Sep 6, 2019 | Uncategorized
Colorado emergency charges vary in price across the state, which prevents patients from seeking care due to the price of their treatments. The article below gives more insight to the unusual healthcare prices that many people are looking to fix. Read below to find out more on this dive.nnDive Brief:n
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- The cost of emergency department visits in Colorado vary enormously depending on facility and condition severity, according to new data from the state’s all-payer claims database analyzed by the Center for Improving Value in Health Care.
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- Colorado’s EDs were paid an average of $3,115 for the most severe life-threatening cases in 2018. The largest single charge was $47,779, and the smallest was $190.
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- But Denver-based CIVHC, which administers the database, only looked at reimbursement from commercial payers to the facility directly, meaning the entire cost of care for a Colorado patient — including common add-ons like lab tests, imaging services, surgical procedures or other physician fees — is likely much higher.
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nDive Insight:nnColorado’s data provides the U.S. an unusual glimpse into healthcare prices, albeit in one state and one type of provider setting.nnThough national ER use remained largely unchanged over the past decade according to the Health Care Cost Institute, ER clinicians are using high severity codes more frequently. Previous research from the CIVHC found that trend held true in Colorado as well, with a decrease in coding for all other lower-tier severity levels across commercial payers between 2009 and 2016.nnLast year, the median statewide facility payment for a low severity visit was approximately $290 and high severity level claims were paid at almost $3,000.nnAs ER costs continue to rise, some payers are taking controversial steps to try and blunt the trend. Anthem faced lawsuits and backlash from a slew of providers in Connecticut, Georgia and Missouri around its cost-cutting policies, including paying patients directly for emergency care and having them reimburse their providers, and no longer reimbursing for non-emergency services given in the ER.nnIf widely adopted, that latter policy from the Indianapolis-based payer could deny payment for as many as one in six ER visits, according to a study in JAMA.nnProvider critics, wary of insurer policies that could further endanger their bottom lines, argue such measures could prevent patients from seeking care in the first place.nnOver a dozen individual states along with Washington, D.C. have put forward proposals to try and mitigate the practice. The Trump administration backs legislation to ban surprise billing, which lawmakers are set to debate after the summer recess. Often, patients hit with surprise medical bills for care not covered by their insurer get them after receiving care in the ER.nnBig hurdles remain to appease both the payer and provider lobbies, which stand diametrically opposed on the way forward to fix the problem.nnOriginal article published on healthcaredive.com
Aug 30, 2019 | Uncategorized
Banner Health is planning to acquire the North Colorado Medical Center which has been in operation since 1995. This new plan would bring great healthcare opportunities to the area. Read below to find out more about the deal.nnPhoenix-based Banner Health plans to acquire North Colorado Medical Center in Greeley, which it has operated since 1995.nnUnder the proposed deal, which requires regulatory approval, Banner would pay $328.4 million to acquire the land, assets and equipment associated with the hospital from Weld County (Colo.).nnA large portion of the proceeds from the transaction will be used to pay off $209.5 million in existing hospital debt, according to a press release from Weld County.nnOriginal article posted on beckerhospitalreview.com
Aug 21, 2019 | Uncategorized
Pinnacol recently announced that Nurse Practitioners could pursue DOWC accreditation to receive higher reimbursement. Also, Pinnacol announced the use of interpretation services to meet contract obligations and the Division of Workers Compensation requirements for injured workers. Read the article below to find out more about these two new regulations.nnDOWC Accreditation for Nurse PractitionersnnNew Colorado Division of Workers’ Compensation regulations that went into effect Aug. 2 impact nurse practitioners.nnHouse Bill 1105 allows nurse practitioners to obtain DOWC Level I accreditation solely for the purpose of receiving the higher reimbursement associated with the designation. It does not allow them to declare maximum medical improvement for an injured worker, the key component of Level I accreditation.nnNurse practitioners may begin pursuing DOWC Level 1 accreditation now via an online course. The next in-person training session will be offered via DOWC in September in Denver, and registration is open.nnBeginning on Aug. 2, Level 1 accredited nurse practitioners with prescriptive authority will be allowed to bill for 100 percent on the DOWC Medical Fee Schedule.nnReference nnWorkers’ Compensation Rules for NPs and PAs nnUse of Interpretation ServicesnnEffective Sept. 1, Pinnacol will implement procedures to meet contract obligations and the Division of Workers’ Compensation requirements for scheduling interpretation services for Pinnacol’s injured workers. These procedures comply with 2019 DOWC Rule 18-6(Q).nnPinnacol Assurance is committed to aligning all parties to provide uninterrupted, quality service for our non-English-speaking injured workers.nnThe following are the guidelines to ensure quality care.n
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- Interpretation must be authorized for patients during office visits, diagnostics, injections, therapy and psychological services.
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- The treating provider will call Pinnacol for authorization for interpretation services.
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- Pinnacol will determine whether the requested provider is contracted with Pinnacol. If contracted, the request will be approved. If the vendor is not contracted,
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- Pinnacol claims reps will refer the requester to the list of approved, contracted providers.
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- Pinnacol may change the interpretation vendor at any time during the life of the claim — with or without cause — after notifying the current vendor and the primary care provider.
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nIf issues arise in the process of assigning an interpreter or with the services provided by an interpreter, please contact the Pinnacol claims representative immediately.nnPinnacol does not intend to direct the type or duration of medical treatment that may be prescribed. Prescribing providers must exercise independent medical judgment in these matters.nnIf you have any questions or need additional information, please contact Pinnacol Assurance at provider_management@pinnacol.com or 303.361.4945.nnReferences nColorado Division of Workers’ Compensation, Rules of Procedure, Rule 18-6(Q)nUse of Interpretation ServicesnPinnacol’s Contracted Interpretation and Translations Service ProvidersnnOriginal article published by pinnacol.com
Aug 21, 2019 | Uncategorized
Do you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected.nn– Click Here to Submit Redacted Surgery Case Study –nnSubjective:nnChief Complaints:n
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- Bilateral L5/Sl TF Epidural PRP. Nosed. No ABX/AC. PM.
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nMedical History:nnMedications: Taking Baclofen 10 MG Tablet TAKE ONE-HALF TO ONE TABLET BY MOUTH AT BEDTIME , Taking Celecoxib 200 MG Capsule TAKE ONE CAPSULE BY MOUTH TWICE DAILY, Taking Belbuca 150 MCG Film 1 film to the gum Buccally every 12 hrs, Notes: DNF: 07/29/19, next due 08/28/19, Taking Oxycodone-Acetaminophen 5- 325 MG Tablet 1 tablet as needed Orally every 12 hrs, Notes: DNF: 07/29/19, next due 08/28/19nnObjective:nnVitals: BP 122/78 mm Hg, HR 92 /min, Ht 71.0 in, Wt 195 lbs, Oxygen sat% 95 %, BMI 27 .19 Index.nnAssessment:n
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- Lumbar spondylosis – M47 .816 (Primary)
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- Lumbar radiculopathy – M54.16
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- Degeneration of lumbar intervertebral disc – M51.36
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nAt this point, patient has failed conservative therapy, has undergone imaging and physical examination which demonstrate facet mediated pain.nnThey also have undergone dual diagnostic MBB with over 80% relief on DOS and the duration of effect was consistent with the local anesthetic used.nnThey have had prior RFA of the same levels (over 6mo ago) with >60% relief for 4mo and, by their report, had improvement in performance of ADLs of home, work and family.nnPlan:n
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- Others
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nNotes:nnFAILURE OF CONSERVATIVE MANAGEMENT OF OVER 4 WEEKSn
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- Prescription strength anti-inflammatory medications and analgesics
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- Adjunctive medications such as nerve membrane stabilizers or muscle relaxants
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- Physician-supervised therapeutic exercise program or physical therapy
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- PAIN SEVERITY IS 3/10 OR GREATER
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- UNABLE TO PERFORM AOL’S of WORK, HOME,and RECREATION,
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nProcedures:nnCPS Procedures:nnPre-op, Diagnosis: Lumbar Radiculopathy and disc degeneration.nnPost-op. Diagnosis: same.nnInformed Consent: The risks and benefits per the informed consent were discussed with the patient.nnAlthough risks are theoretically possible, they are remote. We specifically discussed infection, bleeding, nerve damage, spinal cord damage and paralysis. Patient understands risks and benefits and wishes to proceed. All questions answered..nnProcedure: Bilateral LS/S1 TRANSFORAMINAL EPIDURAL, LS/S1 FACET and LEFT APPROACH Discogram and INJECTION of PLATLET RICH PLASMA .nnSedation : None.nnDetails of Procedure: First 60mL of the patient’s blood was sterll collected from the LEFT AC and processed per Celling Biosciences PRP kit instructions. Strict aseptic technique was maintained. 500 mg ancef was given IV. The patient was placed prone on the fluoroscopy table. after sterile prep and drape with chlorhexidine, C-arm fluoroscopy was used to visualize the lumbar spine. The skin puncture sites were anesthetized with cold spray. Pt placed in the prone position on procedure table. Monitors were applied.nnThe patient’s back was prepped with chloraprep and draped with sterile towels. Using AP, lateral, and oblique fluoroscopy, the neuroformina were identified. After anesthetizing the skin with bicarbonated 1% lidocaine, a 22 G 5 inch quincke needle was advanced into each neuroforamen. Needle tip position was confirmed on lateral view and with the injection of 0.5 cc of Isoview 200. The left needle was then advanced into the disk and confirmed with omnipaque/ancef mixture. Then each needle was redirected to the LS/S1 facet. The inferior aspect of the joint was accessed. ‘ After negative aspiration, injectate of PRP iML was injected through each needle without difficulty at each location ‘ ‘The patient tolerated the procedure very well..nnComplications: None.nnSpecimens: None.nnImpressions: The patient stayed in the recovery room without motor and sensory deficits and was discharged home with an escort.nnTechnically successful block. Follow up in 30 days,
Aug 15, 2019 | Uncategorized
The residents of Colorado are working hard to improve our healthcare system throughout the state. A recent study ranked Colorado number 11 in the US based on several different variables, however, health care costs in Colorado were ranked 47. Read the article below recapping the results from the survey and other placement factors.nnA new study places Colorado’s health care system just outside the top 10 in the nation.nnThe study, released Monday by financial website WalletHub, ranked Colorado No. 11 on its list of best and worst states for health care.nnMinnesota, Massachusetts and Rhode Island took the top three spots, with Mississippi, North Carolina and Alaska coming in at the bottom of the list.nnThe report compared the 50 states and the District of Columbia across 43 measures of cost, accessibility and outcome, using data sets ranging from average monthly health insurance premium costs, hospital beds per capita, cancer and heart disease rates, and percentage of insured people ages 19 to 64.nnColorado ranked No. 47 in terms of health care costs for its residents, which considered factors such as average hospital expenses per inpatient day at a community hospital and average monthly health insurance premium costs.nnThe Centennial State ranked 12th in access to health care — which took into account the number of hospital beds per capita and the quality of the state’s public hospital system — and No. 3 in health care outcomes, which included life expectancy and infant, child and maternal mortality rates.nnToday, the average American spends more than $10,000 per year on personal health care, or about 17.9 percent of the U.S. GDP, according to the most recent estimates from the Centers for Medicare & Medicaid Services.nn“But higher costs don’t necessarily translate to better results. The U.S. lags behind several other wealthy nations on several measures, such as health coverage, life expectancy and disease burden,” the study states. “However, the U.S. has improved in giving more healthcare access for people in worse health, and health care cost growth has slowed somewhat.”nnOriginal article published on csbj.com.
Aug 8, 2019 | Uncategorized
MLNConnects, the official news of CMS, recently proposed 3 new payment rules. CMS released these proposed rules on July 29, which include payment updates for outpatient and physician services and also expanded price transparency initiatives. Read below to find out more information on these proposed rules. n
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- PFS: Proposed Policy, Payment, and Quality Provisions Changes for CY 2020
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- Medicare OPPS and ASC Payment System CY 2020 Proposed Rule
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- ESRD and DMEPOS CY 2020 Proposed Rule
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n1. PFS: Proposed Policy, Payment, and Quality Provisions Changes for CY 2020n
On July 29, CMS issued a proposed rule that includes proposals to update payment policies, payment rates, and quality provisions for services furnished under the Medicare Physician Fee Schedule (PFS) on or after January 1, 2020. This proposed rule is one of several proposed rules that reflect a broader Administration-wide strategy to create a health care system that results in better accessibility, quality, affordability, empowerment, and innovation. It also includes proposals to streamline the Quality Payment Program with the goal of reducing clinician burden. This includes a new, simple way for clinicians to participate in our pay-for-performance program, the Merit-based Incentive Payment System (MIPS), called the MIPS Value Pathways.
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The proposed rule also includes:
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- CY 2020 PFS rate setting and conversion factor
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- Medicare telehealth services
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- Payment for evaluation and management services
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- Physician supervision requirements for physician assistants
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- Review and verification of medical record documentation
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- Care management services
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- Comment solicitation on opportunities for bundled payments
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- Medicare coverage for opioid use disorder treatment services furnished by opioid treatment programs
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- Bundled payments for substance use disorders
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- Therapy services
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- Ambulance services
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- Ground ambulance data collection system
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- Open Payments Program
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- Medicare Shared Savings Program
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- Stark advisory opinion process
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2. Medicare OPPS and ASC Payment System CY 2020 Proposed Rulen
On July 29, CMS proposed policies that follow directives in President Trump’s Executive Order, entitled “Improving Price and Quality Transparency in American Health Care to Put Patients First,” that lay the foundation for a patient-driven health care system by making prices for items and services provided by all hospitals in the United States more transparent for patients so that they can be more informed about what they might pay for hospital items and services.
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The proposed changes also encourage site-neutral payment between certain Medicare sites of services. Finally, the proposed rule proposes updates and policy changes under the Medicare Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System. The proposed polices in the CY 2020 OPPS/ASC Payment System proposed rule would further advance the agency’s commitment to increasing price transparency, (including proposals for requirements that would apply to each hospital operating in the United States), strengthening Medicare, rethinking rural health, unleashing innovation, reducing provider burden, and strengthening program integrity so that hospitals and ambulatory surgical centers can operate with better flexibility and patients have what they need to become active health care consumers.
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In accordance with Medicare law, CMS is proposing to update OPPS payment rates by 2.7 percent. This update is based on the projected hospital market basket increase of 3.2 percent minus a 0.5 percentage point adjustment for Multi-Factor Productivity (MFP).
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In the CY 2019 OPPS/ASC final rule with comment period, we finalized our proposal to apply the hospital market basket update to ASC payment system rates for an interim period of 5 years (CY 2019 through CY 2023). CMS is not proposing any changes to its policy to use the hospital market basket update for ASC payment rates for CY 2020-2023. Using the hospital market basket, CMS proposes to update ASC rates for CY 2020 by 2.7 percent for ASCs meeting relevant quality reporting requirements. This change is based on the projected hospital market basket increase of 3.2 percent minus a 0.5 percentage point adjustment for MFP. This change will also help to promote site neutrality between hospitals and ASCs and encourage the migration of services from the hospital setting to the lower cost ASC setting.
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The proposed rule also includes:
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- Proposed definition of ‘hospital,’ ‘standard charges,’ and ‘items and services’
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- Proposed requirements for making public all standard charges for all items and services
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- Proposed requirements for making public consumer-friendly standard charges for a limited set of ‘shoppable services’
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- Proposals for monitoring and enforcement
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- Method to control for unnecessary increases in utilization of outpatient services
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- Changes to the Inpatient Only list
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- ASC covered procedures list
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- High-cost/low-cost threshold for packaged skin substitutes
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- Device pass-through applications
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- Addressing wage index disparities
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- Changes in the level of supervision of outpatient therapeutic services in hospitals and critical access hospitals
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- Hospital Outpatient Quality Reporting Program
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- Ambulatory Surgical Center Quality Reporting Program
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- CY 2020 OPPS payment methodology for 340B purchased drugs
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- Partial Hospitalization Program rate setting and update to per diem rates
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- Revision to the organ procurement organization conditions for certification
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- Potential changes to the organ procurement organization and transplant center regulations: Request for Information
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3. ESRD and DMEPOS CY 2020 Proposed Rulen
On July 29, CMS issued a proposed rule that proposes to update payment policies and rates under the End-Stage Renal Disease (ESRD) Prospective Payment System (PPS) for renal dialysis services furnished to beneficiaries on or after January 1, 2020. This rule also:
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- Proposes updates to the Acute Kidney Injury (AKI) dialysis payment rate for renal dialysis services furnished by ESRD facilities to individuals with AKI
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- Proposes changes to the ESRD Quality Incentive Program
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- Includes requests for information on data collection resulting from the ESRD PPS technical expert panel, on possible updates and improvements to the ESRD PPS wage index, and on new rules for the competitive bidding of diabetic testing strips.
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In addition, this rule proposes a methodology for calculating fee schedule payment amounts for new Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) items and services and making adjustments to the fee schedule amounts established using supplier or commercial prices if such prices decrease within five years of establishing the initial fee schedule amounts. This rule would also:
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- Make amendments to revise existing policies related to the competitive bidding program for DMEPOS
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- Streamline the requirements for ordering DMEPOS items, and create one Master List of DMEPOS items that could potentially be subject to face-to-face encounter and written order prior to delivery and/or prior authorization requirements
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The proposed CY 2020 ESRD PPS base rate is $240.27, an increase of $5.00 to the current base rate of $235.27. This proposed amount reflects a reduced market basket increase as required by section 1881(b)(14)(F)(i)(I) of the Act (1.7 percent) and application of the wage index budget-neutrality adjustment factor (1.004180).
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The proposed rule also includes:
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- Annual update to the wage index
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- Update to the outlier policy
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- Eligibility criteria for the Transitional Drug Add-on Payment Adjustment (TDAPA)
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- Basis of Payment for the TDAPA for calcimimetics
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- Average sales price conditional policy for the application of the TDAPA:
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- New and innovative renal dialysis equipment and supplies
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- Discontinuing the application of the erythropoiesis-stimulating agent monitoring policy
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- Impact analysis:
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nOriginal and complete article published on cms.gov
