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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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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One of the biggest beneficiaries of healthcare reform's expansion of insurance coverage to more than 13 million people this year has been the nation's safety-net hospitals. At least in the states that have chosen to accept the Medicaid expansion.
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Post date: May 27, 2014
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The Centers for Medicare and Medicaid Services has announced the first group of prospective winners of its Health Care Innovation Awards. The winners could receive receive $2 million to $18 million each over three years for trying innovative care models.
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Post date: May 26, 2014
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With millions of Americans on new health insurance exchange plans now responsible for high deductibles, hospitals, drug makers, insurers and regulators are entering a new frontier of payment disputes.
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Post date: May 23, 2014
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Hospital ownership of physician practices appears to lead to statistically and economically significant increases in hospital prices and spending, according to a recent study published in Health Affairs. But that doesn't mean providers should retreat from integration and tighter alignment.
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Post date: May 22, 2014
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Medicare may be overpaying hospitals an estimated $5 billion as a result of the 18-month moratorium on enforcing the controversial two-midnight rule that tells hospitals when patients should be admitted, according to an independent Medicare auditing company.
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Post date: May 21, 2014
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While majorities of healthcare providers see value-based payment models becoming the reimbursement status quo in coming years, fewer than one-in-three say the reward is worth the risk.
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Post date: May 20, 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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Did you know that ultrasound, as a nonradiation modality, is expected to see an overall increase in reimbursement? Although there are some areas where threats of lower reimbursements are serious, overall, there will be incentives to utilize ultrasound where it is clinically warranted.
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Post date: December 4, 2013
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Fee-for-service methodologies, especially relative-value units (RVUs), keep creeping back into alternative payment models like capitation. Maybe we should take the hint and adapt RVUs to the new environment rather than throwing them out the window.
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Post date: November 22, 2013
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Earlier this year, the Centers for Medicare & Medicaid Services addressed several misunderstandings around ICD-10 in its "Myths and Facts" guide. While CMS debunked some of the most common ICD-10 myths, much of the industry is still confused about key topics.
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Post date: November 15, 2013
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The dental industry is not commonly considered a source of “best practices” for general healthcare reimbursement, but dental practices employ a number of strategic approaches that can be leveraged by other providers.
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Post date: November 14, 2013
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Hanging above physicians like the mythical sword of Damocles, the sustainable growth rate (SGR) provision threatens to impose a 24.4 percent decrease to the Medicare Physician Fee Schedule on Jan. 1, 2014.
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Post date: November 12, 2013
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