Accountable Care Organizations (ACO’s)
Thursday, November 17th, 2011ACO’s will offer providers economic rewards if they can reduce Medicare’s cost growth in their communities.
Each category of care would be paid for differently.
The contract stipulates a modified global payment (fixed payments for the care of a patient during a specified time period) arrangement.
The model differs from past models of fixed payments or capitation because it explicitly connects payments to achieving quality goals and defines the rate of increase for each contract group’s budget over a five-year period, unlike typical annual contracts.
NCQA ACO Accreditation Standards will launch in Fall 2011
Organizational Values in Seven Domains:
1. ACO Structure and Operations
2. Access to Needed Providers
3. Patient-Centered Primary Care
4. Care Management
5. Care Coordination and Transitions
6. Patient Rights and Responsibilities
7. Performance Reporting and Quality Improvement
Three Pillars of NCQA ACO Accreditation
1. Leadership in evaluating patient-centered primary care.
2. Expertise using measurement to improve health and health care.
3. High standards that (by design) only the best-prepared ACOs will be able to meet.
Free EMR’s Meet Physicians’ Fiscal Needs
Monday, April 11th, 2011Like their clinical colleagues, physicians in smaller, office-based practices are also faced with the looming deadlines related to Meaningful Use and adoption of electronic medical records (EMRs). Unlike their hospital-based brethren, these physicians are faced with tight IT budgets, prompting many to question whether it is worth their time, effort and money to invest in a new digital system that may disrupt daily workflows and elicit concerns over security.
Jennifer Dennard, Social Marketing Director – Porter Research
March 23, 2011
Click Here To Read Full Article
Physician Quality Reimbursement Initiative – PQRI
Sunday, October 31st, 2010The 2006 Tax Relief and Health Care Act (TRHCA) required the establishment of a physician quality reporting system, including an incentive payment for eligible professionals (EPs) who satisfactorily report data on quality measures for covered professional services furnished to Medicare beneficiaries. CMS named this program the Physician Quality Reporting Initiative (PQRI).
The following professionals are eligible to participate in PQRI (EP – Eligible Professionals):
1. Medicare physicians
Doctor of (Medicine, Osteopathy, Podiatric Medicine, Optometry, Oral Surgery, Dental Medicine, Chiropractic)
2. Practitioner
Physician Assistant, Nurse Practitioner, Clinical Nurse Specialist, Certified Registered Nurse Anesthetist (and Anesthesiologist Assistant), Certified Nurse Midwife, Clinical Social Worker
Clinical Psychologist, Registered Dietician, Nutrition Professional, Audiologists (as of 1/1/2009)
3. Therapists
Physical Therapist, Occupational Therapist, Qualified Speech-Language Therapist (as of 7/1/2009)
To participate in the 2010 PQRI, individual EPs may choose to report information on individual PQRI quality measures or groups to a qualified PQRI registry.
Individual EPs who meet the criteria for satisfactory submission of PQRI quality measures data will qualify to earn a PQRI incentive payment equal to 2% of their total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during that same reporting period.
Beginning with the 2010 PQRI, a group practice may also potentially qualify to earn PQRI incentive payment equal to 2% of the group practice’s total estimated Medicare Part B PFS allowed charges for covered professional services furnished during a 2010 PQRI reporting period based on the group practice meeting the criteria for satisfactory reporting specified by CMS.
Accountable Care Organizations (ACO’S)
Thursday, August 19th, 2010The concept of Accountable Care Organizations (ACO’s) was given a prominent place in this year’s reform legislation. In essence, an ACO is a network of healthcare providers that manage the full continuum of care for all patients within the provider network.
The goal of an ACO is to reduce costs and improve quality of care through cooperation and coordination among providers.
It is critical to avoid the temptation to act before you have determined what precisely the ACO will do differently.
Physicians used to having control over their own fee-for-service models may well hesitate to sign up for a “shared savings” that is based on reduced billings by ACO providers, especially considering the administrative costs necessary to support the ACO.
Other obstacles to ACO’s include possible FTC and DOJ desires to quash ACO’s on anti-trust grounds.
Further, state governments may need to change laws related to insurance regulation as well as organizational and professional liability.
Stay Tuned!
Increasing Revenue
Friday, May 21st, 2010Have you considered your managed care contracts as a source of increased revenue?
Too often, physician practices overlook the opportunities inherent in managed care contracting for improving revenue performance and building their bottom line.
Effective managed care contracting depends on performing three types of analysis:
1. Internal – comparing performance among your current managed care contracts
2. External – comparing your contracts with those of other payers in your market
3. Payment performance – assessing how contractual provisions affect performance
The managed care contracting process entails a series of distinct phases:
• Negotiation
• Implementation
• Contract monitoring, and
• Renegotiation
Successful managed care contracting requires an organization to view these phases as fluid and overlapping, rather than distinct.
The goal in managed care contracting is to create a framework for payment decisions that is as beneficial as possible for both payers and providers.
Negotiating Managed Care Contracts
Monday, April 19th, 2010Today, most health plans operate with fixed fee schedules. While most are based on a percentage of what Medicare pays, they may be tied to payment levels that are three or more years old. Physicians who question this methodology for paying for professional services are told to take it or leave it.
We are finding, however, that negotiating with Payers for fairer payments is possible. This does not mean Payers are willing to grant large increases just because you ask. But with the right data and a reasonable approach, you will be able to overcome inequities in existing fee schedules.
KEY POINTS
A simple analysis of your fees and your health plans’ reimbursement rates can help you reveal and overcome payment inequities.
Make sure you review your fees annually and set them reasonably.
Negotiating even small increases for a few codes can generate valuable income for your practice.
Solid data and a well-reasoned approach are vital to negotiating better reimbursement rates.
21.2% Medicare Pay Cut Will Take Effect Monday
Saturday, February 27th, 2010February 26, 2010 — Unless a minor bipartisan miracle happens in Congress over the next few days, physicians will go over the cliff on Monday. That’s when a scheduled 21.2% reduction in Medicare reimbursement takes effect.
A recent poll conducted by several medical societies representing neurosurgeons, for example, revealed that almost 40% would cut back on seeing new Medicare patients if reimbursement continues to decline, while 18% would stop accepting new Medicare patients altogether. Another 27% said they would treat fewer established Medicare patients.
Medicare Eliminates Consultation Codes
Monday, January 11th, 2010CMS (Centers for Medicare and Medicaid Services) announced the elimination of consult codes. Officially released and documented in Change Request “CR 6740″as of January 1, 2010 consult codes will be eliminated from the Medicare fee schedule. Medicare will no longer recognize or pay for services billed with consult codes 99241-99245 or 99251-99255.
CR6470 impacts only Medicare claims as of January 10th 2010, Medicare Advantage plans are likely to follow the Medicare rules. Medicare claims will not use consult codes, while private payers will (for now.) Verification of patient insurance prior to the physician visit is more critical than ever.
Declining Doctor Reimbursements Continue Closing Offices
Wednesday, September 10th, 2008 For 26 years, Dr. Joseph Lalka has been a family doctor, treating 3,000 patients in his cramped office in Chatham, N.Y., a small town nestled in the rural northern part of the state. But Lalka recently told his patients he is taking down his shingle and closing his practice. He says he no longer can afford to maintain a family practice.
Now his patients fear a future without the man who has cared for some of them for a quarter of a century. And they say they are angry at a system that has forced their doctor to leave because of escalating operating costs and declining reimbursements. Lalka, 54, says that with an income of only $60,000 last year, and little opportunity to expand his practice, he no longer is able to make ends meet.
The physicians contract is at the center of the reimbursement issue; specifically “payment terms.” This has been un-manageable for many physicians; it’s not that they don’t care; it’s that their practices have turned into revolving doors to try and keep up with declining reimbursements and the demand for healthcare.
Consider this, a family practitioner can spend up to an hour with one patient and be reimbursed in the area of $25.00; factor in expenses and you see the problem. At the end of the day physicians must identify and manage these contracts. It is no longer sufficient to trust their income to others.
If Dr. Lalka, and others like him, had the necessary data; the outcome could have been far different.
Yet Another Fine
Thursday, August 14th, 2008 Yet another payer has been ordered by state regulators to pay restitution of $3.9 million to thousands of members and a $250,000 fine for underpayment of claims related to care in out-of-network hospitals and other medical facilities.
State Insurance Commissioner Mike Geeslin ordered the health insurer to make the payments over the next several months and specified that if they don’t total at least $3.9 million, the balance must be paid to the state as an additional fine, reported the Dallas Morning News.
Doug Danzeiser of the Texas Department of Insurance said the underpayments date to Jan. 1, 2004, and involves thousands of members in Texas enrolled in Preferred Provider Organization plans.
Dallas Morning News, August 9, 2008
