CMS Seeks to Implement New Quality Measures
Wednesday, December 23rd, 2020

CMS is evaluating the possibility of including 20 quality measures to a few of Medicare’s quality and value-based payment programs.

To apply, the department said, all but three of the recommended steps would have to be gathered online, either via electronic health reports or staff feedback. The shift to digital measures is following the Meaningful Measures Framework of the Department, an effort initiated in 2017 that focuses on addressing administrative burdens. Performance measurement, while providing little benefit to doctors or patients, has long been criticized for being burdensome on workers.

The 20 recommended initiatives are part of the annual rule-making phase of CMS, where the department chooses a list of measures that are then evaluated by the collaboration of measure applications of the National Consistency Council, a group of health experts providing suggestions about what CMS should pick for its services. CMS receives input on steps they have in the list that goes to NQF from specialty societies and other stakeholders.

Feedback on the proposed steps would be approved by the NQF by the sixth of January.

Ten of the suggested measures are for the Merit-based Incentive Payment System this year. Several of these measures are cost-related, and one is an impact indicator reported by patients.

A trio of the measures, including one that monitors coronavirus vaccination among healthcare workers, are linked to COVID-19.

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.

Humana Prepares to Launch New Value-Based Program
Wednesday, December 16th, 2020

Humana recently declared an extension of its value-based program expansion with the forthcoming implementation of the Primary Care First (PCF) model. The initiative will expand the availability of coordinated primary care to beneficiaries of some Humana Medicare Advantage services and aims to enhance the quality of treatment and patient safety, minimize the cost of care, and relieve the financial load of primary care agencies.

At the Centers for Medicare & Medicaid Services (CMS) Innovation Center, the PCF model was created to encourage primary care practitioners to migrate to value-based care and to determine whether this new payment model of Original Medicare would improve productivity and minimize costs. Humana will supply a related model for the Humana Medicare Advantage Preferred Provider Organization and Health Maintenance Company policy to participating primary care agencies currently in the network, as a newly approved CMS payer partner and the first insurer in the nation to have its own variant of the PCF model.

The Humana PCF model is scheduled for launch on July 1, 2021. A prospective capitated incentive, which takes into account the achievement of metrics based on quality and results, will be granted to participants every month.

To read more about Humana’s upcoming value-based program, please visit the following link:https://www.businesswire.com/news/home/20201210005023/en/Humana-Announces-New-Primary-Care-Value-Based-Model.

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.

EHR Optimization Saved Medical Practices During the Pandemic
Friday, December 4th, 2020

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
Wednesday, December 2nd, 2020

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.

Major Insurer’s Value-Based Primary Care Gamble Is Paying Off
Friday, November 6th, 2020

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.

CMS Revises Medicare Reimbursement Rate for COVID-19 Testing
Friday, October 30th, 2020

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 Shares COVID-19 Data Reporting Guidance
Friday, October 9th, 2020

CMS recently shared guidance on how it aims to enforce a recent temporary final rule mandating condition of participation (CoP) in Medicare for hospitals publishing COVID-19 results.

The guidelines issued earlier this week declared that, during the pandemic, hospitals risk Medicare termination should they fail to report daily on the more than 30 measures required by CMS. The metrics comprise regular COVID-19 admissions, including those affecting ventilated patients, fatalities from COVID-19, and other virus-related hospital utilization data.

Hospitals will now have to submit weekly supply-related metrics and also report new cases of influenza. This is presently voluntary but will become obligatory in November.

Beginning October 7, 2020, hospitals that do not meet the COVID-19 data reporting standards will be given a CMS warning. The hospitals will have three weeks to address any discrepancies in implementation, according to guidelines. Following these warnings, a second advisory alert will be given by CMS to hospitals failing to send out the required daily information.

In general, before being terminated from federal healthcare services, hospitals have a total of 14 weeks to meet Medicare CoP. These terminations would mean hospitals would not obtain payment for the treatment of recipients of Medicare and Medicaid.

To read more, please visit https://revcycleintelligence.com/news/cms-releases-guidance-on-covid-19-data-reporting-as-medicare-cop.

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.

South Florida Healthcare Practice Rises Early to the COVID-19 Challenge
Thursday, October 8th, 2020

As the coronavirus made its way to South Florida, CareMax Medical Centers was already adjusting its healthcare delivery model to face the challenges practices would soon need to address. CareMax partnered with CareOptimize early on to help proactively address COVID-19 challenges with productive responses. Within three days, the team implemented several policies and procedures to ensure staff and members stayed safe. Many of these have now been made permanent.

CareMax began offering its members virtual appointments before telehealth gained widespread use, enabling CareMax physicians to remain completely available to members. For those members who do not have a computer or may be technologically challenged, CareMax Transportation drivers take tablets to members’ homes, so they can participate in a virtual visit.

Using the CareOptimize service-as-software platform “HeartBeat,” providers have information on all members to facilitate clinical decisions as well as continue to track members with chronic issues, alleviating problems inherent with prolonged breaks in care.  All patients identified as positive or suspected COVID-19 cases are kept on a frequently updated list. Physicians give daily virtual video visits to every single one of these patients to monitor their progress. Anyone admitted to a hospital receives a virtual visit immediately afterward and, if appropriate, an in-home visit from a CareMax home health nurse.

To ensure constant communication, every member receives a weekly wellness check phone call to ensure they are well, continuing safe habits, and maintaining a proper diet. Should there be an issue, members can request a virtual visit with a provider or a visit from a home health nurse.

To keep costs down and better assist those that need attention, the “Call CareMax First” campaign was developed to encourage members to contact CareMax before heading to a hospital. This simple procedure has helped prevent unnecessary hospital visits, while allowing members to connect with a medical professional at all hours of the day, every day of the week.

COVID19 has forced the healthcare industry to rethink the way things are done. Thinking outside the box is something CareOptimize has always done for each and every one of their clients. The challenges continue, so do the solutions.

To read more about CareMax Medical Centers, please visit https://www.prnewswire.com/news-releases/healthcare-with-heart-is-more-than-a-slogan-at-caremax-301143889.html.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR

Advance Medicare Payment Relief Is on the Way
Friday, October 2nd, 2020

Near the onset of the pandemic, many clinicians received advanced Medicare payments through CMS’ Medicare Accelerated and Advance Payment Program. The repayment of those funds was recently extended from 210 days to an entire year as part of a resolution recently signed by President Trump, which includes several healthcare-specific provisions.

The Accelerated and Advance Payment Program was instituted when the sharp decline in admissions and visits hospitals and other services were experiencing due to COVID19 became problematic.

Through the program, CMS advances expected Medicare reimbursement and eventually recoups it. Recoupment usually begins 120 days after receipt of the initial payment. That term was extended to 210 days for the pandemic. The recently signed legislation will grant providers a year until CMS will begin reclaiming the disbursements.

For the first eleven months of recovery, CMS is only allowed to offset a provider’s cost by 25 percent. That rises to 50 percent for the following six months. CMS will postpone Medicare reimbursement for 29 months from the date of the first payment under the initiative.

The bill is a victory for caregivers who, given the current public health emergency, have been pressing on lawmakers to grant them more attractive reimbursement terms.

To read more, please visit https://revcycleintelligence.com/news/lawmakers-provide-accelerated-advance-medicare-payment-relief.

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.

EHR Plays a Role in Value-Based Hospice Care
Thursday, October 1st, 2020

As healthcare transitions towards value-based care, electronic health record (EHR) systems are gradually adding functionality to specifically target providers of end of life and acutely ill care. In order to remain competitive in a packed marketplace and provide data-powered reporting for regulatory obligations, numerous hospice and palliative care providers have stepped up efforts to incorporate electronic systems.

With capabilities to handle treatment plans, prescriptions, and workflows off-site, EHR systems can supply scheduling capabilities for patient intake and continuing visits and evaluations amid hospice clinical and operational teams. To minimize industry-wide worker mental collapse and employee shortfalls, workflow enhancement has been crucial. Electronic analysis of the hospice-specific billing code is an extra function of certain electronic health record-keeping systems to improve productivity and decrease time used on long documentation procedures.

Taking advantage of EHR capabilities may also allow proactive detection of patients who might benefit from severe illness and end of life treatment, facilitating standardized usage of evidence-based screening and evaluation methods. Care coordinators can make use of clinical data to better the quality of reporting, determine the effectiveness of treatment, and enable process and outcome measures to easily extract data.

For more information on our Nextgen EHR products, please visit https://careoptimize.com/products/. 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.