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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.

CMS Is Making Medicare Advantage Risk Adjustment Changes

By | Blog, healthcare management consulting, Nextgen EHR

CMS recently proposed changes to Medicare Advantage and Part D payments for 2022, finalizing a multi-year phase-in of a novel, controversial payment method where plan risk scores are based entirely on encounter data.

In the past, to complement encounter information in calculating payment, CMS has relied on reports submitted through its Risk Adjustment Processing System (RAPS) method but stated that policy would cease in 2022.

Risk scores reflect a beneficiary’s estimated medical expenses and are utilized in tailoring Medicare Advantage plan federal payments. In general, the more ill an individual is, the greater the risk score and, therefore, the greater the payment earned by an MA plan. CMS began collecting encounter data, or data based on claims data generated by a provider, supplier, physician in a practice or hospital setting, in 2012. According to insurers, this data can often be incomplete or inconsistent, so depending entirely on that data for risk scores could potentially lower federal plan payments.

As mandated by the 21st Century Cures Act, CMS will completely transition to this risk adjustment calculation model that has been slowly increasing since 2016, when encounter data made up 10% of a risk score. In 2019, 25% of risk adjustment scores were based on encounter data, and that number increased to 75% in 2021. In 2022, encounter data will be the sole determinant for calculating risk adjustment.

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.

COVID-19 Shines a Strong Light on Medicare Advantage

By | Blog, healthcare management consulting, Nextgen EHR

The strength and versatility of Medicare Advantage has become increasingly evident in the age of COVID-19. When the pandemic began spreading across the country this spring, Medicare Advantage plans responded quickly and were among the first to take charge, identifying and introducing changes to policies and benefits.

Many Medicare Advantage programs quickly identified an exhaustive list of supplemental benefits addressing health social determinants, crucial in the response to COVID-19. Member outreach including meal deliveries, free masks, and regular communication were instituted to help address anxieties made evident early on.

By the time June was over, Medicare Advantage membership reached almost four million, an increase of more than ten percent from the first half of 2019 and up to eight percent from enrollment by the end of the same year. In the first half of the year, insurer Humana added well over 250,000 Medicare Advantage members and predicts more than 330,000 will join before the end of the year. Humana’s success in Q2 mirrors that of many payers as a result of lower utilization during the pandemic. That number is expected to rise in the last half of the year with rising utilization including an expected increase in elective surgeries.

Seniors have recognized the value in Medicare Advantage, as demonstrated by rising enrollment, which has almost doubled during the past years. Close to forty percent of the Medicare population are now enrolled in an Medicare Advantage plan. That number is anticipated only to increase as more seniors become old enough to qualify for Medicare.

To read more, please visit https://www.fiercehealthcare.com/payer/humana-posts-1-8b-q2-profit-as-insurers-continue-to-show-strong-financial-performance-amid.

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.

Value-Based Care May Help Practices Remain Afloat

By | Blog, Nextgen EHR

Primary care practices have had to contend with the possibility of closure due to the pandemic. The conundrum comes in figuring out the best way for physicians to save their practices while still providing patients optimum care. The answer may lie in value-based care.

Primary care is arguably more important than ever, yet it has become increasingly evident that the traditional fee-for-service model, based solely upon actual practice visits, has become untenable. The safest option for many patients is to stay at home to stay healthy, so these physicians and healthcare practices now find themselves facing an uphill battle to remain in operation.

Value-based practices have managed to keep their doors open, take care of their patients, and even prosper in these challenging times. Instead of concentrating solely on patients that walk into the practice, value-based care is more about ensuring patients remain healthy and out of the hospital. With value-based care, practices can, for example, reach out to a patient to contact them and evaluate their care beyond the doors of the practice as well as keep in touch in the event the patient does have to go to the hospital emergency room.

The key is breaking the misconception that fee-for-service is the perfect way to pay for primary care. Primary care should be about the value created, where care is more person-based than transactional.

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 Will Examine Telehealth Reimbursement Rates Following the Pandemic

By | Blog, healthcare management consulting, Nextgen EHR
Telehealth reimbursement is being evaluated by CMS to render Medicare telehealth extensions permanent after the COVID-19 pandemic. CMS administrator Seema Verma recently suggested reforms initiated during the pandemic could become permanent, including payment for telehealth services provided to non-rural patients and the provision of telehealth treatment in patients’ homes.
To settle telehealth reimbursement rates, CMS would need to assess the costs for telehealth vs. in-person services. Medicare payment rates for in-person treatment take supply costs such as hospital gowns, washing, disinfectants, and other service costs into account. Telehealth services do not require these supplies. The costs associated with generating new systems and workflows to enable telehealth visits also need to be considered. For CMS to properly reimburse providers for permanent Medicare telehealth extensions, all such expenses will need to be reviewed.
Short-term payment changes allowed practices to implement telehealth services rapidly. Telehealth has proved essential to COVID-19 approaches for the response. Providers have been able to continue treating patients via telehealth, preventing unnecessary staff or employee exposure to the extremely infectious virus.
Virtual treatment has also proved invaluable in ensuring the health of patients and staff within the hospital setting. Hospitals have been able to reduce interaction with infected patients by using smartphones, laptops, and other mobile devices, while still placing caregivers and family near the patient.
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

Integrating Telehealth and EHR

By | Blog, healthcare management consulting, Nextgen EHR

The telehealth boom as a result of the COVID-19 pandemic has sparked discussions on how to reach the smooth integration of telehealth into electronic health records. Some telehealth platforms provide agnostic integration with a number of EHR systems, whereas some EHRs have their own telehealth solution in-house.

What works for a certain system may not necessarily be the best solution for another. There are many considerations to take into account. when choosing an EHR provider or considering a move to another.

You may wish to begin by understanding whether the vendor for whom you are operating currently provides a unified solution, or have other solutions been developed along the way. Where do you begin, and is it a fully integrated platform versus one vendor with several platforms to offer? A trade-off study should also be considered: What do you lose in feature functions with a single vendor versus integration gain? The third consideration is the case of intended use: More specialized treatment may mean having to find a more specialized solution.

At CareOptimize, we offer a rich array of EHR utilities designed to assist clients and staff in increasing their productivity, including free utilities such as our Document Auto-Completion templates and the Coronavirus Crystal Report.

To read more, please visit https://www.healthcareitnews.com/news/when-integrating-ehr-and-telehealth-one-size-doesnt-fit-all.

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.

Telehealth Compliance Programs Are Imperative

By | Blog, healthcare management consulting, Nextgen EHR

The rapid expansion of telehealth throughout the United States as a result of the COVID-19 pandemic has allowed providers to continue to support their patients while reducing business disruption. The growth of telehealth has also encouraged businesses to leverage technology, find new ways to provide medical care, and lower costs.

Although telehealth offers tremendous provider opportunities, there are also considerable risks. The recent surge of telehealth services has significantly prompted changes to federal and state regulations and requirements. The tangled network of federal and state regulations make legal compliance for telehealth providers exceptionally challenging, reinforcing the need to have robust compliance programs and measures in place.

Providers should make sure written policies that specifically require compliance with relevant federal and state laws, regulations, and requirements have been implemented. Policies enacted prior to the outbreak of COVID-19 should be evaluated and tweaked as needed. To oversee these changes, practices should name a compliance officer, who can also take care of allocating resources to carry out compliance program integration. Along with training all staff, annual compliance program audits should be undertaken to measure compliance activity and its effectiveness. Furthermore, staying on top of evolving laws and regulations is key in maintaining successful and current enforcement policies in place.

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 Latest Insights Webinar Delves Deep into CPT E/M Changes

By | Blog, healthcare management consulting, Nextgen EHR

This week, we’re back with an all-new CareOptimize Insights Webinar highlighting changes coming with CPT E/M codes.

The code changes will go into effect on January 1, 2021, so it’s time to get your providers and coders ready. This comprehensive webinar explains how to navigate all of the Evaluation and Management changes and what they mean for reimbursement, including which codes to use when, which codes belong in conjunction, and what can be reported. There’s also a 10-step guide from acdis.org on how to successfully transition to the 2021 guidelines.

The Insights2020 CPT EM Code Changes for 2021 is up for viewing on the CareOptimize YouTube channel as well as on our Insights page. Remember you can watch all of our webinars by visiting https://www.youtube.com/careoptimize.

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.

How Telehealth Is Changing the Face of Healthcare

By | Blog, healthcare management consulting, Nextgen EHR

Before the COVID-19 pandemic, telehealth was largely used as a secondary tool by clinicians and patients, and mostly for test results delivered via email. Regulatory restrictions helped make for slow adoption. Now that telehealth has been widely implemented, patients and clinicians have quickly discovered its more widespread usefulness. Positive results, especially with virtual doctor visits, ensure telehealth will likely remain a healthcare staple for the foreseeable future.

The rapid implementation of telehealth revealed its many benefits, changing the ways many providers practice. From pediatrics to behavioral health, several common specialties embraced the extensive uses of telehealth. For example, Seattle Children’s hospital was already using it in a limited capacity in the early 2000s but has since seen massive growth. They find it particularly useful when dealing with mental health issues among children and adolescents.

With geriatrics, telehealth creates a considerably greater challenge. Many patients are on numerous medications or suffer from multiple chronic conditions. Others lack even the basic technical abilities. Initiatives to bring this demographic on board are crucial, as these patients are also at significantly higher risk of becoming infected with the coronavirus. Practitioners have doubled down on ways to reach out to these patients not only to help facilitate virtual visits, but also to ensure they have sufficient food, a means of transport, and even housing.

While primary care may be the most obvious fit for telehealth, specialties such as obstetrics, orthopaedics, and even physical therapy have altered their practices dramatically to incorporate telehealth components. To read more, please visit https://medicalxpress.com/news/2020-06-telemedicine-post-coronavirus-world-common-specialties.html.

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.