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

Revenue Cycle Risk

A Provider-Sponsored Health Plan Is A Hospital’s Natural Next Step

July 16, 2018 - Many hospitals and health systems are bypassing the ultimate opportunity to gain greater control of the outcomes and costs of their patients. That opportunity is developing their own provider-sponsored health plan, according to Geisinger Health Plan’s Chief Financial Officer. “It’s important to think about how important hospitals are to local communities. In many...“There's a lot of different forms of risk-taking that can occur,” he elaborated. “You can think about it on a final payment basis. You could think about it on a total cost of care basis. The other would be like what we do here at the Geisinger Health Plan, which is to have the insurance company directly connected to the providers, so you have greater...


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Giving Providers Hospital Cost Accounting Data Will Lower Costs

by Jacqueline LaPointe

Engaging physicians with hospital cost accounting data will be key to lowering costs under accountable care organizations (ACOs) and other population-based reimbursement models, Stanford researchers recently explained. Population-based reim...

Key Issues Impacting Two-Sided Risk Accountable Care Organizations

by Jacqueline LaPointe

Medicare accountable care organizations (ACOs) operating under two-sided financial risk arrangements save the federal healthcare program more than one-sided risk organizations. But policymakers must address financial incentives, benchmarks,...

Medicare Spending Greater on Patients in Downside Risk MSSP ACOs

by Jacqueline LaPointe

Moving accountable care organizations (ACOs) to Medicare Shared Savings Program (MSSP) tracks with downside financial risk may not help the accountable care initiative generate savings, according to a new analysis from the Center for Health...The federal agency also spent significantly more on beneficiaries attributed to Pioneer ACOs. Actual spending per beneficiary reached slightly over $12,250 in 2016. The Pioneer ACO model concluded at the end of that year. MSSP ACOs assuming...Actual spending per beneficiary was also significantly higher compared to MSSP ACOs with upside-only risk. Average Medicare spending per beneficiary was even lower in the 186 Track 1 ACOs that spent more than their financial benchmark. CHQP...Rather than require MSSP ACOs to assume downside financial risk, CHQPR researchers suggested that CMS consider the following options: While CHQPR offered MSSP improvements, the researchers ultimately advised CMS to drop the shared savings payment model of the MSSP in favor or a patient-centered alternative payment model (APM). The Patient-Centered APM created by the CHQPR...

71% of MSSP ACOs Likely to Quit Rather Than Assume Downside Risk

by Jacqueline LaPointe

The Medicare Shared Savings Program (MSSP) is requiring the 82 accountable care organizations (ACOs) that started in upside-only financial risk tracks in 2012 or 2013 to take on downside financial risk by 2019. However, the majority of thes...“The challenges to assuming risk are not surprising and highlight that CMS needs to face the reality about how the majority of ACOs view risk,” Gaus commented. “ACOs need to gain confidence through successful performance i...

Orgs Not Living Up to Risk-Based Revenue Goals, C-Suite Says

by Jacqueline LaPointe

Provider organizations failed to achieve their risk-based revenue goals in 2017, according to the most recent State of Population Health survey by Numerof & Associates. The survey of healthcare C-suite executives showed that the majorit...Additionally, most executives in the 2015 survey thought that their organizations would be prepared to take on downside financial risk by 2017. Over half (59 percent) expected to be “very prepared” by 2017, but just 21 percent f...Possible threat of financial losses emerged as a top challenge to adopting alternative payment models involving risk-based revenue. About one-quarter of executives cited this as their number one obstacle. Researchers noted that executives i...Despite a lack of progress and several challenges, healthcare executives still felt the transition to population health management and risk-based revenue was worthwhile. Almost all respondents (95) percent rated population health a “m...Risk-based revenue from capitated contracts should particularly grow, executives noted. Only about one-half of respondents said their organization was in at least one capitated contract in 2017, and just 14 percent of respondents had more t...

A Holistic View of the Patient Enables Risk-Based ACO Success

by Jacqueline LaPointe

Giving providers a holistic view of the patient resulted in accountable care organization (ACO) success for a risk-based organization in southern Florida, which earned a place on the list of ACOs achieving the greatest shared savings in the...But gathering the data needed to understand a patient’s care is just the first step. “We have copious amounts of data that we have to put into a single platform and be able to actually understand and to drive results from,&rdquo...

Risk-Averse MSSP ACOs Missed $966M By Not Assuming Downside Risk

by Jacqueline LaPointe

Accountable care organizations (ACOs) in the non-risk bearing track of the Medicare Shared Savings Program (MSSP) could have boosted their bottom lines by an additional $966 million in net payments in 2016 if they had assumed downside risk ...The organizations would have earned a total of $966 million in net payments by participating in Track 1+, which was more than Avalere projected in a 2017 simulation that moved MSSP Track 1 ACOs to Track 2. In the 2016 simulation, the consul...However, nearly three-quarters of the organizations that had to repay their shared losses would have offset their financial setback with the Advanced APM incentive payment. The Advanced APM incentive payment should be an effective tool for ...

ACO, Bundled Payments Alignment Key to Success for Both Models

by Jacqueline LaPointe

CMS should align accountable care organizations (ACOs) and bundled payments by creating a blended accountability structure that allows organizations to participate in both alternative payment models without financial conflicts, industry exp...The advantages of joining a gainsharing model including providers not shouldering financial risk under ACO and bundled payment models alone. The model also promotes provider engagement in risk-based value-based care models. However, industr...

Industry Orgs Urge CMS to Lower Risk for MACRA’s Advanced APMs

by Jacqueline LaPointe

Healthcare stakeholders recently encouraged CMS to reconsider the financial risk requirements for Advanced Alternative Payment Models (Advanced APMs), arguing that the risk criteria limit participation in the models. Industry groups, includ...

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...

ACOs Plan to Move to Downside Financial Risk, Capitation Contracts

by Jacqueline LaPointe

Accountable care organizations (ACOs) are planning to enter downside financial risk arrangements, with 47 percent planning on entering a shared savings and losses contract and 38 percent pursuing capitation, uncovered a recent survey of 240...More advanced care delivery redesigns that are “necessary for ACOs to achieve their stated goals of reducing costs and improving quality” were further down on priority lists or not on the top focus areas at all. These activities...Despite differing financial risk adoption levels, both physician- and hospital-led ACOs plan to expand their risk-based arrangements in the near future. On average, ACOs plan to take on downside financial risk contracts within the 10 months...“The stages of adoption of key population health management activities suggest that ACOs are still largely focusing on the initial steps of care redesign,” wrote researchers. “For example, when tackling unscheduled care, A...• Decreasing healthcare costs • Planning participation in mandatory downside financial risk arrangements • Collaborating with payers and a lack of flexibility on their part • Understanding and complying with government r...Based on the survey’s findings, researchers stated that CMS and other payers can better support ACOs to foster their success with downside financial risk and population health management. “For example, CMS could continue to intr...

Creating Alternative Payment Models to Support Health Centers

by Jacqueline LaPointe

Healthcare stakeholders and lawmakers should encourage community health centers to engage in alternative payment models to financially incentivize providers to improve safety-net care, a recent Journal of the American Medical Association re...

61% of ACO Contracts Only Include Upside Financial Risk

by Jacqueline LaPointe

A recent Leavitt Partners study showed that 61 percent of accountable care organization (ACO) contracts are upside risk-only, indicating that ACOs may be risk-adverse or are still in the experimental stage with financial risk. Even though A...

Examining the Role of Financial Risk in Value-Based Care

by Jacqueline LaPointe

As the healthcare industry ramps up its efforts to advance value-based care, providers are expected to take on more financial risk. One of the goals of value-based care is to transition financial risk away from taxpayers and healthcare paye...

The Future of Accountable Care Organizations Involves Risk

by Jacqueline LaPointe

As many healthcare providers know, participating in a value-based care program, such as an accountable care organization, is about more than just tying payment to quality.  It involves shouldering financial risk as a way to motivate cl...

House Reps Ask for FFS Waivers for Alternative Payment Models

by Jacqueline LaPointe

CMS should make it easier for fee-for-service providers to get involved in risk-based alternative payment models by reducing regulatory barriers, House representatives said in a letter this week. The seventy representatives asked CMS to wai...

Risk-Based Alternative Payment Models Key to Value-Based Care

by Jacqueline LaPointe

Although the Department of Health & Human Services (HHS) recently announced that it had already tied 30 percent of Medicare payments to an alternative payment model nearly a year ahead of schedule, a recent study indicates that further ...

Why Accountable Care Organizations Need Revenue Cycle Risk

by Jacqueline DiChiara

Is the "Accountable" part of accountable care organizations being ignored? Over 100 new Medicare Accountable Care Organizations (ACO) participants will keep quality high and costs low, according to the Centers for Medicare &a...

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