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ACO Wars – Pioneer vs Shared Savings Programs

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ACO

Well, it is not a war in the strictest sense of the term, but it does denote the recent developments in the ACO or Accountable Care Organization scene where many Pioneer ACOs have been opting out of the program due to difficulties in meeting the targets and the high risks involved.  About 25% of the Pioneer registered Accountable Care Organizations are in the process of exiting the program and joining the lower-risk option, the Shared Savings Program.   CMS had this to say about the fallout :

 “We’re encouraged that these organizations want to continue in programs that promote better care at lower costs, we fully anticipated that as these programs get up and running, some organizations would shift between models.” 

Health Reforms & ACOs

 For those of you, who have been too busy to register what an ACO exactly is, it is a category of CMS program, which is part of the government health reform, which includes others like Patient Centered Medical Home, Medical Neighborhood, Health Home, etc.  The reforms themselves consist of three main components, which is a superset of any practice models.  They are :

a. Care Delivery Reforms.

b. Payment Reforms.

c.  Health and Healthcare Community Reform.

 ACO is a model which is, to quote a popular definition, “an organization, virtual or real that agrees to take on the responsibility for providing care for a particular population while achieving specified quality objectives and constraining costs.”

 As the above definition clearly points out, an ACO platform is expected to stimulate more integrated care for the patients, which would ultimately result in quality improvements and healthcare cost reduction.  Also, in these programs the ACO gets a share in the costs ultimately saved.

Pioneer vs Shared Savings Programs

 SSP and Pioneer were two landmark ACO programs created by CMS.  The latter has a slightly complex format, which takes into consideration organizations that already have some experience in providing coordinated care.

 The Main Differences between the two are:

 1.  SSP has two payments tracks and it is upto to the ACO to choose either the non-risk sharing one (which has less cost savings share) and the risk-sharing track (which has higher cost savings share but at the same time there are possibilities of losses upto even 60%).

 2.  The Pioneer utilizes a trending methodology that, all other things being equal, produces a slightly higher benchmark than the SSP for high-cost areas.

 3.  The SSP will need to cater to at least 5,000 Medicare fee-for-service beneficiaries, whereas the Pioneer needs to service 15,000.

 4.  The Pioneer program importantly includes a clause that 50% of Pioneer ACOs revenues should come from participating in “risk” contracts with other non-CMS  (private) payers.

 The Significance of events such as the above

Republicans have been ardently opposing the health reforms (which is really an attempt for universal healthcare).  The recent refusal by the National Football League to team up with the government to promote ObamaCare has been touted as some sort of vindication for their stance.  Also, the refusal of some states to adopt the Medicaid expansion plan and the setting up of online HIE, to realize the goal of “healthcare for all” , is seen as further supporting evidence.   And the above developments in the Pioneer ACO scene is construed by some health reform detractors as the “straw that will break the ACO camel’s back”.

 MedicalBillingStar :  A Voice of Sanity

 With a decade of hands-on experience in servicing over 500 clients when it comes to the RCM Cycle, MedicalBillingStar always endeavors to float above the cacophony of healthcare gossips and half-truths, to provide their medical billing and coding clients with information that is relevant, besides of course catering to their entire RCM workflow.   We are aware of the impact that ACO’s will have on payment models, the changes from which ultimately have to be incorporated into the RCM process.  Thus, we keep abreast of the latest happenings in the payment model scene.  Meanwhile you may call MedicalBillingStar at 877-272-1572 or visit our website at www.medicalbillingstar.com if you any questions about any of the above or the Medical Billing/Coding processes in general.

A Few Survival Strategies For Healthcare CFO’s To Handle 2014

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Time for healthcare CFO’s to step up their plate !

2014 is going to be a year of change. Federal mandates, financial constraints and heavy penalties for non –compliance is going to make 2014 a challenging, tumultuous year. It is time to up the game to ensure medical practices don’t crumble under pressure. And as always it is the man at the helm who needs to up the game!

Focusing on wellness programs can help you save on taxes !CFO

The PPACA requires all healthcare organizations to review the wellness plans of all full time employees. Choosing a wellness plan that is highly deductible can be a major tax saver. CFOs will have to examine the current coverage plans.

And freeze in on a wellness plan that works both for their employees and also saves on taxes. This could well be the major priority of healthcare CFOs in 2014.

Systems to record the quality of care…

The healthcare landscape is undergoing a period of transition. From volume based payments. To a model that is based on the quality of care and patient outcomes. It is essential that CFO’s implement systems and upgrades to report and measure clinical variations. Maintaining, longitudinal health records that are detailed and contain data across the care continuum, is important.

Will your clinical documentation cut it ?

Do you maintain pristine clinical documentation ? If yes you are lucky. If, like a majority of health care providers your answer is, no, then it’s time you upped the ante. Review your revenue cycle that coordinate with coders and physicians to ensure more accurate and updated clinical documentation.

Analyze every phase of the RCM to see where you can reduce costs. Have your billing team give a detailed report of key financial metrics.

Outsourcing can be a huge cost saver !

Reducing the number of full time employees can help you cut back on costs. But this is a move that has to be taken after weighing in the pros and cons. 

Here’s a quick presentation for CFO’s to handle the practice.

Forget The Incentive. Can Your Practice Escape MU Penalties?

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How do you avoid MU penalties ? There is just one way, demonstrate meaningful useMU. The primary worry of all healthcare providers is missing out on incentives. But taking steps to avoid the fast approaching penalties should be the top most priority right now. It is time for physicians to get in on the ground floor and work towards MU.

Working hand in hand with patients !

To, meet compliance deadlines, it isn’t enough, that you adopt an EHR, and optimize, your, workflow. Remember that it all boils down to just one thing, the quality of care you provide patients. Explore better ways of working with your EHR to avoid nasty payment cuts and penalties.

Eligible professionals, who are going to demonstrate meaningful use to avoid payment adjustments in 2015, must kick start their EHR reporting period by July 2014. You will have to work at breakneck speed to reach the finishing line on time.

Ramping up patient portal efforts…

Under stage two of Meaningful Use patients should be able to view their data, download it and be able to transmit it. Do you know that a functional patient portal can help you meet, 3 core objectives and 4 menu objectives? That it could be the easiest way of meeting the patient engagement criteria?

 Though a patient portal can be available in the provider’s website or function as a stand -alone online application. A patient portal that is integrated in to your EHR can improve functionality and ensure data security.

Patient engagement the big “gotcha” !

Laura Kreofsky the principal advisor for Impact Advisors predicts that patient engagement and public reporting are going to be the major stumbling blocks for physicians. Make sure you option for an EHR with a robust patient portal. If you are an EHR user insist that your vendor provides you with a fully functional patient portal.

The payment cuts for physicians who’ve missed the boat…mu-penalties

Source:Practice fusion

Smartphones Can Help Your Practice To Achieve MU !

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What do you do when you go meet a physician ? Explain in detail about your medical history and pray that you haven’t left out anything. Now you just need to hand your smartphone to the doctor. The trend of accessing medical data through smartphones is growing at a fast clip.

And major smartphones such as iPhone and Android apps offer applications to, store, download, and manage patient information.

A success story…

The University of Pittsburgh Medical center found that patients joining the medical practice’s patient portal grew exponentially after reports were available through smartphones. The project launched in 2011 has been a roaring success with 700 patients joining the portal every week. Patients’ being able to access their medical records is a major criterion for qualifying for MU. And smartphones have just made it easier for doctors!

How do you get Mrs Linder interested ?

Despite the optimism and euphoria surrounding the success of smartphones to help patients use patient portals, engaging them is a key issue. Mayo clinic found out the hard way that engaging patient is no easy task.

Patient engagement ; an on-going challenge…

When they launched a web based portal three years ago, 240,000 patients joined. Reason to celebrate! But wait. The clinic is having a tough time getting patients to using the portal. To receive MU dollars patients should use the patient portal. Patients who are too old or those who are suspicious of technology need to join the bandwagon as well.

Show that you care !

To engage patients it is important that patient portals are designed from the patients’ perspective. Address their needs and make the portal fit in with their overall healthcare plan. Making the portal easily navigable and using images and text that are easy on the eye is important. And yes the assurance that their data is completely secure.

Not everybody understands encryption protocols or static passwords. Educate and train your patients in handling healthcare IT. Encourage patients to use graphical authentication techniques. And, to separate medical data, from, the other regular features, of their, mobile phones.

Fighting the good fight !

It can be frustrating, pointless and time consuming. But staying the course can help your practice not just receive MU incentive dollars and achieve compliance. But also make hundreds of your patients happy and more involved in their healthcare.

Here is the info-graphics with few stats on patient portal

patient-portal

Can Healthcare IT Help Physicians In Increasing Patient Collections?

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Are you neglecting patient collections? Technology to the rescue !

Adopting technology can help physicians not only stay in compliance but also collect more.patient-collections Patient collections have always been neglected by physicians. Getting a patient to pay is one of the toughest tasks a physician faces. The delicate doctor physician relationship means the doctor has to tread on eggshells to get paid.

With hundreds of patients walking in and walking out collecting reimbursement for every visit is an unenviable task. With latest technologies and electronic tools can help physicians increase their patient billing collection ratio.

Here is the presentation from Angomark on Are Physicians Losing Revenue? Concentrate On Patient Collections. 

Complicated Crosswalks, More Codes And Stricter Documentation Requirements. But ICD 10 Is Not The Loch Ness Monster !

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Are you ready to get cracking on ICD 10 ?

The deadline for adopting ICD 10 is inching a little closer every day ! It is time for the eternal question. Are you prepared? A study by the Health Revenue Assurance Associates says that 20% of medical practices are yet to start an education or training program on ICD 10.

About half of the medical practices surveyed were way behind timelines set by Medicare and Medicaid. The transition is going to be tough. No matter what mild mannered, reassuring experts say ! And that is why the sooner a practice makes the switch, the better.

Confounding crosswalks…

Medical practitioners who think cross-walking ICD 9 codes with the latest codes is just a matter of few mouse clicks, have a second think coming. The General Equivalence Mappings does offer a detailed crosswalk of both the coding systems.

But the fact that there are very few one to one matches between both coding sets is going to make the transition, tricky.

According to a study by researchers from the University of Michigan and Illinois, mappings for specialists are going to be, especially, complex. Emphasis has to be laid on understanding and managing, mapping categories and networks.

ICD-10-Crosswalk

A little bit of effort from everybody…

It isn’t the coding or billing team alone that is going to struggle with the new codes. It is going to take a bit of effort from all concerned.

As ICD 10 is all about greater specificity and granularity, physicians will have to focus more on the medical documentation they send to the billing team. More documentation could mean just one thing, more revenue !

Have you forgotten your insurer ?

Well, your insurer is a part of your team as well. Ask for a testing plan and send a few “test” claims to the insurer. Coordinate with your payers to make sure you are ready for the D day. Keep in mind that you cannot send ICD 10 claims till the compliance date. But don’t let that stop you, from sending out trial claims, to payers.

Why ICD 10 is not the Loch Ness monster, after all !

The entire hullabaloo surrounding ICD 10 makes the codes look like small, poisonous creatures, out to get physicians. In the long run ICD 10 can prove to be good for practices. It could mean more accurate payment for medical procedures. Fewer miscoded claims. And, a better idea of how much you’d be paid, prior, to a medical treatment.

Is It The Insurer’s Responsibility To Pay Out Of Network Physician Providers?

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healthcare

The answer is an obvious “yes”. But most medical practices tiptoe around the out of network issue. It could be because reimbursement policies and healthcare regulations are so complicated; everybody shares a vague discomfort when it comes to medical reimbursement.

The AMA in a recent post encourages medical practices to make the insurer accountable for out of network physician reimbursement. One of the key points the AMA emphasizes on is that medical practices should have a clear cut fee schedule.

Over-billing Controversies !

There have been several controversies surrounding the medical billing practices of out-of-network providers. Patients have cried foul over grossly inflated bills. A physician in California billed a patient $30,000 for a gall bladder removal procedure. The Medicare rate for the surgery is as low as $778.

It is a question of integrity…

Physician practices need to stand up for their patients and for fair medical billing practices. They will have to stand up and intervene to curb the menace of over-billing  And, the browbeating of helpless patients, into paying huge, bills. It is important that physicians are aware of how the insurer calculates the charges for out of network care.

The need for patients to get more involved !

physician

 Providers are certainly pushed to a corner when the affable patient who was okay with the fees, suddenly makes a hue and cry about the charges. The major reason for conflict seems to be the patients’ poor understanding of the billing process. Some patients don’t even know that out of network providers can be more expensive than in network medical care providers.

Unless it is an emergency patients should explore and learn about insurance plans, treatment options and cost of service. Patients need to be aware of their responsibilities and understand EOBs.

The need for more transparency !

The healthcare industry is in an unhealthy state as everybody has a vague feeling of distrust towards one another. Better and more open communication, among-st healthcare practices, physicians, patients and insurers is the only cure for this “pointing fingers” epidemic. 

How Can Misinterpreted ERA’s Affect Your Medical Practice?

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Do you understand what your insurer says ?

Being a part of a busy medical practice means there is no time to sit and analyse. Most medical practitioners hardly have enough time to communicate with insurers.Do you know that physicians are leaving most of their money on the table ? The major reason is not comprehending or following closely what the payer says.

insurer

An, ERA consists details, of the final claim adjudication and payment information. Being able to read between the lines is one skill that physicians need to develop to ensure they don’t get underpaid.

There are a lot many times when a physician just doesn’t know why his claim didn’t translate into a check. Blame it on inconsistent and varied payer policies. Or complicated, state specific, medical billing regulations. But the fact remains that an enormous amount of claims are underpaid or unpaid and most physicians don’t even know what went wrong.

Do you deal with workers compensation and auto injury claims ?

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Agreed it can be tough. Trying to deal with workers compensation laws can be cumbersome. The last thing you need is receiving an ERA that you cannot make sense of. The AMA has come to the rescue of physicians.

AMA has launched a new tool to help physicians make sense of ERAs better. The AMA Claims Assistant Workflow tool can aid physicians in puzzling out payment adjustments. It can help medical care providers easily locate reason and remark codes. Tackling non-payments and denied claims is going to be a whole lot easy at the medical practice, from now on.

No longer left in the dark…

What happens inside the insurer’s office has always been a mystery for medical billers. Why it is certain claims get paid and some don’t ? Why was a claim that was perfectly acceptable last summer now been given the thumbs down? Luckily physicians who deal with workers compensation billing will have an answer to these questions and more.

The Claims Assistant Workflow tool will give providers information about how a claim was processed. And what the codes on the ERA mean.

A smart way to e bill !

The tool developed by AMA also guides physicians on receiving accurate payment. And also offers several template appeal letters to help physicians appeal denied claims. It is definitely a welcome relief for over-burdened physicians and billing companies.

11 Ways To Ensure You Join The List Of Successful EHR Implementation Stories !

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Get Off to a Good start !

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To start on shaky ground can sour your relationship with an EHR forever. Being hasty can prove to be disastrous. Imagine working with an EHR that does nothing to improvise your clinical workflow. Or, being stuck with templates that take hours on end to load ? Being careful during the EHR implementation process will lead to a healthy and beneficial experience with your EHR.

Don’t get swamped by sales talk and sagely advice. Grab a piece of paper and jot down what your expectations are. And make a promise to yourself that you will not make a compromise no matter what.

Here goes with the presentation on ways to implement an EHR with successful stories !

Don’t Fumble Your Way Through EHR Implementation !

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EHR Implementation ; How To Avoid The Tripwires…

Choosing an EHR is tough. A zillion glossy brochures, well-meaning colleagues and pushy sales persons only make the decision harder. The, fact that almost everybody who owns an ehr hates it with a passion makes the most determined of physicians, back-foot.

According to recent reports physicians are reverting to paper records. And some have started looking out for another EHR. A survey by American EHR partners found that user satisfaction levels dropped from 39% in 2010 to 27% in 2012. How do you ensure your EHR implementation process doesn’t turn out to be a harrowing experience ?ehr-implementation

Know What You Want…

Most physicians rush in to ehr implementation without clear direction or expectation. Analyse your workflow and see how the inclusion of an electronic health record impacts your practice operations. Do not fall for the “you can tweak it” line. Manipulating your ehr can prove to be counter-productive.

Customizing your system is fine as long as you don’t miss out on the features and automated comfort your ehr offers.

What Does Your Front Office Team Think ?

Yes, the mousy girl who sits in the reception needs to know whether the appointment scheduling and insurance eligibility feature, makes the cut. Your coders will have to decide if the coding and scrubbing options are easy to work with.

The end users are many and you have to choose an EHR that makes everyone happy. It will increase productivity and morale.

The Person Who Matters The Most !

Your patients are the lifeline of your medical practice. Ask your EHR vendor whether they offer a patient portal. Check if it is patient friendly and secure. Enquire about the level of training and support offered. Caring for your patients is after all the best investment, ever.

Stay The Course !

Adopting an EHR is like parenting. It does get on the nerves and makes you lose sleep. But being a quitter is not going to help. Vow to yourself no matter how tough it is you will not revert to paper. Scribbling down details is easy but not the best way to work. During the implementation stage itself, promise to yourself, you will stick to your EHR.