Reimbursement

Reimbursement for services is what keeps providers in business. Hospitals and clinics draw from a number of different payers for reimbursement, including Medicare, Medicaid and private insurance companies. Reimbursement can be affected by the claims process, out-of-network payments, denials, audits and legislation. The fee-for-service model of healthcare has been hotly debated in the pages of Healthcare Finance News, as Congress, insurers and healthcare providers work together on establishing reimbursement rates and fee schedules that work for the entire industry.

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Rural, critical access hospitals are being left out of some of the biggest shifts in American healthcare initiated by the ACA, leaving some rural healthcare leaders worried about being marginalized and that they could be left behind as reforms spread.
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Post date: October 1, 2014
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Home health agencies can help hospitals reduce readmissions and control overall healthcare costs, according to a new study, but how effective these agencies are in meeting such goals largely depends on the quality of organizational support given to healthcare field workers.
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Post date: September 26, 2014
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Hospitals are projected to save $5.7 billion this year as previously uninsured patients gain coverage through the 2010 health care law, the Department of Health and Human Services said Wednesday.
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Post date: September 25, 2014
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The ranks of Medicaid keep growing, and at record levels. But while that's good news for hospital systems' uncompensated care budgets, there are still challenges.
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Post date: September 25, 2014
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A program that combines a mobile app, analytics and direct intervention is showing promise in reducing the costs associated with hospitals' most expensive patients -- the so-called "super-utilizers."
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Post date: September 19, 2014
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For U.S. community health centers, the recent announcement of $295 million in Affordable Care Act funding was welcome news. But the five-year period of mandatory ACA funding expires next September, meaning CHCs face a reduction of up to 70 percent in grant funding.
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Post date: September 19, 2014
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California's lingering backlog of Medi-Cal applications has left hundreds of thousands of people unable to access the healthcare they are entitled to receive, according to a lawsuit filed Wednesday.
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Post date: September 18, 2014
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The value-based model of healthcare is gradually transitioning from the pilot phase to implementation, as health insurers and providers strive to offer better care while eliminating unnecessary costs. But for providers who have always been paid fee-for-service, it is a different way of thinking.
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Post date: September 17, 2014
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Predictive analytics uses a variety of statistical techniques that analyze current and historical facts in order to make predictions about the future. In the healthcare setting, such data analysis can be effective in addressing a variety of key issues, including preventable readmissions.
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Post date: September 16, 2014
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Weill Cornell Physicians, Cornell University's physician group, has inked a new accountable care agreement with Aetna, intended to enhance care for approximately 9,000 of the insurer's commercial and Medicare members in New York.
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Post date: September 11, 2014
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As regional payers and providers take the first steps to begin working together in the era healthcare reform, one area they can start with is the issue of readmissions.
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Post date: September 11, 2014
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US not-for-profit children's hospitals are likely to remain financially stable in the next year or two although changes on the horizon, including those related to healthcare reform, could affect the sector's traditional niche role.
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Post date: September 10, 2014
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In this essay, Bill Pugh, CFO of PinnacleHealth, addresses the challenges and opportunities the Harrisburg, Pa.-based health system experienced moving towards the accountable care model. He offers some "lessons learned" for other health systems embarking on the ACO journey.
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Post date: September 30, 2014
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The Centers for Medicare & Medicaid Services has published a final rule updating the hospice wage index and payment rate for Fiscal Year 2015. It adopts a number of payment reforms addressing concerns about program integrity, beneficiary protection and quality.
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Post date: September 22, 2014
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In its new rules, CMS places great emphasis on the physician's documentation regarding his or her expectation of a patient's need for hospital care and anticipated length of stay. Therefore, it is essential that all hospital physicians are educated about the heightened importance of documentation within the medical record.
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Post date: September 15, 2014
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In its new rules, CMS places great emphasis on the physician's documentation regarding his or her expectation of a patient's need for hospital care and anticipated length of stay. Therefore, it is essential that all hospital physicians are educated about the heightened importance of documentation within the medical record.
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Post date: September 15, 2014
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Congress returned on Monday with just a few weeks until they adjourn to campaign. The Senate is set to adjourn by September 23 while the House could be in session for as little as 2 weeks. Here's a look at what happened in healthcare while Congress was in recess.
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Post date: September 12, 2014
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Inpatient rehabilitation services are already a big target area for recovery audit contractors, and there will likely be more denials as audits ramp back up. Providers must remain consistent, proactive and vigilant to protect their revenue.
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Post date: September 8, 2014
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While others have dispassionately made the point that there are unexplained variations in Medicare physician billing data that warrant careful consideration when using such data, one doctor thinks CMS has devious motives.
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Post date: September 4, 2014
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Accountable care has taken a stronghold in today's healthcare environment, and the trend is progressing, according to respondents from Premier's semiannual Outlook survey.
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Post date: September 2, 2014
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Imagine trying to run a successful business when employers, competitors, and other service providers have launched focused campaigns that encourage consumers to avoid you. If you run a restaurant or an auto-repair shop, this scenario is far-fetched. If you run a hospital, it's reality.
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Post date: August 8, 2014
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Just in case you didn't get the memo earlier this week, hospitals should take note that the Centers for Medicare & Medicaid Services will soon allow Recovery Auditors to restart some reviews.
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Post date: August 7, 2014
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Chief financial officers at hospitals and health systems must track a multitude of difficult financial issues these days. One question, however, always stops a conversation cold: Why are our reimbursements declining?
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Post date: August 7, 2014
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Last month the Centers for Medicare & Medicaid Services published its proposed rule to update the Medicare Hospital Outpatient Prospective Payment System and the Ambulatory Surgical Center Payment System rates and policies for calendar year 2015. Here's what you need to know.
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Post date: August 6, 2014
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