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Note: This is the fifth and final part in a series on how physicians can prepare for MACRA, the new Medicare physician payment law. Read Part 1 for a breakdown of how the Merit-based Incentive Payment System (MIPS) works, Part 2 on applying change management to practices ahead of the new law, Part 3 on what is required to succeed in MIPS, and Part 4 on charting a path in the Advanced Alternative Payment Model track.
The recently released final rule for the Medicare Access and CHIP Reauthorization Act (MACRA) repeals the sustainable growth rate and introduces the Quality Payment Program (QPP), which is designed to encourage Medicare Part B providers to focus on care quality and keeping patients healthier. Although the future of the Affordable Care Act (ACA) is tenuous, MACRA seems to be on more solid ground given the bipartisan support it received in Congress. Eligible clinicians and medical groups should plan to move forward as the shift to value-based care is expected to continue, with a greater focus on payments based on quality reporting and patient outcomes.
Compared with the proposed rule released in April, the QPP final rule is flexible and seems intent on reducing the short-term administrative burden, with the Centers for Medicare & Medicaid Services (CMS) viewing 2017 as a transitional year and aiming to encourage and educate clinicians. Unlike in some other initiatives, CMS seems to be genuinely encouraging better quality and care coordination by rewarding providers not only based on various quality metrics but also for undertaking meaningful improvement activities. Many clinicians and groups are all too familiar with having to be accountable for a whole gamut of quality metrics to qualify for rewards. Although it cannot be predicted how this final rule may evolve, at least for 2017, clinicians and groups have flexible options.
As in the proposed rule, the QPP has two tracks: Advanced Alternative Payment Models (APMs) and the Merit-based Incentive Payment System (MIPS). Clinicians are required to be in the QPP if they bill Medicare more than $30,000 and provide care for more than 100 Medicare patients annually or are in an advanced APM.
The final rule includes several key changes from the proposed rule.
Expansion of APMs. Groups that participate with sufficient volume (more than 25 percent of Medicare payments or 20 percent of Medicare patients) in advanced APMs in 2017 will qualify for a 5 percent incentive payment in 2019. CMS is encouraging advanced APM participation by designating new qualifying models that have lower risk levels or that are tailored to smaller practices or specialties (the final list is available on the QPP website). One important point is that clinicians who do not have sufficient volume to qualify for the Advanced APM track still would benefit from APM participation under the MIPS scoring system.
Although they may be focused on MIPS next year, clinicians and groups should be planning a transition to the Advanced APM track to potentially receive greater payments and to better position themselves in the marketplace. Such an approach is consistent with the opportunity to significantly and innovatively transform care delivery while also getting rewarded for the hard work required for organizational alignment.
Relaxation of MIPS criteria. MIPS aims to combine and align the current CMS quality programs, including the Physician Quality Reporting System (PQRS) and Meaningful Use (MU). It establishes four performance categories: Quality, Advancing Care Information, Improvement Activities, and Cost (in the final rule, Cost was dropped as a category for 2017 but will be added in 2018).
Scoring in 2017 will be based on a 100-point scale, with Quality comprising 60 percent of the score, Advancing Care Information 25 percent, and Improvement Activities 15 percent.
Eligible clinicians who fully participate in each performance category will have the following typical requirements in 2017 (for groups in APMs that do not qualify for the Advanced APM track, special MIPS scoring will apply in accordance with the APM scoring standard; these groups are considered MIPS APMs)
Because of past participation in PQRS and MU programs, most clinicians are completing 85 percent of the MIPS requirements for 2017. The remaining 15 percent (based on Improvement Activities) likely will be an easy task given that most clinicians are already engaged in some of the qualified improvement activities. The focus needs to be on performance.
Although not a 2017 requirement, clinicians and groups should keep an eye on the cost category by obtaining and reviewing their QRUR report and claims data. The data will inform patient migration so that tactics can be deployed to minimize leakage, allowing the organization to better manage overall costs.
CMS developed an educational and interactive website on the QPP with detailed information about the program, including webinars, fact sheets, and a search tool for measures.
Ability to pick your pace. Based on the quantity of data submitted in 2017, as well as performance, clinicians will have either a positive, neutral, or negative payment adjustment in 2019:
To maximize the chance for a positive adjustment, therefore, clinicians need to start collecting data on Jan. 1. Additionally, CMS is funding a pool of $500 million that will be distributed to organizations or individual clinicians that achieve exceptional performance, defined as a final MIPS score of 70 or greater. Performance in the Quality category matters because it represents the biggest opportunity to achieve a high score.
As mentioned, clinicians, groups of independent providers and employed medical groups initially have several options for QPP participation. But going strong with implementation for 2017 should bring benefits in four areas.
Patient care. By identifying key quality measures and tracking performance, clinicians can make improvements in patient care by redesigning workflows, engaging patients, and exchanging health information to better coordinate care. Many such advancements in care would constitute improvement activities and also contribute to the Quality score, given that Quality scores are relative and based on performance compared with other enrolled providers in the same measures. In an era of increased transparency and public reporting, staying competitive requires providers and medical groups to pay particular attention to this aspect.
Social reputation. CMS established the Physician Compare website to allow individuals to research clinician’s quality score and participation in quality programs. Many physician practices in highly competitive environments depend on the ability to grow or at least preserve their patient volumes. Maintaining or, better yet, building patient loyalty thus becomes an important driver. Medicare patients tend to change their physicians less frequently than do younger individuals, while quality and coordination of care are perhaps even more crucial to seniors when choosing a physician. Consider what people will see when they view your clinicians or group on the CMS website. Will it persuade them to seek care with your practice, or will they go elsewhere?
Financial rewards. QPP presents a significant chance to not only earn up to a 4 percent positive Medicare fee adjustment in payment year 2019 but also to take advantage of additional positive adjustments for exceptional performance. By simply reporting performance on many of the measures, clinicians and groups may be able to share in the $500 million bonus pool that CMS is allocating to exceptional performers. Few experts believe that such generous incentives will remain in place year after year.
Readiness for the future. Future MACRA-related challenges undoubtedly lie ahead in areas such as complex and chronic population health management. To a certain degree the first year of MACRA is reminiscent of the first year of the Pioneer ACO model (performance year 2012), when participants were rewarded for adequately reporting quality data to CMS. The road became much more challenging in subsequent years, when specific quality outcomes were required to share in savings.
Participating fully in the QPP will position the clinician or group well for the future. In addition to mitigating the risk of missing out on bonuses (which only increase in future years), early participation will help clinicians feel more confident and will establish the infrastructure to participate in value-based programs with commercial health plans.
Implementing this roadmap takes a sense of purpose, a solid plan, and the right resources, including executive and physician leadership, key stakeholder engagement, communication plans, and operational and IT support. Clinicians and groups should perform an assessment and review current data to understand where they are, where they need to go, and where the gaps are. This approach will inform an actionable plan that may include provider education, development of comprehensive dashboard reports or scorecards, care redesign, and patient engagement activities.
This time, performance really does matter. To reap a positive payment adjustment in 2019 and build on that result in subsequent years, clinicians and groups will be well-served to go strong and aim for exceptional performance in 2017.
Lucy Zielinski and Mark Krivopal, MD, MBA, are vice presidents with GE Healthcare Camden Group.
Publication Date: Monday, December 05, 2016
Andrew Motz, assistant vice president, supply chain consulting at HealthTrust, discusses the value of a data-driven approach when procuring purchased services.
Jason Williams, vice president for strategy and business analytics, Change Healthcare, discusses the importance of technology and technology-enabled services in reinventing the revenue cycle.
Judson Ivy, president of Ensemble Health Partners, discusses the value of revenue cycle outsourcing and the importance of selecting the right partner.
Bill Slama and Ken Deakyne of Grant Thornton LLP Business Consulting and Technology and Technology Solutions Services discuss the importance of enterprise asset management.
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities. Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care. Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy? Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands. This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing). The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process. One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.
TRENDSETTER
Learn how Premier Inc. partners with health systems to reimagine workforce management, offering integrated data and advisory services to improve efficiency, reduce costs, and drive performance.
This article discusses how Imprivata is transforming the patient identification process, leveraging next-generation biometric solutions to ensure accuracy and improve efficiency.
Of all the transformations reshaping American health care, none is more profound than the shift toward value. Access HFMA’s Value Project to discover how healthcare finance leaders are joining this transformation.