Beware The EHR “Ripple Effect”

Beware the EHR “Ripple Effect”

  • February 29, 2016

EHR conversions can be complicated and disruptive. So don’t make them more problematic by making unnecessary changes to revenue cycle management systems. By Carmen Deguzman Sessoms Like any major IT system implementation, an EHR conversion can be seriously disruptive to hospital operations—and finances. In addition to the many technical and clinical considerations of these projects, hospitals and health systems typically face an array of revenue cycle implications that may pose significant financial risks. Most of the pitfalls, however, are entirely avoidable, and those providers that align the technical, clinical, and financial elements of the project from the start can convert…

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The Two-Midnight Rule: Changes For 2016

The Two-Midnight Rule: Changes for 2016

  • February 1, 2016

Medical Necessity Documentation Still Required Have you heard the news? In the 2016 Outpatient Prospective Payment System Final Rule the Centers for Medicare & Medicaid Services (CMS) has modified the two-midnight rule evaluation and enforcement process. The “probe and educate” period ends on January 1, 2016. Enforcement of the rule will be the responsibility of the two BFCC Quality Improvement Organizations (Livanta and KEPRO). Their charge is to evaluate the appropriateness of short-stay inpatient admissions that extend over less than two midnights. Both BFCC Quality Improvement Organizations (BFCC-QIOs) will use InterQual as a decision support tool to help evaluate whether…

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How To Engage Providers Differently To Satisfy The New Healthcare Consumer

How to Engage Providers Differently to Satisfy the New Healthcare Consumer

  • December 21, 2015

Transforming provider relationships can be the key to engaging consumers By Dianne Wagner and Carolyn J. Wukitch U.S. health plans today operate in a world of rising expectations. They must work to contain increasing healthcare costs, while at the same time cater more to consumers. Members are the ultimate users of healthcare and health plans can no longer seek to solely satisfy the demands of employers. Health plans are redesigning their networks in search of value—finding the providers who deliver the best quality care, preventing health problems before they occur, and doing so efficiently and cost-effectively. In addition to the…

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Getting In Front Of The Problem: How Can Hospitals Empower Denial Prevention And Management?

Getting in Front of the Problem: How Can Hospitals Empower Denial Prevention and Management?

  • November 22, 2015

Healthcare providers are chiefly concerned with two things: Ensuring patients receive the highest quality of care, and getting paid for that care. Despite advances in medical technology and a declining number of uninsured Americans, hospitals still experience difficulty getting paid fully and in a timely manner today. Hospital and health system CEOs have named financial challenges as their No. 1 concern every year from 2012 to 2014, according to the American College of Healthcare Executives.1 Claim denials are a significant contributor to these challenges. Denials are a pervasive and persistent problem, as up to 1 in 5 claims is delayed or…

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Five Ways To Improve Medi-Cal Claims Processing

Five Ways to Improve Medi-Cal Claims Processing

  • September 23, 2015

Roughly one in three California residents— approximately 12 million people—are enrolled in Medi-Cal, the state’s publicly funded Medicaid program. To put this in perspective, California has 12% of the U.S. population, and yet accounts for 17% of the nation’s Medicaid enrollment. And the enrollment is growing—with 2.7 million people added since federal healthcare reform was enacted. Given the large percentage of revenue that Medi-Cal claims constitute for California hospitals, efficient and accurate Medi-Cal claims processing is a high priority for healthcare providers. But in reality, many providers find that Medi-Cal claims can be difficult to manage. The root causes of…

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Revenue Cycle Payment Clarity

Revenue Cycle Payment Clarity

  • April 10, 2015

What It Is, Why It Matters, and How It Can Help Your Patients and Your Bottom Line Healthcare providers today are principally concerned with two things: first and foremost, providing quality care to patients; second, getting paid for that care. Unfortunately, while advances in medical science and technology are making it easier to help patients get well, a tidal wave of reform is making it harder to get paid. Higher deductible plans and cost sharing mean that insured patients owe more. And as patient out-of-pocket expenses rise, so will the amount of bad debt carried by hospitals. Hospitals’ total cost…

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The Top 10 Things Payers And Providers Can Do Today To Start Aligning With VBR Tomorrow

The Top 10 Things Payers and Providers Can Do Today to Start Aligning with VBR Tomorrow

  • March 11, 2015

CMS says VBR is now an imperative. What can you do to make the grade? By Carolyn J. Wukitch and Andrei Gonzales, M.D. The stakes have just been raised for payers and providers who are besieged by a rapidly changing market. In an announcement that reverberated throughout healthcare, HHS Secretary Sylvia M. Burwell introduced an initiative to make alternative payment the standard for 50% of Medicare reimbursement by 2018. That’s the first time HHS established goals for alternative payment models for Medicare. HHS wants 30% of fee-for-service payments to be tied to quality or value through ACOs, bundled payment, or…

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How We Can Make Healthcare Payment And Delivery Reform Work

How We Can Make Healthcare Payment and Delivery Reform Work

  • January 9, 2015

By Andrei Gonzales, M.D. Powerful incentives and inertia remain intact, limiting stakeholders’ willingness to experiment with the range of innovative reimbursement models that promise to make the effort and cost of reform worthwhile. The result: growing agreement that transition to a system that fosters experimentation with mixed reimbursement schemes is required to ease away from the existing FFS model and the entrenched processes and technologies that are already in place. It’s said that imminent execution concentrates the mind. It could also be said that the looming specter of draconian cuts to healthcare, and their financial impact on stakeholders, are driving…

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Credible, Defensible Estimates

Credible, Defensible Estimates

  • October 14, 2013

More Accurate Upfront Financial Calculations Bring Increased Revenue, Satisfaction With Entire Care Experience By Carmen Deguzman Sessoms Executive Summary In healthcare, every interaction with the patient matters. Especially in today’s environment of continuous improvement, efforts have been concentrated on coordination among providers, the patient care experience and quality outcomes–all laudable goals. Often overlooked in these improvement efforts are the front-office and back-office functions that intersect with the care experience from beginning to end. A patient’s perception of the care experience begins when the phone rings for the initial appointment or appearance in the ED, and doesn’t end until the final…

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