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 Care

04:01 Optimizing Patient Care Experience

09:37 Risk Adjustment and Eligibility Alignment

14:00 Coordinating Care for Diabetic Members

17:48 CMS Launches Overdue RAD Audits

20:29 Enhancing Health Plan Audit Processes

22:35 Healthcare Industry Shift Forecast

27:16 Health Plan Overdocumentation Issues

31:02 Healthcare System Risk Score Management

33:38 Aligning Health KPIs and Outcomes

35:56 Chronic Care Spending Concerns

40:19 Healthcare Data Interoperability Challenges

43:18 Integrating Home Data in Care

Subbu 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/