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Value Based Care Advisory (VBCA) Podcast

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by Carenodes

25 episodes

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FairBased on show quality, social media presence, reviews, charts, and more

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Podcast Overview

The VBCA Podcast is a solution-focused platform dedicated to advancing the transformation of healthcare through value-based care (VBC) models. Our mission is to break down complex healthcare topics into accessible, actionable insights for leaders, entrepreneurs, engaged consumers, and anyone passionate about meaningful change in healthcare. By challenging the healthcare industrial complex, we provide tools, strategies, and expert perspectives that empower our listeners to navigate and accelerate the shift toward better outcomes, lower costs, and improved patient experiences. Each episode delivers thought-provoking discussions and practical advice from industry experts, spotlighting innovative approaches to healthcare reform and highlighting voices that are often overlooked in traditional dialogues. Whether you're a healthcare executive, provider, payer, policy influencer, entrepreneur, or informed patient, we aim to inspire new ideas and support you in driving transformation in the healthcare space. Powered by Carenodes.

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6/5/2021

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Recent Episodes

August 1, 2026

The Ghost Network Behind Pediatric Home Nursing: When Authorized Hours Go Unfilled

<h2>Episode Summary</h2>A pediatric patient in a New Jersey hospital is medically ready for discharge — equipment arranged, family ready, nursing hours authorized by the health plan. The only missing piece: an actual nurse. This episode uses that scenario to examine the structural gap between authorized private duty nursing (PDN) hours and filled hours in Medicaid managed care, why standard provider directories overstate real pediatric home health capacity, and what CMS's 2024 Medicaid managed care access rule signals for how plans will need to prove — not just claim — network adequacy going forward.<blockquote>"When the network looks broad on paper, but families still cannot get care, the question is not, do we have enough providers listed? The question is, can a child actually get home?"</blockquote><h2>Chapters</h2><ol><li>The Discharge That Doesn't Happen — A clinically ready child, an authorized care plan, and no nurse to staff it.</li><li>The Directory Problem — Why a state can show hundreds of home health agencies while only a handful actually serve pediatric high-acuity cases.</li><li>Authorized vs. Filled Hours — The distinction that matters most for families, and the 20–40% unfulfilled-hours range documented by MACPAC.</li><li>What Makes a Network a "Ghost Network" — Six reasons a directory listing doesn't equal real access.</li><li>Why Pediatric Home Health Is a Different Labor Market — Ventilators, trachs, feeding tubes, and why acuity narrows the real provider pool.</li><li>The CMS Rule — Secret shopper surveys, wait-time standards, and the shift from "is the directory complete" to "can members get care."</li><li>The Pediatric PDN Access Audit — A 7-step framework for MCOs to move beyond static network adequacy reporting.</li><li>What Providers and Advocates Should Document — Turning anecdote into evidence health plans and regulators can act on.</li></ol> Companies mentioned in this episode:<ul><li><a href="affirmedhomecare.com" rel="noopener noreferrer" target="_blank">Affirmed Home Care</a></li><li>Pediatrics and Adolescent Therapy Associates</li><li>Active Pediatrics Therapy Services</li><li>Growing Hope</li><li>Pediatric Care for Kid Care</li><li>Family Care Agency</li><li><a href="https://www.rwjbh.org/childrens-hospital-of-nj-at-newark-beth-israel/" rel="noopener noreferrer" target="_blank">New Jersey Children's Hospital</a></li><li><a href="https://www.njha.com/" rel="noopener noreferrer" target="_blank">New Jersey Hospital Association</a></li><li><a href="Carenodes.com" rel="noopener noreferrer" target="_blank">Carenodes</a></li></ul> Sources cited in this episode:<ul><li>Baxley, J. <a href="https://www.cityviewnc.com/stories/will-increased-pay-solve-north-carolinas-home-nursing-shortage/" rel="noopener noreferrer" target="_blank">"Will increased pay solve North Carolina's home nursing shortage?"</a> North Carolina Health News, via CityView NC.</li><li>Brown, J. <a href="https://coloradosun.com/2024/02/22/medicaid-private-duty-nurses/" rel="noopener noreferrer" target="_blank">"Nurses for medically fragile kids are underpaid and hard to find. Parents want the state to step in."</a> The Colorado Sun.</li><li>AHA News. <a href="https://www.aha.org/news/headline/2025-10-20-oig-says-ma-medicaid-managed-care-plans-have-limited-inaccurate-behavioral-health-provider-networks" rel="noopener noreferrer" target="_blank">"OIG says MA, Medicaid managed care plans have limited, inaccurate behavioral health provider networks."</a> American Hospital Association.</li><li><a href="https://www.managedhealthcareexecutive.com/view/ghost-network-busters" rel="noopener noreferrer" target="_blank">"Ghost Network Busters."</a> Managed Healthcare Executive.</li><li>Fierce Healthcare. <a href="https://www.fiercehealthcare.com/payers/oig-report-raises-red-flags-about-maternal-health-ghost-networks-medicaid-managed-care" rel="noopener noreferrer" target="_blank">"OIG report raises red flags about maternal health 'ghost networks' in Medicaid managed care."</a></li></ul> <h2>Key Data Points Referenced</h2><ul><li>MACPAC has documented that a meaningful share of authorized private duty nursing hours nationally go unfulfilled — often cited in the 20%–40% range.</li><li>CMS's 2024 Medicaid Managed Care Access, Finance, and Quality final rule introduces secret shopper survey requirements, moving oversight from directory completeness toward actual service access.</li></ul>

June 29, 2026

Your Billing Problem Started in the Contract

Most revenue cycle teams are chasing the wrong fire. Persistent underpayment, denials that don't respond to appeals, patterns nobody can explain — these are often contract problems wearing a billing problem's disguise.In this episode, Alex breaks down the structural gap between contracting and RCM that costs providers real money every day, and delivers three things you can take to your next denial review right now.WHAT YOU'LL HEAR<ul><li>The real story behind a multi-specialty group underpaid for 12 months — and why their billing team did nothing wrong</li><li>Why contracting and RCM live in separate worlds — and why that gap is your biggest revenue risk</li><li>Fee schedule effective date clauses: the most dangerous amendment language in managed care contracts</li><li>Carve-out clauses and why behavioral health denials keep looking like coding errors</li><li>Contract dispute timelines vs. your denial management cycle — what happens when they don't match</li><li>The one question to add to every denial review</li></ul> THREE THINGS TO APPLY NOW<ol><li>Check your fee schedule effective dates. Know the execution date on every amendment. Confirm your billing system actually flipped to the new rates. 73% of providers don't know what they're contracted to receive.</li><li>Map your carve-out clauses. Know which services are excluded from the base agreement and where those claims need to route — behavioral health is the most common gap.</li><li>Find the contract dispute window in every active agreement. If it's shorter than your internal denial cycle, that's a configuration problem costing you money today.</li></ol> THE DIAGNOSTIC QUESTIONWhen a denial pattern doesn't respond to standard appeals, ask: Is this a billing problem or a contract problem? They need entirely different escalation paths. If your team is routing both into the same queue, contract-based underpayments are being written off — silently.GO DEEPER: HBMA WEBINAR — AUGUST 12Alex presents the full framework — denial categorization methodology and a contract audit checklist — live through the Healthcare Business Management Association (<a href="https://www.hbma.org/meeting_calendar/details.php?event=3148" rel="noopener noreferrer" target="_blank">HBMA</a>). 1 CEU credit available. Your Billing Problem Started in the Contract: What Revenue Cycle Leaders Need to Know Before a Claim Is Ever Filed. Presented by Alex YarijanianRegister: <a href="https://www.hbma.org/meeting_calendar/details.php?event=3148" rel="noopener noreferrer" target="_blank">https://www.hbma.org/meeting_calendar/details.php?event=3148</a>Checklist directly: <a href="vbcapodcast.com" rel="noopener noreferrer" target="_blank">vbcapodcast.com</a>

May 31, 2026

Deciding to Contract with a Payor: Joining "the Network"

You've built the operation — clinicians credentialed, tech stack running, compliance buttoned up. Then a regional Medicaid managed care plan wants to talk about contracting. Your first instinct: great, let's do it. Then someone pulls up the 40-page contract with a 43-code prior authorization matrix and a data-sharing provision you're not sure sits cleanly with your other obligations.The fee schedule is fine. Not great — fine. And now the question isn't can we do this. It's should we, and on what terms?In this episode, Alex breaks down the payer contracting decision as what it actually is: a market entry and operational alignment commitment that happens to include a rate negotiation inside it. He walks through the six-dimension evaluation framework every health operator should run before signing anything.On the Out-of-Network AlternativeStaying out of network intentionally can be a viable model — particularly in specialty markets where a practice can command premium rates on a self-pay or direct-pay basis. But it requires an honest accounting of trade-offs:<ol><li>Payment at UCR (usual and customary rates) — not your billed charges, not in-network contracted rates</li><li>Limits on what patients can recover from their own plans, affecting your ability to attract and retain members</li><li>Collection burden shifts to the practice, along with associated staff time and friction</li><li>The No Surprises Act materially changed the out-of-network landscape for behavioral health providers in certain care settings — understand your exposure before assuming OON is a clean alternative</li></ol> Key Takeaways<ul><li>Treat payer contracting as a market entry and operational alignment decision — not just a rate negotiation</li><li>In high-concentration markets, staying out of network often means locking out of the majority of the addressable population</li><li>Your value proposition — especially HEDIS gap closure and measurement-based care data — is a negotiating asset most practices leave on the table</li><li>Operational alignment costs don't show up in the fee schedule. Map them before you sign</li><li>The intersection of payer data sharing requirements and 42 CFR Part 2 is not hypothetical risk — it's real compliance exposure</li><li>For contracts involving risk-sharing, value-based payment terms, or complex data provisions, involve experienced healthcare counsel before execution</li></ul> Chapter Markers00:00: Opening scenario — the 40-page contract lands in your inbox01:30: Reframing the network decision — it's not a rate negotiation02:40: Dimension 1 — Market access and concentration reality04:00: Dimension 2 — Knowing and articulating your value proposition05:10: Dimension 3 — Operational alignment and hidden administrative costs06:20: Dimension 4 — Payer's past performance and claims adjudication reality07:30: Dimension 5 — Physician profiling and measurement programs09:00: Dimension 6 — Data sharing, 42 CFR Part 2, and compliance exposure10:15: The out-of-network alternative — honest trade-offs11:20: Practical takeaways and when to involve healthcare counsel

25 total episodes available

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What is Value Based Care Advisory (VBCA) Podcast?: The VBCA Podcast is a solution-focused platform dedicated to advancing the transformation of healthcare through value-based care (VBC) models. Our mission is to break down complex healthcare topics into accessible, actionable insights for leaders, entrepreneurs, engaged consumers, and anyone passionate about meaningful change in healthcare. By challenging the healthcare industrial complex, we provide tools, strategies, and expert perspectives that empower our listeners to navigate and accelerate the shift toward better outcomes, lower costs, and improved patient experiences.

Each episode delivers thought-provoking discussions and practical advice from industry experts, spotlighting innovative approaches to healthcare reform and highlighting voices that are often overlooked in traditional dialogues. Whether you're a healthcare executive, provider, payer, policy influencer, entrepreneur, or informed patient, we aim to inspire new ideas and support you in driving transformation in the healthcare space.

Powered by Carenodes.
How often does this podcast release new episodes?: This podcast updates daily.
Where can I listen to this podcast?: This podcast is available on 4 platforms including Apple Podcasts, Spotify, and more. You can also use the RSS feed directly.
Does this podcast accept guests?: Yes, this podcast regularly features guests.

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