Where the Rubber Meets the Road – Correcting Improper Payments

Health plans and care providers need to open the lines of communication with each other in ways that they have never done before. In order to maintain compliance and receive accurate payment from the Centers for Medicare and Medicaid Services (CMS) that reflects the severity of illness, utilization of resources and the increasing number of chronic ...
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Overall Hospital Quality Star Ratings

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...
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The Hospital’s Role in the Opioid Epidemic

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. Wi...
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Changes Proposed to Medicare Appeals Process

Current Process Description 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, the...
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CMS-HCC Risk Adjustment Auditing—A Necessary Evil

IntroductionThe 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. The CMS-HCC model design uses two risk segments with separa...
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Understanding Risk Adjustment and the Hierarchical Condition Categories Methodology

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 beneficiar...
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DOJ and NC Attorney General File Antitrust Suit Challenging Anti-Steering Restrictions

Healthcare costs in the United States (U.S.) are rising faster than the rate of inflation. Since 2009, healthcare inflation has outpaced the Consumer Price Index by as much as 3.5 percent in a single year.1 The cost of providing care is skyrocketing. Providers and payers need to look for ways to reduce costs so our healthcare system can continue to...
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OIG Views Favorably Arrangements Aimed at Assisting Patients with Financial Obligations

The Office of the Inspector General (OIG) has issued a pair of Advisory Opinions that could impact non-profit organizations that want to help patients pay for treatment. In the Opinions, 15-16 and 15-17, the OIG views favorably non-profit organizations seeking to financially assist patients with their out-of-pocket expenses associated with the pres...
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Boomer Healthcare 101

PerspectiveBy 2030, one in five Americans will be a senior citizen, nearly double the 12 percent in 2000, according to The State of Aging and Health in America, a 2013 special report from the U.S. Centers for Disease Control and Prevention (CDC). By 2029, when the last round of boomers reaches retirement age, the number of Americans 65 or older wil...
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Patients’ Ability to Shop for Services Has a Modest Effect on Healthcare Spending

If patients know the prices that various providers of healthcare services will charge, they will shop for the best value and in the process drive prices down. That assumption underlies the numerous governmental and health system efforts to deliver price transparency seen over the last few years. Is the assumption valid? It is, but to a rather limit...
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Buy Versus Build or Both?

Lately, technology security has taken center stage as health organizations face increased challenges of maintaining the security of patient health information. While securing data is of concern, determining the most applicable and cost-efficient technology is the most important priority. Accelerating digital transformation and leveraging emerging t...
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HIPAA Audit Program—Phase 2

The Health Information Technology for Economic and Clinical Health Act (HITECH) requires the HHS Office for Civil Rights (OCR) to conduct periodic audits of covered entity and business associate compliance with the HIPAA Privacy, Security and Breach Notification Rules. In 2011 and 2012, OCR implemented a pilot audit program (Phase 1) to assess the ...
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Healthcare Price Variation is Alive and Well

It is no secret that the cost of healthcare services varies greatly between geographic regions. A major new study from the Health Care Cost Institute (HCCI), National Chartbook of Health Care Prices, examined price variation for 242 common medical services across 41 states and the District of Columbia and found a two- to threefold difference. The g...
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MACRA and the Medicare Payment Reform Juggernaut

More Changes Coming to Healthcare Delivery The passage of the Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 (MACRA)1 has contributed to changes in healthcare delivery by redesigning Medicare's payment and delivery methods for physicians and other clinicians. MACRA repealed the highly debated sustainable ...
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CMS Proposes Eliminating Payment Reduction Under Two-Midnight Rule

After much pushback from industry stakeholders and from the judicial system, the Centers for Medicare and Medicaid Services (CMS) propose to eliminate the notorious payment reduction under the Two-Midnight Rule in its FY 2017 Medicare Inpatient Prospective Payment System (IPPS) Proposed Rule (Proposed Rule). Though not slated to be finalized until ...
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Changing Demographics in our Physician Workforce Supply, Demand and Assessment

IntroductionAccording to a new report from the American Association of Medical Colleges (AAMC), the U.S. faces a shortage of physicians ranging between 61,700 and 94,700 over the next decade. This report includes updated supply and demand data and refined medical school graduate data, and fully integrates the effects of the growing ranks of physici...
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Ransomware is a Serious Threat to Healthcare Systems

IntroductionA few months ago most of us were blissfully unfamiliar with the word "ransomware." Now, after several large healthcare systems have been the victims of attacks, we are seeing and hearing the word everywhere. Every provider that stores information on computers that can access the Internet should consider how best to protect itself agains...
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Ready or Not Here They Come – The OCR HIPAA Phase Two Audits

IntroductionThe U.S. Department of Health & Human Services (HHS) Office for Civil Rights (OCR) announced the beginning of the 2016 Phase Two Health Insurance Portability and Accountability Act (HIPAA) Audit Program. This program is designed to evaluate the compliance efforts of covered entities and their business associates (BA) with the HIPAA ...
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OCR Releases Guidance Regarding Patients’ Access to PHI

The U.S. Office for Civil Rights (OCR) has been actively releasing new information regarding the Health Insurance Portability and Accountability Act of 1996 (HIPAA) compliance, including releasing a frequently asked question (FAQ) aimed at clarifying the rules for fees charged to patients in need of access to medical records. HIPAA requires covered...
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Bundled Payments Building Momentum

A bundled payment is defined as reimbursement to healthcare providers on the basis of expected costs for clinically-defined episodes of care. It has been described as a middle ground between fee-for-service reimbursement and capitation. Bundled payments have long been a part of the healthcare reform debate as a strategy for reducing healthcare cost...
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