Where Do Payers Fit Into Population Health Management?
Successful population health management is not possible without data. The form that information takes depends on the role being played by a particular player in population health management: provider, patient, or payer.nnWith passage of the Affordable Care Act and the movement toward value-based reimbursement, health plans find themselves facing challenges similar to those of the providers they’re working with in the pursuit of accountable care and population health.nn“The landscape is certainly changing and there are many changes. How payers are interacting with providers really depends on the type of structure they have set up,” says the newly-appointed IDC Health Insights Research Director Deanne Primozic Kasim.nn“In the last two to three years in particular, there have been many developments in terms of providers forming patient centered medical homes and accountable care organizations, not just with Medicare but also with some payers doing their own types of ACO arrangements,” she continues. “That has a different dynamic for the types of data being given to payers and the kinds of reimbursement coming back to providers.”nnThe challenge is made harder by the series of healthcare mergers, acquisitions, and partnerships that have an impact on reimbursement for providers and payers. ” You see these hospital systems just eating up provider practices and as their operations are being integrated there are more billing processes are in place in terms of how these groups now get reimbursed,” adds Primozic Kasim.nnIn looking for guidance in the area of accountable care in particular, Primozic Kasim admits that health plans can look to the approach taken by the Centers for Medicare & Medicaid Services (CMS) in its Medicare Shared Savings Program (MSSP) and Pioneer ACO Model, but that does not necessarily provide real clarification.nn
“What Medicare has put out there is being used as a guideline, but there is unfortunately not one roadmap,” explains Primozic Kasim. “It is a real challenge for payers in looking at the types of quality metrics they are going to use as different programs pop up, including what they do with the federal government if they choose to play there. There are so many quality metrics that they are challenged to keep up with them.”nnOne thing that is clear to payers is the need to understand individuals as consumers as well as patients where Primozic Kasim sees great potential for improvement.nn“There isn’t one-size-fits-all just like there’s not one type of consumer or patient,” she stresses. “It’s really about trying to reach people by respecting their different healthcare literacy overall, their social use of technology, their access to technology, and what’s going to hit home with them because there are different messages and cultural and demographic concerns as to how to reach people.”nnAccording to the research director, certain payers have a leg up on others in the makeup of their patient populations. “The ones that have more of a target population, such as the Medicaid and Medicare Advantage plans, have an advantage over the larger national plans because their patient population is a lot more focused and more centered geographically as opposed to those plans that are trying to cover everybody in different market segments,” claims Primozic Kasim.nnGetting to know their patient populations is leading payers toward gathering intelligence through business and clinical analytics solutions and services. Given the inchoate of healthcare analytics choosing the right vendor partner or partners is not an easy one.nn“In terms of analytics, there is not one vendor that has a complete, defining market share,” says Primozic Karim. “There are many companies out there doing everything from the backend edge server to some of the more clinical analytics and looking at population health of these exchange populations because clearly setting premiums for this is going to be key to moving forward.”nnFor value to replace volume in healthcare, premiums and reimbursements must be properly configured. Without meaningful insight into the needs of the provider and patient populations, payers will not be able to rise to the requirements of this new era in healthcare.nnSource: www.ehrintelligence.com; Kyle Murphy; April 30, 2014.
This is just a short delay to the industry’s inevitable transition away from the 30 year old ICD-9 to ICD-10. ICD-10 is coming and Welter Healthcare Partners, Inc. is pulling out all the stops to help our clients prepare for it and be successful. nnICD-10 is a richer data set allowing for more data to be used and transmitted. It will absolutely help the industry document care, document what treatments and modality’s work and how well they work. It will allow providers to better describe their services and why they are necessary.nnICD-10 will also help tremendously as we continue to transition away from a fee-for-service system of reimbursement to a quality and outcomes based reimbursement system like physician centric bundled or episodic payments.nnWe are excited about ICD-10 and the opportunity it will bring to our clients and the industry. We encourage providers, practices, and hospitals to continue training efforts already underway. Determine deficiencies now, as the clinical documentation improvement process and getting your staff proficient with the ICD-10 code set can take time! Take advantage of being ahead of the game! If you haven’t started, we encourage you to do so as this is a huge transition and being completely prepared is the only way to prevent negative impacts on productivity and revenue!n
W56.01XA — Bitten by dolphinnnW56.22XA — Struck by orcannW58.13XA — Crushed by crocodilennW61.09XA — Other contact with parrotnnIn 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 
The Senate voted today, (March 31st) to delay the switch to ICD-10 billing codes to October 2015. This is just a short delay to the industry’s inevitable transition away from the 30-year old ICD-9 to ICD-10. ICD-10 is coming and Welter Healthcare Partners, Inc. is pulling out all the stops to help our clients prepare for it and be successful.nnICD-10 is a richer data set allowing for more data to be used and transmitted. It will absolutely help the industry document care, document what treatments and modalty’s work and how well they work. It will allow providers to better describe their services and why they are necessary. ICD-10 will also help tremendously as we continue to transition away from a fee-for-service system of reimbursement to a quality and outcomes based reimbursement system like physician centric bundled or episodic payments. We are excited about ICD-10 and the opportunity it will bring to our clients and the industry.nnWe encourage providers and practices to continue any training efforts already started, as the clinical documentation improvement process and getting your staff proficient with ICD-10 can take time! Take advantage of being ahead of the game! If you haven’t started, we encourage you to do so as this is a huge transition and being fully prepared is the only way to prevent productivity and revenue loss!
The 2014 Medicare Physician Fee Schedule (MPFS) final rule stipulated a negative update to the MPFS that was to be effective January 1, 2014. That reduction was averted for three months with the passage of the Pathway for SGR Reform Act of 2013, which provided for a 0.5 percent update for services paid under the MPFS through March 31, 2014.nnCMS is hopeful that there will be congressional action to prevent the negative update from taking effect on April 1, 2014. CMS has instructed the Medicare Administrative Contractors to hold claims containing services paid under the MPFS for the first 10 business days of April (i.e., through April 14, 2014). This hold would only affect MPFS claims with dates of service of April 1, 2014, and later. The hold should have minimal impact on provider cash flow, because under current law, clean electronic claims are not paid any sooner than 14 calendar days (29 days for paper claims) after the date of receipt. All claims for services delivered on or before March 31, 2014, will be processed and paid under normal procedures, regardless of any Congressional actions.