Engage Front-Line Clinicians to Drive Down the Costs of Care

The Centers for Medicare and Medicaid Services' 2018 target date for having 50 percent of all Medicare fee-for-service payments made through a value-based model is not far away. The transition to value requires hospitals, physicians and post-acute care providers to unite in delivering a high quality and cost-effective patient experience. Indeed, pr...
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Quantros Study Finds No Correlation Between CMS Star Ratings and Quality

As we reported in an earlier briefing, the Centers for Medicare and Medicaid Services (CMS) published hospital quality star ratings on July 27th, despite pressure from industry stakeholders and Congress to delay their release. The ratings are a composite metric of one to five stars, with five being the best. They intend to convey the overall qualit...
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Three Research Studies Indicate Early Discharge Puts Patient Lives at Risk

Today hospitals operate under a microscope. Consumerism has motivated healthcare leaders to become more transparent in publically sharing their pricing, quality and performance data. In addition, they must comply with a barrage of new reporting requirements thrust upon them by governmental mandates. These trends along with other operational challen...
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How Hospitals Can Avoid the Risks of Moving to the Cloud

Eighty-three percent of healthcare organizations have systems in a cloud environment, and an additional nine percent are in the planning phase, according to a 2014 survey by the Health Information Management Systems Society (HIMSS). Other research shows that 55 percent of hospitals have already migrated mission-critical and sensitive data to a clou...
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Improving the Patient Experience Drives Superior Patient Satisfaction

The Colossal Shift from Fee-For-Service to Value-Based Reimbursement Anyone who has followed the healthcare industry over the past few years understands the transition that is underway moving from the traditional fee-for-service (FFS) model of reimbursing providers for delivering care where physicians and organizations are incentivized to do more a...
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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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