Summary: Do you understand Relative Value Units (RVUs) as they relate to Medicare reimbursement? Is your physician compensation model based upon RVUs or a derivative thereof? What is an RVU? RVU stands for Relative Value Unit and is currently used by Medicare to determine the amount of reimbursement to providers. RVUs are basically a way of standardizing and comparing service volumes across all continuums.
Summary: CMS has reversed its original proposal to cutback Medicare Advantage plan reimbursement for 2015. The reversal is a result of aggressive lobbying from organizations such as the American Medical Association. What is Medicare Advantage? According to www.medicare.gov, a Medicare Advantage plan is “a type of Medicare health plan offered by a private company that contracts with Medicare to provide you with all your Part A and Part B benefits. Medicare Advantage Plans include Health Maintenance Organizations, Preferred Provider Organizations, Private Fee-for-Service Plans, Special Needs Plans, and Medicare Medical Savings Account Plans. If you're enrolled in a Medicare Advantage Plan, Medicare services are covered through the plan and aren't paid for under Original Medicare. Most Medicare Advantage Plans offer prescription drug coverage.”
As a result of the Affordable Care Act as well as other healthcare legislation, a shift is occurring in healthcare from the provider's perspective. In order just to survive (not even prosper), physicians are changing the way they conduct business and choosing which patients will be seen. Shifting Landscape and Mindset - Changes in Medicare •Medicare reimbursement is certainly on the forefront. Reductions, even if 1% or less, can drastically affect a provider's bottom line. Consequently, some providers are limiting the number of Medicare patients seen by their practice. Some providers have completely eliminated access to these patients.
Hospital Acquired Infections (HAIs) occur when a patient is exposed to a bacterium, virus or fungi during their hospital stay that leads to an additional condition. These additional conditions can cost hospitals thousands of dollars in lost revenue.
What is CMS doing to reduce healthcare costs? CMS has added observation units which are an additional level of care between inpatient and outpatient. What Are Observation Units? In general, observation units are used to bridge the gap between inpatient and outpatient. They are designed for the patient in which the attending physician cannot determine whether a patient should be classified as outpatient (released within 48 hours) or inpatient (expected to stay at least 2 midnights). The observation units enable the physician to have a bit more time to stabilize the patient and based on medical necessity determine the estimated length of stay. They are billed as outpatient and do not count toward an inpatient admission.
What is the 2 Midnight Rule? What does it mean for your organization? How does it affect the amount Medicare patient’s pay out of pocket? How does the 2 Midnight Rule affect reimbursement from both inpatient and outpatient perspectives? The 2 Midnight Rule establishes guidelines as to whether or not a physician should admit a patient from outpatient to inpatient. The general rule is if the patient, based upon medical necessity, is expected to require care that will span at least 2 midnights, the patient should be admitted as inpatient, and therefore reimbursable under Medicare Part A. In determining the 2 midnights, all care including outpatient is used in the determination. However, in terms of reimbursement, outpatient is reimbursed via Medicare Part B provisions and inpatient is reimbursed via Medicare Part A provisions.
Those of us who work in Health Information Management understand the value of good documentation -- and we have especially keen senses when it comes to recognizing excellent documentation when we see it. That being said, we also know when we’re seeing documentation that isn’t so great. And together with medical billers and coders, we’re always looking for ways to improve it.
A patient-centered focus will provide optimal care for the patient which will in turn drive revenue. Do you remember the movie “Field of Dreams”? The basic premise was if you build a stadium they will come. We can adapt this adage to healthcare as well. So many organizations become so focused on the bottom line and don’t realize that if patients aren’t satisfied, they will not return to your facility, they will relay their bad experience to all of their friends, and you will lose revenue.
When faced with a denied claim, your first question as a physician, biller or consumer should be why? Your best defense against these denied claims, and your greatest chance of winning an appeal, comes from understanding why the claim was denied by the insurer.
