Hitting the Trails: Take a guide on your value-based care journey

Posted by Continuum on Jan 10, 2017 11:00:00 AM

The healthcare payment landscape seems to change every week. Developing a strategy for success is nearly as tough as assessing what alternative payment model (APM) programs you should pursue. Is there a benefit to staying focused on
fee-for-service? Are pay-for-performance models the right path for your organization? How much risk is too much risk for you?New Call-to-action

The good news is there’s no one path to value-based care success. The various programs offer different benefits to healthcare organizations of all types. Understanding the full ecosystem of programs available to you is critical to make sure you start your journey to future success on the right path.

As with any journey, keeping a guide handy is a smart plan. Continuum’s value-based payment experts have developed a new reference to help you make sure you’re on the right track. This infographic, “The Trail Guide to Value-Based Care Success,” offers key insights and reminders about the benefits for various payment programs, common challenges, and tips for making the most of your participation.

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Topics: value-based reimbursement, payment reform

Medicare Quality Data: Who Must Report?

Posted by Continuum on Aug 16, 2016 11:00:00 AM

Starting next year, most doctors will be required to report quality data under Medicare’s new Merit-Based Incentive Payment System (MIPS). MIPS will apply to other clinicians, too, such as physician assistants and nurse practitioners. However, many thousands of practitioners will be exempt from these requirements, if they meet certain criteria.

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Topics: value-based reimbursement, MIPS, APMs, Alternative Payment Models

Understanding Alternative Payment Models' (APMs) Impact on a Practice

Posted by Continuum on Jun 21, 2016 4:28:25 PM

As healthcare shifts from a fee-for-service to a value-based system, Medicare is making sweeping changes to how it reimburses physicians. The Centers for Medicare and Medicaid Services (CMS) has introduced new regulations and reporting requirements – as well as unprecedented potential for financial rewards and penalties.Commercial payers are adopting similar models, further expanding the potential impact of these changes.

Choose Your Path

The Medicare Access & CHIP Reauthorization Act (MACRA) of 2015 created the Quality Payment Program (QPP), which offers physicians a choice between two different reporting paths. Both start in the 2017 reporting year; the Merit-Based Incentive Payment System (MIPS)  and Advanced Alternative Payment Models (APMS). For more information on MIPS, see our previous blog post and read our whitepaper.

In this blog, we focus on APMs, payment arrangements in which clinicians accept financial risk for providing coordinated, high-quality care. As an incentive to take on this risk, CMS offers increased monetary rewards. CMS has designated specific payment models as Advanced APMs – including certain medical homes, accountable care organizations (ACOs) and bundled payment models -- and it will continue to approve new models. Advanced APMs are similar to one another, with variations based primarily on the different quality measures they use – such as those for primary care, oncology, and end-stage renal disease. 

The APM track offers higher financial rewards than the MIPS track, but requires more advanced levels of value-based activities. APMs also require physicians to be part of a larger group (such as an ACO or medical home), and to bear greater financial risk (more on that below). Most physicians who see Medicare patients will be required to report under either the MIPS or Advanced APM track starting in January 2017. Those in Advanced APMs must still complete MIPS reporting for the first year (2017) so CMS can determine whether they meet the Advanced APM requirements. Additionally, 2017 MIPS reporting will provide spending benchmarks for a prospective Advanced APM.

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Topics: value-based reimbursement, CMS, Alternative Payment Models

Alternative Payment Models (APMs) Preview

Posted by Continuum on Jun 7, 2016 11:00:00 AM

As healthcare shifts from a fee-for-service to a value-based system, Medicare is making sweeping changes to how it reimburses physicians. The Centers for Medicare and Medicaid Services (CMS) has introduced new regulations and reporting requirements – as well as unprecedented potential for financial rewards and penalties. 

Indeed, doctors who achieve the highest levels of “value” will earn substantial increases in their Medicare Part B payments. Conversely, those who do little or nothing to address the new requirements will incur significant reductions. Commercial payers are adopting similar models, further expanding the potential impact of these changes – positive or negative – on a practice.

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Topics: value-based reimbursement, CMS, Alternative Payment Models

Managing Patients' Cost of Care Essential Under New Reimbursement Models

Posted by Continuum on Apr 18, 2016 11:00:00 AM

Quality. Cost. Patient Satisfaction.

There are the three main areas in which physicians will be measured, as our healthcare system shifts from volume to value. The Centers for Medicare and Medicaid Services (CMS) has already begun tying reimbursement to these measures, and commercial payers are creating similar, value-based models.

In a previous post, we discussed how doctors can succeed under the new quality metrics. Here, we’ll explain how physicians can meet cost benchmarks.

Defining “cost”

The cost that’s relevant to payers is the annual amount spent by patients and their insurance providers for the patients’ care. It is not the provider’s cost of doing business, such as overhead costs. Moreover, “cost” is the total amount received by all of a patient’s providers.

To illustrate: Dr. Smith is a primary care physician with 100 attributed patients. He received $10,000 for their care. Dr. Smith’s patients also spent $90,000 with other providers. Therefore, Dr. Smith’s cost of care is $100,000.

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Topics: value-based reimbursement, medicare, CMS, lower cost of care

Understanding Quality Metrics Under New CMS Reimbursement Models

Posted by Continuum on Apr 5, 2016 11:00:00 AM

As our healthcare system shifts from fee-for-service to value-based reimbursement, physicians face increasing requirements to report on the quality of the care they provide.The Centers for Medicare and Medicaid Services (CMS) has established a complex system of financial rewards and penalties tied to quality and costs of care. And commercial payers are starting to follow suit. For these reasons, doctors need to understand the quality metrics against which their performance will be measured, and how to optimize the quality results they report.

Under the Group Practice Reporting Option (GPRO) Web Interface, CMS requires primary care physicians to report annually on several point-of-care measures – from how many patients received flu vaccines, to the number screened for colorectal cancer. 

Know the requirements

On the plus side, most doctors already provide high-quality, evidence-based medicine. Where they typically fall short is in understanding the requirements for meeting the quality standards -- including proper documentation.

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Topics: quality metrics, value-based reimbursement, medicare, CMS

Next Generation RCM and Value-Based Reimbursement

Posted by Continuum on Dec 19, 2014 10:13:00 AM



Not your father's RCM anymore

In the days of strictly Fee-for-Service (FFS) reimbursement, the revenue cycle management process for physician groups was more straightforward. Deliver a service and receive a payment. Today's revenue cycle management (RCM) is changing to meet the challenges of today’s value-based healthcare environment, including new tools and practices that increase revenue collection performance. Providers have always regarded high quality care as imperative, but now must embrace additional competencies required to thrive in complex payor arrangements, especially those associated with accountable care programs.

Key factors affecting today's RCM process

Until the onset of healthcare insurance, payment for services was a matter simply between patient and provider. The entry of insurers meant the introduction of a third party and the use of claims with their even greater need to convey accuracy of patient data and coding. Managed care requirements introduced yet another level of complexity in the claims process. Databases that once featured a relatively simple set of data now include a vast amount of information, ranging from patient coverage and ICD-9 coding, to payor requirements and performance measurements.

Today at least four factors have made RCM a significant challenge:

  • The increasing complexity of medical care itself (witness the impending introduction of ICD-10 coding)

  • Each payor’s development of its own set of payment rules and standards, calling for each clinical practice to acquire large, multi-layered and highly complex data sets for any number of payors

  • Growing patient self-payment or high deductible obligations, a significant change in reimbursement patterns

  • Revenues based increasingly on performance measures, again varying by payor

As a result of all these factors, physician practices now face a highly complex revenue cycle. Consider the enormous variety of reimbursement models alone: fee-for-service, capitation, bundled payments, pay-for-performance and shared savings, and add to that the challenge of different rules and guidelines for each of a long list of payors, including many different payment models, reimbursement and incentive.

Where does billing begin?

Consequently, billing begins not at submission of the claim, but far earlier at the point of patient contact with the provider, sometimes even before patient registration. What is the patient’s insurer? What is the patient’s eligibility, correct billing address, previous denials? Once the patient has been seen, what is the correct coding? What treatment was actually delivered? Is this a patient with a chronic condition that qualifies the provider for non-face-to-face reimbursement associated with new CPT-9 code 99490 (effective Jan., 2015)? How much has the patient paid to date? What are the particular requirements and standards of the patient’s insurer?

A next generation RCM platform contains complete data about each payor’s requirements and also applies complex algorithms that access every piece of that data. Technology can perform many of the tasks, such as checking whether a claim has been paid, further freeing up staff from tedious manual work. 

Next generation RCM platforms must address:

  • Claims Accuracy

  • Tracking Claim Status

  • Improved Workflows

  • Tracking Patient Eligibility 

Two new challenges to futher complicate the process

Revenue cycle management is undergoing two additional changes that will continue into the foreseeable future: patients are responsible for a growing percentage of payment for services, and value-based reimbursement calls for a degree of reporting with its own complexities.

Read more about these areas, as well as challenges facing hospital-owned practices in our FREE whitepaper: Next Generation Revenue Cycle Management for Value-Based Healthcare.

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Topics: Value-Based Healthcare, value-based reimbursement, Insurance, Self-Pay, High-Deductibles, Next Generation RCM

Driving Value for Physician Groups & IPAs

Posted by Continuum on Nov 21, 2014 9:44:00 AM


The Challenge to Remain Independent

Although the passage of the Affordable Care Act (ACA) in 2010 has resulted in more insured Americans–about 10 million to date–it has also created new challenges for independent physician groups and independent physician associations (IPAs). Under the current Fee-for-Service (FFS) model, payors created volume-based provider economics, where providers were paid each time they delivered a service. The new approach is “accountable care,” a model that places the focus on value over volume. Payment is tied to patient outcomes and appropriate use of healthcare resources.

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Topics: clinical integration, Independent Physician Associations, value-based reimbursement, clinically integrated network

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