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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.

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

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 !

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 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.

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.

Increased Reimbursement For Primary Care Physicians, A Closer Look !

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A welcome respite for primary care physicians !

Everybody knows that primary care physicians are struggling to stay in business. A mandate by the Affordable Care act has announced that Medicaid rates for certain primary care procedures will be paid on par with Medicare rates.

 To receive additional reimbursement physicians will have to fill out, a, state specific Medicaid self-attestation form.

Medicare

Who are covered ?

Family practices, pediatricians and general internal medicine physicians are eligible for increased reimbursement. So are several other sub-specialties and physicians who perform high levels of primary care services. The major criteria are that, physicians should be board certified and have a billing history that indicates that about 60% of their billing is for primary care codes.

The rate increase will be in effect till the end of 2014. Physicians, who’ve registered through MITS and are approved by the Office of Medical Assistance, can see more digits in their pay check from April 2013.

The code to more dollars !

Primary care physicians will be reimbursed in accordance to HCPCS codes related to primary care. Evaluation and management codes from 99201 through 99499 are eligible, as are certain vaccine administration codes.

The rough and tumble of practicing primary care…

Primary care physicians are working under heavy financial pressure. The sequestration cuts of 2013 have taken a heavy toll on medical practices. The sustainable growth rate formula has quickly turned in to a nightmare for physicians.

 Reimbursement cuts, operational pressures and complicated regulations scared the daylights out of physicians.

Quite arguably it was primary care practices that were the hardest hit. Primary care centers were soon shutting their doors as it became increasingly difficult to practice. Primary care practitioners were finding it almost unfeasible to take care of their elderly Medicare patients.

At a time when it was needed the most !

The increase in reimbursement has come at a time when physicians need it the most. The increased Medicaid reimbursement means physicians are offered a reprieve after all the financial pressures they’ve gone to.

Want a few tips to increase the revenue of primary care practices ?

Want To Save $ 23,000 ? Switching To E-Billing Will Improve Your Practice’s Financial Health

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Still Stuck With Paper ?

What is your carbon footprint ? If you are still sending out paper claims, you are felling more trees. Agreed, this is an argument that is as old as fossils. Apart from saving trees there are a lot more advantages to using e bills ! It helps to track claims easily and lessens the amount of time your insurer takes to sign your check.

ebilling-infographic

Save More Dollars !

According to the American Medical Association submitting claims electronically can save a practice 55% of its claims submission costs. The AMA further states that physicians stand to gain above 23,000 dollars a year by switching to electronic claims.

Electronic billing also reduces the TAT of insurers. The overall efficiency and cost effectiveness of the process is just what overworked medical practitioners need. Paper claims are time consuming to generate, transmit, and maintain a record of. Electronic bills are quite simply put, the smarter way to bill !

Joining The e-club !

According to a recent survey of America’s health insurance plans the usage of billing electronically has doubled. From a measly 44% in 2002 to 94% in 2012 there’s been an exponential increase in providers who are switching to e billing.

Almost 79% of claims are now automatically adjudicated without manual support. Physicians are finding e billing helpful as it helps their staff to focus on patient engagement.

A Huge Relief For Billers…

What is the biggest headache of a medical biller ? No. It is not getting claims paid. The bigger headache is finding out which claim is in what stage of processing. An average medical office sends out dozens of claims per day. Keeping tabs on each one of them can trip up the most determined of medical billers.

ERA’s and EFT’s help medical billers to hasten the pace of the billing process. And make it easier for them to maintain a clear cut billing record.

Ask Your Insurer To Move On From The Stone Ages !

It is time for insurance companies to stop working with paper claims. Physicians need to put their foot down and ask insurers to accept electronic claims! Concerted and continuous effort across the continuum will ensure that the healthcare industry functions a lot more smoothly and efficiently. And yes, save a billion trees in the process !

Should Patients Be Allowed To Access Their Physicians EHRs? Weighing The Pros And Cons

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Whose EHR Is It Anyway ? !

 This far and no further, is the approach physicians are taking when it comes to patient EHR access. Patient electronic access is an important objective of Meaningful Use. It can help physicians to deliver better quality of care.  And to bring everybody across the care continuum in one single, secure platform.

EHR-access

Data security risks is the key reason why the debate on patients access to EHR is still up in the air. Nothing can scare physicians more than a data breach. The average housewife in New Jersey may not be up to date on HIPAA regulations  And there is also the potential threat of patients misinterpreting their medical data.

A physicians understanding of a medical problem is not the same as that of a patients. It could cause unnecessary stress and anguish, and make patients vulnerable to self-medication dangers.

I Don’t Want My Patients In The Drivers Seat…

According to a recent survey conducted by Accenture, around 65% of doctors feel that patients should be given limited access. About 82% of physicians endorse the view that patients should be actively involved in their healthcare. Around 4% of doctors told they’d like to ban patients from having an online access to medical records.

Most physicians were of the opinion that other than demographics, patients shouldn’t be allowed to edit or update any other medical data.

The Way Around This Catch 22 situation !

  • Talk to your EHR vendor about including patient identity proofing and authentication features.
  • Standardize the information you want your patients to access.
  • Educate your patients about your EHR.
  • Work with a  biller who has experience in working with your EHR so patient billing is streamlined to a great extent
  • Follow a clear cut privacy policy and usage guidelines.

Will Doctors Fade Into Oblivion? The Survival Guide For Newyork Physicians !

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Can I Meet A Physician ?

The answer would most probably be “no” in a few years time. It is going to get increasingly hard to find a physician in New York. The State University of New York center (SUNY) has predicted that there will be severe physician shortage in New York by 2030. The study further reveals that the average age of physicians in New York is alarmingly high.

Medical-Billing-Newyork

I Have An Insurance Number, But Not Medical Care…

The huge physician deficit can leave millions of newly insured patients, under Obama-care  have insurance numbers. But it is no guarantee they will get to meet a doctor. The physician workforce is slowly dwindling and finding a doctor can be the biggest challenge, in the years to come.

The problem is steadily getting worse and it is not just the healthcare law that is to be blamed. Proprietary and complicated EHRs and ambiguous reimbursement models are driving physicians out of the business.

84% Docs Feel The Profession Is In Decline !

And nearly 60% wouldn’t recommend medicine as a career choice. About 75% of physicians feel they are being overworked. These are just a few worrying markers of the disillusioning climate the healthcare industry is in.

Doctors Across New York ; The Much Needed Relief For Physicians !

The DANY program offers physicians based in New York the life support they need. It offers physician practice support, physician loan repayment and help for facilities that recruit new doctors. The application process has also been streamlined to help practices based in NY meet the financial pressures they’re under.

Large health plans are also working in tandem with local medical practices and community health centers to bring in more primary care doctors.

Joining Forces…

Nurse practitioners can fill in the void by offering primary care to patients. Physicians and NPs instead of being at loggerheads, can work together to provide better care for patients across the state. As the shortage worsens team based care will act as the most effective solution.

Outsourcing documentation and billing needs will also offer harried Newyork physicians a brief respite in an otherwise blistering healthcare climate !