Third Party Payer Update – COLORADO
The Triple Aim:n
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- Improving the patient experience
- Improving the health of populations
- Reducing per-capita cost
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nThe Triple Aim is on all the payer’s minds these days. These three tenants are now being woven into many of the decisions being made about cost, quality, reimbursements, network size, etc. Using these three items in your contracting strategy will help your success. Measuring and being able to report your ability to positively affect these three goals will make your practice more valuable to the health plans.nnThe payers are continuing to engage in the soft-narrowing of their various networks, using the direction of member volume to leverage rates. The “Value Based” PCP relationship appears to be the primary mechanism of this process. Therefore a member is not a member until you have their benefits carefully verified.nnThese days your referral people need to take a couple of extra steps:n
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- Is the member eligible?
- Are we on the PCP and Members list?
- What benefits are available for this plan type, product type, etc?
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PAYER UPDATES:
nAetna is in the process of buying Humana.nnAetna is sub dividing its Medicare Advantage product into sub-groups – watch for proper referrals and authorizations!nnAnthem is buying CIGNA. This is a huge merger and will require FTC approval. It will likely take a year or more to happen. The interesting thing about this merger is CIGNA is almost 100% self-funded (ASO) business. Anthem is currently about 50/50 self-insured and fully insured. They are capturing an enormous amount of the ASO business with this merger, an interesting reaction to the Affordable Care Act.nnJuly 1 Anthem updated its RBRBS year to 2014 – The more recent RBRVS years tend to favor the E&M codes at the expense of some surgical procedural codes – watch your reimbursement!nnMergers – Is There Opportunity for Your Practice? Usually during merger activity the health plans want a stable network. There may be a time for each of these (four different major health plans) to take a look at better rates! They all react to these things differently, so we will all need to keep our ears to the ground and look for opportunity.nnColorado HealthOP – They have had an incredible increase in members this year as a partial result of very favorable rate filings with the state. It will be interesting to see their rate fillings and growth as the New Year approaches.nnUnited Healthcare is updating their RBRVS year! They are also increasing their focus on the use of Out-Of-Network (OON) providers. If you are in-network but routinely refer to OON providers it is nearly impossible to increase your in-network rates. United appears to be following Anthem’s recent program to locate and weed out the use of OON providers.nnMedicare and Orthopedics: Medicare has initiated an Orthopedics bundled program called Comprehensive Care for Joint Replacement (CCJR). This program requires 800 pre-selected hospitals in 75 areas of the country to participate. They call it a Bundled Program but really it is a form of Pay-for-Performance in which the hospital gets the money and makes the decisions. More to come on this!nnICD-10 – so far so good? We haven’t seen any wholesale issues just yet. If you are experiencing any trouble please let us know!
The Colorado Division of Workers’ Compensation (DOWC) recently issued final utilization standards and the final Colorado Workers’ Compensation Medical Fee Schedule that affect all workers’ compensation billing, and will go into effect January 1, 2016. Among several significant changes are that these rules and regulations require payers to adopt Medicare’s Resource-Based Relative Value Scale (RBRVS) method of payment. You should be aware of regulatory changes that will affect your billing, coding and processes, and make any necessary business adjustments now to ensure a smooth transition.nnThe DOWC set out to ensure that the transition to the new fee schedule and payment system would be budget-neutral overall; however, providers should examine the rules closely and analyze specifically how fee schedule changes may impact their payments for certain specialties.
As part of the ongoing effort to educate providers about the most effective treatment protocols for workers’ compensation, Pinnacol Assurance is amending their SelectNet network credentialing standards for nurse practitioners and physician assistants practicing in the following urban counties: Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas, El Paso, Elbert, Garfield, Jefferson, Larimer, Mesa, Pueblo, and Weld. Mid-level providers in these counties will be required to complete Division of Workers’ Compensation (DOWC) Level 1 training.nnEffective 
Colorado Medicaid and CHP+ Provider Revalidation & Enrollment Begins September 15, 2015
S61.451A — Open bite of right hand, initial encounternW55.81XA — Bitten by mountain lionnY93.01 — Activity, hikingnnIn preparation for the upcoming deadline for ICD-10 implementation, Welter Healthcare Partners presents weekly ICD-10 Codes of the Week! Our goal is to familiarize you with the new and expanded code set and the additional clinical documentation needed from your providers to comply with ICD-10 coding, and more importantly, for accurate and clean claims submission to keep your revenue stream flowing! We are to help YOU prepare for the October 1, 2015 implementation date. Please don’t hesitate to