Building a Proactive RADV Audit Readiness Plan: People, Process, Technology, and More
Welcome to a brand new episode of Care Decoded! In this episode, host Mark McKeown is joined by renowned risk adjustment and coding expert Colleen Gianatasio to kick off a special two-part series diving into CMS’s heightened focus on RADV (Risk Adjustment Data Validation) audits. As Medicare Advantage plans face unprecedented scrutiny with CMS now pledging to audit all eligible contracts every year, the stakes have never been higher for compliance, documentation, and risk management.Together, Mark and Colleen unravel the far-reaching impact of these changes across the healthcare industry, from the increased resource demands on health plans to building a culture of compliance and leveraging people, process, and technology for audit readiness. Drawing on her expertise, Colleen shares actionable strategies for integrating risk adjustment compliance into the fabric of organizations, explains the most common pitfalls in documentation and coding, and explores how AI and prospective tools can improve audit outcomes.Whether you’re part of a health plan, provider group, or just interested in the world of healthcare compliance, this episode is packed with practical advice and insights on navigating the evolving landscape of RADV audits and value-based care. Tune in as we decode the latest industry challenges and get ready for the next episode, where we’ll dive deeper into the provider’s role in RADV success.Disclaimer: The opinions expressed by any participants in this podcast recording are solely their own and do not represent any organization they worked for in the past or present.Timestamps:00:00 Medicare Advantage Under Scrutiny06:18 Proactive RADV SWAT Strategy07:18 Continuous Provider Communication Strategy12:17 Top Coding Issues in Risk Adjustment15:29 Optimizing Risk Adjustment with Data Analytics19:34 Risk Adjustment Reporting Overhaul23:09 Prospective Risk Beats Retro AdjustmentPodcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/
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Closing Care Gaps and Turning Data Into Action for Better Patient Outcomes
Welcome to another episode of Care Decoded, the podcast where we break down the most pressing issues in modern healthcare. In today’s episode, host Michael Lesnik, VP of Provider Sales at Inferscience, sits down with Dr. Sunil Nihalani, CEO of Inferscience and a practicing physician, to unravel the complexities of “care gaps”, those critical yet often overlooked opportunities to improve patient care and outcomes.Drawing on over fifteen years of experience in healthcare IT and value-based care, Michael and Dr. Nihalani dive deep into why care gaps persist, the challenges providers face in closing them, and why it’s about more than just checking a box on a metric sheet. From the realities of data accuracy and insurance hurdles to the vital importance of patient communication and trust, this episode explores the human side of healthcare quality. You'll also hear firsthand strategies for closing care gaps effectively, how technology, including AI, is changing the landscape, and why these efforts matter for both health equity and patient relationships.Whether you’re a healthcare provider, a member of a clinical team, or simply passionate about better patient care, this conversation offers practical insights and fresh ideas to help you and your organization “decode” the intricacies of care gap closure.Let’s get started!Timestamps:00:00 "Optimizing Patient Care Opportunities"05:17 Patient Data and Trust Issues08:07 Patient Education on Health Screenings13:32 "Small Practice, High Ratings Success"14:18 AI's Role in Healthcare Gaps18:57 AI-Powered Care Gap Detection23:11 "Closing Care Gaps: A Holistic Approach"23:50 "Decoding Care Together"Podcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/
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Decoding CMS HCC V28 for Real-World Impact
Welcome back to Care Decoded, the podcast where we make sense of the evolving world of healthcare documentation, coding, and clinical AI. In today’s episode, hosts Dr. Sunil Nihalani and Biodun Kajopaiye, Risk Adjustment and Stars Manager at CareFirst BlueCross BlueShield, dive into the seismic changes brought about by version 28 of the CMS HCC risk adjustment model. Whether you’re a seasoned pro or new to the world of risk adjustment, this episode will break down exactly what V28 is, how it’s shaking up provider and health plan workflows, and why specificity in documentation is more crucial than ever. From the altered landscape of risk score coefficients for common conditions like diabetes and obesity, to the growing role of pharmacy data and the challenges these shifts bring to providers, Dr. Nihalani and Biodun Kajopaiye share real-world insights, actionable advice, and strategies to help you lead with confidence through this moment of major change. If you want to understand how policy updates connect with patient care on the ground, you’re in the right place: let’s get decoding!Timestamps:00:00 Healthcare Advocate and Risk Adjustment Expert06:29 "Improving Diagnosis Documentation and Risk Management"10:25 RADV Impact on Health Providers12:04 Risk Adjustment Incentives Explained15:20 Health Care's Shift to Value-Based Contracts18:28 Reducing Stress in Healthcare Providers24:03 Towards Focused Healthcare Management25:51 Optimizing Risk Adjustment Strategies29:40 "Prioritize Clinical Perspective First"Podcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/
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Tackling Physician Burnout: The Hidden Costs of Clunky Documentation Systems
Welcome back to Care Decoded, the show where we break down the complexities of risk adjustment, documentation, and the evolving role of AI in healthcare. In today’s episode, host Lucy Medina sits down with Dr. Sunil Nihalani, CEO of Inferscience and practicing physician, to tackle a topic that hits close to home for every clinician: documentation burnout. Together, they pull back the curtain on how clunky EHR systems, endless documentation demands, and poorly designed workflows are taking a toll not just on clinicians’ efficiency but also on their emotional well-being, patient relationships, and even financial outcomes.From the frustrations of lost patient moments to the hidden costs of delayed or inadequate documentation, Lucy and Dr. Nihalani explore the very real burdens today’s healthcare professionals face. But it's not all doom and gloom; they’ll also shed light on how AI-powered tools and smarter EHR integrations are starting to transform the landscape, offering hope for a future where technology truly works in service of both providers and patients.If you’re a clinician who’s ever felt buried under paperwork or a health system leader looking for real solutions, this conversation is for you. Let’s decode the path from burden to benefit together.Timestamps:00:00 Disruptive Documentation in Healthcare04:16 Physician Documentation Overload07:05 EHR Challenges Impacting Patient Care10:52 "Ambient Scribe: AI in Practice"16:10 Dual Life: Doctor and Entrepreneur17:51 Improved Data Flow in HealthcarePodcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/
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Bridging Risk Adjustment and Quality: Turning Data Into Meaningful Patient Outcomes
Welcome to another episode of Care Decoded, the show where we break down the complexities of risk adjustment, documentation, and AI to power better healthcare. In today’s episode, host Dr. Sunil Nihalani is joined by Subbu Ramalingam — a seasoned former health plan executive and expert at the intersection of star ratings, risk adjustment, and healthcare quality.Together, Sunil and Subbu dig into why star ratings aren’t just about checking boxes, but about truly improving patient care and experience. They discuss how health plans and providers can bridge the often-siloed worlds of risk adjustment and quality improvement and why accurate data and collaboration are key to better — and more meaningful — outcomes.You’ll hear real-world examples illustrating how documentation and coding impact patient care, the latest updates on CMS risk adjustment data validation (RADV) audits, and why aligning risk and quality programs matters more than ever. Plus, Subbu shares actionable advice for healthcare leaders looking to turn mountains of data into engines for quality while keeping the patient at the center of it all.If you’re a healthcare leader, clinician, or just passionate about making sense of the care ecosystem, this episode is packed with the insights you need to help decode the path toward better care. Let’s dive in!Timestamps:00:00 Data's Role in Meaningful Care04:01 Optimizing Patient Care Experience09:37 Risk Adjustment and Eligibility Alignment14:00 Coordinating Care for Diabetic Members17:48 CMS Launches Overdue RAD Audits20:29 Enhancing Health Plan Audit Processes22:35 Healthcare Industry Shift Forecast27:16 Health Plan Overdocumentation Issues31:02 Healthcare System Risk Score Management33:38 Aligning Health KPIs and Outcomes35:56 Chronic Care Spending Concerns40:19 Healthcare Data Interoperability Challenges43:18 Integrating Home Data in CareSubbu Ramalingham - https://www.linkedin.com/in/subburamalingam/ATTAC Consulting Group (ACG) - https://www.attacconsulting.com/Podcast's Website - https://caredecoded.com/ Dr. Sunil Nihalani - CEO and Founder at Inferscience - https://www.linkedin.com/in/sunil-nihalani-a6983a5/ Inferscience - https://www.inferscience.com/ Podcast Powered by TopHealth - https://tophealth.care/
Care Decoded is the go-to podcast for clinicians, health plan leaders, and quality champions navigating the evolving world of risk adjustment, value-based care, and smarter documentation. Hosted by Inferscience, this show takes you inside the workflows, decisions, and technologies that turn clinical complexity into clarity. From demystifying HCCs and RAF scores to decoding CMS changes and exploring the impact of AI, we help you understand the data behind every diagnosis.This show isn't about theory. It's about impact. Not about compliance. But confidence. Not about more clicks. But clarity at the point of care.If you're building the future of care – one chart, one visit, one code at a time – Care Decoded is your ultimate guide.
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