Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Revenue Cycle Management Interviews

Team-Based Care for Kidney Disease Saves Park Nicollet $1.2M

by Jacqueline LaPointe

End-stage renal disease comes with a hefty price tag for both patients and providers. But Park Nicollet Health Services, an integrated care system in Minnesota, found that a team-based care approach to late-stage kidney disease helped to dr...These patients with late-stage kidney disease are also typically already sick to begin with, suffering from conditions such as long-standing hypertension, uncontrolled diabetes, or other medical diseases that result in kidney function deter...“Our team works with these companies and tries to get patients situated, especially patients who are already on dialysis and came to the emergency department for some ailment, but don't necessarily need to be admitted to the hospi...

How Mercy Improved Care Transitions for Risk-Based Care Success

by Jacqueline LaPointe

For the thousands of patients released from their 23 acute care hospitals a year, Mercy Health ensures that each patient receives the highest value care. But there is only so much providers can do within the walls of their health system to ...

Predictive Analytics Improve Nursing Schedules, Saving Mercy $4.3M

by Jacqueline LaPointe

Even with 40,000 physicians, nurses, and other employees, St. Louis-based Mercy still relied on staffing agencies and employee incentives to fill critical nursing schedule gaps until a predictive analytics platform helped operations leaders...“At the same time, we were seeing some human resource data showing that we had staff who were not being fully utilized at their full-time commitment, or what we hired them to do,” he continued. “We felt we had a mismatch b...

Value-Based Contracts Rely on Patient Attribution, Data Sharing

by Jacqueline LaPointe

CMS aims to tie 90 percent of Medicare fee-for-service payments to quality by the end of 2018, with one-half of those payments to be paid under a value-based contract with some degree of financial risk. With ambitious goals from the federal...Under value-based contracts, providers are responsible for the sophisticated definition of patient. The contracts attribute a population ranging from 15 to 2,000 or more patients to a provider, who is then responsible for the care quality a...With most of their patient population moving to value-based arrangements in a few years, the public hospital system is working to understand their patient populations. But Medicaid and uninsured patients belong to transient groups. Medicaid...To effectively manage patients across the care continuum, the main brain requires a plethora of data assets, such as “structured EHR data elements, paid claims, and ideally concurrent information on patients moving particularly throug...

Addressing Quadruple Aim, Physician Burnout Key to Risk Success

by Jacqueline LaPointe

From capturing patient risk to meeting quality measures, providers face a daunting list of items needed to achieve the Triple Aim of value-based care. But healthcare organizations will not see lasting cost savings and care quality improveme...Unfortunately, that whole bunch of value-based care capabilities and tasks are still required to achieve the Triple Aim despite physician burnout. Healthcare organizations still need to invest in population health management infrastructure,...

Automating Healthcare Contract Management Improves Business Ops

by Jacqueline LaPointe

Improving care access at hospitals is key to ensuring the health of pregnant women and their babies. But the business operations behind improving care access, such as employee and vendor contract management, must be as efficient as possible...

The Pros and Cons of Quality Measure Choices In MACRA, MIPS

by Jacqueline LaPointe

Uprooting the fee-for-service payment system and changing the way clinicians provide care is no easy feat. With this in mind, CMS designed MACRA’s Merit-Based Incentive Payment System (MIPS) to gradually ramp up participation and offe...“There have been some surveys done that show that a very substantial portion of healthcare providers really do not understand what MIPS stands for, let alone what it or MACRA is,” he recently told RevCycleIntelligence.com. &ldqu...

Importance of Post-Acute Alignment, Integration to Value-Based Care

by Kyle Murphy, PhD

To achieve the ultimate goals of value-based care, healthcare organizations will need to assume greater responsibility over the patient’s experience across multiple care settings based on the appropriate level of acuity.   While ...“Alternative reimbursement models really put the emphasis on post-acute as a way to reduce cost,” Campbell continued. “We should be able to optimize the patient journey starting at the acute all the way back to home, hopef...But that approach points to the road ahead for most of the healthcare industry insofar as forging connections between care facilities specializing in different levels of acuity. “Post-acute is sometimes overlooked,” said Campbel...“Six or seven years ago, each of our entities was a separate entity with a separate leadership team — these almost semi-autonomous hospitals and delivery sites within our own network within the larger network of Partners,”...

Full Risk Value-Based Care Key to Treating Vulnerable Patients

by Jacqueline LaPointe

Oak Street Health, a 24-primary care network headquartered in Chicago, aims to rebuild healthcare as it should be using value-based care contracts with full financial risk. The health system’s mission is to deliver personal, equi...“This is a population that has not traditionally thrived in a fee-for-service environment,” he said. “Frankly, the healthcare system is not really built to take care of them.” Medicare, Medicaid, and dual eligible po...

Health Centers Use Business Tactics to Compete with Private Orgs

by Jacqueline LaPointe

Federally qualified health centers (FQHCs) are the backbone of the healthcare safety net. But rising competition from hospitals and other healthcare organizations may be the straw that breaks that back. FHQCs receive enhanced Medicare and M...“Many of them [private, larger healthcare organizations] would not accept Medicaid patients several years ago,” the FQHC’s President and CEO Joan Quigley recently explained to RevCycleIntelligence.com. “But since New...“It is a battle every day as we try to operate the health center as a business,” he said. “Even though we’re a non-profit, we try to operate as if we were a profitmaking company. By that I mean there’s an oppor...

Using EHR Systems, Supports to Aid MIPS Reporting, Boost Scores

by Jacqueline LaPointe

Delivering high-quality care is already a complicated process for healthcare providers. Understanding, as well as reporting, to MACRA’s Merit-Based Incentive Payment System (MIPS) has made the task even more complex, explained Brad J....

Provider Data Integrity Key to Directory Accuracy, Value-Based Care

by Jacqueline LaPointe

Providers and their payers oftentimes have a love-hate relationship. Payers boost the number of patients walking through physician office doors using provider directories as well as reimburse providers for treating those patients. But navig...Provider data is at the center of a range of payer responsibilities, from claims reimbursement, membership, and provider directories to performance measurement, quality reporting, and customer relationship management. Despite staff from acr...Phone calls are the staple of payer outreach initiatives, Vaitla added. However, when a provider experiences a change, such as moving to a new address, every health plan he contracts with is calling him to update their information. “I...

Physician Advisors Crucial to Navigating Reimbursement Rules

by Jacqueline LaPointe

When physicians are asked why they went into medicine, the classic response is that they wanted to help people. But as value-based reimbursement takes hold and clinical documentation demands increase, providers are finding that the business...“Doctors go to school to learn how to take care of patients,” she recently told RevCycleIntelligence.com. “They do not go to school to learn governmental and payer rules for things like whether or not billing is appropriate for inpatient. I...

CO’s Pediatric Care Network Brings Value-Based Care to Children

by Jacqueline LaPointe

Medicare has led the healthcare industry as it shifts from fee-for-service to value-based care, with 30 percent of traditional Medicare reimbursements already paid under an alternative payment model. The federal government plans to further ...“All of us, whether private practice, at the hospital, or specialists, were seeing increased pressure to reduce the total cost of care,” Leishman recently told RevCycleIntelligence.com. “Payers have started to develop a nu...“If we were not working in collaboration with those cost centers, it makes it very difficult to move that cost needle,” he continued. “This conversation and giving us the opportunity to get to the table like this is allowi...

MIPS Quality Reporting Flexibilities Trouble Providers, EHR Vendors

by Jacqueline LaPointe

It’s good to have options when it comes to the clothes we wear, cars we drive, and things we do. But having too many options when it comes to quality reporting under MACRA’s Merit-Based Incentive Payment System (MIPS) may prove ...But providers are not the only healthcare stakeholders feeling anxiety from a wide range of MIPS quality reporting options, she stated. With eligible clinicians using a patchwork of reporting mechanisms to attest to MIPS, EHR vendors may fi...

Bringing Back House Calls to Cut Spending on High-Risk Patients

by Jacqueline LaPointe

Before the early 1960s, the majority of healthcare visits were performed in patient homes. But as healthcare evolved, providers could no longer fit their tools in a transportable medical bag and the proportion of visits made by house calls ...“The reason for doing house calls is to really focus on these patients who have to call 911 and they land in the emergency room,” the system’s Director of Geriatrics said. “The program is there to really prevent 911 ...

How Palomar Health Created a High-Value Post-Acute Care Network

by Jacqueline LaPointe

Ensuring patients receive high-value care delivery during their hospital stay or office visit is a top priority for healthcare providers. But value-based purchasing models are pressuring doctors to extend that same cost-efficient, high-qual...The California-based system started by identifying high-value skilled nursing facilities to serve communities in their 850-square mile healthcare district. “We’ve formulated a skilled nursing facility pilot program with six diff...“About a year and a half before we actually put the performance network together, we invited our skilled nursing facilities in to just have dialogues on what the barriers were that they were facing and the barriers that the hospital w...

Private Sector to Drive Bundled Payments After CMS Cancellations

by Jacqueline LaPointe

CMS recently announced its intention to modify its bundled payments strategy by proposing to eliminate forthcoming mandatory cardiac models and decreasing the scope of the Comprehensive Care for Joint Replacement (CJR) program. The pull awa...“The rationale provided makes it clear that such models are considered to have value in encouraging care redesign to improve quality and lower cost,” Abrams commented. “The pullback is framed as a move to moderate change d...

Real-Time Data for Denials Management Aids Practice’s Lagging A/R

by Jacqueline LaPointe

Without transparency throughout the claim denials management process, healthcare organizations are leaving a significant portion of potential revenue on the table. Limited access to timely claim denial and reimbursement data can prevent pro...“The biggest problem was transparency,” John Kulin, DO, FACEP, Urgent Care Now’s President and CEO, recently explained to RevCycleIntelligence.com. “By that I mean, it was getting a report. Understanding our dat...

Physician Expert, Clinical Documentation Key to MIPS Success

by Jacqueline LaPointe

Since the Obama administration signed MACRA into law in 2015, healthcare providers have been attempting to understand the Quality Payment Program and its Merit-Based Incentive Payment System (MIPS). But regular updates and tweaks to MACRA h...Understanding the changes while keeping track of performance periods for the Quality Payment Program’s value-based reimbursement tracks have proved to be an obstacle for providers, Rebecca Altman, Managing Director at Berkeley Re...Altman recommended that practices across the size spectrum identify one to two physicians to become experts in MACRA implementation and Quality Payment Program requirements. “It is hard to get physicians to take time out of seeing the...While the additional time may help practices of all sizes implement the resources necessary for quality measurement and reporting, Altman argued that it may not be enough to truly help small practices prepare. “They have bumped the or...Hardwiring quality measure checklists that align with MIPS is key to maximizing performance scores and earning a value-based incentive payment rather than a penalty. “Folks need to really optimize and utilize their EHR to hardwire som...

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