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The Health Plans’ Role in Meeting MACRA Requirements – MACRA Monday

Posted on July 17, 2017 I Written By

The following is a guest blog post by Karen Way, Health Plan Analytics and Consulting Practice Lead at NTT DATA Services. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

When the Medicare Access and CHIP Reauthorization Act (MACRA) became an official federal ruling for the healthcare industry in 2015, the act replaced the previous Medicare reimbursement schedule with a new pay-for-performance program focused on quality, value and accountability. In short, the legislation rewards healthcare providers for quality of care, not quantity.

While many discuss the impact on providers, what is the health plans’ role in aiding health systems and physicians to meet MACRA requirements?

MACRA provides multiple opportunities for health plans to increase and improve collaboration with provider networks. Recommendations on how health plans can accomplish this include sharing information and services, creating new partnerships and bringing about financial awareness as the legislation continues to take effect.

Sharing Data

One of the requirements under MACRA is for providers to enhance clinical measures and data analytics to strengthen members’ experiences. Health plans can assist by recognizing where providers lack expertise in data-related facts to offer input and support where it’s most beneficial.

For example, a provider may not have as much knowledge on advanced data science, but health plans can share their predictive models and tools to strengthen analytics. Sharing advanced technical infrastructure to facilitate data exchange will enable providers to access a more complete picture of members’ profiles. In return, the picture will provide a higher quality service to individual members, as well as opportunities for health plans to continue offering tailored consulting and data support.

At its best, sharing data to improve clinical measures is a win-win scenario. The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America’s health plans to measure performance on important dimensions of care and service. Just as HEDIS calls for measurement, MACRA also encourages health plans to aid providers with reporting standards. Under these rules, health plans are required to record a wealth of information on members, and when shared with providers, the tide lifts all boats.

Partnering to Manage Risk

Some of the changes under MACRA are reminders for providers to be highly aware of risk management. Providers will seek strong partners with the necessary skills, experience and knowledge to ensure they do not take on risk greater than they can support. To assist, health plans should enter into risk-sharing relationships, such as value-based contracts, with high-performing providers.

Health plans should actively strive to be strong partners by enabling robust data analytics that support quantitative action plans in the areas of quality and clinical care gaps, medical cost and trend analysis, population health, as well as member-risk management. As health plans partner with providers, they should also stay flexible on potential changes to provider payments as the pay-for-performance model(s) mature over time.

Financial Awareness

Health plans also need to be aware of the financial considerations that result from increased value-based contracting for small and large providers.

Under MACRA, smaller providers and individual physicians are more likely to be exposed to potential increase in costs, which may result in additional provider considerations. As Medicare payments shrink, these providers will look to shift costs to other payers, making contract negotiations more difficult and potentially increasing unit costs for some services. Large physician groups, or those located in markets with progressive healthcare systems, will look to negotiate even higher reimbursement rates due to the potential for increased competition.

Health plans should also be aware of potential impacts beyond Medicare fee-for-service (FFS), which is the initial focus of the MACRA legislation. Pay-for-performance is likely to extend beyond Medicare FFS into other health plan lines of business, such as Medicaid or commercial plans. For example, under MACRA, Centers for Medicare and Medicaid Services stated it would consider permitting Medicaid Medical Homes to count as an alternative payment model if participating practices would risk at least four percent of their revenue in 2019 and five percent in 2020.

Why This Matters

Overall, MACRA creates a tall order as it aims to increase pay-for-performance and decrease care based on quantity. This notion is an altruistic adjustment for the health system and each party has a specific role to play to achieve the dream. But the backbone of this goal is collaboration between health plans and providers. Collaboration will result in shared clinical measures, awareness and management of risk, lower healthcare costs and, most importantly, improved patient outcomes.

The Top Three Hidden Impacts of MIPS – MACRA Monday

Posted on July 10, 2017 I Written By

The following is a guest blog post by Tom S. Lee, PhD, CEO & Founder, SA Ignite. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

While most providers know the Merit-based Incentive Payment System (MIPS) will have escalating financial impacts, there are additional strategic and operational concerns that go along with managing MIPS participation. The MIPS score will impact areas beyond just clinicians’ Medicare reimbursement, including public reputation, clinician recruiting and compensation, and reporting for participants in alternative payment models (APMs).

  1. Public Reputation

Clinicians participating in MIPS and most Medicare accountable care organizations (ACOs) will have a MIPS score that determines their Medicare Part B reimbursement. The same score can impact public reputation because CMS will publish the scores on the Physician Compare website and make the data freely available to the public. Companies like Google, Healthgrades, Consumer Reports, Yelp, and others can use that data to incorporate the MIPS score into its clinician ratings and review systems. If an organization chooses to do just the minimum in 2017 to avoid the penalty, it means its clinicians could have a public performance score as low as 3 out of 100, while competitors who fully perform and report could have much higher publicly reported scores.

MIPS scores become a permanent part of each clinician’s resume because CMS binds the annual score to the clinician’s unique national provider identifier (NPI). So even if a clinician switches organizations, the historical score, along with the reimbursement or penalty, will follow the clinician, with the new organization absorbing the financial impact earned by the clinician up to two years prior at a different organization.

Estimates indicate that the revenue impact of consumers swayed by MIPS scores can be significantly larger than just the direct reimbursement impacts of MIPS. According to this article, a 1-star increase on Yelp leads to 5 to 9 percent increase in a business’ revenue. Using CMS’ data on Medicare Part B payments by specialty, this could mean an increase ranging from $4,468 to $8,042 per year per clinician for an internal medicine doctor and up to $10,705 to $19,269 per year per clinician for a cardiologist.

And, it may be much harder to convince a consumer who did not select a clinician based on an unfavorable MIPS score to re-evaluate that clinician in the future, even if the clinician’s score ultimately increases.

  1. Clinician Recruiting and Compensation

Understanding a clinician’s historical MIPS scores will be important to an organization properly evaluating and contracting with that clinician. When recruiting new clinicians or acquiring practices, healthcare organizations are mindful that they can inherit poor scores from other organizations’ program decisions. Conversely, clinicians will increasingly seek to join organizations with a good track record enabling its clinicians to achieve high MIPS scores, which positively impacts the resumes of all those clinicians.

In addition, organizations are seeking to align clinician compensation with MIPS financial and reputational impacts so look for an increasing number of compensation plan designs to directly incorporate MIPS scores and category scores as key performance indicators.

  1. Reporting Obligations of APM Participants

Although a healthcare organization may make a strategic decision to join an Alternative Payment Model (APM), such as a Medicare Shared Savings Program Accountable Care Organization (ACO), clinicians who are part of that organization are not necessarily exempt from MIPS. For example, if a clinician joins the organization after the final August 31st CMS determination of APM participation, then those clinicians will still need to fully report for MIPS or face a penalty. This is true for late-joining clinicians in both MIPS APMs as well as Advanced APMs, which typically qualify for a MIPS exemption.

Regardless of when clinicians join a Medicare Shared Savings Program (MSSP) Track 1 ACO, the ACO must manage MIPS eligibility, performance, and reporting for all clinicians, in addition to its ACO program obligations. This stems from the fact that MSSP Track 1 ACOs are not Advanced APMs.

How to Engage Clinicians Regarding MIPS

Beyond educating clinicians and leadership about the hidden impacts of MIPS, much of the important work to be successful under MIPS involves engaging clinicians in taking ownership of their responsibilities under the program. Some best practices:

  1. Recognize the importance of patient and clinician satisfaction
    • Reinvigorate support from leadership on the importance of both pillars
  2. Collaborate with clinicians
    • Let their voices be heard regarding both the explicit and hidden impacts of MIPS
  3. Provide feedback loop to clinicians and staff teams
    • Clinicians want to understand how they are being scored and where they have the best opportunities to improve
  4. Provide transparency
    • Communicating successful as well as failed efforts and the learnings accrued builds trust

Independent Primary Care Practice Success and MACRA – MACRA Monday

Posted on July 3, 2017 I Written By

The following is a guest blog post by Christina Scannapiego who currently writes the technical documentation and educational content for HealthFusion MediTouch. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

Can participating in a PCMH and programs like Chronic Care Management improve your MIPS total score?

The shift to fee-for-value healthcare may feel like discouraging, foreign territory. However, if you’re already participating in value-based models like a patient centered medical home or chronic care management, your practice is more poised for success during this transition.

Chronic Care Management

The Centers for Medicare and Medicaid Services (CMS) have increased reimbursement for Chronic Care Management (CCM) services. Now, a provider has the potential to earn more than $50,000 per year under the CCM program. Patient-centered care, patient engagement and better care coordination are the core objectives of CMS. Participation in CCM could weigh heavily on your total MIPS score. CCM helps patients by extending care support beyond face-to-face appointments. Participation in this program will help you move the needle in four performance categories by extending care between office visits, controlling costs, increasing care coordination, enhancing doctor-patient relationships to help improve patient outcomes.

CCM and MACRA overlap across several MIPS components:

  • Advancing Care Information: Previously Meaningful Use, meant to achieve patient engagement and promote the electronic exchange of information, practice analytics and reporting capabilities using an EHR.
  • Quality measures: At least 30 measures including many high priority items are common to the CCM program.
  • Clinical Practice Improvement Activities: Patient engagement is one of the main objectives of both CCM and MACRA. Providing 24/7 access to clinicians and coordinating care across provider settings plays an integral part in the CCM objectives and will boost your score in this performance category.
  • Cost: Although providers aren’t responsible for reporting data in this performance category, participating in CCM can lower costs due to preventable hospitalizations from poor medication adherence and care transitions to other providers. Patients with multiple chronic conditions can often pose the highest costs in healthcare. Effectively managing the care of patients will ultimately benefit their overall well-being and the health of your practice.

Patient Centered Medical Home

The PCMH model was established to help deliver patient-centered care through care coordination, preventative services, population health management and extended access to care services. This model thrives from robust patient engagement, which is one of MACRA’s most important goals. MIPS scoring methods favor those participating in PCMH by automatically scoring providers with 100% in the Advancing Care Information performance category. PCMH recognized practices will also likely get credit in the Advancing Care Information performance category because of their experience with NCQA standards.

The importance of both CCM and PCMHs in the new healthcare regime have placed primary care physicians in a unique and opportune position; one in which the independent provider stands to find success amidst change. The impact of MACRA on healthcare is “monumental” and “herculean,” said the Director of Provider Innovation Strategies at DST Health Solutions in her presentation, “The Role of PCMH Under MACRA.” MACRA isn’t a momentary, passing legislation — it’s had bipartisan support from the beginning and it’s here to stay. Luckily for PCHM and CCM participators, this new legislation and enormous impact becomes more manageable.

About the Christina Scannapiego:
Christina Scannapiego has been a technical, health and lifestyle writer for more than 10 years. Christina currently writes the technical documentation and educational content for HealthFusion MediTouch, an Electronic Health Records software platform. HealthFusion and its MediToch cloud software suite is a subsidiary of Quality Systems/next Gen. MediTouch is comprised of a range of web-based software solutions for physicians, medical practices and billing services.

2018 QPP Proposed Rule: What it Means for MIPS & Quantifying the Impact on Specialty Practices – MACRA Monday

Posted on June 26, 2017 I Written By

The following is a guest blog post by Justin Barnes, Board Advisor at iHealth Innovations. This post is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

The Centers for Medicare and Medicaid Services (CMS) recently released a Proposed Rule highlighting recommended updates to the 2018 reporting period of the Quality Payment Program (QPP). Like flexibilities extended in 2017, the proposal seeks to further reduce reporting burdens on small practices and rural providers in the program’s second-year reporting period.

Merit-based Incentive Payment System (MIPS) reporting track updates include:

  • Increased low-volume exemption thresholds (<200 patients or <$90,000 in payments)
  • New virtual group options for solo practitioners and groups with 10 or fewer Eligible Clinicians
  • Extending “pick your pace” flexibilities into 2018
  • Postponing introduction of the Cost category to MIPS composite scores
  • Factoring MIPS performance improvements into quality scores
  • Permissions for facility-based providers to report through the facility where they do most of their work instead of the practice
  • Permitting the use of 2014 CEHRT in 2018 reporting

The Rule introduces new MIPS bonus point opportunities for:

  • The use of 2015 CEHRT
  • The care of complex patients

Recommendations also extend small practice relief including:

  • Up to 5 bonus points for practices with 15 or fewer Eligible Clinicians
  • Hardship exemption for Advancing Care Information category measures
  • Additional points on Quality measures that don’t meet completeness requirements

Comments on the Proposed Rule are due by August 21, 2017. Physicians have until October 2, 2017, to begin collecting performance data for the inaugural 2017 MIPS reporting period.

Calculating MIPS: The Financial Impact on Specialty Practices

Results from a crowdsourced survey fielded by Black Book Research among nearly 9,000 physician practices from February through April of 2017 reveal that 94 percent of physician participants were unaware or unsure of how to predict their 2017 MIPS performance scores. Seventy-seven percent of practices with three or more clinicians reported intentions to purchase MIPS compliance technology solutions by the fourth quarter of this year, largely driven by an inability to independently determine earning potential under MACRA.

Orthopedics, cardiology and radiology are among the highest incentivized specialties under MIPS. To help specialty practices quantify the fiscal impact MIPS poses, we evaluated average Medicare earnings by specialty to establish the MIPS calculations below. These estimates are based on bare minimum earnings and losses that could be greater for practices with larger Medicare patient populations and/or more physicians. (Calculations are strictly illustrative estimates.)

Cardiology Practices
Estimated average payment adjustment for a 5-clinician cardiology practice in 2019 alone: $43,601
Number of cardiology-specific QPP measures: 20

Orthopedics Practices
Estimated average payment adjustment for a 6-clinician orthopedics practice in 2019 alone: $34,603
Number of orthopedics-specific QPP measures: 21

Radiology Practices
Estimated average payment adjustment for a 6-clinician radiology practice in 2019 alone: $30,117
Number of radiology-specific QPP measures: 22

Note: The above projections assume the full incentive and penalty will be paid out as outlined in the MACRA law. However, the positive and negative payment adjustments will be scaled so the program is budget neutral. This means that the positive payment adjustments will have to be offset by penalties.

Navigating the Transition to MIPS
As clinicians prepare for reporting under MIPS, establishing specialty-specific expertise on financial, clinical and technical objectives can help practices thrive rather than just survive.

Tips as you for prepare for MIPS:

  • Know your reporting options and pick your path.
  • Choose measures that play to the strengths of your specific specialty practice. Review your current billing codes and Quality and Resource Use Report to help determine these areas.
  • Do a technology asset inventory to make sure you can track the required CQMs.
  • Customize your EHR for track your selected measures or ID an outsource vendor to assist.
  • Work towards minimum reporting requirements to avoid a penalty with a stretch goal to report on the full required measures to maximize positive adjustment earnings potential.

Additional resources:
QPP website
An overview and support documentation is available at the CMS QPP website here.

MIPS EDU Program
A new “Quality Payment Program in 2017: Pick Your Pace Web-Based Training” course with Continuing Education Credit is available through the Learning Management System. Learn more here.

2017 CMS-Approved Qualified Clinical Data Registries
Additional specialty-specific measures are available via approved 2017 QCDRs to meet MIPS reporting requirements. Options for cardiology, radiology and orthopedic practices are included. Learn more here.

About the Author:
Justin Barnes is a nationally recognized business and policy advisor who serves as Chairman Emeritus of the HIMSS EHR Association as well as Co-Chairman of the Accountable Care Community of Practice. As Board Advisor with iHealth, Justin assists providers with optimizing revenue sources and transitioning to value-based payment and care delivery models. Justin has formally addressed Congress and the last three Presidential Administrations on more than twenty occasions on the topics of MACRA, value-based medicine, accountable care, interoperability, consumerism and more. He is also host of the weekly syndicated radio show “This Just In.” Justin can be found on Twitter at @HITAdvisor.

Embracing Quality: What’s Next in the Shift to Value-Based Care, and How to Prepare

Posted on June 13, 2017 I Written By

The following is a guest blog post by Brad Hill, Chief Revenue Officer at RemitDATA.

Whatever the future holds for the Affordable Care Act (ACA), the shift to value-based care is likely here to stay. The number of providers and payers implementing value-based reimbursement contracts has grown steadily over the past few years. A survey of 465 payers and hospitals conducted in 2016 by ORC International and McKesson revealed that 58 percent are moving forward with incorporating value-based reimbursement protocols. The study, “Journey to Value: The State of Value-Based Reimbursements in 2016” further revealed that as healthcare continues to adopt full value-based reimbursement, bundled payments are the fastest growing with projections that they will continue to grow the fastest over the next five years, and that network strategies are changing, becoming narrower and more selective, creating challenges among many payers and hospitals as they struggle to scale these complex strategies.

Given the growth of adoption of value-based care, there are certainly many hurdles to clear in the near future as policymakers decide on how they plan to repeal and replace the ACA. A January 2017 report by the Urban Institute funded by the Robert Wood Johnson Foundation revealed that some of the top concerns with some potential scenarios being floated by policymakers include concerns over an immediate repeal of the individual mandate with delayed repeal of financial subsidies; delayed repeal of the ACA without its concurrent replacement; and a cutoff of cost-sharing subsidies in 2017.

With the assumption that value-based healthcare is here to stay, what steps can you take to continue to prepare for value-based payments? The best advice would be to continue on with a “business as usual” mindset, stay focused and ensure all business processes are ready for this shift by continuing to:

  1. Help providers establish baselines and understand their true cost of conducting business as a baseline for assuming risk.
  2. Analyze your revenue cycle. Look at the big picture for your practice to analyze service costs and reimbursements for each – determine if margins are in-line with peers.  Identify internal staff processing time and turnaround times by payer. Evaluate whether there are any glaring issues or problems that need to be addressed to reduce A/R days and improve reimbursement rates.
  3. Determine whether there are reimbursement issues for specific payers or if the problem is broader in nature. Are your peers experiencing the same issues with the same payers?
  4. Capture data analysis for practice improvement. With emerging payment models, hospitals and practices will need expertise in evaluating data and knowledge in how to make business adjustments to keep the organization profitable.
  5. Determine how you can scale and grow specific payment models. Consider, for example, a provider group that maintains 4 different payment models and 10 different payers. The provider group will need to determine whether this system is sustainable once payment models shift.
  6. Break down department silos in determining cost allocation rules. Providers need a cost accounting system that can help determine exact costs needed to provide care and to identify highest cost areas. Cost accounting systems are typically managed by the finance team. There needs to be clinical and operational input from all departments to make a difference. Collaborate across all departments to determine costs, and design rules and methodologies that take each into account.
  7. Compare your financial health to that of your peers. Comparative analytics can help by giving you insights and data to determine your practice’s operational health. Determine whether you are taking longer to submit claims than your peers, have a higher percentage of denied claims for a specific service, percentage of billed to allowed amounts and more.

Though change is a part of the healthcare industry’s DNA, ensuring business processes are in line, and leveraging data to do so will help organizations adapt to anything that comes their way.

Make Your Medical Practice Website Patient-Friendly

Posted on March 9, 2017 I Written By

The following is a guest blog post by Yasmin Khan from Bonafide.

It’s a sad truth that many websites are simply not effective at being a resource for visitors, including most medical practice and healthcare service websites. The key element to a service-oriented business website is accessibility or ease of use.

Unfortunately, accessibility is the element most lacking in websites for healthcare organizations.

  • The content is written at the graduate school level.
  • There is too much jargon, unfamiliar acronyms, and unfamiliar words.
  • Too much in-depth medical knowledge is required to understand what is presented on the website.

An example of writing above the audience is using the term nosocomial infection instead of the self-explanatory hospital-acquired infection.

Optimizing your website requires you to look at it from the intended user’s point of view and using proven techniques to increase the probability your website will be found. The entire goal of your website is to attract and convert leads into patients.

Below are three areas of optimization you can use to improve your medical practice’s website to be more patient-friendly.

Provide Relevant, Well-Written Content, and Attractively Presented Content

Does your present website look just like the brochure at your front desk? If so, you are not leveraging the power of your website. You have at your fingers a tool that can be designed to appeal to a wide variety of information needs that is easily navigated.

Every piece of content on your website should be targeted to your ideal patient profile. You must also have content that speaks to each segment of the patient journey, written in the patient’s language and at their level of education.

Your content should be written to no more than the 11th-grade level to be accessible to most of your visitors. Communicate urgency without scaring or pressuring the reader. Above all, do not patronize.

Create clear calls to action to guide people where you want them to go and provide something of value that encourages them to share their contact information to obtain it.

Practice Search Engine Optimization (SEO)

You need to address two areas of SEO:

  • On-page: refers to everything within the website
  • Off-page: refers to SEO opportunities, not on your website

On-page SEO refers to the building and optimization of your website.

  • Indexable content, including images, videos, and plug-ins
  • Crawl-able link structures
  • Search engine friendly URL structures
  • Optimized pages, title tags, and meta-descriptions

Avoid duplicate content to avoid being penalized by Google and other search engines. Each page of your website should have unique content that adds value to the user while achieving a clear marketing goal for your practice.

Off-page SEO includes ways to attract attention to your website through link-building, sharing and promoting content, and optimizing for local and mobile search.

Building quality links is the first principle of successful SEO. The key is to build quality links, relevant links from authoritative websites, blogs, and other areas of the web back to your site. High-quality links are what Google uses to judge trust and confer higher search engine rankings.

Optimize for Localization

As a geographically based service, you need to optimize for local search. When patients search for a medical practice, they typically add the city name to the search:

Primary Care Physicians in Kansas City

Each of your location pages should be optimized with your city and other identifying information such as the name of the medical center your office is in.

If your website is not responsive, meaning it will display appropriately regardless of the device, you need to convert it. Mobile devices have blanketed the globe, and most are used to search for local businesses as well as serving as a primary device for online activity.

The mobile version of your site should have:

  • Large, legible fonts
  • A fast load speed
  • Bullet lists and less text
  • Simple navigation with few internal links
  • Fewer images

Don’t lose opportunities because you cannot be found via smartphone or tablet.

A Quick Summary

Your website is your marketing engine. Take full advantage of online technology to develop a patient-friendly website that:

  • Contains relevant, well-written content
  • Is optimized for search engines
  • Has high-quality sites linking to it
  • Is optimized for local search and mobile devices.

Building a medical practice is a business, just like any other. Today’s patients expect to be able to find you online and engage with you when they are ready. Make sure you give them the information they need to put you at the top of their list.

About Yasmin Khan
Yasmin Khan is the marketing manager for Bonafide, a digital marketing agency in Houston, Texas. She loves writing, tweeting, and positive change. She’s all about the big picture and the greater good.

Reinventing Claims Management for the Value-Based Era

Posted on February 16, 2017 I Written By

Provider claims management as we once knew it is not enough to thrive in a value-based era. Here’s what you need to know about taking claims management to a higher level.

The following is a guest blog post by Carmen Deguzman Sessoms, FHFMA, AVP of Product Management at RelayAssurance Plus RelayHealth Financial.

Provider claims management as we know it can no longer exist as a silo. With the rapid transformation from fee-for-service to value-based models, denial rates remain high–nearly 1 in 5 claims–despite advances in technology and automation. The complexity of value-based payment models almost guarantees an increase in denials, simply because there’s so much to get wrong.

For provider CFOs and their organizations to be effective–and thrive–in this environment, the touchpoints across the revenue cycle continuum must be re-examined to see if there are opportunities for improvement that have not presented themselves in the fee-for-service era. One such area is claims management, which is ripe to be elevated into an integral part of a denials management strategy.

What are the implications for providers? Well, for perspective, consider the savings realized through electronic claims submission.  CAQH research reveals that submitting a claim manually costs $1.98, compared to just $0.44 per electronic transaction. Likewise, a manual claims status inquiry costs $7.20 versus $0.94 for processing electronically.

This paper outlines the features and benefits of a technology platform that is geared toward elevating traditional claims management into the realm of strategic denial prevention and management, along with some recommended denial management best practices.

From Claim Scrubbing to Strategic Denial Management

Simple claims management as we know it is becoming obsolete. By “simple” we mean a claims process with a basic set of capabilities: creating claims, making limited edits, and ensuring that procedures are medically necessary. Today, a new class of integrated claim and denials management solutions augment this traditional approach to include pre- and post-filing activities that help automate and streamline claim submission, proactively monitor status, and expedite the appeals process for those that are denied.

In its simplest form, denials management can be defined as a process that leads to cleaner submitted claims and fewer denials from payers. But there are a lot of interim steps and variables that lead to “clean” claims, and a growing number of factors that influence denials. With the shift to alternative payment models and increasing consumerism, it’s more important than ever for providers to process claims properly the first time and to keep staff intervention to a minimum.

A big part of denials management is to improve the quality of patient data at registration, the source of many errors that lead to denials. Nonetheless, integrated claim and denial management processes span the entire revenue cycle, and technology brings new opportunities to manage costs and improve efficiencies. For example, having the ability to manage claims within a unified platform that can share and integrate data with the organization’s EHR prevents the need to toggle back and forth between systems to determine the status of a patient encounter.

A comprehensive claims management platform that advances denials management efforts integrates the following capabilities:

  • Eligibility verification prior to claim submission. It sounds pretty basic, but eligibility and registration errors on claims continue to be the top reason for denials. Automating the real-time verification of eligibility data helps identify avoidable denials and alert staff to claims needing attention before submission.
  • Maintenance of and compliance with oftenchanging payer business rules and regulatory requirements, including Medicare and state-specific updates, so that claims go out as cleanly as possible on the front end. With multiple payers and a growing roster of alternative payment models, manual in-house maintenance of edits is becoming an overwhelming task.
  • Digitization of attachments for Medicare pre- and post-payment audits, commercial claims adjudication and integrity audits, and workers compensation billing support. Integrating digital data exchange into the claims management workflow can help providers better control administrative costs, ensure regulatory compliance, and help automate and streamline claims processing and reimbursement.
  • Visibility into claim status lifecycle, with guidance for proactive follow-up. This lets providers only focus on those potential “problem” claims, and address any issues, before they are denied or delayed.
  • Automation of repetitive and labor-intensive tasks such as checking payer portals or placing phone calls to determine the status of pended or denied claims. This helps drastically reduce the amount of staff time spent perusing payer sites, and sitting on the phone on hold when an answer can’t be found.
  • Predictive intelligence to determine timing of payer acknowledgements and requests for additional information, as well as when payment will be provided. Analytics-driven claims management provides insight into how long responses should take, alerting providers when follow-up is required.
  • Management of remittances from all sources. Automated management of transaction formats, adjudication information, remittance translation and posting can help reduce A/R days, boost staff productivity, and accelerate cash flow.
  • Denial management and data analysis to guide corrective action and prevent future denials. Revenue cycle analytics can monitor the number of claims per physician, payer, or facility, enabling the health system to be proactive in interventions.
  • Creation and tracking of appeals for denied claims, including pre-population and assembly of appropriate forms. This not only helps cut down on resource-intensive manual work and paper attachments, but streamlines the appeals process.

Tying these capabilities together within an exception-based workflow helps address the challenge by providing visibility into problem claims. At-a-glance access to claim status helps cut down on the back-and-forth between billing departments and payers, and allows staff to focus only on those claims that require attention.

Pulling it all Together

Once you’ve integrated these capabilities, what are some of the claims management best practices to improve denial management and prevention? Consider the following actions:

  • Embed denial management within the entire workflow–Strong edits lead to clean claims, whether they pertain to Medicare, commercial payers or state-specific regulations. Edits should be constantly refined and seamlessly implemented, and pushed out to providers as often as possible–at minimum on a twice-weekly basis.
  • Adopt analytics-driven claims management–Claims management systems and connectivity channels to payers (i.e. clearinghouse) produce a wealth of operational information, most importantly data evidencing the speed of the payment path and claim status. Analyzed and served up in meaningful formats, this data becomes targeted business intelligence that can help providers better see obstacles and identify the root cause of denials and payment slowdowns.
  • Resolve issues before they result in denials–Providers should know claims location and status at all times. For example, has the claim been released by the EHR system? Has it been received and approved by the payer—or does a problem need to be addressed? Has a problem been rectified? Has the claim been released to a clearinghouse? Historical trends establish guidelines for the timing of events (e.g., whether claim status or payment should have been received from a particular payer by a certain date).
  • Be ready to identify claims denials and submit appeals. Nationwide revenue cycle statistics show that 1 in 5 claims are denied / delayed and can be avoided with the right software and better business processes.  In addition 67% of these denied claims are recoverable Identifying denials and submitting appeals to supply information not included on the initial claim can recoup lost revenue. To help streamline the process, additional claims information, such as medical records or lab results, should be supported by structured electronic attachments rather than faxed paper records or uploaded files to payer portals.

An Ounce of Prevention = Big Returns

Reducing and managing denials will have a significant impact on any healthcare organization’s bottom line. First, it costs $25 to rework a claim, and success rates vary widely. Additionally, when denials must be written off, the drop in patient revenue may total several million dollars for a medium-sized hospital, according to Advisory Board estimates.

The new look and feel of claims management is moving quickly toward analytics-driven, exception-based processing. By implementing and leveraging these capabilities and best practices in a cloud environment, providers can look forward to accelerated cash flow, reduced denials, increased automation with less staff involvement, and lower IT overhead.

About Carmen Sessoms
With over 20 years of progressive strategic leadership and healthcare experience in product management, business development, strategic planning and consulting, Carmen Sessoms has worked with all organizational levels in the ambulatory and acute care markets for patient access and reimbursement.

Prior to joining RelayHealth, Carmen was the regional vice president of operations for an outsourcing firm, where she led the eligibility side of the business and was instrumental in many process improvements that brought efficiencies to the company, its provider customers and their patients. Additionally, she has 10 years’ previous experience with McKesson in Product Management roles in which she directed projects related to the design and development of revenue cycle solutions, including initiatives with internal and external partners.

Carmen is a past president of the Georgia HFMA chapter, a recipient of HFMA’s Medal of Honor, and holds the designations of CHFP (Certified Healthcare Financial Professional) and FHFMA (Fellow in HFMA).

Slick Setups to Make Your Health Clinic’s Processes Simple

Posted on December 26, 2016 I Written By

The following is a guest blog post by Eileen O’Shanassy.

Medical technologies have come a long way since the days of manual appointment and check-in books, clip-board health information, gathering forms, and huge patient medical chart walls. Today, health clinics can enjoy far more simple and efficient processes with only a few changes to traditional methods of providing healthcare. Consider these following four easy-to-use and inexpensive technologies for your own health clinic.

Touchscreen Check-In Desks
You do not have to pay your front office staff any longer to check in patients. With this slick setup, a patient walks up to a desk that features a wide, large LCD monitor located inside the waiting room or near the receptionist’s desk. Instructions at this touchscreen check-in desk explain to the patient that they only need to tap the screen and then tap out the letters of their name using large virtual buttons to check themselves into your clinic. In some clinics that offer a variety of diagnostic and treatment services, patients also select a clinic area.

Health Information Kiosks
A lot of front office staff time is wasted every day providing patients with information that is already available on your clinic’s website or local affiliated health system’s site. With the slick setup of a health information kiosk, your front office staff can direct patients to the kiosk and return to other tasks. Beyond information about the services offered at your clinic and local healthcare systems, health information kiosks can also be set up to provide patients local news and weather conditions, health and safety tips, emergency alerts, and even details about local restaurants and businesses.

Identification Scanning Software
One of the slowest processes at a clinic with new patients is establishing a record that contains accurate personal and health information. Some healthcare systems now provide clinics with the ability to quickly access information about patients already in their medical data storage programs. This is done electronically via scanning software that can be used with a patient’s driver’s license, medical insurance card, or a special system healthcare card. This type of slick setup also makes it possible for your clinic to save important information about a patient who is entirely new to the area and share it with local specialists and their staff members in hospital and other facilities.

These are only a few examples of the types of slick setups that can make traditional processes in your health clinic simple. These and other cutting edge methods can also result in positive testimonials that attract more new patients to your clinic.

About Eileen O’Shanassy
Eileen O’Shanassy is a freelance writer and blogger based out of Flagstaff, AZ. She writes on a variety of topics and loves to research and write. She enjoys baking, biking, and kayaking. Check out her Twitter @eileenoshanassy. For more information on medical data storage and new technology check out Health Data Archiver.

Online Reputation Management: Trending Topic or Industry Shift?

Posted on December 20, 2016 I Written By

The following is a guest blog post by Erica Johansen (@thegr8chalupa).

It seems that in healthcare this year online reputation management has taken center stage in conversations as consumers have a larger voice in the healthcare purchasing experience. Reviews, in particular, provide an interesting intersection point between social media technology and healthcare service. It is no surprise that there is pervasive, and exciting, conversation around this topic across the industry at conferences and online.

During the #HITsm chat on Friday, we had an excellent conversation about the value of online reputation management by physicians and other healthcare providers, and what lessons could be learned from one managing their own reputation online. During our chat, we asked the #HITsm community (as patients) about their behavior leaving and reading reviews as a part of their care selection process, as well as the role that social technology plays today in the patient experience. There were some exceptional insights during our conversation:

1. Should providers be interested in their online reputation? Does it matter? There was a resounding “yes” among attendees that attention should be given to a practice’s online brand.

2. As a patient, have you ever read a review after being referred to, or before selecting, a new physician? Perhaps unsuprisingly, most attendees supported trends in consumer behavior by reading reviews of physicians online.

3. Have you ever written an online review for a healthcare experience? If so, was it generally positive or negative? Suprisingly, the perspective of our attendees suggested that the consumption of reviews was more common than the creation of them. Most folks just won’t review unless they felt compelled by an experience that surpassed,or fell too short, of expectations.

4. Is there an expectation that providers (individual and/or organizational) respond to social media engagements by patients? Our attendees chimed in that maybe it isn’t so much that there is an expectation, but it could signifantly help a negative review or solidify a positive one.

5. What would a healthcare provider who is exceptional at managing their online reputation look like? Examples? Stellar examples shared illustrated folks that have harnessed the power of social media to augment their patient expierence and brand. For example:

Bonus. What lessons could be learned from managing your personal online reputation that could guide provider reputation management? This question took a different turn than I initially anticipated, however, for the better. Many insights shared included mentions to social platforms and meeting the patients where they are. There is so much opportunity for the next phase of healthcare social media as platforms begin to cater more to feature requests and uses based on consumer trends. (One great example of this is the Buy/Sell feature added to Facebook Groups.)

Additional thoughts? There were some flavorful insights shared during the chat that are worth an honorable mention. Enjoy these as “food for thought” until our next #HITsm chat!

I’d like to say a big “thank you” to all who participated in the last #HITsm chat (and are catching up after the fact)! You can view a recap of these tweets and the entire conversation here.

#HITsm will take a break for the next two weeks over the holidays, but we will resume in 2017 on Friday, January 6th with a headlining host Andy Slavitt (@ASlavitt) and the @CMSGov team (@AislingMcDL, @JessPKahn, @AndreyOstrovsky, @N_Brennan, @LisaBari, and @ThomasNOV).

What the Final Rule Means for Small Practices – MACRA Monday

Posted on November 14, 2016 I Written By

This guest blog post by John Squire, President and COO of Amazing Charts, is part of the MACRA Monday series of blog posts where we dive into the details of the MACRA Quality Payment Program.

With the long-awaited issuance of the MACRA Final Rule earlier this month, the Centers for Medicare and Medicaid Services (CMS) tried to soften the blow for small practices in the first year of the program. Depending on the 2017 data you submit by March 31, 2018, your 2019 Medicare payments will be adjusted up, down, or not at all. This flexible timeline casts a wide net and should get everyone to participate.

Here’s a breakdown of all the options for 2017, from opt-out to maximum bonus, open to a small practice using a 2014 Certified EHR Technology (CEHRT). As you’ll see the sections get longer as we progress since each stage becomes more complex.

Be excluded from Medicare’s Quality Payment Program
In the Final Rule, CMS increased the exclusion threshold from $10,000 or less in Medicare Part B allowed charges, to $30,000 or less in billings, or seeing fewer than 100 Medicare Part B patients during the 2017 calendar year.

CMS estimates that this change will exempt approximately 30 percent of eligible clinicians from the Quality Payment Program. If you fall below the threshold, CMS will automatically exclude you. If you don’t meet the exclusion criteria, keep reading.

Do nothing… and take a penalty
Unlike previous programs such as Meaningful Use, there is no opt out for MACRA. If you don’t meet the exclusion requirement above, you are subject to downward adjustments. The Merit-based Incentive Payment System (MIPS) is the most likely option for small practices.

MIPS has a scale of 100 points. If you don’t report on any 2017 data by March 31, 2018, you’ll earn zero points and receive a four percent downward adjustment on your Medicare payments in 2019. This penalty rises over time, becoming five percent in 2020, seven percent in 2021, and nine percent in 2022!

A small minority of providers might be willing to make this financial sacrifice, but the vast majority of small practices using CEHRT are more likely to take a few simple steps to avoid the penalty.

Test out for a neutral outcome
You can avoid a downward adjustment by reporting just one quality measure, attesting to one improvement activity, or attesting to the four required Advancing Care Information (ACI) measures (formerly Meaningful Use) – for any length of time period in the calendar year of 2017. You’ll earn three points and there will be no downward adjustment to your 2019 payments.

This is a no-brainer for most small practices. If you use a 2014 Certified EHR, you’re already doing many of these activities, such as e-Prescribing, today. Belong to a Health Information Exchange? You’ve just earned your three points.

Participate for a bonus
You can earn four to 100 points for the chance of a small, moderate, or high positive adjustment to your payments in 2019. Submit at least 90 days of data on more than the minimum (i.e. on two or more quality measures, two or more improvement activities or more than the required four advancing care information measures) to earn more than three points.

Basically, the more information you submit over the longer length of time translates to more points and the more points you earn, the larger a positive adjustment on your payments will be, up to the maximum of four percent.

To earn the most possible points, (1) report for a full year on at least six quality measures (or a measure set); (2) attest to improvement activities worth 20 or 40 points (depending on the geography, size and make up of your practice); and (3) attest to all four of the required ACI measures as well as the five optional ACI measures, plus the one bonus ACI measure. Every 2014 Certified EHR technology has the functionality to support all ten ACI measures.

It could be easier than you think
CMS allows you to get a bonus for ACI when you use 2014 CEHRT to complete one of 94 eligible activities from the eight improvement activities categories. These include telehealth services, care coordination, or any kind of population health management. It could be something as simple as setting a flag for regular check-ups for your Medicare/Medicaid dual-eligible patients. A complete list can be found at this excellent CMS resource: https://qpp.cms.gov/measures/ia.

Even better news: providers participating in a patient-centered certified medical home (PCMH) will automatically receive full credit for the practice improvement category of MIPS. Similarly, providers participating in an Advanced Alternative Payment Model (APM) like an accountable care organization (ACO) will receive 50 percent of the full score for the practice improvement category.

Don’t get complacent – start today
While the agency’s idea of implementing a transition period was necessary, providers in small practices can’t get complacent. The formula for success is going to change very quickly. January 1, 2018 brings the full-year reporting requirement on the expanded measures.  The quality measures will still be required and the cost measures (previously called “resource use”) are going to dial up.  The year 2022 is only six years away, so unless the provider prepares next year, they could start facing some rather significant penalties.

About John Squire
John Squire, President and COO of Amazing Charts, has more than 27 years of high tech industry experience, 15 of them in Health IT. Before joining Amazing Charts, John was Senior Director of Alliances and Cloud Strategy for Microsoft’s U.S. Health and Life Sciences Business Unit.

Be sure to check out all of our MACRA Monday blog posts where we dive into the details of the MACRA Quality Payment Program.