Latest news with #regulatory
Geek Vibes Nation
3 hours ago
- Business
- Geek Vibes Nation
Navigate CMS-HCC Model V28 With AI, Accuracy & Clarity
CMS-HCC Model V28 demands precision. With expanded specificity, it reshapes how risk scores are calculated and forces organizations to realign clinical documentation with coding. Multi-vendor confusion, data integration issues, and coding inconsistencies are roadblocks. The good news? AI tools and Digital Health Platform integration offer a clear path forward. Businesses that embrace interoperability, organized planning, and more intelligent workflows will be most equipped to handle this change with assurance. Healthcare organizations are aligning with a sharp regulatory shift. With the CMS-HCC Model V28, clinical documentation needs to be more specific and coding more compliant than ever. Health plans and providers must now collaborate more closely and in more detail as a result of the push for specificity. Broad-stroke diagnoses will no longer qualify under the V28 Risk Adjustment framework, making precise clinical documentation a top priority. In this environment, risk models require coding that reflects real-world complexity rather than administrative simplification. The implications of the CMS-HCC Model V28 extend well beyond compliance. Delays in preparation put organizations at risk for workflow disruptions, audit risks, and revenue loss. It is no longer optional to have strategic alignment across platforms, people, and processes. The time has come to evaluate, modernize, and take charge of the information that determines financial performance. The Multi-Vendor Puzzle The operational load tied to risk adjustment is not just about codes and compliance. It's about navigating a fragmented ecosystem of tools, workflows, and vendors. As new models like CMS HCC V28 bring higher specificity, every disconnected system adds more friction. Discussions at the forum demonstrated how important it is for businesses to eliminate inefficiencies and create platform-wide end-to-end visibility. The challenge of fragmented systems Healthcare organizations face a jigsaw puzzle of disconnected technologies. Executives shared how managing 30+ vendor steps from clinical documentation to CMS submission introduces risk, delays, and confusion. Each vendor operates in silos, making it hard to align processes or ensure consistency. The solution Reduce complexity. By combining suppliers or implementing integrated technologies that unify everything under a single interface, organizations are simplifying their IT stacks. The outcome? Stronger compliance, improved accountability, and fewer manual interventions. Bridging Clinical Workflows and Coding Standards Aligning clinical workflows with coding expectations has emerged as a strategic priority due to the strain of new compliance requirements. With the added specificity in CMS HCC V28, the stakes are even higher. Organizations can no longer afford disjointed communication between clinical teams and coding professionals. Bridging this gap ensures not only regulatory compliance but also accurate risk capture and better care quality. Clinical accuracy drives compliance. One of the biggest pain points? The disconnect between what physicians document and what coders interpret. Misalignment here leads to missed HCCs or even inaccurate risk capture. Leading approaches include: Creating shared documentation protocols across clinical and coding teams Training on how V28 changes the diagnosis code requirements Embedding assistive tools into the physician workflow to guide documentation in real time The emphasis is on precision. Under CMS HCC V28, vague or broad documentation won't cut it. Advancing Interoperability Across Systems As organizations transition to more complex coding models like CMS HCC V28, interoperability becomes a strategic differentiator. A lack of clean data flow between systems can delay submissions, reduce the accuracy of risk scores, and limit the effectiveness of population health efforts. Aligning platforms, interfaces, and workflows to communicate without friction is central to operational success under evolving models. Making data move where it matters Timely and clean data exchange is mission-critical. Many organizations still struggle to get real-time data into the hands of decision-makers and coders. To solve this: Map all data flows between systems to identify gaps Regularly assess integration performance Set up rules for quickly resolving discrepancies Track data exchange metrics to measure progress When systems communicate effectively, risk scores improve, errors drop, and compliance strengthens. Strategic moves to stay ahead With implementation due in 2026, organizations have a tight window to prepare. The forum stressed practical steps being taken by leaders across the board. Key strategies include: Rolling out incentive-based programs to boost staff engagement Deploying dashboards to monitor V28-specific performance indicators Running test scenarios that simulate new V28 workflows Building cross-functional readiness task forces Structured preparation today translates to fewer surprises tomorrow. Role of AI and NLP in Smarter Risk Adjustment Modern risk adjustment depends on speed, accuracy, and data-driven insight. That's why the strategic use of AI and NLP is rapidly becoming a cornerstone of success under V28 Risk Adjustment. These technologies, particularly when combined with a scalable, user-friendly system architecture, simplify documentation procedures, identify lost coding opportunities, and comprehend difficult clinical terminology. When used properly, they complement human judgment rather than take its place. Technology fuels accuracy and speed. V28 Risk Adjustment demands more than manual chart reviews. AI and NLP are being used to process clinical notes, uncover overlooked diagnoses, and deliver coding suggestions rooted in clinical logic. These tools: Flag incomplete documentation instantly Suggest valid HCCs based on medical language Analyze patient history across multiple systems A strong Digital Health Platform ties these elements together, driving both speed and precision. Strengthening Trust Between Stakeholders As organizations move toward more accountable risk models like CMS HCC V28, fostering trust across stakeholders becomes non-negotiable. Providers need visibility into how their documentation translates into coding. Payers seek consistency and accuracy in submissions. Patients deserve clarity on how their care is categorized. Without mutual trust, even the best tools can falter. Strengthening these relationships begins with shared visibility and audit-ready transparency. Documentation done right supports everyone. Risk adjustment works best when there's transparency. Trust between payers, providers, and patients grows when everyone sees how diagnoses are captured and why they matter. Trusted strategies include: Giving clinicians control over accepted or rejected HCCs Showing clearly why AI flagged a certain condition Using audit-friendly interfaces to back every decision with data This is not just about compliance, it's about empowering the entire ecosystem. Integrating Instead of Layering Fragmented tools and disconnected workflows create noise, not clarity. Leaders at the forum stressed how layering new technologies on top of outdated systems only amplifies complexity. As expectations around risk adjustment grow sharper under CMS HCC V28, organizations must shift focus from stacking systems to integrating them. Unified platforms simplify operations, reduce rework, and promote data integrity across departments. Solving the multi-system chaos Risk adjustment shouldn't rely on patchwork systems. The forum echoed one truth loudly: integrated tools that span documentation, coding, and submission outperform cobbled-together vendor networks. With unified platforms, organizations: Avoid duplicate data entry Improve turnaround times Keep all departments aligned on coding priorities This approach supports real-time updates, especially vital when transitioning to CMS HCC V28. Sustaining Change Through Smart Execution Turning strategy into outcomes Execution matters. Tools alone won't move the needle unless they're tied to smart processes and metrics. Practical execution tips: Monitor workflow efficiency weekly Pilot innovations before system-wide rollout Get regular feedback from clinical and coding users Continuously adapt documentation protocols to match V28 standards This adaptive, measurement-driven approach ensures compliance is never a one-time event. Final Thoughts CMS-HCC Model V28 changes the game. Healthcare organizations that invest in interoperability, data accuracy, AI tools, and smarter workflows are best positioned to adapt. Documentation needs to be intentional, specific, and traceable. Experience Integrated Intelligence with Persivia Healthcare doesn't need more vendors, it needs better ones. Persivia offers Risk Adjustment Solution that empowers providers with transparent AI, NLP-backed insights, and full V24/V28 compatibility. With bidirectional EHR connectivity and a white-box AI engine, it enables clinicians to act on real opportunities without second-guessing algorithms. Learn more today.
The Guardian
11 hours ago
- Business
- The Guardian
Cunliffe's reforms for water should have happened 20 years ago
Farewell, Ofwat, soon to disappear down the regulatory U-bend. Its leadership has been up against some serious corporate miscreants and boardroom financial engineers over the years, but abolition is the right decision. The original sin – overseen by New Labour – was to allow the leveraged takeover boom of the mid-2000s, which was the point at which regulatory control over the sector started to be lost. The past decade has been about trying to undo the damage, which has only exposed yawning gaps in regulatory knowledge, such as the storm overflow scandal that broke in 2021. A 'reset' moment is overdue by about 20 years. Sir Jon Cunliffe's review goes to the heart of one main problem: the fragmented, overlapping and inflexible nature of a regulatory system that takes in not just Ofwat and the Environment Agency (a regulator that lost its way as severely) but also the Drinking Water Inspectorate, Natural England and Natural Resources Wales. That structure is simply confused. A super-regulator in England (and equivalent in Wales) should, the theory goes, solve the problem of duplication and lack of coordination. Simpler is better. One line of criticism says the government is merely rearranging the deckchairs. Not necessarily. The bite in Cunliffe's recommendations, if they are to succeed, will be the switch to a 'supervisory' model. The description is bland but, if done correctly, it could make a difference, as it has in financial services, from where Cunliffe, one of the clean-up officials at the Bank of England after the great crash, has drawn his analysis. The Prudential Regulation Authority is capable of striking fear in bank boardrooms. For water, it will require the regulator to know a company's operations in detail at a basic engineering level, and thus be equipped to know when excessive returns are being made or when, genuinely, the company hasn't been given the financial resources to do the job. It is, for example, amazing that Ofwat's board does not include anyone with the job title 'chief engineer'. (The new regulator should have one, says Cunliffe.) And it is even more astonishing, 36 years after privatisation, that nobody seems to have a clear idea of the real state of companies' assets. (Fix that too, says the report.) Add it up and there is a framework for a more commonsense approach than the current cycle of reviews and exchanges of documents running to thousands of pages. 'Ofwat has relied too heavily on a data-driven, econometric approach, and has not taken sufficient account of company-specific conditions and challenges,' says Cunliffe's commission. It is hard to disagree. In the end, it is not possible to run a privatised system without strong regulators who form their own judgments. New powers, under Cunliffe's advice, would allow regulators to block certain owners and to apply a financial-style suitability test for senior executives. Both sound like improvements if backed by 'public benefit clauses' in water company licences that would allow the regulator to interfere more aggressively. Given the sector's history of financial engineering, Cunliffe could have gone further and suggested caps on debt levels. Instead, he opted for new regulatory powers to set minimum capital levels. That is weaker, but at least we may see an end to the nonsense of Ofwat announcing a leverage ratio for its 'notional' company (55% of assets currently) and then being ignored. In other respects, the report will read as investor-friendly: 'company-specific' supervision and the possibility of 'regulatory forbearance' in turnaround situations will be music to the ears of the sector laggards. If the latter is to achieve public consent, the other side of that coin will have to be tougher day-to-day enforcement of environmental laws, which comes down to the government's willingness to fund boots on the ground. That part is the gift of ministers. Indeed, Steve Reed, the environment secretary, should take note of what this report demands of government – a 'step change' in strategic approach, including setting medium- and long-term priorities and an acknowledgment of trade-offs. Step one, one can suggest, would be for Reed to stop claiming the government has 'secured £104bn of private sector investment' when everybody knows the vast bulk of the sum comes from customers' bills. Sign up to Business Today Get set for the working day – we'll point you to all the business news and analysis you need every morning after newsletter promotion For some, nothing less than full nationalisation will do. On that score, the government's resistance is justified. Nationalisation would take years, would be challenged in court if attempted at less than market value, and offers no guarantee of success if the HS2 debacle is a guide to departmental talents in building critical infrastructure. Cunliffe's vision of a 'low-risk, low-return' sector for investors is a better pragmatic bet if the goal is to clean up lakes and rivers as quickly as possible and actually build some reservoirs. Low-risk cannot mean risk-free: it must still be possible for the owners of outright corporate flops to lose their shirts, as the mugs who bought Thames Water from Macquarie will. Everything will depend on execution, of course. In the meantime, the Thames crisis rumbles on and special administration remains a highly possible outcome for that disaster, not least because Cunliffe's review should remove the 'contagion' risk for the wider sector. For now, the forward-looking aspect of his review is the thing to focus on. A tally of 88 recommendations illustrates how much has gone wrong. But the core advice to create a single, stronger regulator – one that can throw its weight around on the basis of up-to-date information – should be unarguable.
The Independent
18 hours ago
- Business
- The Independent
Ofwat to be abolished, minister confirms in major overhaul of Britain's ‘broken' water industry
Water regulator Ofwat will be abolished as part of an overhaul of a "broken'' regulatory system, the environment secretary has confirmed. Steve Reed said the water industry is "broken" and has been allowed to fail under a "regulatory system that let them get away with it". Speaking in south-west London, he said: "Our rivers, lakes and seas are polluted with record levels of sewage." Mr Reed blamed soaring water bills for straining household finances and warned that poor infrastructure is holding back economic growth. He thanked Sir Jon Cunliffe and his team for their "outstanding" report and said he would give a fuller response in the Commons this afternoon. "Water companies have been allowed to profit at the expense of the British people," he said.
Bloomberg
3 days ago
- Health
- Bloomberg
Otsuka, Lundbeck's PTSD Drug Fails to Win US FDA Panel Support
Otsuka Pharmaceutical Co. 's medicine for post-traumatic stress disorder with partner H. Lundbeck A/S failed to win the backing of US regulatory advisers, a major setback in the drugmakers' bid to bring the first new drug for the condition to market in more than two decades. The panel of external advisers to the Food and Drug Administration voted 10-to-1 on Friday that the efficacy of the companies' brexpiprazole tablets marketed under the brand name Rexulti — in combination with sertraline — hadn't been established.
Bloomberg
3 days ago
- Business
- Bloomberg
Paramount Suitor Meets With FCC Chairman, Seeking OK for Deal
Skydance Media Chief Executive Officer David Ellison met with Federal Communications Commission Chairman Brendan Carr on Tuesday appealing to the regulatory chief to approve his film studio's pending merger with Paramount Global. The transaction has 'significant public interest benefits,' according to a letter to the FCC signed by Skydance attorney Matthew Brill recapping the meeting. Ellison, the son of Oracle Corp. co-founder Larry Ellison, his family and RedBird Capital Partners, 'represent fresh leadership with the vision and experience' needed to drive the new company's long-term growth 'in a changing media landscape,' according to the letter that was made public on Friday.
