If you’ve ever been a member of ACDIS you’ve almost certainly encountered Dr. Trey LaCharite’. ACDIS advisory board member? Check. Regular columnist for CDI Journal? Check. Author of the CDI Field Guide to Denial Prevention and Audit Defense? Check. Speaker at the physician advisor pre-conference every year since (at least) 2010? Yes, put a checkmark there, too.

Trey is the Medical Director for CDI and Coding and Clinical Associate Professor for University of Tennessee Medical Center. He’s got the holy trinity of credentials—a MD, plus CCS and CCDS (and others). On this show he brings his unique clinical and coding perspective, combined with real-world applications and trademark tell it like it is/no-nonsense perspective, in a candid interview.

Note: This show was recorded prior to the 2024 ACDIS conference in Indianapolis last week, where Trey presented the session “Beyond Problem Lists: How to Document Is Just as Important as the What.”

On this show we discuss:

• Trey’s path from hospitalist to CDI

• Problem lists: How UTMCK uses them and keeps them updated

• Denials and creating a “defendable narrative” using the patients’ clinical story

• Trey’s opinion on sepsis-2 vs. sepsis-3, now back in the news due to the recent OIG Work List update

• What ACTUALLY resonates with MDs, regarding the eternal question “what’s in it for me”?

• CDI pet peeves, proudest career accomplishment, things to do in TN, and an unexpected OTR playlist addition

Small community hospitals are the backbone of healthcare for most of the country, even today in this era of sprawling healthcare organizations and massive mergers.

But while they’re critical to the health of our nation, resources are often scarce, and CDI is no exception.

Jennifer Cummins, BSN, CCDS, is one of just two CDI professionals covering a 222-bed not-for-profit community hospital in rural Kentucky. Advanced technology and sophisticated AI are not in her toolbox, but that doesn’t mean Jennifer doesn’t take pride in her work.

In fact, she and her colleague are making a big impact with some old-school methods. Their CDI work helped the hospital earn the title of one of the 100 Greatest Community Hospitals in America. Proof that determination, creativity, and teamwork are still more important than tech, even in this day and age.

On this show we cover:

• Jennifer’s origin story—ICU and ER nurse, finding her way into CDI with the help of a nursing colleague

• CDI program--when it began, focus of reviews, and success metrics

• Conducting chart reviews with a basic encoder, books, creativity, and the help of other departments

• Logistical challenges as a small community hospital, including weekend coverage and PTO in a department of two, and rising to meet new initiatives with limited resources

• Expansion to mortality reviews: Identifying the need, process, early successes, and conducting deeper, more intensive reviews

• Fun things to do in Kentucky (aka., Bourbon Trail). Plus Jennifer’s addition to the Off the Record Spotify playlist (Kentucky bluegrass? Find out)

I don’t know about you but I'm FASCINATED with Medicare Advantage (MA). Massive growth, fueled by its shrewd marketing of added benefits beyond traditional Medicare. But also chaotic, messy, a program in need of reining in.

It’s a bit of the wild west.

I like some things about MA, including its emphasis on preventative care and aligning patients outcomes with rewards. But I'm also routinely disappointed by its excesses and denial of medically necessary care.

Some days MA seems poised to overtake and end traditional Medicare. But every time I think that, another shoe drops. Intensive audits from the OIG, and sharp criticism from the likes of former CMS administrator Don Berwick. Two weeks ago we saw the nation’s largest ACO get hit with a whistleblower lawsuit for alleged upcoding abuses.

To get a big picture overview and figure out where we are with the program I invited 4Sight Health’s David Burda to join me on the podcast. David is 4SightHealth’s news editor and columnist and hosts a podcast, the 4sighthealth roundup, covering MA and other adjacent topics.

Listen in as we discuss:

• David’s journalism background and eventual path into covering healthcare

• MAs rapid adoption: Will it continue until Medicare is phased out—or is a reckoning coming?

• The problems with MA: Gaming of risk adjustment/upcoding to make patients appear sicker, denial of medically necessary care, prior authorization nightmares, and sky-high insurer profits

• What MA is doing well, should be preserved, and what needs reform

• Is healthcare compatible with a free-market economy and shareholder ROI? 

• How David stays on top of the torrent of healthcare news, and his cool addition to the #OTR Spotify playlist

Additional reading from 4sighthealth:

• What Will Happen to Traditional Medicare? https://www.4sighthealth.com/ken-terry-what-will-happen-to-traditional-medicare/ 
• Spy vs. Spy? More Like Medicare vs. Medicare Advantage https://www.4sighthealth.com/spy-vs-spy-more-like-medicare-vs-medicare-advantage/