value based

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

Value Based Reimbursement: CMS Dials Back; Large Employers Forge Ahead

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Last week, CMS announced in proposed rulemaking its proposal to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model.  It also announced plans to revise certain aspects of the Comprehensive Care for Joint Replacement (CCJR) model, such as granting certain hospitals selected for participation in the CCJR model a one-time option to choose whether to continue their participation in the CCJR model, and a change to increase the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model track.  CMS noted in the proposed rulemaking that it “continues to believe that cardiac and orthopedic episode models offer opportunities to redesign care processes and improve quality and care coordination across the inpatient and post-acute care spectrum while lowering spending.”  CMS qualified that statement, however, by noting “it is appropriate to propose to rescind the EPMs and CR incentive payment model, and reduce the geographic scope of the CJR model” for several reasons, but most notably due to