Managed Care Experts

Payment Models: Taking a Closer Look

2017-07-04T17:22:56-04:00By |Health Care Reform, Managed Care|

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.

Department of Health and Human Services Releases Final Rule on Managed Care in Medicaid & CHIP

2017-04-02T13:28:06-04:00By |Managed Care, Medicare and Medicaid|

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.”

CMS Announces Finalized Mental Health & Substance Use Disorder Parity Rule for Medicaid

2017-04-02T13:28:07-04:00By |Behavioral Health Integration, Managed Care, Medicare and Medicaid, News and Events, Webinars|

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."

4 Trends for Rural Hospitals for 2015

2017-04-02T13:28:22-04:00By |Care Coordination, Financial, Health Care Reform, Managed Care, Services, Strategic Planning|

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.

Managed Care Organizations and Medicaid

2024-06-14T09:04:39-04:00By |Health Care Reform, Managed Care|

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.

Managed Care – Not New but our Healthcare Perspective Might Be

2017-04-02T13:28:26-04:00By |Care Coordination, Financial Analysis, Health Insurance, Healthcare Fraud and Abuse, Managed Care, Physician Advisor/Peer Review, Services|

Managed care has been around for almost one hundred years, at least in theory. When placed up against fee-for-service payment models, however, it was a hard sell. Traditionally, the way that physicians were compensated for their services was a fairly straight-forward invoicing process: they would bill the patient (or later, the payer) for everything they did in terms of diagnosing or treating the patient. Everything.

Medicaid Expansion | How Does it Affect You?

2017-04-02T13:28:28-04:00By |Managed Care, Services|

It’s almost time for open enrollment - and this year, there are some changes to Medicaid that might affect you, depending on what state you live in. So far, states have begun expanding their Medicaid programs, with the help of additional federal funding. This funding for Medicaid expansion is meant to provide assistance to adults who are under 65 years of age, and therefore don’t qualify for Medicare yet, who are at 138% of the poverty level in terms of income.

Eeny Meeny Miney Money | Understanding Fee for Service Alternatives

2017-04-02T13:28:28-04:00By |Accountable Care Organizations, Financial Analysis, Health Care Reform, Managed Care, Services|

When we look at the fee-for-service model from only one perspective, it’s easy to condemn it as “the reason” healthcare spending has spiraled out of control. When it comes to how providers bill for services, having the ability to bill for anything and everything could, and certainly did, encourage the ordering of too many tests and procedures, even unnecessary ones. The idea of value-based payment models not only encourages providers to make more mindful choices, but cost-effective ones too. It also challenges healthcare systems, pharmaceutical companies and patients to be even more vigilant about healthcare costs. Fees are relative to each party involved.

A Three Pronged Approach to Organizational Analysis

2017-04-02T13:28:30-04:00By |Accountable Care Organizations, Clinical Analysis, Financial Analysis, Managed Care, Medicare and Medicaid, Operational Analysis, Organizational Analysis, Readmissions, Services|

When was the last time your organization performed a SWOT analysis? If you aren’t familiar with SWOT (strengths, weaknesses, opportunities and threats) it’s a widely used strategy in many industries, not just healthcare, for identifying areas for improvement. You can break SWOT down even further: Strengths: What sets your hospital apart from all the rest? What can you offer that makes you competitive? Weaknesses: What puts your hospital and employees at a disadvantage compared to other hospitals? What of these factors can you change? Opportunities: How can you show your strengths to others? Threats: What could cause big trouble for your hospital or employees?

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