Understanding and determining medical necessity criteria challenges can be very complex for physicians, clinicians, coders, and billers.
Medical Necessity and Levels of Care (LOC) criteria are interdependent sets of objective and evidence-based health guidelines used to standardize coverage determinations, promote evidence-based practices, and support a patient’s recovery and well-being. Being such, LOC application, documentation, and accuracy plays a pivotal role in care and reimbursement.
The healthcare industry is undergoing an inevitable shift away from fee for service payment models towards reimbursement models that align with the healthcare triple aim, such as value based payments. The approach and question of which value-based model to implement still remains elusive for many organizations. Let’s take a look at some payment types on the value-based reimbursement spectrum.
On April 26, 2016 the Department of Health and Human Services (HHS) announced the finalized version of a new rule on managed care in Medicaid and the Children’s Health Insurance Program (CHIP). The “rule advances delivery system reform, strengthens quality and consumer protections, promotes accountability, and aligns Medicaid managed care rules with other health insurance coverage programs.”
The Centers for Medicare and Medicaid Services (CMS) have announced the finalization of a new rule that will help strengthen access to mental health and substance-use services for individuals who receive Medicaid benefits though managed care organizations and those who have Children's Health Insurance Program (CHIP) coverage. According to CMS' press release, this "final rule strengthens access to mental health and substance use disorder benefits for low-income Americans." The new provisions of this rule will benefit the over "23 million people enrolled in Medicaid managed care organizations (MCOs), Medicaid alternative benefit plans (ABPs), and CHIP."
If you read our post on the NCQA's Patient Centered Medial Home Recognition, you might have a good idea of what a patient-centered medical home (PCMH) is or you might want more information. This mini-graphic will define the basics of patient-centered medical homes, their benefits and the four accreditation bodies that have a PCMH recognition.
Since 2010 there have been 47 rural hospital closures. The reasons behind the closures vary but the message rings true, rural hospitals are struggling. With difficulties from implanting EHR to the re-evaluation of Medicare reimbursements, rural hospitals are looking for new ways to stay afloat. Here are the top 4 trends we see effecting rural hospitals in 2015.
As healthcare organizations continue to make the leap to Accountable Care status, post-conversion optimization services will be in demand. Those who made the transition over the last few years will find that 2015 is a great time to start taking a look at how they can optimize their ACO experience.
A November 2014 audit from the Office of the Inspector General (OIG) showed that as many states move from Medicaid to Managed Care Organizations (MCOs), access to a primary care physician involves some serious wait time. Because of these wait times, more and more Medicaid patients are filtering into healthcare systems through their emergency rooms, which impacts the continuum of care in a negative way.