Support Services

ACK Hotline

 

What are Quality Measures? 

Quality measures are tools that help us measure or quantify healthcare processes, outcomes, patient perceptions, and organizational structure and/or systems that are associated with the ability to provide high-quality health care and/or that relate to one or more quality goals for health care. These goals include: effective, safe, efficient, patient-centered, equitable, and timely care.

 

National Quality Measures: 

A database of measure sets for practitioners, health delivery systems, and health care providers, with standardized abstracts and ordering details 

HEDIS:

 

The Healthcare Effectiveness Data and Information Set (HEDIS) is a tool used by more than 90 percent of America's health plans to measure performance on important dimensions of care and service. Altogether, HEDIS consists of 81 measures across 5 domains of care. Because so many plans collect HEDIS data, and because the measures are so specifically defined, HEDIS makes it possible to compare the performance of health plans on an "apples-to-apples" basis. 

NQF Measures 

NQF-endorsed consensus standards for ambulatory care, representing an initial set of ambulatory care voluntary consensus standards, conducted under "Phase 2" of NQF's ambulatory care work.

 

Other Changes: 

·       The switch to value-based reimbursement has turned the traditional model of healthcare reimbursement on its head, causing providers to change the way they bill for care. Instead of providers being paid by the number of visits and tests they order (fee-for-service), their payments are now based on the value of care they deliver (value-based care). 

·         ICD-10 

·         Coding and Reimbursement 

·         ACO

·         PCMH 

Trying to navigate Healthcare and Its New Models for Reimbursement can be overwhelming. However, ACK Hotline can you assist you. Online / Phone Support covers  all these changes and more: 

How it Works: 

• $59.00 per month
• Unlimited Phone Support
• Unlimited Email Support
• No Contract , cancel whenever
• Hours of Operation : [Mon-Thurs 8-5 and Friday 8-1]

 

ü  Claims Analysis

ü  ICD-10 Mapping

ü  HEDIS

ü  PQRS

ü  ACO

ü  PCMH

ü  Medical Policy

ü  Coding and Reimbursement

ü  Credentialing

 

·         Your Source of Information a phone call away

·         Comprehension of  the Changes, phone call / email away

 

 

 

ACK Hotline:

305-227-2383
1-877-938-9311

Value Based Performance

Value Based Modifier - VBM

 

In health care, the days of business as usual are over. Around the world, every health care system is struggling with rising costs and uneven quality despite the hard work of well-intentioned, well-trained clinicians. Health care leaders and policy makers have tried countless incremental fixes—attacking fraud, reducing errors, enforcing practice guidelines, making patients better “consumers,” implementing electronic medical records—but none have had much impact.

It’s time for a fundamentally new strategy.

 

At its core is maximizing value for patients: that is, achieving the best outcomes at the lowest cost. We must move away from a supply-driven health care system organized around what physicians do and toward a patient-centered system organized around what patients need. We must shift the focus from the volume and profitability of services provided—physician visits, hospitalizations, procedures, and tests—to the patient outcomes achieved. And we must replace today’s fragmented system, in which every local provider offers a full range of services, with a system in which services for particular medical conditions are concentrated in health-delivery organizations and in the right locations to deliver high-value care. 

The transformation to value-based health care is well under way. Some organizations are still at the stage of pilots and initiatives in individual practice areas. Other organizations, such as the Cleveland Clinic and Germany’s Schön Klinik, have undertaken large-scale changes involving multiple components of the value agenda. The result has been striking improvements in outcomes and efficiency, and growth in market share.

 

There is no longer any doubt about how to increase the value of care. The question is, which organizations will lead the way and how quickly can others follow? The challenge of becoming a value-based organization should not be underestimated, given the entrenched interests and practices of many decades. This transformation must come from within. Only physicians and provider organizations can put in place the set of interdependent steps needed to improve value, because ultimately value is determined by how medicine is practiced. Yet every other stakeholder in the health care system has a role to play. Patients, health plans, employers, and suppliers can hasten the transformation—and all will benefit greatly from doing so. 

Facing severe pressure to contain costs, payors are aggressively reducing reimbursements and finally moving away from fee-for-service and toward performance-based reimbursement. In the U.S., an increasing percentage of patients are being covered by Medicare and Medicaid, which reimburse at a fraction of private-plan levels. These pressures are leading more independent hospitals to join health systems and more physicians to move out of private practice and become salaried employees of hospitals. (For more, see the sidebar “Why Change Now?”) The transition will be neither linear nor swift, and we are entering a prolonged period during which providers will work under multiple payment models with varying exposure to risk.

 

How to Solve the Cost Crisis in Health Care

 

1: Organize into Integrated Practice Units (IPUs)

2: Measure Outcomes and Costs for Every Patient

3: Move to Bundled Payments for Care Cycles

4: Integrate Care Delivery Systems

5: Expand Geographic Reach

6: Build an Enabling Information Technology Platform

 

 

 

What is an Accountable Care Organization (ACO)?

The Accountable Care Organization concept is one that is evolving, but generally, an ACO can be defined as a set of health care providers—including primary care physicians, specialists, and hospitals—that work together collaboratively and accept collective accountability for the cost and quality of care delivered to a population of patients.

An ACO potentially could be formed around a variety of existing types of provider organizations.  Many multispecialty medical groups, physician-hospital organizations (PHO), and organized or integrated delivery systems already function as ACOs or have the management and/or payment structure required to quickly evolve into an ACO.  Other provider organizations, such as tightly managed independent practice associations (IPAs), are also likely candidates to become ACOs but some may require more time and/or infrastructure support to provide the care and cost benefits of an ACO. 

The Affordable Care Act’s most significant contribution to creating ACOs is in the traditional Medicare fee-for-service system.  The law includes a provision that allows Medicare to reward healthcare organizations with a share of the savings that would result from improving care quality and reducing the cost for their eligible Medicare populations..  To participate in this “shared savings program,” healthcare organizations need to become Accountable Care Organizations (ACOs).

The Centers for Medicare and Medicaid Services (CMS) are currently testing several models of care delivery re-design that aim to improve the efficiency of American healthcare systems, improve quality, and contain costs—in other words, to provide accountable care.  These include such initiatives as the Advanced Payment Incentive, Pioneer ACO demonstrations, in addition to the Medicare Shared Savings ACO program. 

Private commercial payers, such as Cigna, Anthem, and Aetna are also supporting ACO formation, testing the concept either by aligning incentives with more organized provider groups and health systems in their marketplaces or by purchasing physician groups and providers to attempt to improve care delivery. 

These types of insurer-directed payment approaches to care delivery remind many of the HMO movement of the 1990s.  Since that time, however, the term HMO has come to mean different things.  Today, HMOs generally refer to:  1) Fully integrated delivery systems like Kaiser Permanente, where the insurer, physician groups, and hospitals are part of one integrated organization, and care is provided to only those who are insured by that organization; and 2) private health-plan products that call themselves HMOs, but are fundamentally only payment contracts with a network of mostly disaggregated physicians and hospitals. 

In the former, care and cost can be managed much more effectively because clinical information and care processes are shared and supported by all providers.  In the latter, care and cost are less easily managed because the providers are bound only by contractual agreements, not by care processes, shared incentives, or a common mission or shared values.  Kaiser Permanente, an HMO, has for many decades delivered strong care coordination and integration of clinical services, care management, and clinical integration systems that many people are looking for in the ACO model.  While some HMOs could meet the test of an ACO, not all of them have currently the capability.

For more details  call 786-231-7585 

 

Accountable Care Organizations (ACOs)

The number of Accountable Care Organizations (ACOs) has grown significantly since the implementation of the Affordable Care Act. ACOs now provide care for 15-17% of Americans, according to Forbes.

For many patients, ACOs are improving the quality of care provided by hospitals, post-acute facilities and other health care facilities. “Shared Savings Program ACOs improved on 30 of the 33 quality measures in the first 2 years,” reported the Centers for Medicare & Medicaid Services.

While there is evidence of success, improving ACOs is still a government priority. Challenges have resulted in ACOs dropping out of government incentive programs, dismantling and/or lacking in improvement initiatives.

Obstacles Challenging ACOs Nationwide:

1. Adjusting to the new evidence-based reimbursement system
2. Low staff to patient ratio, leading to exasperating caseloads for physician and nurse practitioner (NP)
3. Outdated technology
4. Inefficient leadership and/or management
5. Insufficient number of qualified physicians
6. Communication barriers between physicians and collaborating facilities

The Patient Protection and Affordable Care Act (PPACA) gives new impetus to physicians to form accountable care organizations (ACOs) to better coordinate the care of their patients, especially those with chronic diseases, and to ensure a continuum of care. Of course, the devil is in the details.

Before we get into those details, some background is needed. An ACO, which may affiliate with a hospital, consists of a group of doctors working together under one legal umbrella. ACOs create incentives for healthcare providers to treat an individual patient across care settings–including doctors' offices, hospitals, and long-term care facilities. Various models exist. Some ACOs consist only of primary care doctors, whereas others include specialists. When ACOs own the practices, its doctors are employees. Well-designed
integrated delivery networks such as the Mayo Clinic, Geisinger Clinic, Cleveland Clinic, and Marshfield Clinic could be reorganized to comply with the new Centers for Medicare and Medicaid Services' (CMS') definition of an ACO under the PPACA.

The PPACA specifies that an ACO may include the following types of groups of providers and suppliers of Medicare-covered services:

• ACO professionals (that is, physicians and hospitals meeting the statutory definition) in group practice arrangements;
• networks of individual practices of ACO professionals;
• partnerships or joint ventures arrangements between hospitals and ACO professionals, or
• hospitals employing ACO professionals; and
• other Medicare providers and suppliers as determined by the secretary of the Department of Health and Human Services (HHS).

On March 31, CMS proposed new rules and incentives to help doctors, hospitals, and other healthcare providers better coordinate care for Medicare patients through ACOs. The Medicare Shared Savings Program will reward ACOs that lower growth in healthcare costs while meeting performance standards on quality of care and putting patients first. Patients and provider participation in an ACO is purely voluntary. Under the above proposal, ACOs would coordinate and improve care for patients with Original Medicare–Medicare Parts A and B. ACOs would have to meet high quality standards to ensure patients are satisfied with the care they receive and have better health outcomes. And, if ACOs can help save money by getting patients the right care at the right time, they can share in those savings with Medicare. As proposed, ACOs also would have to pay back Medicare for failing to provide efficient, cost-effective care. The new program is set to begin on January 1, 2012.

ACO ALTERNATIVES

A "hybrid" alternative to the ACO model described above brings together certain segments of the private practice community physicians, primary care physicians, and specialists, under a legal umbrella. This hybrid model can affiliate with hospital(s). The physicians in this ACO provide care for patients under "fee for service" or the ACO can contract to care for a segment of a population under a "risk-sharing formula." Because the providers are under one umbrella, medical care can be coordinated to be successful. This hybrid ACO has to pay particular attention to not unduly control the providers nor make money off the practices.

Another model operates virtual, networked systems for private practices using Web-based health information technology to achieve true integration of patient care across a community. These practices are located in multiple locations and operate as separate entities linked together clinically through a common electric health record (EHR) system. Using this electronic link, this model can coordinate patient care, fulfilling the requirements of an ACO.

Any healthcare reform or ACO must put serving patients first by improving quality, efficiency, and customer service, and by decreasing cost, waste, bureaucracy, and errors. If we were able to design from scratch a "practical" ACO that meets these criteria, what would it be?

First and foremost, all parties must put aside their individual interests. Because we live in a democratic, capitalistic society, and because we are dealing with human nature, we have to consider each stakeholder's interest to make it successful. We always should remember to not diminish the fundamental mission of an ACO. Some government programs are proposing a "risk-gain" model for ACOs. The government formula is not clear and can change from year to year. It is imperative that an ACO be formed to take better care of patients at lower cost, rather than be formed just to chase federal or state money. The latter reason to form an ACO is ill advised. However, if an ACO is first formed for the correct reason, and has the proper infrastructure and business plan, it can then entertain the idea of participating in the federal/state programs.
 

CREATE A WIN-WIN

The U.S. capital market is successful because of a mixture of many small businesses and some large corporations. The entrepreneurial spirit with the 24/7 working mentality is the hallmark of small business enterprises. Private practice community doctors are small business entrepreneurs who function best in their own element when they have oversight over their practices. These community private practices may be small but usually are run very efficiently and do not go bankrupt.

When PhyCor, a publicly held physician practice management company, was recruiting to buy practices in New Haven, Connecticut, in the 1990s, it stated that small private practices would be a thing of the past. A solo, private-practice doctor from Hamden, Connecticut, countered that PhyCor would go bankrupt before him. True enough, PhyCor is gone and this doctor is still in practice with a large following of patients.

Although these small private practices may not have the so-called "economies of scale," they operate with low overhead without layers of bureaucracy. Economy of scale sounds good, but it can be elusive. These small business enterprises know their sources of revenue and how to collect it. They know their overhead and where every dollar is spent. The appointment schedulers know their providers well, some having worked for their bosses for years or even decades. Instinctively, they know when and where to add a patient without disrupting the provider's schedule. They know which patient should get a courtesy discount and which unpaid accounts should be sent to the collection agency. Such local-level attention to details should be part of any ACO's business plan.

The above comments are not meant to put a value judgment on either system, but merely to point out some of the realistic day-to-day pitfalls that lead to increased overhead and decreased efficiency. The comments point out that it is an exercise in futility for institutions to purchase doctors' practices and try to manage these offices to increase efficiency in the name of "economies of scale." Doing so leads to frustrations on both sides, and the history of the 1990s may repeat itself. Besides, once the practice has been bought, even if the physicians are paid through many various bonus schemes, the productivity of the physician is never the same as when he or she was a private-practice entrepreneur. This fact of life has to be factored into the business plan of any proposed ACO.

A PROPOSED STRATEGY

The institution or any administration forming an ACO should not plan to make money off the doctors' practices. The institution or the ACO will do well by creating user-centric facilities that allow the doctors to provide their medical/surgical services efficiently for their patients and with great customer service. The institution must operate within its core businesses, "in the facility business," and makes its profit in that mode. By the same token, the doctors should be in their core profession/business, which is practicing medicine or surgery.

To increase efficiency and enhance customer service, the doctors within their practices should have the ability to obtain certain low-cost diagnostic tests and the results within their practices. This ability is not as much to generate revenue as to make things convenient for the patients. This way, the patients do not have to wander around town to get the tests or wait for days for the results. The ability to have a diagnosis made during the same office visit and within the same office setting brings great convenience and comfort to the patient. Additionally, treatment can be started right away. Having these simple diagnostic tools in the physicians' offices, as well as having the ACOs' caregivers readily available to their patients diminishes, the number of emergency department visits. It saves costs and enhances patient satisfaction.

The second tier of tests, more sophisticated, high-cost tests, should be centralized to be more cost-effective and achieve better quality control. Through a "tests and referrals" tracking system, within an EHR system results of such high-tech tests should be available, reviewed by the doctor in a timely manner, and the patient informed of the results as soon as possible.

The purchase of professional liability insurance through the ACO and its affiliated hospital(s) also could be centralized. Doing so creates a win-win for the institution and the providers.

The group purchase of health insurance also can be centralized. However, in doing so, one has to offer multiple option plans, as a one-size-fits-all approach does not work. Each practice needs to be able to determine the level of health coverage for its staff. By the same token, each practice knows its staff well and each practice needs to determine the compensation and benefits for its staff.

An efficient, user-centric EHR system reduces staff and reduces the floor space for paper chart storage. It is true that an EHR system allows clinical information to be stored in a digital structured data format and can be pulled for review, analysis, and to compare doctors' performances. However, an EHR system that does not have a user interface that is extremely intuitive nor follows the workflow of the patient/doctor encounter can be disastrous, creating huge bottlenecks, decreasing efficiency, and generating a new host of medical errors. It leads to loss of revenue for the doctors, and the institution also loses revenue because of decreased utilization of the institution's facilities. Besides, the office staff is rattled because instead of caring for the sick, the doctors and their staff become key punch operators. The ACO's EHR system needs to have a user interface that follows the day-to-day workflow of the physician, one that allows the caregiver to capture the richness of the sacrosanct patient history taking and the unique physical findings of each patient.

The following steps are what enables the physician to provide quality care without error: the uninterrupted carefully taken history; the undistracted, astutely performed physical examination; and the focused deliberation to analyze the history; the physical, and the test results. The EHR system's user interface has to enable the physician to access the results of all the tests from his or her portable tablet from a secured Web server within seconds. The EHR system must enable the physician to do all the above while keeping eye contact with the patient. An ACOs should offer this user-centric interface module for the physicians.
 

DEFINITE TIME AND PLACE

There is a definite place and time for forming a practical ACO. However, a new strategy can be like fire. ire can warm our houses, cook our food. If misused, it can kill us and burn down our homes. For example, the Health Insurance Portability and Accountability Act (HIPAA) is a good rule, but due to its poor implementation by many, it has caused great frustration among patients and physicians. Ridiculous as it may sound, HIPAA has inadvertently raised the cost of healthcare. Numerous tests had been repeated because it was easier to repeat the tests than to obtain the test results ordered by another provider.

If we collaborate, combining the wherewithal of large corporations and the energetic spirit of the small businesses, we can deliver the answer that healthcare reform is waiting for. The practical ACO needs both primary care providers and specialists.

Let's take the time and energy to form the practical ACO with the main goal "to serve," not "to control" or "profit" from another profession, and not to create an unnecessary bureaucracy that increases costs to our unsustainable national healthcare spending. We need to centralize only those items that bring value, do not decrease efficiency, and do not dampen the entrepreneurial spirit of the community small businesses. It can be done. Any geographic area with a large number of private practice community physicians may be the place to showcase a successful and practical ACO.

Provider-Based Rule [PBR]

Hospitals are making efforts to establish provider-based clinics of all types. The provider-based rule (PBR) is quite complex and confusing; and there are definite ambiguities that make it challenging. HPP Management Group can assist you with the information you need , on explaining different aspects of CMS, and why is it interested in making a determination that an operation is provider based. HPP will also touch upon the importance of CMS-855 enrollment forms and completion to provider-based clinics.

 Understand the advantages of provider-based clinics to hospitals, the role of the hospitals to establish provider-based clinics, various ambiguities in the provider-based rule (PBR), the art of selecting criteria and meeting the demand to establish a provider-based clinic; and to brace up for the upcoming challenges..

Important questions:

• What is the advantage of provider-based clinics to hospitals?
• What do hospitals have to do to establish provider-based clinics?
• Why are there ambiguities in the provider-based rule (PBR)?
• What are the criteria that we must meet to establish a provider-based clinic?
• Do we have to meet each and every criterion in order to establish provider-based status?
• When is CMS interested in making a determination that an operation is provider-based?
• What CMS-855 enrollment forms must be completed relative to provider-based clinics?
• What specìal codìng and billing requirements are required for provider-based clinics?
• How do we set up a proper fee schedule for both the facility and professional components?
• What if we are outside the 35-mile default limit?
• What if we have a facility in which part is provider-based and part is freestanding?
• What if we have space that is used jointly by both the hospital and other providers?
• What kind of signage is really necessary?
• How do we report changes in provider-based operations?
• Should we routinely ask for determinations from out MAC?

For more details , please call 786-231-7585.

The New Business of Medicine

HPP Management Group, Corp.

Responsive phone and email support 

 

The New Medical Reimbursement

 

PQRS -2015                                                                Meaningful Use

HEDIS                                                                         Core Measures

Quality Indicators                                                       Value Based Modifier 

 

Whether we like it or not , it is the new way of doing business in the medical field.

 

The Value Modifier provides for differential payment to a physician or group of physicians under the Medicare Physician Fee Schedule (PFS) based upon the quality of care furnished compared to the cost of care during a performance period. In the future, the Value Modifier will be used to adjust Medicare PFS payments to non-physician eligible professionals (EPs), in addition to physicians. The Value Modifier is an adjustment made on a per claim basis to Medicare payments for items and services under the Medicare PFS. It is applied at the Taxpayer Identification Number (TIN) level to physicians (and beginning in 2018, to non-physician EPs) billing under the TIN.

 

Section 3007 of the Affordable Care Act mandated that, by 2015, CMS begin applying a Value Modifier under the Medicare PFS. We are phasing in the Value Modifier gradually to different sizes of physician group. In terms of the phase in, we are applying the Value Modifier in 2015 based on performance in 2013 for groups of 100 or more eligible professionals (EPs).  In 2016, we will apply the Value Modifier to groups of physicians with 10 or more EPs based on 2014 performance.  The Affordable Care Act requires CMS to apply the Value Modifier to all physicians and groups of physicians starting in 2017.  For 2015 and 2016, the Value Modifier does not apply to groups of physicians in which any of the group’s physicians participate in the Medicare Shared Savings Program, the Pioneer ACO Model, or the Comprehensive Primary Care initiative during 2013 and 2014, respectively.  For 2017, the Value Modifier applies to participants in the Medicare Shared Savings Program, Pioneer ACO Model, and Comprehensive Primary Care Initiative.  For 2018, the Value Modifier will also apply to Medicare PFS payments made to non-physician EPs.  

 

The time is NOW, and HPP Management Group, Corp., is the solution in navigating all the Quality Indicators that will allow and guarantee your correct reimbursement. If you are involved in RISK Management or Fee For Service, call our experts for details.

 

From Our Clients :

 

ü  I recommended this solution to my colleagues and they're signing up too!  

 

ü  We used a popular, more expensive PQRS Registry last year and had issues with the website but could not get anyone on the phone and had to leave voicemail and follow-up with an email.  For the money that we paid, they should have better customer service. HPP customer service is a Cadillac compared to the Hyundai I experienced last year. When I called, I spoke to someone right away!

MD,  Private Internal Medicine Practice , Miami, FL 

ü  After trying for a couple years to receive the bonus, we finally received it this year using your system.

ü  We are very satisfied with your process and service and confident that our practice will benefit from the incentive and avoid the penalties.

Family Medicine Practice,  San Antonio, TX

 

 

HPP Management Group, Corp.

5201 Blue Lagoon Drive

Suite 815

Miami, Florida 33126

Phone: (305) 227-2383