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CMS has taken the lead in driving this movement. As the largest single payer for healthcare, CMS has made significant changes to the healthcare reimbursement landscape by tying Medicare and some commercial rates to quality, and has also set goals for continued movement to the value-based model.
Congress and providers are also proponents of this shift. Further, providers are increasingly embracing value-based care, focusing on being the highest quality providers possible, because new payment models require that they do so.
Because a shift to value-based care is occurring, companies need to develop a strategy to adapt and should be well versed in the different types of value-based payment models. There are many different value-based reimbursement models that can be implemented to link financial rewards with clinical performance and cost control. These models range from a FFS base with extra payments for providers who meet quality goals, to a shared-risk framework, to full capitation.
The common thread is that the models incentivize providers to deliver not only top quality care, but also low-cost care. The primary new payment models include the following:.
Pay-for-Performance Model Under pay-for-performance types of arrangements, providers continue to be paid through the FFS model. However, in addition to the base rate, providers would be paid an additional amount for meeting certain quality benchmarks or would be penalized for not achieving certain thresholds. Under this model, the provider receives performance-based adjustments to its FFS rates in the form of bonuses for exceeding certain standards or clawbacks for falling short.
An episode is defined to include all necessary inpatient and outpatient services required to treat a specific injury or illness from the time of diagnosis through recovery. The single fixed fee covers the costs of the physicians and other clinicians, drugs, devices, facilities, and any other resources dedicated to the episode of care.
This approach incentivizes providers to collaborate across the continuum of care to deliver high-quality, low-cost health care. There is no incentive to focus on preventive care because the payment begins at the time that the episode starts after there is already a health care issue.
However, there is a significant incentive to ensure that there are no gaps in care when a patient moves from one care setting to the next during recovery. The bundled payment rate is based on the average cost of an episode, so providers will profit by keeping spending below the bundled rate.
Accountable Care Organization Model ACOs are physician-led groups physician practices or integrated health systems that collaborate to deliver quality care at a low cost. The goal of coordinated care is to ensure that patients receive appropriate and timely care, while avoiding unnecessary duplication of services. The financial incentives are similar to capitation described below in that providers are assigned a number of enrollees and there is a benchmark spending target for that pool of members.
Unlike capitation, where providers are paid the full rate each month, ACOs are usually paid on a fee for service basis during a given time period. However, at the end of the period, actual spending is compared against the benchmark level of spending and if there are savings, the providers share a percentage of the upside.
Two-way risk models usually share a greater percentage of the upside with providers in return for providers taking risk to the downside. The physician coordinates all aspects of patient care both inside and outside the clinic. The goal of this model is to provide higher quality and better care coordination, especially for those with chronic conditions, and to prevent hospital readmissions and emergency department visits.
To cover the costs of infrastructure and staff for care coordination, providers often negotiate a FFS rate increase or a per-member-per-month payment in addition to standard FFS payments. Capitation Model Under the capitation model, providers are paid a set amount per each enrollee per month, regardless of the services that the enrollee needs.
This population-based approach incentivizes a long-term commitment to and associated investment in patient health and wellness with a focus on preventative care and ensuring that when services are provided that they are provided in the lowest cost setting appropriate.
If the provider can keep the costs below the capitated rate, then it makes money, while if costs go above the capitated rate, it loses money. Essentially, the managed care organization is fully assigning risk to the provider. Regardless of the type of capitation, the provider is at full risk for the services that are covered.
Often, the capitated amount will be risk adjusted to ensure that providers are not disincentivized to care for high risk patients. In response to the need to reduce rising healthcare spending and to strive for better patient care, the healthcare industry is shifting toward value-based care models. This shift has put providers at the forefront of managing population health. Managed care companies and CMS appear willing to steer payments in the direction of a value-based model by paying in part based on quality with incentives to control costs.
Major healthcare payers have already seen significant cost savings due to implementing value-based care reimbursement. As these examples illustrate, key players in the healthcare industry are already significantly invested in the shift to new payment models and have experienced positive results as a result of the transition to value-based care.
Anne M. Many stakeholders consider the reversal of the phaseout a benefit to patients, providers, and hospitals in terms of improved patient safety, increased reimbursement, reduced physician burden, and more. This comes only a year after the phaseout of the IPO list began. For years CMS has published a list of procedures that providers could only perform and receive reimbursement for in the hospital inpatient setting.
Completing these procedures in a hospital outpatient department or an ambulatory surgical center ASC was considered unsafe, according to the rationale behind the IPO list. Each year CMS has reviewed the IPO list more than 1, services and removes or adds procedures based on certain criteria. For example, if data showed a procedure can now be safely performed in the outpatient setting, CMS removed it from the IPO list. However, with the OPPS final rule, the IPO list will remain intact and continue to designate which procedures qualify for the out- or inpatient setting.
CMS created the Two-Midnight rule to address the higher frequency of beneficiaries receiving treatment as hospital outpatients for extended i. The original Two-Midnight rule stated that inpatient admissions would generally be payable under Medicare Part A if the admitting physician expected the patient to require a hospital stay crossing two midnights, with documentation in the medical record supporting that expectation.
The initial Two-Midnight ruling also eliminated almost procedures from the IPO list, the majority of which were high-volume orthopedic and spine-orthopedic procedures. Many stakeholders consider the reversal of the original Two-Midnight ruling in the OPPS Final Rule a major win for patients, providers, and hospitals in several significant aspects:.
Improved patient safety : Services on the IPO list are often complex and sometimes invasive procedures that require close care and coordinated services in the hospital inpatient setting.
The reinstatement of the IPO list ensures that patients do not return home prematurely and have the opportunity for a successful recovery. Hospitals with high volumes of procedures eliminated from the IPO list saw a decline in both reimbursement and case mix index. This decline coupled with the financial impact of the COVID pandemic presented some hospitals with a real financial threat to their security.
Reinstated procedures on the IPO list mean an increase in reimbursement for many facilities. Decrease in billing denials : Many stakeholders felt that commercial payers interpreted the Two-Midnight ruling as a restriction to appropriate care settings based on the cost alone. As a result, hospitals have had to devote time and resources to appealing these denials and have often had to accept lower payment even though the provider believes the patient was appropriately admitted as inpatients.
With CMS regulating that the procedures on the IPO list should be performed in the inpatient setting, insurance companies are less likely to deny these cases based on patient status. The intended result is a decrease in denials and ultimately more timely and appropriate payment to the facility.
Reduced burden on physicians : The reinstatement of the IPO list means that the procedures are no longer subject to the Two-Midnight rule requirements. Hospitals can prepare for the reinstatement of the IPO list as of January 1, For some health systems, inpatient volumes will increase at a time when many hospitals are already at inpatient capacity due to the pandemic, and some hospitals may see increased need for inpatient coders.
Cross-training between inpatient and outpatient coders can take some time and effort, but such preparation will support shifts in patient volumes anticipated with reinstatement of the IPO list. In addition, revenue cycle teams may find it helpful to put an account check in place to hold accounts with IPO codes. This way, they can review the patient status before dropping the claim. Some systems may be sophisticated enough to hold a claim if an IPO procedure code is detected with any status other than inpatient.
Even healthcare reimbursement changes designed to improve the delivery of care for patients and experience for providers requires adjustment and adaptation that, without preparation, can interrupt operations and the revenue cycle. Therefore, understanding the updated rules and following the above preparation measures will help facilities code and bill in a timely manner and avoid denials and delays in payment. Would you like to use or share these concepts? Download presentation highlighting the key main points.
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