The ABC of Healthcare is split and sold!

In healthcare news this week, it was announced that The Advisory Board Company agrees to be acquired for $2.58 billion dollars. The news on Tuesday this week that this stalwart of healthcare consulting and advisory services, with an estimated *5,700 healthcare organizations as clients, was being purchased by Optum, a division of UnitedHealth Group surprised many, including yours truly. The merger is expected to be finalized by the end of 2017.

The Press Release here mentions details of the sale. It is understood that Advisory Board chief executive, Robert Musslewhite will head the combined healthcare advisory services after the merger is completed.

*Source – Washington Post, 8/29/17

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Holy MACRA! Patient Engagement rides again!

Regulatory-signage“What was that masked legislation? Why that, my boy was CMS! The greatest regulator in the west!” (Cue The March of the Swiss Soldiers in the William Tell Overture aka, theme song for one of my childhood heroes, The Lone Ranger).

What is MACRA?

MACRA is the abbreviated version of the “Medicare Access and CHIP Reauthorization Act of 2015” which was signed by President Obama on April 16th of this year. (Healthcare and CMS sometimes really can’t help it’s communication to the public when they make these abbreviations something that only so called “healthcare insiders” will understand).

The new law repeals Medicare’s sustainable growth rate (SGR) formula and creates a way to increased Medicare payments. At HIMSS16 this year, there was a focus was on “MIPS” or Merit Based Incentive Payment System which is the program that the SGR will be replaced with.

Physician rates are understood to be increased by 0.5% starting in July and each January through 2019 and then, bonuses could reach 12% and then 27% by 2022 (physicians could also face penalties for not meeting quality targets down the road).

On the CMS site, it asks the question, “How does the Medicare Access & CHIP Reauthorization Act of 22015 (MACRA) reform Medicare payment?”

Apparently, in a couple of ways:

It makes 3 changes to how Medicare pays those who give care to Medicare beneficiaries. The changes create a Quality Payment Program (Abbreviated to ‘QPP’).

  1. Ending the SGR formula for determining Medicare payments for health care providers services.
  2. Making a new framework for rewarding heal care providers for giving better care not just more care.
  3. Combining CMS’ existing quality reporting programs into one system.

The changes have been named QPP and replace other Medicare reporting programs with a flexible system that allows providers to choose from 2 paths that link quality to payments either MIPS or something called Alternative Payment Models (APMs)

MIPS – This combines parts of the PQRS (Physician Quality Reporting System), the Value Modifier (VM or Value Based Payment Modifier) and the Medicare Electronic Health Record (EHR) incentive program in which EPs (Eligible Professionals) will be measured on:

  1. Quality
  2. Resource Use
  3. Clinical Practice Improvement
  4. Meaningful Use of Certified EHR technology.

APMs – Alternative Payment Models give new methods to pay healthcare providers for the care they give to Medicare recipients as from the year 2019 to 2024, CMS will pay some participating healthcare providers an incentive lump sum; increase transparency of physician focused payment models and starting in 2026, offer some participating healthcare providers higher annual payments.

 

 

 

 

 

Claim Denial! Definitely not a river in Egypt!

Revenue Cycle ManagementHaving worked with Revenue Cycle professionals over the last few years, gives me a finer appreciation of the work that provider organizations have to do to get paid. We’ve all received those bills we thought that the insurance company would have taken care of and wondered why are we receiving this? Why can’t I get through to the company that has sent me this? Did I really get disconnected after holding on this phone for 15 minutes? Frustration can certainly mount. I know it does for my family when trying to figure out next steps. According to an article from Healthcare Finance that I recently read, the top 5 medical claim denials that are the most common are:

1) Duplicate claims – When hospital administration resubmit claims when they have not heard back from the payer and end up restarting the clock for that claim and end up mostly with a denial due to re-submission

2) Lack of information on the claim – When a claim is processed but due to human errors, information such as a date of birth or the spelling of a name is incorrect, the claim gets denied.:

3) Expiration of Eligibility – When both the patient and the provider organization are unaware that the insurance eligibility of a patient has expired with that organization. This is a common mistake that can be avoided if the provider does an eligibility verification before and during when the patient comes in for their appointment.

4) Claim not covered by the payer – Providers can easily avoid this by leveraging the ability to use real time verification capabilities.

5) Time limit expiration –  Basically, the provider did not send the claim in on time as apparently many times, smaller providers don’t focus on smaller claims, but want to make sure larger claims are paid leaving a lot of smaller claim dollars on the table that eventually add up.

All in all, payer organizations also leverage the system to their benefit as any organization would. It is up to the patient to understand their eligibility options and the provider to recoup the money that they are owed. There are many opportunities for revenue cycle improvements that are more often than not, simple to deduce, but more difficult to achieve.

 

One Month to go! CSO HIMSS Spring Conference

There’s only one month to go for the Central & Southern Ohio Spring Conference – The Hacker’s Guide to Hacking Healthcare. THE Conference on Privacy and Cyber-Security you just can’t miss!

We’re looking forward to seeing many of you at the OCLC Conference Center in Dublin, OH on May 20th, 2016. AHIMA members get 4 AHIMA CEUs for attending so make sure to be there in force and get education and have a great time networking and interacting with the best of our community.

Please go to http://csohio.himsschapter.org to register!

See you there!

HIMSS16 – One week to go!

Las VegasI know many folks are eagerly looking forward to next week in Vegas and HIMSS16. I’m looking forward to meeting my “Conference Buddies” those folks we see once a year at the Big Show! I’ll be looking forward to the keynotes from  Sylvia Mathews Burwell, Secretary of Health & Human Services & Michael Dell, Founder of Dell, Inc next Monday the 29th at the Palazzo Ballroom at the Venetian Hotel.

I try and encourage a balanced approach; educational sessions in the morning, lunch and then exhibit hall and vendors in the afternoons. This gives me the opportunity to experience a full conference experience along with some of my friends from the CSO HIMSS chapter and other chapters I’m connected with. Areas focused on project management in the areas of interoperability solutions (of course focused on CCD’s) analytics and datawarehousing, tele- health (after my recent visit to Cisco in Bangalore), Clinically Integrated Networks and revenue cycle optimization post ICD-10 are at the top of my agenda of mandatory sessions to attend. The Interoperability Showcase is my favorite area of the exhibit hall area to visit after my HIMSS15 experience. Best part of the entire conference in my humble opinion. Don’t miss it. You’ll be glad you saw it when you did. I’ve been pushing for it to go on the road to each state. I’m rarely a petition type of guy, but I’ll sign a petition for an “Interoperability Road Show” if I have to. It’s basically the essence of this blog entirely so “hell ya!” I’ll sign it.

If you haven’t already, register for the CSO HIMSS Luncheon on Tuesday March 1st. I’ll be there as well as many of our CSO HIMSS Board and our esteemed Chapter President, Scott Mash.

We can’t end without obviously the perfunctory “Viva Las Vegas!”

See you on the flip side folks!

Ajay Sharma - Professional Photo-10-25-14

Miami University Healthcare IT Speaker Series – November 3rd, 2015

Come and see us at the Miami University Healthcare IT Speaker Series where Victor Simha and I will be talking about what we call “Healthcare Version 3.0” and where we believe, when we look into the crystal ball, that the healthcare IT ecosystem is heading and the opportunities for students in the program to focus their attentions on. Check out the link for more information about the series.
http://www.regionals.miamioh.edu/hit-speakers/schedule.htm

Thanksgiving Message 2014

imageHere’s giving thanks to all of the followers of Healthcare Interoperability. Thank you for your support and encouragement of this blog site. Thank you for being a Healthcare Advocate for all of us. It’s through all of our efforts that we will improve the efficiency and quality of healthcare for our families and friends, both in our country and around the world. I want to give thanks for our shared responsibility in making it through this paradigm shift with flying colors and for positively affecting better patient care through healthcare IT.

Happy Thanksgiving.