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”.
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.
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.
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 $280 million. The phase in included an increase in penalties from 2013 to 2015 from 1% to 3%, where it is currently capped. Initially, there were 3 conditions included: Acute Myocardial Infarction, Heart Failure, and Pneumonia. For 2015, CMS is proposing 2 additional conditions: Chronic Obstructive Pulmonary Disease and Elective Hip and Knee Replacements.
What do the ACA, ACO, FFS, DHS, and QHP all have in common? They are healthcare acronyms and most are related to the Affordable Care Act. The healthcare industry is not unlike any other industry or almost any aspect of our lives these days, especially with the advent of texting. There is always a shorter way to say something i.e. “BFF” – best friends forever or one of my favorites “*$” - Starbucks. By the way, the title “FFOF” is Fun Facts on Friday. The ACA, which is part of the “PPACA” - Patient Protection and Affordable Care Act of 2010, is regulated by “HHS” - the division of Health and Human Services, the “DOL” – Department of Labor and the “IRS” – Internal Revenue Service. HHS designates many responsibilities to “CMS” – the Centers for Medicare and Medicaid Services.
Pundits began outlining the downfall of Obamacare as soon as the President was elected in 2008. Now that many programs have come to fruition, many folks who originally voiced concerns are tallying up the negative outcomes.
Summary: Are you ready for a shift in risk from payer to provider? Will you be ready for value-based purchasing when it becomes required? Are you utilizing other reimbursement models such as bundled payments, Accountable Care Organizations, and Population Health Management? From a provider perspective, healthcare reform is aimed at tightening the purse strings, working more efficiently, reducing waste, and improving quality. The shift of risk has begun which will transform healthcare from a fee-for-service to fee-for-value. When the ultimate transformation ends, is still uncertain. As such, fee-for-service is still being utilized and providers are still generating profits and revenue based on the volume mentality while simultaneously trying to transition to a volume and quantity mentality. Juggling the opposite ends of the spectrum is no easy task.
When a patient needs medical treatment of any kind, their insurance company needs a way to establish how much they’re going to pay for the services. An insurance company may review a treatment or procedure to determine if it is appropriate, and therefore, if they’ll cover the cost. If an insurance company denies coverage, a patient or healthcare provider can appeal the decision.
Summary: Accountable Care Organizations (ACOs) are gaining in popularity as a result of the Affordable Care Act. Have you considered the benefits of ACOs from both the patient and provider perspectives? One of the goals of the Affordable Care Act (ACA) is to provide coordinated care which, in turn, increases quality and efficiency within the healthcare field, and reduces costs. ACOs – What is an ACO? ACOs are groups of providers which form an organization based upon the Medical Home (or PCMH) concept. The Medical Home places responsibility for the coordination of care with the primary physician. The primary care physician coordinates with other physicians and providers such as specialty physicians, laboratories and diagnostic imaging, providing a central point for the patient’s medical information.
As Obamacare policies have gone into effect, more and more people are realizing their quality of care has been sacrificed. They are unable to schedule an appointment with their doctor, and their insurance covers little of what it used to. Unfortunately, the Affordable Health Care Act could have used more work before going into effect, and both the doctors and patients are suffering. As people and government officials are beginning to realize, the solution to healthcare cannot be fitted with a one size fits all package. As a result, direct primary healthcare (private healthcare) and concierge medicine is growing in popularity amongst both physicians and patients. Here are three reasons why.