Feb 5, 2024 | Uncategorized
If you’ve ever worked with healthcare costs and insurance, you’re likely familiar with the term “risk adjustment coding.” But what does it entail, and why is it a critical component for both healthcare organizations and insurance companies? In essence, this serves as a mechanism to ensure accurate accounting for the health status of patients and to adjust payments accordingly.
Risk Score for Patients
The intricate process of risk adjustment coding involves healthcare providers using diagnostic codes to denote various aspects of a patient’s health, including age, sex, and any pre-existing conditions. These codes collectively formulate a “risk score” for each patient, estimating the probable cost of providing care over the year. Insurance companies then use these risk scores to modify payments to providers, ensuring that those treating sicker patients are compensated adequately compared to those handling healthier individuals.
Risk Adjustment Coding System
At its core, risk adjustment coding acknowledges that some patients naturally incur higher treatment costs. This could be due to pre-existing conditions or other health factors. This system helps prevent unfair penalization of patients by insurance companies and ensures that healthcare providers receive appropriate reimbursement for the care they deliver.
Risk Adjustment is a Safeguard
Risk adjustment coding safeguards patients from potential denial of coverage or exorbitant premiums based on pre-existing conditions. This ensures that individuals, irrespective of their health status, have access to the necessary care. Simultaneously, risk adjustment coding is pivotal for healthcare providers, particularly those catering to higher-risk patients. Without accurate coding, providers may face unfair penalties from insurance companies, jeopardizing their ability to maintain their practice and deliver high-quality care.
Crucial to Patient Care
Risk adjustment coding is an important component of the healthcare system. It guarantees that patients receive the care they require and that healthcare providers are fairly reimbursed for their services. Understanding the intricacies of risk adjustment coding sheds light on its importance in maintaining a balanced and just healthcare ecosystem.
Jan 30, 2024 | Uncategorized
In a groundbreaking move, the Centers for Medicare & Medicaid Services (CMS) has recently implemented a final rule, led by Administrator Chiquita Brooks-LaSure, that promises to revolutionize the prior authorization process. These reforms, aimed at cutting patient care delays and streamlining the process for physicians, are anticipated to result in substantial savings of $15 billion over the next decade. At Welter Healthcare Partners, we applaud these significant strides towards improving the healthcare landscape and recognize the positive impact they will have on both patients and healthcare providers.
Prior Authorization Reforms:
The final rule addresses prior authorization for medical services across various government-regulated health plans, including Medicare Advantage, State Medicaid and CHIP fee-for-service programs, Medicaid managed care plans, CHIP managed care entities, and qualified health plan issuers on federally facilitated exchanges. This comprehensive approach reflects a commitment to tackling challenges across different sectors of the healthcare system.
Technological and Operational Enhancements:
One of the key highlights of the reforms is the incorporation of an electronic prior authorization process embedded within physicians’ electronic health records. This transformative change is set to bring much-needed automation and efficiency to a previously time-consuming and manual workflow. We appreciate CMS for recognizing the importance of embracing technology to streamline processes and enhance the overall quality of patient care.
Enhanced Transparency and Patient Empowerment:
The administration’s action not only focuses on efficiency but also aims to enhance transparency around prior authorization. By requiring specific denial reasons, public reporting of program metrics, and making prior authorization information available to patients, the reforms empower individuals to make informed decisions about their healthcare. This marks a crucial step towards fostering a more patient-centric healthcare system.
Shortened Processing Time Frames:
CMS’s mandate for shortened processing time frames is a noteworthy aspect of the reforms. Starting in 2026, affected payers will be required to send prior authorization decisions within 72 hours for urgent requests and within a week for nonurgent requests. This commitment to faster response times aligns with the urgency of providing timely and essential care to patients.
Physician Advocacy and Potential Legislative Impact:
The collaboration between CMS and physician organizations, including the American Medical Association (AMA), showcases the power of advocacy in influencing positive change. The $15 billion estimated savings, coupled with the potential impact on the Improving Seniors’ Timely Access to Care Act, reinforces the significance of these reforms in shaping the future of healthcare legislation.
Addressing Concerns and Building a Better Future:
While payers argue that prior authorization is necessary for cost and quality control, physicians often highlight the adverse impact on patient care. The AMA’s survey findings underscore the urgent need for reform, with one-third of physicians reporting serious adverse events resulting from prior authorization protocols. The final rule is a crucial step towards addressing these concerns and creating a more efficient and patient-friendly healthcare environment.
At Welter Healthcare Partners, we recognize the monumental significance of CMS’s $15 billion victory for physicians in the realm of prior authorization. These reforms not only promise substantial financial savings but also signify a commitment to improving patient care, streamlining processes, and fostering transparency. As stakeholders in the healthcare industry, we look forward to witnessing the positive impact of these changes on both healthcare providers and the individuals they serve.
Read the original article here.
Jan 22, 2024 | Uncategorized
California Assemblyman Jim Wood has championed a groundbreaking bill, AB-815, aimed at simplifying the often cumbersome process of credentialing practitioners seeking to join healthcare plans. The bill proposes the establishment of a state board tasked with certifying private and public entities as delegated credentialing entities for health plans. Instead of health plans conducting their own credentialing, they would utilize the information provided by these certified entities.
The proposed state board is set to be a collaborative effort, comprising representatives from health plans, state health departments, physicians, and other healthcare providers. The goal is to have the board operational by July 1, 2024, with the application process for entities seeking certification expected to be in place by July 1, 2025. This move is poised to streamline the credentialing process, reducing redundancies and ensuring a more efficient and standardized approach.
The bill has already cleared the California Assembly and is now on its way to the senate for a vote, marking a significant step toward reforming the healthcare credentialing landscape in the state.
However, as the healthcare industry in various states grapples with evolving credentialing requirements, a broader perspective emerges. The landscape is rife with complex and dynamic regulations, often payer-focused, requiring meticulous attention from Credentialing Verification Organizations (CVOs). The insights shared by industry experts shed light on the nuanced challenges and opportunities within this realm.
One notable observation is the growing trend inspired by Arkansas, where states like California and West Virginia are considering or actively working towards creating or contracting with statewide CVOs. Arkansas has already set up a state-run CVO, and California is slated to accept applications in 2024 for a CVO to contract with. West Virginia has established provisions for contracting with a CVO but has not executed the plan as of yet.
This shift towards centralized credentialing entities indicates a recognition of the need for standardized, efficient processes that can navigate the intricacies of varying state requirements. As the healthcare industry continues to evolve, it becomes increasingly crucial for payers to stay ahead of these changes, ensuring compliance with state-specific mandates and optimizing the credentialing workflow.
California’s AB-815 signals a promising leap towards a more streamlined and efficient healthcare credentialing process. While challenges persist, the industry’s response, as seen in the pursuit of statewide CVOs, reflects a commitment to adaptability and improved operational efficiency. As the bill progresses through the legislative journey, it stands as a beacon of progress in the ongoing efforts to enhance the healthcare system’s effectiveness in California and potentially beyond.
Nov 16, 2023 | Uncategorized
The practice of value-based care has gained significant momentum, driven in part by the COVID-19 pandemic, which highlighted the limitations of fee-for-service reimbursement. Healthcare providers now face increasing pressure to stay up-to-date with emerging trends in the field. In this article, we’ll explore five key trends in value-based care.
1) Embracing Value-Based Care:
A heavy reliance on fee-for-service reimbursement can leave healthcare providers vulnerable to volatility and changes in demand. Those who had invested in value-based care were better equipped to weather the storm, as they had a consistent source of revenue even during periods of low utilization. The rapid changes in healthcare delivery driven by the pandemic underscore the importance of embracing value-based care. Providers have the opportunity to realize a rapid return on their investment in value-based care, thanks to stable revenue streams and new regulatory flexibilities. Innovative care delivery models further enhance this potential.
2) Continued Innovation and Disruption:
Value-based care has long been a hotbed for innovation, and we are seeing a surge in innovation and disruption in both payment and care delivery models. The Centers for Medicare and Medicaid Services (CMS) had prioritized value-based care during the Trump administration, and the Biden administration’s health care goals are likely to further emphasize cost savings, driving a greater push towards value-based care. Commercial payers are also seeking innovative payment and care models, especially in light of the disparities highlighted by the pandemic.
3) Leveraging COVID-19 Infrastructure:
The COVID-19 pandemic prompted transformative changes to the healthcare system. These changes created ongoing opportunities to manage patient care and provide high-quality services in lower-cost settings. Telemedicine and digital health modalities, initially introduced as temporary measures, have become permanent fixtures in healthcare. Providers who adopted digital health solutions during the pandemic can now capitalize on this investment to manage patient care efficiently and see returns on services that were traditionally unreimbursable under fee-for-service arrangements. Programs like the Hospital Without Walls and Acute Hospital Care at Home have also opened doors for lower-cost services that benefit providers.
4) New Opportunities for Provider Alignment:
Recent changes in federal law have aimed to lower barriers to value-based care. CMS and the Office of Inspector General (OIG) have introduced new flexibilities under the Stark law and Anti-kickback Statute for value-based arrangements, allowing providers to enter into arrangements that were previously restricted. These exceptions and safe harbors provide new opportunities for providers. Careful crafting is required to take advantage of these allowances. They enable providers to align and incentivize activities that promote value-based goals. Additionally, information blocking rules ensure patients and providers can access health information, further reducing structural barriers to value-based care.
5) Focus on Social Determinants of Health:
In the value-based care space, especially in Medicaid programs, there is a growing emphasis on addressing social determinants of health. Providers and payers recognize the significant role that non-medical factors play in patient health. Providers and payers can achieve notable improvements in patient health and outcomes by addressing issues such as transportation, food, housing, and language services. Simultaneously, they can maintain relatively low medical costs. The focus on social determinants of health is an emerging trend in value-based care. This trend is expected to grow as stakeholders seek creative ways to manage patient arrangements.
Healthcare providers and payers are emerging from the upheaval caused by the pandemic and the revolutionary changes in healthcare. A renewed interest in value-based care is expected! Opportunities abound to fully investing in patients.
Post adapted from original article published on natlawreview.com
Photo from NCI
Oct 25, 2023 | Uncategorized
The Healthcare Code Landscape Is About To Witness A Significant Transformation
The Centers for Medicare & Medicaid Services (CMS) have recently unveiled the ICD-10-CM 2024 codes. These updates, slated for use by all provider types, encompass both Inpatient and Outpatient settings. The release includes crucial components such as the 2024 Addendum, Code Descriptions in Tabular Order, and Code Tables, Tabular, and Index. Alongside these, the FY 2024 Conversion Table and Present on Admission (POA) Exempt Code List (to be posted soon) complete the comprehensive package of changes.
The 2024 ICD-10-CM changes take effect from October 1st, 2023, to September 30th, 2024. Providing the medical community with a significant overhaul of
395 New Codes, 25 Deletions, and 13 revisions across 17 of the 21 Chapters!
Notably, “Capturing the Context”. Great Job Docs! Your excellent documentation of Where and/or How injuries happened has given way to a major boom in Chapter 20: External causes of morbidity! A whopping 123 new codes out of the 395 overall additions to be exact! These additions range from “Foreign bodies entering through a natural orifice” like batteries, buttons and plastic toys to sharp glass, swords and daggers”!
Some Other Major Changes Include:
- Chapter 3, Neoplasms, a notable addition to includes 13 new codes for desmoid tumors, a rare type of tumor that presents unique challenges in terms of classification and treatment. Chapter 3 introduces 8 new codes related to Sickle-cell conditions with dactylitis. This is a condition marked by severe inflammation of fingers and toes, commonly observed in infants with sickle cell anemia.
- Chapter 6, the Nervous System, focusing on diseases of the nervous system, welcomes 24 new codes, including those for Lafora Body Disease and chronic migraine with aura. These additions reflect a growing understanding of neurological conditions and their complexities.
- Chapter 21, Factors Influencing Health Status and Contact with Health Services, 30 New Codes include a variety of conditions such as carrier status, history codes, and codes related to Social Determinants of Health (SDOH), like New Subcategory Z62 which addresses “Problems Related to Upbringing”; and New Subcategory Z91.A9 “Caregiver’s Noncompliance with Patient’s Medical Treatment and Regimen”.
The changes aren’t limited to specific areas; they permeate through various chapters, addressing an array of conditions and diseases.
Learn more about the author Delana Williams, CPC, CPCI, CEDC
ICD-10 Questions?
If you have any questions or need clarification about the 400 changes to ICD-10 CM for 2024 please contact us. We are here to help!
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Welter Healthcare Partners stands ready to navigate these modifications effectively and provide the utmost support in adapting to the evolving ICD-10-CM landscape. Our team is well-equipped to ensure the accurate coding and compliance essential for seamless healthcare billing operations in this changing environment.
Information collected and condensed by
Delana Williams, CPC, CPCI, CEDC
Coding and Compliance Manager at Welter Healthcare Partners.
Want to learn more? WHP will be hosting TWO ICD-10-CM UPDATE WEBINARS. Stay tuned for more info!
Photo by National Cancer Institute on Unsplash
Oct 17, 2023 | Uncategorized
Specialty Healthcare in the US
Many doctor visits involve seeing a specialist at some point in the process. The specialty healthcare system in the United States needs to be improved in order to help patients and doctors alike. Specialists are important in American healthcare.
Almost 9 out of 10 doctors specialize in different areas. They handle a big part of medical visits, cost a lot in Medicare and private insurance, and their role in outpatient visits and overall healthcare costs is increasing. To improve healthcare in the U.S., we need to make specialty care better. We can do this by breaking it down and making the various services offered by specialists work well together.
Core Activities of Specialists
Specialists are problem-focused experts responsible for the care of individuals with specific health conditions. They expand their expertise through a range of core activities, including:
- Consultations (providing advice to fellow clinicians)
- Co-management (sharing the long-term management of a particular issue)
- Principal care (assuming full responsibility for a specific problem)
- Primary care (offering a medical home)
- Procedures
The blend of these activities varies based on a specialist’s field and individual practice. For example:
- Cognitive-based specialists, like endocrinologists and nephrologists, tend to engage in consults, principal care, primary care, and co-management, often with minimal or no procedures.
- Procedural-based specialists, such as gastroenterologists and cardiologists, also partake in consults, principal care, and co-management, in addition to procedures but provide little to no primary care.
- Surgical specialists, including orthopedists and neurosurgeons, primarily engage in consults and procedures.
Challenges of Bundling
In various industries, bundling products and services with multiple components is commonplace to reduce production and distribution costs. However, including elements that some consumers never utilize can lead to increased costs and a potential mismatch with individual consumers’ specific needs. Specialists often employ uniform processes, resources, and business models to deliver widely differing services.
This bundling approach makes specialty care less accessible; for instance, individuals in need of prompt attention may face delays due to specialists’ schedules being occupied by those receiving ongoing care. It also inflates costs for simpler services due to unnecessary overhead, disrupts the patient experience with cumbersome processes, and diminishes effectiveness when resources are insufficient for complex requirements. Additionally, it places undue strain on specialists and their staff, who must frequently shift their focus between highly disparate tasks.
Unbundling as a Path to Improvement
The internet’s influence in reducing distribution costs has allowed many companies to unbundle products and services into stand-alone offerings that are more affordable and cater to specific consumer needs. Breaking down specialist activities into modular components and delivering each with tailored clinical, operational, and business models could potentially make specialty care more accessible, cost-effective, efficient, and patient-friendly. Below are strategies for unbundling the four core services of specialists:
- Consultations: Provide stand-alone consultation services, enabling patients to seek expert advice without committing to long-term care.
- Co-Management: Develop specialized co-management programs for patients with ongoing conditions, streamlining their care without compromising efficiency.
- Principal Care: Offer principal care as an independent service, providing individuals with comprehensive management of specific health issues.
- Procedures: Establish specialized procedure clinics, ensuring that patients receive necessary treatments promptly without delays caused by bundled care models.
In conclusion, revamping the U.S. specialty healthcare system involves breaking down the traditional bundled approach and reimagining specialist services as individualized, efficient, and accessible components. This shift towards unbundling holds the potential to address the existing challenges and enhance the overall quality of specialty healthcare in the United States.
Original article published on hbr.org
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