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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How do hospitals survive if they keep patients healthy and at home? For New Hampshire’s New London Hospital, the answer is to partner with the largest hospital in the state to keep costs low and possibly boost patient volume.
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Post date: June 17, 2014
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"Clinical integration" and "organizing for value" are two key themes at the HFMA 2014 ANI conference. Both are crucial in preparation for the transition from a fee-for-service reimbursement system. Here's an example of how one health system is preparing, by teaming with a health plan on a new care management venture.
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Post date: June 14, 2014
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The breakthrough hepatitits C drug Sovaldi has brought the high price of specialty pharma to recent public attention. But less examined are proactive approaches that could be used to curb the growth trend without depriving patients of needed therapies.
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Post date: June 13, 2014
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Of the states that built their own health insurance exchanges that are now operational, Washington, Kentucky and Minnesota enjoyed some successes that might be replicated.
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Post date: June 12, 2014
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The value-based reimbursement model predicted by hospital/health system and payer leaders to dominate the reimbursement market is also the one they say will be hardest to implement.
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Post date: June 12, 2014
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Medicare's ACOs have had mixed early outcomes, but some commercial accountable care ventures, including PPO plans, are showing promise.
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Post date: June 10, 2014
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Hospitals in states that have expanded Medicaid eligibility under the Affordable Care Act are already bringing in fewer self-pay and charity care patient cases, according to an analysis by the Colorado Hospital Association.
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Post date: June 5, 2014
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As providers continue adjusting to the reimbursement changes wrought by the Affordable Care Act, it appears increasingly likely that hospitals will place more emphasis on collecting payments at the point of service.
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Post date: June 5, 2014
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States' taxing of Medicaid managed care organizations to raise revenue for state-share Medicaid payments may be illegal, according to the HHS Inspector General. If so, this raises serious questions that could shake up MCO financing models.
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Post date: June 3, 2014
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Hospitals in Georgia have struggled financially in recent years, as uncompensated care costs rose after the recession and the state rejected Medicaid expansion. But one standalone facility decided that affiliation and clinical integration might be the right path to stave off closure.
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Post date: June 3, 2014
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One third of Pennsylvania's hospitals had negative operating margins in the 2013 fiscal year, according to the Pennsylvania Healthcare Cost Containment Council, an independent state agency. The crisis is forcing health systems to rethink organizational mergers and management.
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Post date: June 2, 2014
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For the second year in a row, Humana ranked first in overall performance among 148 payers, according to the 2014 PayerView Report. The report ranks health insurers according to specific measures of financial, administrative and transactional performance.
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Post date: May 28, 2014
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The Congressional Budget Office has raised the specter that reform to the Medicare physician fee schedule statutory update formula could increase the likelihood that the ACA's Independent Payment Advisory Board mechanism would be triggered potentially resulting in as much as $0.6 billion in Medicare provider cuts.
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Post date: January 30, 2014
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Yesterday the American Hospital Association, four regional hospital associations and four health systems launched a federal court challenge to the controversial two-midnight inpatient admissions policy established by the Centers for Medicare & Medicaid Services.
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Post date: January 23, 2014
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With the growing complexity and unpredictability of reimbursement, the existing back-end model of managing patients' payments is no longer sufficient. Hospital executives must focus on a proactive approach to collecting payment upfront as well as improving patient education.
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Post date: January 15, 2014
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This week, CMS released a proposed rule that would make significant revisions to the Medicare Advantage and Part D prescription drug program regulations. The agency estimates that the rule changes would reduce Medicare spending by $1.3 billion between 2015 and 2019.
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Post date: January 14, 2014
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While certain key generic drugs will take billions in drug costs out of the healthcare system in the next 3 to 4 years, this anticipated decline in spending is masking the growth of specialty drug costs.
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Post date: January 9, 2014
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Since the passage of the Affordable Care Act, there’s been an industry focus on accountable care organizations. This movement towards ACOs has major market implications for providers that are considering joining the Medicare Shared Savings Program for the January 2015 start date.
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Post date: January 6, 2014
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In late December, President Obama signed into law the Bipartisan Budget Act of 2013, which includes the Pathway for SGR Reform Act of 2013. While SGR drew most of the media attention, the Act includes a number of other provisions impacting the Medicare and Medicaid programs.
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Post date: December 31, 2013
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While the past year was relatively tame regarding ICD-10, at least in regard to the mad scramble some expect leading up to October 1, 2014, there were some significant developments.
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Post date: December 30, 2013
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Planning for ICD-10 is overwhelming, but attempting the transition without a well-organized plan could be catastrophic for your organization. Here are five steps to help make your ICD-10 plan more manageable.
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Post date: December 20, 2013
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Healthcare prices in October 2013 rose 0.9 percent above October 2012, the lowest reading in 50-plus years, according to a recent brief from the Altarum Institute.
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Post date: December 11, 2013
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In an effort to raise awareness of hospital price variation, the California Public Employees’ Retirement System and Anthem Blue Cross started a “reference pricing” initiative in 2011. It appears to be having an impact.
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Post date: December 9, 2013
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Dual coding is probably the best idea to support the ICD-10 transition that many healthcare providers may not be able to afford. Here's why.
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Post date: December 5, 2013
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