Points of Interest
April 22, 2014
Warding off fraud suits after CMS
physician payment revelations
The release of Medicare’s payments to doctors
could impact medical practices and health systems in a lot of ways, including
being fodder for fraud accusations – a problem that’s worth getting ahead of
from the get-go.
Medicare Advantage final rule benefits insurers and
providers
Insurers offering Medicare Advantage plans
got a bit of a reprieve this week when the Centers for Medicare & Medicaid
Services gave them a rate increase instead of the expected cut. CMS’ 2015 rate
announcement also addressed concerns over provider terminations and beneficiary
cost sharing.
New entrants in the healthcare market could snatch
billions of dollars of revenue from traditional healthcare companies if the
traditional companies do not move faster to provide services in the setting consumers
want.
Medicare RACs at a crossroads
With the new contracts CMS leaders are promising to
“refine and improve” the Medicare Recovery Audit program. Among the changes are
a 30-day auditor-provider discussion period before claims can be sent to MACs
for adjustment and revised additional documentation request limits based on a
providers denial rate, with lower limits for those with fewer claims denials.
All of that comes after enormous provider frustration
with recovery auditors, and amid an appeals backlog so long it’s out of
compliance with federal law.
PCMHs a boon to providers and payers
The latest patient-centered medical home
study suggests that cost and utilization reductions are noticeable for only the
highest-risk patients – a boon for payers. But there are pluses for providers
too, including better patient and clinician satisfaction, more roles for
specialty care and a roadmap for accountable care.
Accountable Care Organizations (ACOs)
General
Information
ACOs are groups of doctors, hospitals, and
other health care providers, who come together voluntarily to give coordinated
high quality care to the Medicare patients they serve. Coordinated care helps
ensure that patients, especially the chronically ill, get the right care at the
right time, with the goal of avoiding unnecessary duplication of services and
preventing medical errors. When an ACO succeeds in both delivering high-quality
care and spending health care dollars more wisely, it will share in the savings
it achieves for the Medicare program.
ACO
Programs at CMS
Medicare offers
several ACO programs, including:
·
Medicare Shared Savings Program (cms.gov) -
For fee-for-service beneficiaries
·
Advance Payment ACO Model - For certain
eligible providers already in or interested in the Medicare Shared Savings
Program
·
Pioneer ACO Model - Health care
organizations and providers already experienced in coordinating care for
patients across care settings
A series of
three Accelerated Development Learning Sessions were held in select cities
across the country. Additional information on each Session can be accessed
below:
·
ACO: Accelerated Development Learning Sessions
- For existing or emerging Accountable Care Organizations (ACOs) to develop a
broad and deep understanding of how to establish and implement core functions
to improve care delivery and population health while reducing growth in costs.
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