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EHR Optimization Saved Medical Practices During the Pandemic

By | Blog, healthcare management consulting, MIPS consulting

The COVID-19 pandemic impacted the operations and finances of nearly 97% of medical practices in the U.S. It revealed a stark contrast between the resilience of healthcare providers focused on value-based care versus those who focused on the traditional fee-for-service (FFS) model.

Physician practices still using FFS suffered heavy financial losses when in-person patient volume dropped by 60% on average at the start of the pandemic. The providers that experienced minimal disruption to their operations were the early adopters of the principles and latest technology of value-based care in their long-term business strategy.

Successful implementation of value-based care requires a robust electronic health record (EHR) that supports data collection, clinical decision-making tools, and multidisciplinary care management. Even though the use of EHRs is widespread in the U.S., most EHRs in their current form don’t support value-based care.

EHR optimization is an ongoing process of improvement that affects all aspects of a healthcare organization practicing value-based care. Medical practices that lean into EHR optimization can see more effective patient care plans, decreased physician burnout, and increased ROI. The most common optimizations include:

  1. Workflow and business process improvement for more efficiency
  2. Clinical decision support to achieve better clinical outcomes and improve quality of care
  3. Identification of areas where cost savings are possible

Major stakeholders agree on the role and value of EHRs in transforming the U.S. health system to value-based care. Physicians and patients now feel increased comfort with telehealth and like the safety of virtual engagement during the pandemic. Payers are looking for physician partners who can conduct value-based care with measurable outcomes. EHR optimization is a big step towards realizing industry-wide change.

This update is provided by CareOptimize, a healthcare management consulting firm. We offer managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

CMS Nails Down Its Stark Law Changes

By | Blog, healthcare management consulting, MIPS consulting

Recently, the Centers for Medicare and Medicaid Services added the finishing touches to its Physician Self-Referral Rule revisions, commonly referred to as the Stark Law. The law forbids a doctor from referring a patient for several forms of services to a provider owned by the doctor, under their employment, or otherwise getting payment from them.

The old federal rules were meant for reimbursing providers on a fee-for-service basis, in which further services were supplied as a financial reward. These federal regulations have weighed down hospitals with increased operating expenses and obstructed the transition towards value-based compensation. The healthcare sector, nevertheless, is proceeding steadily toward financial reimbursement systems related to value.

CMS’ move comes as self-referral does not have the same risks as before since providers are increasingly more responsible for patients’ total cost of care. Lack of clarity in the Stark legislation, however, has caused many providers to stay put, afraid of breaking the law even with favorable agreements, which may have critical and expensive implications.

The law finalizes several of the draft policies from the October 2019 notification of planned rulemaking. All the provisions in the revised Stark law are expected to be in effect within sixty days from the Federal Register display date, unless stated otherwise.

To read more, please visit https://www.healthcarefinancenews.com/news/cms-finalizes-changes-stark-law-hindered-physician-referral.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

Insights20 Value Based Care Basics

By | Uncategorized
The COVID19 pandemic uncovered the many benefits of Value Based Medicine, including better outcomes and higher revenue. But Value Based Care comes with its own challenges.
In this video, CareOptimize Chief Commercial Officer Kegan Williams outlines:
– VBC Basics
– How VBC Fits into Today’s Market
– CareOptimize: Revolutionary VBC Technology
– How VBC Can Benefit You

 

 

What to Consider When Transitioning to Capitation Payments

By | Blog, healthcare management consulting, Nextgen EHR

In view of the COVID-19 pandemic, more providers are contemplating moving to capitation arrangements. The decision cannot, however, be made lightly; the risks and complexities of lump sum payments need to be carefully addressed by provider organizations before any decision to switch is made.

Organizations need to recognize the effect the restructuring of the healthcare industry would have on capitation payments. There is a strong financial opportunity for physicians to scrutinize hospitalizations and emergency room admissions and offer higher care levels to patients. This could be a challenge for consolidated health networks that involve hospitals and clusters of doctors. To offset fixed and variable costs of inpatient treatment while still financing alternate care facilities, these organizations may have to determine resource distribution.

Specialist benefits under capitation payments continue to be discussed. Organizations aim to place the primary care provider at the forefront of a healthcare team in alternative payment structures, and capitation payments definitely urge organizations to do so. However, under the alternative payment arrangement, specialists do need to be accountable for total care costs.

Under capitation fees, health services would need to consider how to handle financial risk. The success of capitation payments is jeopardized by complications, debilitating illnesses, and other avoidable problems. But with stop-loss insurance and payment allocation for high-cost products, such as specialty medications and equipment, providers can minimize the effects of these problems.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

Major Insurer’s Value-Based Primary Care Gamble Is Paying Off

By | Blog, healthcare management consulting, MIPS consulting

Humana is reaping the rewards of its decision to gamble on value-based primary care, with the national health insurer receiving well over $600 million in additional income, resulting in a third-quarter profit of $1.3 billion. Humana’s venture into better primary care arrives at a time when healthcare prices are increasing, and insurers are searching for ways to cut costs on medical claims.

When more money is allocated initially for primary care, including screenings and preventative care, research has shown long term cost savings. Humana beneficiaries tend to be seniors in Medicare Advantage programs and cost more than younger, healthier patients, so that investment pays off. Better care with better outcomes has also led to more member retention, a key element in creating value.

Instead of paying physicians for each treatment they offer, which is how health plans historically charged for medical care, Humana pays primary-care practices a fixed monthly fee per patient. This practice is becoming more widespread, especially after the coronavirus outbreak stopped patients from accessing regular care and drained income from medical practices. When people stopped visiting their doctors’ offices, several value-based practices still received payments.

Humana’s Medicare Advantage members receiving treatment from physicians in value-based contracts last year could have spent an additional $4 billion in medical costs if they had continued their care from doctors paid the conventional way, according to the current annual value-based care study from Humana. In contrast with standard Medicare, participants of value-based plans have seen thirty percent fewer hospital stays and ten percent fewer ER visits.

To read more, please visit https://www.businessinsider.com/humana-ceo-lays-out-approach-to-primary-care-clinics-2020-11.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

The Difficulties Involved in Capitated Payment Models

By | Blog, healthcare management consulting, Nextgen EHR

The pandemic and subsequent need to find innovative ways to retain patients while offices remained closed uncovered a basic truth: value based medicine is here to stay. Risk-bearing arrangements can be very successful for providers and allow for more flexibility, but varying state regulations and guidelines make deciding what type of model is good for any particular practice challenging. Under the umbrella of value-based care, reimbursement models take on varying levels of risk for providers and insurers.

Full capitation is an arrangement term when a provider is paid a fixed rate to provide patient or group care. While the rewards for this model can be high, this type of value-based arrangement can be quite complicated and is not advised if a provider has never dipped their toes into value-based care. Capitated models require the ability to track patient data along with an understanding of the cultural changes inherent in the change.

Shared-savings agreements, when providers are compensated for achieving financial and quality benchmarks, are good places for an initial value-based arrangement. Tightly aligned with Medicare, shared savings agreements can also be offered by private insurers. Some bear only upside risk while others contain some downside risk.

Instituting value-based care across the country is challenging because states have a hodgepodge of distinct regulations. Some have loose regulations, while others are quite stringent with their policies. There are some states where providers are treated like insurers, which implies they have to keep a certain amount of financial capital and undergo a burdensome registration process. Semi-annual filings are compulsory in a few circumstances, including fees and disclosing ownership.

The goal is to avoid what transpired in the 1990s from happening again. During this decade, some providers eventually filed for bankruptcy or closed their doors after taking on full-risk contracts, which resulted in insurance companies incurring significant losses. Following these events, legislation was introduced by federal and state governments mandating providers who bear financial risk to keep similar levels of reserves around as the insurance companies.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

CMS Revises Medicare Reimbursement Rate for COVID-19 Testing

By | Blog, healthcare management consulting, MIPS consulting

According to a recent announcement, CMS will decrease the base Medicare reimbursement rate for COVID-19 studies conducted by laboratories making use of high throughput technology. The announcement made late last week declared that, according to the revised Administrative Ruling (CMS-2020-1-R2), the rate would decrease to $75 from $100 starting in 2021.

At the height of the COVID-19 pandemic, CMS had increased the Medicare payment limit for high throughput COVID-19 research from about $51 to $100. However, should labs complete COVID-19 experiments within two calendar dates of the specimen being obtained, labs will be eligible to charge at the higher cost of $100, the regulation also specified.

Under the modified rule, labs using high-throughput COVID-19 research technology must have the ability to complete diagnostic tests within a pair of calendar days or less in order to apply for the higher reimbursement rate. This applies to the majority of patients versus solely those under Medicare.

The new Medicare payment rates are designed to encourage quicker, high-throughput research that will allow patients and clinicians to respond rapidly and resolutely with regard to their options for treatment, contact tracing, and more. Using an automated method that can administer more than 200 daily, high-throughput technologies allow improved testing power.

Laboratories would need to utilize the Healthcare Common Procedure Coding System (HCPCS) code U0005 to obtain a higher reimbursement rate and meet revised coding guidelines, which were also issued last week.

To read more, please visit https://revcycleintelligence.com/news/cms-reduces-medicare-reimbursement-rate-for-some-covid-19-tests.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

CMS Guidelines Promote Value-Based Medicaid Payments

By | Blog, healthcare management consulting, Nextgen EHR

Recently, CMS provided guidelines to assist states with increasing the acceptance of a value based system through their Medicaid programs. The organization has pledged to promote value-based care within Medicare and is encouraging states to make similar attempts to make the same promotion through their Medicaid services. Medicare, Medicaid, and commercial providers overlap greatly. The guidance emphasizes the value of multi-payer alignment in assuring value-based care moves toward the conversion of the healthcare delivery system.

The guidelines include a host of additional concerns Medicaid directors may need to address, including how ready the delivery system is, stakeholder involvement, and financial uncertainty for providers. It also explains how states may utilize their current leverage in their Medicaid systems to implement value-based payments, including with managed care and Medicaid fee-for-service.

Numerous politicians and healthcare authorities have long supported widespread acceptance of value-based payments, which connect financial incentives from providers to the quality of treatment they offer to their patients. Per the Health Care Payment Learning and Action Network, roughly a third of healthcare payments were value-based in 2018.

To read more, please visit https://www.modernhealthcare.com/transformation/new-cms-guidance-encourages-value-based-payment-medicaid.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

Worries About the Medicare Physician Fee Schedule Rule for 2021

By | Blog, healthcare management consulting, Nextgen EHR

Provider organizations are worried certain proposals in the 2021 Medicare Provider Fee Schedule regulation will worsen the financial difficulties doctors are currently experiencing during the COVID-19 pandemic, including the inadequacy of sufficient payment for telehealth and profits from sustainable practice. The legislation released in early August suggested several improvements to next year’s Medicare Physician Fee Plan, including steep rate increases for certain specialties, improvements to the list of telehealth services, and additional standards for accuracy monitoring.

Increasing relative value units (RVUs) and payment for primary care facilities and treatment of chronic disorders are the key proposals of the rule. However, the regulation also requires a drop in the payment exchange factor to $32.26 from $36.09 in order to offset the improvements to RVUs for the services.

Provider industry groups have encouraged CMS to beef up telehealth scope recommendations in the finalized version of next year’s Medicare Physician Fee Schedule. Several proposals that would increase telehealth coverage were included in the rule, including the inclusion of eight codes to the Category 1 list of telehealth providers and the development of a separate Category 3 list to extend provisional coverage.

Another leading issue affecting multiple provider groups was the tweak to quality reporting regarding the Quality Payment Program and other value-based reimbursement models. The substitution of the APM Scoring Standard with the current Alternative Payment Model Efficiency Pathway was largely opposed, particularly by provider groups.

To read more, please visit https://revcycleintelligence.com/news/top-3-concerns-with-the-2021-medicare-physician-fee-schedule-rule.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

CMS Releases 2021 Medicare Advantage Star Ratings

By | Blog, healthcare management consulting, Nextgen EHR

Earlier this month, the Centers for Medicare and Medicaid Services (CMS) released its 2021 Medicare Advantage and Part D star ratings. Just over twenty health plans earned five stars, including familiar names like Cigna and CarePlus by Humana. Only four health plans had low ratings of 2.5 stars, and there were no plans with ratings below that.

The CMA star rating system began for Medicare Advantage plans in 2008 to monitor performance on selected criteria for beneficiaries. By 2012, those metrics were tied to payments and bonuses for quality incentives. On a scale of one to five stars, CMS rates Medicare Advantage health and drug plans, with one star indicating bad results and five stars meaning outstanding performance.

The new star ratings are good news for the more than one-third Medicare beneficiaries who choose a Medicare Advantage plan. Medicare Advantage premiums in 2021 will be the lowest since 2007. The average star rating has increased from 4.02 in 2017 to 4.06 in 2021, and, according to CMS, approximately 77% of beneficiaries enrolling in Medicare Advantage plans with drug coverage will participate in plans with four or more stars.

Up to 44 separate consistency and success metrics are classified for Medicare Advantage with Medicare Part D prescription drug coverage contracts, and up to 32 metrics are classified for Medicare Advantage-only contracts (without coverage for prescription drugs). No new measures have been introduced for 2021. However, CMS is taking into account patient comments and experiences more heavily, including the quality of care being received by the plans. The effect of the coronavirus on star ratings has been tracked by CMS and several improvements have been implemented to forestall the impact.

To read more, please visit https://www.healthcarefinancenews.com/news/21-medicare-advantage-plans-earn-5-stars-cms-release-star-ratings.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.