Regulatory Headwinds: Medicare Advantage and Value-Based Care Mantra for Success

1 CEU

Description

CDI professionals must be aware of the regulatory and documentation requirements at play to perform their roles effectively. This session will provide an overview of the latest updates to the Medicare risk adjustment program, including findings from the Office of Inspector General and Health and Human Services audits, CMS recommendations and action plans to address coding compliance issues. Attendees will then learn how these audits and recommendations have implications for the False Claims Act and will impact the future of the Medicare risk adjustment program, hierarchical condition category coding, and value-based care.

Learning Objectives:

  • Understand the regulatory compliance framework around Medicare Advantage and Value-based care risk contracting.
  • Learn about common systemic defects and pitfalls of aggressive HCC coding and riskier area of operational non-compliance.
  • Learn about recent enforcement actions in the Medicare Advantage and OIG and DOJ actions against health plans and other VBC entities.
  • Understand the regulatory compliance framework around Medicare Advantage and Value-based care risk contracting.

Featured Speaker

Khush Singh, MD, MHA, CPC<CRC, CPCO, CPMA, CDIP 
CEO, Bulwark Health

Dr. Khush Singh is a trained clinician and an experienced healthcare executive with nearly two decades of combined experience in health information management (HIM), value-based care (VBC), and Medicare risk adjustment. Throughout his recent career, he has held several senior leadership roles with Medicare Advantage health plans, MSOs, ACOs, and risk-sharing entities in the VBC space, as well as health-technology companies, where he has led technology development aimed at optimizing HCC coding for managed care operations.

With his expertise in Risk Adjustment (RA), Value-Based Care (VBC) operations, and population health, Dr. Singh leads targeted initiatives that provide insights into optimizing risk adjustment operations, claims data analytics, HCC coding, and the operational compliance aspects of the value-based care program. He regularly engages with physician practices focused on value-based care and managed care, educating providers on HCC coding and documentation. He has helped numerous clients enhance their value-based care operations, improve HCC recapture, streamline EMR workflows, and resolve claims and EDPS submission issues. Leading with a team of consultants, he has assisted several entities in establishing and enhancing their clinical documentation integrity (CDI) processes to accurately recapture appropriate HCC risk scores, HEDIS recapture, and ensure compliance with regulatory guidelines.

Dr. Singh has spearheaded the development of AI-enabled SaaS technology solutions to optimize value-based care, HCC coding, and quality operations for revenue integrity and compliance. He has also played a key role in restructuring and improving various Risk Adjustment, Quality, and VBC operations for multiple risk-bearing VBC programs within several large and mid-sized healthcare organizations.

Dr. Singh has collaborated with various entities, including EMR vendors and risk adjustment technology providers specializing in NLP, AI, and advanced HCC analytics. He has also worked with and advised organizations engaged in billing, coding, and revenue cycle management that support hospital systems, MA plans, MSOs, ACOs, and provider practices. Furthermore, he has assisted clients, such as private equity firms, with M&A transactions by analyzing encounter data submissions and RA processes while structuring and conducting due diligence and audits.

Dr. Khush Singh often speaks at national and regional conferences, including AAPC, RISE, ACDIS, AHIMA, HCCA, and others, on topics related to CDI, risk adjustment, HCC coding, RADV audit compliance, MAO operations, and technology solutions for managed care and VBC entities.

Focus areas of expertise:

  • Development of AI-enabled SaaS technology solutions to optimize value-based care
  • Optimizing Revenue Integrity workflows for health systems and provider groups in VBC
  • Prospective, concurrent, retrospective risk adjustment process re-design & implementation
  • Development of diagnosis ICD-10-CM coding and compliance audit workflows
  • Clinical Document Integrity (CDI) focused HCC recapture workflow re-designs for IPAs
  • Design and implementation of medical provider and coder HCC coding education programs
  • Clinical suspect analytics & HCC logic development (CMS & HHS-HCC & CDPS-Rx)
  • Actuarial Risk adjustment Matrix modelling with Risk Stratification
  • RAPS/EDPS reconciliations for supplemental data submission for MA plans
  • Design and interfacing of NLP technology-driven risk adjustment coding workflows
  • Risk adjustment focused claims analytical architecture development (for IPAs & MA plans)
  • Interfacing MA Risk adjustment with HEDIS & Quality programs
  • Retrospective chart reviews campaign management for MA and ACA commercial plans
  • RADV audit preparedness, designing, and conducting HCC-focused mock RADV audits

Speaking Engagements:

  • “Bad, Better, & Best Practice: Avoiding FCA Liability for False or Invalid HCC Diagnoses from HRAs” at HEALTHCON 2025, Orlando, FL, April 8, 2025
  • “Value-Based Care - Is it a Mirage? Regulatory Update on Medicare Advantage” at HEALTHCON 2025, Orlando, FL, April 9, 2025
  • “Lessons from the Front Lines: How to Avoid FCA Liability from HRAs and Chart Reviews” HCCA Managed Care Compliance Conference 2025, Scottsdale, AZ, February 3, 2025
  • “Regulatory Headwinds: Medicare Advantage and Value-Based Care Mantra for Success” AHIMA 2024, Salt Lake City, UT, October 24, 2024
  • “Risk Model Transition Overview – v24 to v28” AAPC RISKCON 2024, June 25th, 2024
  • “Using AI to combat Medicare Reimbursement Fraud” CTEL Digital Health Summit, Capitol Hill, Washington D.C., June 12th, 2024
  • “Regulatory Guidance for Medicare Advantage and Value-Based Care” & “Risk Adjustment Compliance Panel” at HEALTHCON 2024, Las Vegas, NV - April 15-, 2024
  • “Do’s and Don’ts of an Outpatient CDI Program” HEALTHCON 2024, April 15th, 2024
  • “Differences in Value-Based Contracts” AAPC RISKCON 2023, June 27-28, 2023
  • “Regulatory and Compliance Headwinds in Medicare Risk Adjustment” AAPC HEALTHCON 2023, Nashville TN - May 22, 2023
  • “Processing Submission Reconciliation for Inter-Departmental Alignment” Risk Adjustment Innovation Conference, April 17-18, 2023
  • “Diagnose Risk Adjustment Data to Create Guardrails with Coding and Compliance”, RISE Forum 2023, Chicago, IL - May 10, 2023
  • “Regulatory and Compliance Headwinds in Medicare Risk Adjustment”, RISE Forum 2023, Chicago, May 10, 2023
  • “Strategies for Accurate Capture and Submission of Data”, RISE Value-based Care summit, June 21, 2023
  • “Risk Adjustment Roundtable With the Experts”, AAPC Workshops Jan 28th, 2022 • “Payer Audit Findings: Medicare and OIG Audits,” AAPC RISKCON 2022, June 22-23, 2022 • “Technology Solutions for Risk Adjustment”, AAPC RISKCON 2021, Sep 13-14, 2021
  • “Leveraging Data Analytics for Risk Adjustment.”, RISKCON 2021, Sep 13-14, 2021
  • “Strategies for Successful Payer Audits with Coding Compliance”, AAPC RISKCON 2021, Sep 13-14, 2021
  • “Streamlining Telehealth Code Capture (Do’s and Don’ts) for Risk Adjustment”, RISE West Roundtable, September 10th, 2020
  • "Risk Adjustment & Quality Metrics”, AAPC Regional Conference, Seattle, October 13, 2019