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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At the behest of affected patients and providers, Intermountain Healthcare decided to build what it calls a Personalized Care Clinic, an initiative that has the look of a patient-centered medical home, but offers services for a specific patient demographic facing complex, ongoing medical issues.
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Post date: October 24, 2014
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Like healthcare facilities across the country, Louisiana's hospitals must confront formidable financial challenges as care delivery models evolve and reimbursement mechanisms change.
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Post date: October 24, 2014
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Last week the HHS Office of Inspector General and the Centers for Medicare & Medicaid Services published a joint notice continuing the effectiveness of fraud and abuse law waivers granted in 2011 in connection with the Medicare Shared Savings Program.
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Post date: October 20, 2014
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Rising interest rates and regulatory oversight will be the top challenges confronting the senior care industry over the next year, according to a new survey of housing and care providers. But industry leaders feel good about a stronger business performance outlook.
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Post date: October 17, 2014
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This week CMS launched an ACO Investment Model, which will provide up to $114 million in upfront investments, to up to 75 Medicare Shared Savings Program ACOs. The program aims to help ACOs succeed in the MSSP by providing upfront capital to cover startup and ongoing infrastructure costs.
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Post date: October 17, 2014
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Physician practices have the lowest revenue growth in the healthcare industry. When every dollar counts, anything from a lost referral to a bad online review can impact profitability. Here are some common revenue leaks and tips on plugging them.
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Post date: October 16, 2014
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Health systems as well as independent providers have an opportunity to drive best practices in specialty care and secure sustainable revenue with a new business and care model.
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Post date: October 16, 2014
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Some health systems see value in becoming part of branded health plan networks for limited provider plans, as other providers try to launch their very own plans.
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Post date: October 15, 2014
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With an improving fiscal climate, some states are paying their Medicaid providers more. More states are increasing fees to specialists, nursing homes and managed care organizations, but 31 states were cutting or freezing Medicaid hospital rates, compared to 19 that were increasing them.
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Post date: October 14, 2014
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Many Medicare beneficiaries treated at primarily rural "critical access" hospitals end up paying between two and six times more for outpatient services than do patients at other hospitals, according to a report released Wednesday by the HHS inspector general.
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Post date: October 9, 2014
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The U.S. Supreme Court has agreed to hear a case brought by Idaho providers over an issue that has split many lower courts: whether Medicaid providers have a Constitutional right to sue states to enforce Medicaid funding regulations.
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Post date: October 7, 2014
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Are hospitals exploiting the 340B drug discount program? Critics of the federal government's program have some new evidence in the debate over healthcare subsidies.
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Post date: October 6, 2014
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The 2015 Medicare Part A deductible -- for inpatient hospital, skilled nursing facility and home healthcare services -- will increase by $44 in calendar year 2015 to $1,260, while the monthly Part A premium will decline by $19. Medicare Part B monthly premiums and deductibles will remain unchanged.
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Post date: October 13, 2014
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The HHS Inspector General continues to fault CMS for failing to issue final regulations to enforce the location requirements for rural health clinics. The agency's inaction is costing taxpayers millions.
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Post date: October 8, 2014
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With one year left, it's time to chart your map to the new code set. And given that so many payers and providers are lagging behind recommended timelines, these tactics will help you get organized.
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Post date: October 2, 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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