5 Healthcare Payer Pain Points | What Are Your Pain Points?

As a payer, what type of pain points are you facing? How are you overcoming these challenges?

With the onset of the ACA and other healthcare regulation, payers are experiencing many issues. Complying with these regulations is both cumbersome and costly. What pain points are you experiencing as a payer?

Exchanges

Healthcare exchanges became effective October 1, 2013. These exchanges are basically marketplaces where individuals can shop for insurance in one place – comparing plans, costs, and benefits. Many payers jumped on the bandwagon and joined the exchanges.

The Quest for Healthcare Quality: Part I

A standardized definition for quality has been elusive; though most will agree that the term “quality” in healthcare refers to the patient’s overall experience, or, encounter with the healthcare system.

Play or Pay | The Triple Aim for 2015 and Beyond

What will you decide for your organization beginning 2015? Will you “play or pay”?

The “play or “pay” principle basically says that if employers with 50 or more full time employees don’t meet the minimum requirements of offering insurance coverage, they will pay very steep penalties. The provision will be phased in beginning in 2015. The “play or pay” principle is part of the PPACA, specifically under the provision of “shared responsibility”.

Are ACOs The New HMOs?

Historically, HMOs are notorious for incurring poor health among patients and bolstering already bloated administrative costs. When healthcare reform was on the horizon, the promise of Accountable Care Organizations in lieu of traditional HMOs lifted the wilted spirits of doctors and patients alike. A few years of ACOs, however, seems to have done little to assuage the initial fears of these groups that ACOs are just nicely dressed HMOs.

Defining Healthcare Value

One of the greatest challenges in healthcare currently is not so much a matter of practice, but definition. How has ‘value’ been defined and do we need to alter our definition to reflect the ongoing evolution of our healthcare system?

Can Google Make Us Live Forever? What is ‘Google Calico’ and What Does It Have To Do With Modern Healthcare?

You may recall some murmurings last year about a new Google venture cryptically called Calico. In the heyday of 23andMe, Apple’s many health apps and the hefty focus on technology in healthcare, Google wasn’t about to miss out on the hoopla. But just as soon as we started hearing chirps about “Google’s war on aging”, it sunk into the deep obscurity of the web.

10 Reasons Your Claim Was Denied

There are many reasons a claim might be denied, but did you know that many of them are actually simple oversights that can easily be corrected? Check your denials against this list to see how many preventable errors might be costing your hospital money.

7 Ways to Improve Your Readmission Rates

As most of us are aware, readmissions is a hot topic, especially in terms of the penalties assessed for readmission rates which are excessive. What can you do to reduce or eliminate your readmission rates?

There has been a lot of talk about readmissions (avoidable), specifically the healthcare costs associated with them and the effects on the quality of patient care being provided. In order to crack down on these avoidable readmissions, CMS created the Readmissions Reduction Program. The premise of the program is to ding hospitals, with higher than average readmissions (readmitted within 30 days of discharge), by assessing penalties against overall Medicare payments. There has been a lot of hoopla surrounding the program, with many criticisms being cited, such as treating all hospitals alike, not accounting for socioeconomic factors, and the way the penalty is calculated.

Are You Ready for 2015 Readmission Penalties?

What are you doing to make sure you are not one of the 66% of hospitals who will be assessed readmission penalties in the next round? Can you afford the penalties which are increasing again in 2015? Are you aware of the proposed conditions to be added in 2015?

What do you get when you combine Medicare, high readmissions, within a 30 day window, for specific conditions? A reduction in Medicare spending to the tune of about $280 million annually. Of interest is that penalties were assessed in 49 states, all with the exception of Maryland, who has a unique reimbursement payment system.

9 Criticisms to the Readmission Reduction Program

The Readmission Reduction Program is designed to reduce healthcare spending while improving quality. There are both proponents and opponents of the program. Let’s delve into the improvements that could be made to the current system.

So, as most of you are aware, CMS under the direction of HHS created the Hospital Readmission Reduction Program in order to reduce healthcare spending while improving the quality of care. The program is being phased in beginning with a 3 year baseline period in which hospitals were required to report all readmissions (within 30 days). CMS assessed and analyzed all of the available readmission data to determine how penalties should be assessed, for which conditions, and excluding certain circumstances. Beginning in October 2012, penalties were assessed to over 2,200 hospitals, equating to about $280 million. The phase in included an increase in penalties from 2013 to 2015 from 1% to 3%, where it is currently capped. Initially, there were 3 conditions included: Acute Myocardial Infarction, Heart Failure, and Pneumonia. For 2015, CMS is proposing 2 additional conditions: Chronic Obstructive Pulmonary Disease and Elective Hip and Knee Replacements.