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HHS Proposes Significant Changes to Patient Access Rules
February 11th, 2019
By Wyn Staheli, Director of Research | Published February 11th, 2019
In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...
By Wyn Staheli, Director of Research | Published January 3rd, 2019
Back in August of 2018, as part of the Medicare Shared Savings Program (Shared Savings Program), CMS proposed some sweeping changes for Accountable Care Organizations (ACOs). There has been some controversy over these changes which require ACOs to move to two-sided models. In this Final Rule which was scheduled to be published in the Federal Register ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 26th, 2018
Sooner or later ICD-11 will be released, and it sounds like it will be sooner than later. WHO released the news on June 18, 2018. The World Health Organization stated “ICD-11 will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come ...
By Wyn Staheli, Director of Research | Published June 14th, 2018
On May 11, 2018, the Department of Veterans Affairs (VA) released its final rule on the "Authority of VA Health Care Providers to Practice Telehealth." Effective June 11, 2018, VA providers will be able to provide telehealth services across state lines. This move will make it easier for veterans to obtain ...
Will Medicare's Proposed Reformations Affect Your Practice?
June 12th, 2018
By Wyn Staheli, Director of Research | Published June 12th, 2018
Recently, Medicare's Innovation Center released an informal Request for Information (RFI) seeking input on several different system reformation proposals. As the market moves towards more value based payment systems, innovation and new models are being sought to both reduce costs and increase quality. This article outlines the ideas presented in the ...
Understanding The Healthcare Fraud Prevention Partnership's Commitment to the Management of Opioid Misuse and Opioid Use Disorder
February 27th, 2018
By Jared Staheli | Published February 27th, 2018
The opioid epidemic continues to ravage communities nationwide. Since 1999, opioid deaths have quadrupled. 91 Americans die every day from opioid overdoses, and these numbers show no signs of declining. To address an epidemic of this magnitude, unprecedented cooperation between all involved parties needs to occur. In January 2017, CMS released a ...
MIPS - To Participate or Not Participate - That is the Question
January 10th, 2018
By Wyn Staheli, Director of Research | Published January 10th, 2018
Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...
Appropriate Use Criteria for Advanced Diagnostic Imaging Services - 2018 Final Rule
December 13th, 2017
By Jared Staheli | Published December 13th, 2017
What is the AUC program? From the CMS website:
Section 218(b) of the Protecting Access to Medicare Act of 2014 amended Title XVIII of the Social Security Act to add section 1834(q) directing CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging ...
By Wyn Staheli, Director of Research | Published November 28th, 2017
In 2015, the CMS Innovation Center announced plans for new value-based Medicare Advantage plans in an effort to reduce healthcare costs while improving quality of care. This five year pilot program began in 2017 with seven states and is expanding to ten states for 2018. Results must have been positive because they ...
By Dr. Ray Foxworth, Certified Medical Compliance Specialist, President of ChiroHealthUSA, Chiropractor | Published August 16th, 2017 - Last Review/Update February 5th, 2019
While scanning my news feed this morning, a few alarming words caught my eye: "Opioids could kill nearly as many Americans in a decade as HIV/AIDS has killed since the epidemic began in the early 1980s." Across America, people are talking about chiropractic as a safer alternative to opioid medication for pain relief, and yet, I don't think the magnitude of this opportunity has been realized by most doctors of chiropractic in this country.
In 2017, President Trump signed into law changes to the Veteran's Choice program, which allows veterans to seek care from a civilian (privately contracted) healthcare provider, closer to home, when obtaining care through the VA has become burdensome to the veteran or requires the veteran to wait too long for an appointment.
By Wyn Staheli, Director of Research | Published August 1st, 2017
Annual Wellness Visits (AWVs) are a preventive medicine service. It is a comprehensive evaluation and management service which is covered by payers as part of the Affordable Care Act (ACA)'s covered services and there are typically no deductibles or co-pays.
Certified Community Behavioral Health Clinics (CCBHC) Moving Forward
May 3rd, 2016
By Wyn Staheli, Director of Research | Published May 3rd, 2016
Certified Community Behavioral Health Clinics (CCBHCs) were created in an effort to improve access and outcomes behavioral healthcare by providing community-based mental and substance use disorder treatment through an integrative approach to care.
Provider/Patient Dynamic Changes as Result of High Deductible Plans
May 3rd, 2016
By Wyn Staheli, Director of Research | Published May 3rd, 2016
High-deductible plans are changing the way patients utilize medical services, therefore, providers must also adapt by adjusting both their communication and billing practices to keep pace with these changes.
By Instacode Institute | Published April 5th, 2016 - Last Review/Update January 2nd, 2019
Providers need to understand that even though there are now federal laws, state laws are often different. It is important to ascertain patient coverage before treatment begins. This article contains some federal laws which address mental health services.
First Physician Fee Schedule Proposed Rule Since SGR Repeal
August 19th, 2015
By Wyn Staheli, Director of Research | Published August 19th, 2015
Even though the SGR has been repealed, providers still need to be aware of annual fee revisions by CMS. On July 8, 2015, CMS announced their first proposed Medicare Physician Fee Schedule (MFPS) since the SGR repeal. As in years past, there will continue to be reviews of the Relative Value ...
Medicare Rules: What You Need to Know About the Value-Based Modifier
July 20th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 20th, 2015
The Affordable Care Act requires CMS to begin applying a new modifier known as the "value-based modifier" in 2015, part of its ongoing effort to move away from fee-for-service towards pay-for-performance.
For 2015, the modifier will only apply to physicians who are in a group of 100 or more participating providers, ...
For services furnished on or after January 1, 1987, the U.S. is considered one locality.
The U.S. constitutes a "medical service area comparable to the concept of trade areas," for the furnishing of enteral and parenteral therapies. The therapies, nutrients and associated supplies are available only from nationally recognized manufacturers and ...
By Wyn Staheli, Director of Research | Published February 3rd, 2015 - Last Review/Update June 9th, 2016
Even though the health care system in the United States is one of the most expensive per capita in the world, we have a dismally low quality of care ranking. Healthcare reform (HCR) in its simplest terms is addressing these shortcomings in order to improve healthcare coverage, delivery, policies, or ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 9th, 2015 - Last Review/Update March 1st, 2016
The Purpose of Risk Adjustment
Risk adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll. By risk adjusting plan
payments, CMS is able to make appropriate and accurate payments for enrollees with differences in expected costs. Increased accuracy benefits patients, providers, health plans, and the nation as ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update January 30th, 2017
Risk adjustments are used to compare Actual and Expected Mortality Rates using Risk Adjustments calculated by patient risk score.
BC Risk Adjustment — Risk Adjustment 101
WA Regence Administrative Manual
Risk adjustment is part of the Regence Medicare Program Management for Medicare Advantage plans. Commercial risk adjustment is a requirement of the U.S. Department ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update January 30th, 2017
How to calculate a risk score: In CMS’ calculation of the MA payment, CMS includes an additional factor in the risk score based on the original reason the beneficiary became legible for Medicare.
Below outlines the application of the factor based on original reason for entitlement.
Original Reason for entitlement Codes and ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
The outcome of care measures and the utilization measures are risk adjusted. The process of care measures aren't risk adjusted. Risk adjustment of the outcome of care and utilization measures is a multi-step process. These are the major steps in this process displayed in temporal order:
OASIS-C assessment data collection and ...
CMS Will Begin Applying the Value Modifier in Calendar Year (CY) 2017 to All Physicians
November 21st, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
CMS will begin applying the Value Modifier in calendar year (CY) 2017 to all physicians; including those in groups with two or more eligible professionals (EPs), and to physicians who are solo practitioners. This policy completes the phase-in of the Value Modifier to all physicians and groups of physicians as ...
By | Published July 24th, 2014 - Last Review/Update January 29th, 2016
Are Medicare fees going up? Or down? Results for the following:
Sequestration
Chiropractic Demonstration Project
Electronic Health Record/Meaningful Use
Physician Quality Reporting System - PQRS
Value-Based Modifier
Will mandatory Medicare payment cuts (due to the SGR) get repealed?
March 2nd, 2014
By | Published March 2nd, 2014 - Last Review/Update January 27th, 2017
Since 2003, healthcare providers have been dealing with the the short term patches to the Medicare payment system. After all this time, it now appears that Congress is making a move to address the ongoing issues with the Sustainable Growth Rate (SGR). This is the formula that has caused the payment problems with Medicare. Many professional organizations are endorsing the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015, S. 2000) and encouraging providers to contact their congressional leaders and lend their support for this legislation. If you wish to join those lending their support CLICK HERE for a helpful tool to contact YOUR congressional leaders.
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