privacy and security

Payor Approaches to Cost Concerns: Considerations for Provider Contracting and Revenue Cycle

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Hospitals and health systems face ongoing pressure to migrate away from fee-for-service models, reduce costs, and improve quality. From MACRA to commercial risk arrangements to self-insured employer cost containment models, it is important for hospitals and health systems to take a strategic approach to revenue cycle and contract negotiations.  The recent press surrounding Anthem’s rollout of its new policy regarding hospital-based imaging, which will redirect a significant portion of imaging away from hospitals to free-standing facilities, highlights the nuanced approaches insurance companies are taking to rein in what they regard as high cost services.  Add to that the proliferation of consumer-driven health care models where patients are on the hook for more of the costs of the health care services they consume and thus look for ways to shop for best quality and price.  Further, “repricing” companies engage with self-funded employers to redesign their plans to remain out of network for a host of services for which the plan will pay a percentage of Medicare, which for many

Patient Safety Issues Highlighted in DOJ Settlement and Health Care Industry Cybersecurity Task Force Report

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As we know, the move away from fee for service reimbursement models is not only intended to reduce costs by no longer paying providers based on the volume of services performed, but is also intended to improve the overall value in healthcare delivery by improving quality, outcomes, collaboration across the continuum of care, patient engagement, and, of course, patient safety. Clinical care delivery has undergone substantial transformation over the last several years prompted by the value based reimbursement movement.  We have seen a substantial uptick in telemedicine, an explosion of apps and wearables, as well as initiatives designed to support patients who wish to remain in their homes.  Technology of course plays a key role in the transformation of healthcare.

The DOJ’s recent announcement of a settlement with eClinicalWorks (“eCW”) generated a lot of interest insofar as it addressed False Claims Act allegations against a vendor of electronic health records that caused providers to submit false claims for incentive payments as a result of