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MiraMed’s eAlerts are distributed via email every Wednesday, and contains the latest industry information regarding business process outsourcing solutions, helpful coding news, or any number of relevant topics in the fast-paced, ever-evolving world of healthcare. To subscribe, simply complete the form below. Below the subscription form, you will find the archived eAlerts available.

July 27, 2016

As part of their continuing efforts to make quality of care information more readily available, the Centers for Medicare & Medicaid Services (CMS) has developed a rating system that reflects comprehensive quality information about the care provided at our nation’s hospitals.  The ratings are intended to convey a hospital's overall quality with a single, composite metric of one to five stars, with five being the best.  The CMS originally planned to publish those ratings on its Hospital Compare website in April but delayed doing so after 60 senators and 225 representatives wrote letters urging it to hold off.  The CMS already publishes hospital star ratings based on patient experience; however, the Overall Hospital Quality Star Rating (Star Rating), which was developed through a public and transparent process, takes 62 existing quality measures already reported on the Hospital Compare website and summarizes them into a unified rating of one to five stars.  The rating includes quality measures for the routine care an individual receives when being treated for heart attacks and pneumonia to quality measures that focus on hospital-acquired infections, such as catheter-associated urinary tract infections.  Key measures included in the Star Rating ask questions such as:

Read more: Overall Hospital Quality Star Ratings

July 20, 2016

According to the U.S. Centers for Disease Control, 44 people die every day in the United States from overdose of prescription painkillers.1  In order to combat the devastating effects of the growing epidemic, the American Hospital Association (AHA) and the Centers for Disease Control (CDC) have joined forces to educate the public about the issue.  With the help of various experts from within the healthcare industry, the organizations formed a document entitled, Prescription Opioids: What You Need to Know, detailing the risks and side effects of opioids.  In light of this release and the current national focus on opioid prescription use and abuse, it is important to understand what facilities and hospital systems can do to assist in curtailing this rapidly growing epidemic.

Read more: The Hospital’s Role in the Opioid Epidemic

July 13, 2016

Every year, Medicare Administrative Contractors process an estimated 1.2 billion fee-for-service claims on behalf of the Centers for Medicare & Medicaid Services (CMS) for more than 33.9 million Medicare beneficiaries.  When beneficiaries or providers disagree with a coverage or payment decision made by Medicare, they have the right to appeal and the Social Security Act established five levels to the Medicare appeals process:

Read more: Changes Proposed to Medicare Appeals Process

July 6, 2016

The Centers for Medicare and Medicaid Service’s (CMS) Hierarchical Condition Category (HCC) risk adjustment model is used to calculate risk scores, which will adjust capitated payments made for aged and disabled beneficiaries enrolled in Medicare Advantage (MA) and other plans.

Read more: CMS-HCC Risk Adjustment Auditing—A Necessary Evil

June 30, 2016

Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding is a payment model mandated by the Balanced Budget Act of 1997 (BBA) and implemented by the Centers for Medicare and Medicaid Services (CMS).  The RA program allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries.  By risk adjusting plan payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs.  RA is used to make payments based on the health status and demographic characteristics of an enrollee.  Risk scores measure individual beneficiaries’ relative risk and they are used to adjust payments for each beneficiary’s expected expenditures.  By risk adjusting plan bids, CMS is able to use standardized bids as base payments to plans.

Read more: Understanding Risk Adjustment and the Hierarchical Condition Categories Methodology

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