025 publication of QSO-25-20-NH. The updated guide details how Five-Star ratings will now be calculated and these changes are significant. 📖 Three Key Updates from the Technical User’s Guide: 🔹 Removal of Third Cycle Standard Surveys Only the two most recent standard surveys now contribute to the Health Inspection score. The most recent survey is weighted at 75%, and the second most recent at 25%. This gives far more weight to current survey performance than in the past. 🔹 Refined Deficiency Weighting and Handling Complaint and infection control surveys are weighted by recency (¾ if within 12 months, ¼ if 13–36 months). Duplicate deficiencies (within 15 days of other inspections) are counted only once, using the highest scope/severity. 🔹 Updated Cut Points for Claims-Based Measures In July 2025, CMS revised the scoring thresholds (cut points) to reflect updated risk-adjustment models. These models now better account for case-mix and severity, meaning your scores may shift even without changes in actual performance. 💡 Why This Deserves Your Full Attention: This is one of the most consequential Five-Star updates in years. The health inspection score is the backbone of your overall star rating — and now, your most recent survey matters more than ever. For years, providers flagged the impact of survey delays during the COVID PHE. Now, as backlogs clear, older surveys are being phased out, and current deficiencies carry far greater weight. ✅ Why this matters: Your overall star rating affects: ➡️ Eligibility for Value-Based Care contracts ➡️ Participation in ACOs ➡️ Access to the 3-Day Hospital Stay Waiver ➡️ State-based Medicaid quality incentive payments, where Five-Star components are often tied to bonus eligibility and distribution 📣 Your next survey won’t just affect compliance — it will influence your role in the future of long-term care partnerships, revenue opportunities, and payment model participation. #CMS #FiveStar #CareCompare #QSO2520NH #SurveyReadiness #HealthInspection #LTC #PostAcuteCare #VBC #ACOs #3DayWaiver #SNF #QualityMeasures #MedicaidIncentives #ValueBasedCare

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Cyber security threats are real, and deep fakes are becoming more frequent with the proliferation of AI. Society for Clinical Research Sites (SCRS) is hosting a global cyber security panel for #scrs26. Privacy, compliance, and data security are particular passions of mine. At McCreadie Group, we take security very seriously, so seriously sometimes we get raised eyebrows about how strict our infosec protocols are. I cannot emphasize enough these challenges and recommended steps. Here are some tips Nelly Nauman , Anna Titkova 💫 MD, PhD, MBA , and Scott Sumner recommend for individuals and clinical research sites: *Prepare: pause, ask questions, & think. If something is unexpected or comes across urgent, report it. Turn on multi-factor authentication. Do not use public wifi, enable a VPN. Challenge everything you get, with "does it make sense?" *Call for help: If you click on something, don't assume nothing has happened. Pick up the phone and call your CISO. *Notify authorities: if you are impacted, let local and federal authorities know. If you are a business, use Endpoint Protection. Have someone 100% responsible for security and scanning potential threats. Post COVID, threats have shifted to the clinical research industry and healthcare, in addition to financial institutions. Brittni Homer, Justin Webster, others ... what recommendations would you share for healthcare industry professionals? #cybersecurity #clinicalresearch

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In this episode of the CodeCast podcast, Terry discusses the differences between APCM and CCM services and what is needed to report either. Compliance issues are seen with many care management service records. Terry covers how to follow best practices to ensure you follow the published guidance. Tune in here: https://lnkd.in/gviq-m4B #TerryTuesday #CodeCast #APCM

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Earlier today, #CMS released a new 2026 #MedicareAdvantage Final Rule with new Provider Directory requirements as they continue cracking down on #GhostNetworks. New 2026 rules include: ➡️ Requirement for #MA provider directory data to be submitted to CMS/ #HHS for publication online. ➡️ Requirement that MA plans update the online provider directory data within 30 days of learning of changes in the data. ➡️ Requirement for at least annual attestation that provider directory information is accurate at the time of the attestation. These requirements take effect 1/1/2026, requiring MAO’s to make their directory data available to CMS by 1/1/2026. CMS has not committed that the data will be available on #MPF by 1/1/2026 for public use. CMS expects a period of testing to occur to ensure MPF accurately reflects the data provided, and plans to release an operational guide soon to outline technical specifications and milestones. This new 2026 #compliance requirement is accompanied by last week’s related announcement of a new #SEP for members who choose a plan only to later learn that their doctors are not in-network. Link to document: https://lnkd.in/eEJqD_jk

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