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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A Setback for Health Data Transparency

Healthcare providers as well as health policy opinion leaders favor data transparency. If detailed data about the costs and quality of healthcare are publicly available, the theory goes, we will be able to address matters of cost, quality and access through analysis of comprehensive payment information. We will also have the information needed to f...
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Improving Patient Satisfaction the Disney Way

Do you remember when you first discovered the magic of Disney? Whether you're a child or adult, chances are the Disney experience changed the perception of how a consumer should be treated. Disney follows three philosophical tenants to ensure they consistently deliver the world-class service that consumers have become accustomed to receiving: Move...
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CMS Finalizes Rule Regarding Reporting and Returning Overpayments

The Affordable Care Act (ACA) established a new Section 1128J(d) as part of the Social Security Act (Act) requiring that a person who has received an overpayment to report and return the overpayment. Failure to identify and refund overpayments exposes providers and suppliers to False Claims Act liability pursuant to 31 USC 3729. In the February 16,...
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Telemedicine Trends and Opportunities

Telehealth is broadly defined as the use of telecommunications and other information technologies to deliver healthcare, health information or health education at a distance. While telemedicine is most commonly used to improve access to medical services in rural areas where such services are not consistently available, Peter Rasmussen, MD, Medical ...
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Medicare’s Foray into Mandatory Bundling: The Comprehensive Care for Joint Replacement Payment Model

Medicare's Comprehensive Care for Joint Replacement (CJR) regulation,1 issued on November 16, 2015, requires bundled payments for joint replacements to the lower extremities over a 90-day "episode of care" in 67 Metropolitan Statistical Areas (MSAs) across the country.Under the CJR program, nearly 800 hospitals2 will be financially responsible for ...
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Patient Payment Liability Just Ain’t What it Used to Be

Baseball is America's past-time and Yogi Berra was one of its most colorful heroes. Berra was an 18-time All-Star, appeared in 14 World Series as a member of the New York Yankees and won 10 championships. He was a sportswriter's favorite because he had countless expressions and phrases that were memorable because most of them didn't make any sense....
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CMS Outlines Expansion of Audit Program to Medicare Advantage

Medicare's Recovery Audit Contractor (RAC) program was implemented nationwide for Medicare Parts A and B in January 2010. The Affordable Care Act calls for the program to be expanded to cover Medicare Advantage plans, and last month CMS released a draft Scope of Work to "solicit comment on, and interest in CMS entering into a contract with RACs to ...
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Results from Medicare’s Hospital Acquired Conditions Reduction Program – 758 Hospitals Penalized

One of the Affordable Care Act's tools for shifting from a volume-based to a value-based payment system is the Hospital Acquired Conditions (HAC) Reduction Program. The HAC Reduction Program cuts payments by one percent for the hospitals that rank in the worst-performing quartile of all hospitals on risk-adjusted HAC quality measures. The program t...
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The New CJR Program: Everything You Need (But May Not Want) to Know

A Mandated ProgramOn November 16, 2015, the Centers for Medicare and Medicaid Services (CMS) announced the final rule for the Bundled Payments for Care Improvement Initiative and the mandatory bundled payment test called Comprehensive Care for Joint Replacement known as CJR. Effective April 1, 2016, acute-care hospitals in 67 geographic regions (kn...
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The OIG Work Plan for 2016

The Department of Health and Human Services' Office of the Inspector General (OIG) released its Work Plan for Fiscal Year 2016 on November 2, 2015. The Work Plan is published annually and describes OIG's new and ongoing audit, compliance and enforcement priorities for the upcoming year. It allows providers to identify corporate compliance risk area...
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Healthcare and the FCC Duke it Out Over the Telephone Consumer Protection Act

The Federal Communications Commission (FCC) issued a Declaratory Ruling and Order (Declaratory Ruling)1 on July 10, 2015 in response to 21 separate requests2 seeking clarifications to the Telephone Consumer Protection Act (TCPA).3 The Declaratory Ruling has acute implications for any organization that uses an autodialer or prerecorded messages to m...
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Protecting the Privacy and Security of Healthcare Data

A misplaced flash drive; a lost cell phone or laptop computer; a message forwarded to a personal email account; a database hacked by a cybercriminal. While they implicate very different levels of severity, all are examples of cyber-security incidents that are in the news every day. Prevalence and Related Costs In the Poneman Institute Study on Priv...
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Health Insurance Company Mergers and Acquisitions

Health insurance companies are once again seeking to grow through consolidation. The potential for a landscape dominated by just a handful of insurance behemoths is raising concerns across the industry. Anthem, Inc. announced on July 24th that it had entered into a definitive agreement to acquire all the outstanding shares of Cigna Corporation...
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Demystifying the Bundled Payment Initiative

​America's healthcare system is on an unsustainable path. There are well-documented gaps in care and variation in quality. The federal government projects that from 2014-2024 national health spending will grow at an average rate of 5.8 percent per year, rising from $2.8 trillion to $4.8 trillion. To put this into perspective, healthcare spending is...
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The Tuomey Saga Has Finally Come to a $72.4 Million End

Many have heard of the landmark whistleblower case of U.S. ex rel. Drakeford v. Tuomey Healthcare System, Inc. where Tuomey Healthcare System engaged in part-time employment contracts that violated the Federal Stark Law (Stark) and the Federal False Claims Act (FCA). This month Tuomey and the federal government reached a $72.4 million settlement, e...
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Patient Engagement—Theory and Trends

The movement towards making it easier for patients to access their health records electronically is a key component of "patient engagement." The theory is that easier access to, and a greater awareness of, personal health information will be empowering, causing patients to feel more in control and fostering a more collaborative approach to per...
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Compensating Physicians for Referrals: Hospitals Settle Costly Lawsuits

There are good ways in which to accomplish physician-hospital integration, and then there are bad ways. More specifically, aligning the financial interests of physicians and hospitals can implicate the federal Stark Law, which prohibits paying physicians for referrals. Two recent settlements entered into between health systems and the Department of...
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The Healthcare Industry Should Prepare for Increased HIPAA Oversight and Enforcement with the Release of Two OIG Reports

On September 29, 2015, the Department of Health and Human Services Office of Inspector General (OIG) released two reports aimed at bolstering the action and reaction of the Office of Civil Rights (OCR) with respect to its administering and enforcing the Health Insurance Portability and Accountability Act of 1996 (HIPAA). In its reports, OCR Should ...
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An Updated Healthcare Information Technology (Health IT) Plan

On Monday, the U.S. Department of Health and Human Services' Office of the National Coordinator for Health Information Technology (ONC), outlined their continued vision, goals and strategy for health IT with the release of the Federal Health IT Strategic Plan 2015–2020 (Plan). The Plan's aim is to improve the health IT infrastructure. However, its ...
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