From Humana to Highmark, Health Insurers Leave Insurance Marketplace, but Consumers are Undeterred

Recently, federal funds that assist Americans signing up for health insurance coverage under the Affordable Care Act (ACA) were cut by 40 percent and the ACA advertising budget was slashed from $100 million to $10 million.

These moves demonstrate the determination of the current administration and many in Congress to minimize the ACA insurance market and overturn the healthcare law. While these efforts appeared to stall initial sign-ups, they did not deter people. The fifth annual season for Americans to buy insurance under the ACA opened on Wednesday, November 1, 2017, with reports of crowds, technical difficulties and a public confused as never before by the political turmoil surrounding the law.

The funding decrease is problematic for the 2018 enrollment period, which just got started and will only last six weeks this fall instead of three months as in previous years. Sign-ups are taking place with many consumers confused by the political fighting in Washington over whether the law and its marketplaces will continue to exist.

Open Enrollment Begins

The federal website HealthCare.gov says, “2018 ACA Open Enrollment is here” and “Start a 2018 application now!” as both the federal and state insurance marketplaces attracted the year’s first customers. They came despite the 90 percent reduction in federal advertising about the sign-up window and the decision to send advance emails about enrollment to millions fewer Americans than in past years.

The emails went only to people with current health plans through marketplaces created under the law, leaving out most of the names in a database of about 25 million consumers who once had such coverage or at some point explored the federal website.

Nonetheless, plenty of people in certain states appeared eager to register on November 1 at places still offering in-person assistance through the navigator program.

In the first few days of open enrollment, the number of participants swelled compared with past years, according to federal officials who spoke on the condition of anonymity because the administration has yet to release official numbers.

More than 200,000 Americans chose a plan on November 1, the day open enrollment began, according to one administration official. That’s more than double the number of consumers who signed up on the first day of enrollment last year. More than one million people visited HeathCare.gov, the official said, which amounts to roughly a 33 percent increase in traffic compared with 2016.

These figures capture only a portion of the nation’s overall ACA enrollment because they encompass states that either uses the federal healthcare marketplace or rely on its website for their consumers to sign up for coverage. More than a dozen states and the District of Columbia run their own programs and do not use HealthCare.gov.

Many industry stakeholders were concerned that consumers wouldn’t sign up for coverage because Congress had tried to repeal it multiple times this year. But on opening day, many state exchange officials said that enrollment had exceeded their projections.

Connect for Health Colorado spokesman Luke Clarke said state officials had expected that 2,700 residents would log on to their exchange on November 1, but more than 4,000 did. “It’s way ahead of where we were last year, and a big surprise,” he said.

That same day in Connecticut, 1,596 residents enrolled in qualified health plans on the state exchange, while another 2,293 people either completed Medicaid applications or determined that they were eligible for the federal entitlement program. Access Health CT CEO Jim Wadleigh said in a statement that the state’s call center and website experienced a 15 percent increase in volume compared to opening day last year.

It’s all well and good that 2018 enrollment has been initially brisk, but what will the enrollment figures look like when the period ends on December 15, 2017, and how many insurers have made insurance plans available at a reasonable cost to consumers?

Healthcare Insurance Marketplaces

Many critics of the ACA say the law is “collapsing” and claim many insurers have left the ACA’s insurance exchanges or state-based online marketplaces where people can buy individual health insurance policies.

Today, it appears that about one-third of counties are projected to have just one insurer available for their insurance exchanges. That leaves 2.9 million consumers with little choice but to select the only insurer available in their county, which, ultimately, could put them in a financial bind due to high costs.

That statistic was echoed in a May 2017 editorial by former Health and Human Services Secretary Tom Price, in which he portrayed the ACA as a house on fire and “many of our fellow Americans are trapped inside.”

Some insurers already have decided to hike their 2018 premiums more than they would otherwise to position themselves for a possible adverse decision affecting the ACA. Consumer choice is limited due to insurers leaving the insurance marketplace. As of the November 1, 2017, open enrollment date, the following insurers have left the 2018 marketplace:

ATRIO Health Plans

Oregon – 6 counties

 Aetna

Delaware – 3 counties

Iowa – 76 counties

Nebraska – 93 counties

Virginia – 51 counties

 Anthem

California – 30 counties

Indiana – 92 counties

Kentucky – 61 counties

Maine – 16 counties

Missouri – 17 counties

Ohio – 87 counties

Virginia – 61 counties

Blue Cross Blue Shield Healthcare Plan of Georgia

Georgia – 73 counties

Blue Cross Blue Shield of Kansas City

Kansas – 2 counties

Missouri – 30 counties

BridgeSpan Health

Idaho – 44 counties

Oregon – 17 counties

Washington – 8 counties

Cigna Healthcare

Maryland – 24 counties

Community Health Plan of Washington

Washington – 14 counties

Health Tradition Health Plan

Wisconsin – 14 counties

Highmark

Pennsylvania – 7 counties

Highmark Health Insurance Company

Pennsylvania – 4 counties

Humana

Florida – 7 counties

Georgia – 9 counties

Illinois – 30 counties

Kentucky – 9 counties

Louisiana – 7 counties

Michigan – 9 counties

Missouri – 5 counties

Mississippi – 32 counties

Ohio – 7 counties

Tennessee – 30 counties

Texas – 10 counties

Innovation Health Insurance

Virginia – 19 counties

LifeWise Health Plan of WA

Washington – 4 counties

MDwise Marketplace

Indiana – 92 counties

Medica Health Plans

North Dakota – 49 counties

Minuteman Health, Inc.

New Hampshire – 10 counties

Massachusetts – 9 counties

Molina

Utah- 7 counties

Washington – 6 counties

Wisconsin – 30 counties

Northwell Health w/CareConnect

New York – 8 counties

Optima Health

Virginia – 17 counties

Premera Blue Cross

Washington – 1 county

Premier Health Plan

Ohio – 9 counties

Prominence Health

Nevada – 7 counties

Texas – 3 counties

Regence BlueShield

Washington – 2 counties

UnitedHealthcare

Virginia – 32 counties

Wellmark

Iowa – 4 counties

Final Thoughts

Clearly, the decisions by insurers to pull out of the insurance exchanges have been driven by the financial risk and an uncertain outlook for the marketplace. Insurers face continued uncertainty even in the midst of open enrollment. Some insurers explicitly have factored this uncertainty into their initial premium requests, while other companies say if they do not receive more clarity or if cost-sharing payments stop, they plan to either refile with higher premiums or withdraw from the market altogether.

What does this mean for consumers? They should expect a reduction of choices for insurers offering plans in their area and higher insurance rates due to the uncertainty of the marketplace.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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The level of respect, compassion and sensitivity to healthcare consumers is increasingly being used to judge patient satisfaction regarding quality of care and is an important component of a healthcare system’s care delivery.

There is an increasing focus on encouraging individuals to be more involved in their care, which has prompted providers to deliver healthcare in a more patient-centered way. Patient-centered care is focused on adapting services around the needs of consumers. These efforts are designed to engage patients, their family members and caregivers to achieve better clinical outcomes.

Today, patients expect to receive respectful treatment, enough information to make good decisions about their care, clear and abundant communication and quality clinical outcomes. Positive patient and staff experiences lead to good health outcomes through clinical effectiveness, which drives high levels of patient satisfaction and loyalty.

The new patient-centric care model is not without its challenges. The cost of delivering healthcare is rising quickly, and the consumer must now shoulder more of the costs. The new financial demands on patients have created a conundrum. Patients are enjoying newly implemented consumer-driven healthcare, but they are now paying handily for it. A study by Black Book™ indicates that since 2015, patients have experienced a 29.4 percent increase in both deductible and maximum out-of-pocket costs.

The Savvy Healthcare Consumer

A patient’s healthcare journey is a complex one. Beginning with pre-care, treatment, and ending with a measure of patient satisfaction, the emerging concept of patient-centric healthcare has many touchpoints that can break down and cause dissatisfaction. To satisfy savvier consumers, industry experts must address the gaps in the current patient experience by focusing on the entire patient healthcare continuum, from initial patient decision-making, scheduling, registration, administrative simplification, price transparency and effective consumer payment methods.

In March 2016, the Healthcare Information and Management Systems Society (HIMSS) Revenue Cycle Improvement Task Force study, A Roadmap to The Patient Financial Experience of the Future, reported that “the growth in consumer financial responsibility has led to the expected billing and collections challenges that were known to be weak points of a patient-centric revenue cycle. Many industry experts did not consider how much more information a patient with greater financial responsibility would come to expect.”

Traditional models for accessing and sharing health insurance, financial and clinical information, and a lack of interoperability between the systems that support these models are insufficient to meet the increasing demand for real-time information and price transparency.

As consumers shoulder larger amounts of financial responsibility for their healthcare, they begin to view healthcare as a retail experience, which means:

  • They are likely to transfer their expectations as a typical retail consumer to their healthcare experience.
  • More patients are researching their healthcare options before deciding where to go for care.
  • They are leveraging technology to determine the level of care available to them.
  • They expect to have pricing and quality or patient satisfaction information at their fingertips.
  • They think they should be able to use this and other information to compare providers in the same way they might compare consumer products they would purchase online.

Providers Address Consumerism with New Payment Financial Solutions

The new era of patient consumerism demands more technology-driven financing options, engaging patients early, analyzing consumers’ propensity to pay, managing expectations and genuine cost transparency.

Black Book announced key findings from its 2017 Revenue Cycle Management surveys part of a larger study of trends in consumer satisfaction and patient experiences and payment challenges and strategies for healthcare providers.

They determined that 83 percent of surveyed providers plan to meet the rise in patient consumerism with more retail-like technology solutions and practices.

“Emerging healthcare pay trends reveal the opportunity to help patients better anticipate, manage and track the costs of their care,” said Doug Brown, Managing Partner of Black Book. “Innovative patient-friendly payment solutions that meet consumer preferences and enable fast transactions are playing a key role in this transition.”

Black Book conducted two sets of focused polls in the second and third quarters of 2017 with both patients and providers. Consumer panel surveys aimed to determine how patient responsibility for medical costs, which has shifted from employers to patients, is impacting uncollected provider revenue. Black Book found that since 2015, patients have experienced a 29.4 percent increase in both deductible and maximum out-of-pocket costs, with an average deductible for consumers at $1,820 and out-of-pocket costs rising to over $4,400. The combined surveys included 2,698 providers and a focus group of 850 healthcare consumers with high deductible health plans.

Survey findings from 1,595 physician practices, 202 hospitals and 49 health systems reveal profit margins continue to be impacted negatively by traditional collection solutions, steering 82 percent of medical providers and 92 percent of hospitals to eliminate time-intensive, error-prone, manual effort to implement back-end process and reconcile bills by the fourth quarter of 2018. With millions of dollars of unpaid medical bills, many providers are instituting new processes and technologies to recover the monies owed them.

“Employing these solutions at the front end of the revenue cycle has given patient risk to providers and the attention has turned to establishing funding mechanisms to benefit not only the hospital or physician but the consumer,” said Brown. “Patients truly are the new payers.”

Results also determined that in the first half of 2017, nearly 62 percent of medical bills were paid online and 95 percent of consumers polled would pay online if the provider’s website had the option.

Seventy-one percent of patients also reveal that mobile pay and billing alerts have improved their actual satisfaction with the provider.

Online estimation, payment plan administration and on-demand instructions support (all of which were ranked by consumers in the top five improvements providers could make to improve satisfaction) produce more cost transparency for consumers. “For providers, that brings faster posting and collection of payments without manual processing errors,” added Brown.

Guest pay (allowing spouses, family members, friends, attorneys and others to pay patient bills without accessing patient medical records) is also improving consumer satisfaction. Fifty-nine percent of consumers appreciate the convenience and simplicity of online payments without the hassles of registration and passwords.

Summary

Industry stakeholders have acknowledged the need for health plans and providers to share information with consumers in a more coordinated fashion to enable improved consumer financial activities. The seamless connection between healthcare financial and clinical systems is critical to respond to the new revenue cycle demands. Consumers expect an improved financial experience in healthcare and providers must step up to provide the healthcare services, payment systems and technology to serve patients at higher levels.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Join Us for This Special One of a Kind Webinar. Learn Inside Secrets from a Vendor Who Codes Over 2 Million Charts Per Month

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Learn about how to stay in compliance and maximize reimbursements – Medicare Advantage makes up 31 percent of total Medicare spending, serves over 17 million enrollees and it is expected to double in size by 2024. The average monthly premium for a Medicare Advantage plan will decrease while enrollment in Medicare Advantage is projected to reach a new all-time high in 2018.

These changes, plus the overall complexity of the program further complicate HCC coding. Why wait until year end to review your HCCs? Learn the secrets MiraMed uses to catch coding errors, maintain compliance and improve revenue capture.

You will learn:

  • What’s happening in healthcare today
  • The type and specialty of the organization
  • The scope of HCC audit project, why there was a need for the external HCC audit and coding work.
  • The client’s baseline prior to HCC audit
  • The findings of coding and HCC audit
  • The impact to the organization

Presenters:

Amber Broadwater – MBA, RHIA, LHRM, ICD-10 Trainer – Vice President of Client Services, Coding Division at MiraMed Global Services.

Phil C. Solomon – Vice President of Marketing Strategy and Thought Leadership at MiraMed Global Services and Publisher of Revenue Cycle News Blog.

Save Your Spot – Register today: 

https://attendee.gotowebinar.com/register/3633988570364620289

For more information, contact Phil Solomon at phil.solomon@miramedgs.com

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Safety-net hospitals rely on disproportionate-share hospital (DSH) payments to help cover uncompensated care costs and underpayments by Medicaid. The Affordable Care Act (ACA) anticipated that insurance expansion would increase safety-net hospitals’ revenues and planned to reduce DSH payments accordingly.

However, decreases in uncompensated care costs resulting from the ACA insurance expansion may not offset the Act’s DSH reductions after all due to the high number of people who will remain uninsured, low Medicaid reimbursement rates, and medical cost inflation.

The DSH payment program was established in 1981 and provides over $20 billion each year in special Medicare and Medicaid funding to hospitals that treat a disproportionate share of indigent patients. Over 3,000 hospitals nationwide currently receive DSH payments.

The ACA originally called for reductions to DSH payments between 2014 and 2020, assuming that ACA coverage expansions would reduce the need for the funding of uncompensated care. Ensuing legislation delayed DSH payments cuts until the fiscal year 2018, which began October 1, 2017. Under the current structure, the DSH program funding will be cut by a total of $43 billion between fiscal years 2018 and 2025.

DSH Payments to Provider Hospitals

DSH payments are statutorily required to offset hospitals’ uncompensated care costs in order to improve access for Medicaid and uninsured patients and improve the financial stability of safety-net hospitals.

States began making Medicaid DSH payments in 1981. As states had broader discretion over hospital payment, Congress became concerned that this shift might threaten hospitals serving large numbers of Medicaid beneficiaries and the uninsured. In response, in 1981 Congress required states to “take into account” the situation of hospitals serving a disproportionate share of low-income patients when designing payment systems (§1902(a)(13)(A)(iv) of the Social Security Act).

Limits on DSH Allotments and Payments

When Congress first required states to make DSH payments, states had discretion as to how the funds were paid, and in turn, states were slow to make payments. In the Omnibus Budget Reconciliation Act (OBRA) of 1986, Congress clarified that Medicaid’s hospital payment limitations did not apply to DSH, and then in 1987 required states to submit state plan amendments authorizing DSH payments. At about the same time, a 1985 federal regulation permitted states to use both public and private donations as sources of non-federal Medicaid financing. The 1987 policy guidance indicated that taxes imposed on only Medicaid providers could also be used to finance Medicaid (National Health Policy Forum 2002). This combination of unlimited DSH payments and financing flexibility generated significant growth in DSH spending. From 1990 to 1992, the total amount of DSH payments increased from $1.3 billion to $17.7 billion (Urban Institute 1998).

As DSH spending increased, Congress grew concerned over the level of DSH spending and the possibility that some states were misusing DSH funds by making large DSH payments to state-run hospitals.  Congress addressed these concerns by enacting national and state-specific caps on the DSH funds and creating hospital-specific limits equal to the actual cost of uncompensated care for hospital services provided to Medicaid enrollees and uninsured individuals.

State DSH Payment Requirements

States have flexibility in determining which hospitals receive DSH payments and how those payments are calculated. States may make DSH payments to DSH hospitals if they meet one of two criteria specified in federal statute:

  • The hospital has a Medicaid utilization at least one standard deviation above the mean for hospitals in the state that receive Medicaid payments, or
  • The hospital has a low-income inpatient utilization more than 25 percent.

States’ DSH payment practices must be outlined within their Medicaid state plans. Federal statute requires that minimum payments to DSH hospitals must be determined using one of the following methodologies:

  • The Medicare DSH adjustment methodology,
  • A methodology that increases DSH payments in proportion to the extent that a hospital’s Medicaid utilization exceeds one standard deviation above the mean, and
  • A methodology that varies by hospital type and that applies equally to all hospitals of each type and is reasonably related to Medicaid and low-income utilization.

ACA Medicaid DSH Allotment Reductions

Under the ACA, federal DSH allotments were to begin reductions beginning in 2014 to account for the decrease in uncompensated care anticipated under health insurance coverage expansion. However, since 2010, several pieces of legislation have been enacted, thus delaying the ACA’s Medicaid DSH reduction schedule:

  • The Middle-Class Tax Relief and Job Creation Act of 2012 (P.L. 112-96), enacted on February 22, 2012, extended the reductions to FY 2021.
  • The American Taxpayer Relief Act of 2012 (P.L. 112-240), enacted on January 2, 2013, extended the reductions to FY 2022.
  • The Bipartisan Budget Act of 2013 (P.L. 113-67), enacted on December 26, 2013, delayed the onset of reductions until FY 2016 by eliminating the FY 2014 reduction and adding the FY 2015 reduction to that for FY 2016; also extended the reductions to FY 2023.
  • The Protecting Access to Medicare Act of 2014 (P.L. 113-93), enacted April 1, 2014, eliminated the FY 2016 reduction, thus delaying the reductions until FY 2017; also adjusted amounts of reductions in future years and extended them to FY 2024.
  • The Medicare Access and CHIP Reauthorization Act of 2015 (P.L. 114-10), enacted on April 16, 2015, eliminated the FY 2017 reduction, which delayed the reductions until FY 2018, adjusted amounts of reductions in future years, and extended them to FY 2025.

As a result, the schedule below reflects the pending amounts for the Medicaid DSH reductions:

  • $2.0 billion in FY 2018;
  • $3.0 billion in FY 2019;
  • $4.0 billion in FY 2020;
  • $5.0 billion in FY 2021;
  • $6.0 billion in FY 2022;
  • $7.0 billion in FY 2023;
  • $8.0 billion in FY 2024; and
  • $8.0 billion in FY 2025.

The Centers for Medicare and Medicaid Services (CMS) published its final rule describing its methodology for implementing the Medicaid DSH allotment reductions beginning in 2014 and 2015. The reductions were authorized by meeting the following:

  • One-third on its relative level of uninsurance;
  • One-third on the extent to which it targets DSH payments to hospitals with high Medicaid utilization; and
  • One-third on the extent to which it targets DSH payments to hospitals with high levels of uncompensated care.

Since there have been delays in the onset of the DSH reductions, the payment methodology necessary to implement them has not been rolled out. The current payment methodologies are no longer valid, creating a conundrum for CMS. They must now scurry to create a new payment methodology before the DSH payment reductions go into effect in 2018.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Healthcare stakeholders should be educated on the policy proposals contained in the Graham-Cassidy Healthcare Bill proposal.  This updated chart provides a comparative analysis of the Graham-Cassidy Bill, the Better Care Reconciliation Act (BCRA), the American Health Care Act (AHCA) and the ACA.

The chart highlights each bill’s treatment of a number of core issues, including:
•    Insurance subsidies
•    Individual mandate
•    Employer mandate
•    Young adults
•    Essential health benefits
•    Prohibition on annual and lifetime limits
•    Age-rated limit
•    Health status premium underwriting
•    Preexisting condition coverage
•    Relief for high-risk individuals
•    Medicaid expansion
•    Traditional Medicaid
•    Health Savings Accounts (HSAs)
•    Tax provisions

Healthcare_Comparison_Chart_9-18-2017

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Healthcare providers, if you serve Medicare, Medicaid and Children’s Health Insurance Program (CHIP) patients in the counties and geographical areas impacted by Hurricane Irma and Hurricane Harvey, or see patients who have been displaced from their homes in these areas who are in need of care, you need to know how government payers are responding to the crises, as well as the compliance implications of their actions for your facilities.

“Hurricane Irma has proven to be highly destructive and poses a significant threat to the health and safety of all Americans in its path,” said Health and Human Services (HHS) Secretary Tom Price, MD.  “HHS has pre-positioned assets and personnel who can rapidly deploy to assist local responses in Florida to Hurricane Irma, and this declaration will help ensure that access to care is maintained for those with Medicare and Medicaid.”  Secretary Price also authorized emergency efforts in Texas in the aftermath of Hurricane Harvey.

Beyond deployment of emergency resources, Secretary Price has declared a public health emergency in Florida, Georgia, South Carolina, Puerto Rico and the U.S. Virgin Islands in response to Hurricane Irma and in Texas and Louisiana in response to Hurricane Harvey.

The public health emergencies have enabled the Centers for Medicare and Medicaid Services (CMS) to issue several blanket programmatic waivers of certain requirements for providers who care for Medicare, Medicaid and CHIP beneficiaries, based on Section 1135 of the Social Security Act.  The blanket waivers are designed to offer beneficiaries—including those who are evacuated, transferred or dislocated as a result of the hurricanes—access to medical care during the emergency.  The waivers give hospitals, skilled nursing facilities (SNFs), other healthcare facilities and clinicians more flexibility to deliver emergency and other healthcare services in the wake of the disasters.

The flexible temporary policies regarding specified requirements are designed to bolster the effectiveness of the emergency response by, for example, allowing hospitals to share medical records without the usual restrictions and permitting doctors accredited by other states’ Medicaid programs to provide emergency treatment.  Individual facilities in the impacted areas or those treating patients evacuated from the impacted areas need not apply for these blanket waivers.

Following is a summary of the blanket waivers for both Hurricane Irma and Hurricane Harvey, under Sections 1135 or 1812(f) of the Social Security Act (for the impacted areas in the U.S. Virgin Islands, Puerto Rico, Florida, Georgia, South Carolina, Texas and Louisiana).

  • 1812(f):  Waives the requirement for a three-day prior hospitalization to obtain coverage of a stay in a SNF providing temporary emergency coverage of SNF services without a qualifying hospital stay for individuals evacuated, transferred or otherwise dislocated in 2017.  For certain beneficiaries who have exhausted their SNF benefits, the waiver authorizes renewed SNF coverage without first having to start a new benefit period.
  • 483.20:  Provides relief to all impacted SNFs on the timeframe requirements for Minimum Data Set (MDS) assessments and transmission.
  • 484.20(c)(1):  Provides relief to all impacted home health agencies on the timeframes related to OASIS transmission.
  • Waives the requirement for Critical Access Hospitals to limit the number of beds to 25 and limit the length of stay to 96 hours.  This is a blanket waiver for all impacted hospitals.
  • Waives the requirement for Inpatient Prospective Payment System (IPPS) hospitals to house acute care patients in distinct units, where the distinct part unit’s beds are appropriate for acute care inpatients.  The IPPS hospital should bill for the care and indicate in the patient’s medical record that the patient is an acute care inpatient being housed in the excluded unit due to capacity issues related to the hurricane.  This is a blanket waiver for all IPPS hospitals located in the affected areas that need to use distinct part beds for acute care patients as a result of the hurricane.
  • Waives the requirement for a face-to-face visit with a physician, a new physician’s order and new medical necessity documentation for suppliers of durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) when DMEPOS are lost, destroyed, irreparably damaged or rendered unusable.  Under this waiver, suppliers must continue to provide a narrative description on the claim explaining the reason why the equipment must be replaced.  They are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable as a result of the hurricane.
  • Allows coverage for replacement prescription fills for a quantity up to the amount originally dispensed of covered Part B drugs in instances in which the dispensed medication was lost or rendered unusable by damage due to the hurricane.

For providers in the states of Texas and Louisiana, CMS has extended the September 1, 2017 deadlines to October 2, 2017 for the following:

  • Applications for sole community hospital (SCH) status
  • Written requests for low-volume hospital status in order to receive the low-volume hospital payment adjustment for discharges in fiscal year (FY) 2018
  • Applications for reclassification to the Medicare Geographic Classification Review Board (MGCRB)
  • Extensions for IPPS Wage Index revisions

Please note that, according to CMS, these temporary emergency policies apply to timeframes specified in the waiver(s) issued under Section 1135 of the Social Security Act.  More information is available on the CMS website here.

For instances in which there is no blanket waiver, providers can request an individual Section 1135 waiver by following the instructions available here.  According to CMS, “specific waivers granted as a result of the emergency or disaster may be retroactive to the beginning of the emergency or disaster if warranted.  CMS also has the authority to exercise certain flexibilities, which are agency policies or procedures that can be adjusted under current authority—and generally speaking, can be adjusted without reprogramming CMS’s systems.”

The effects of these natural disasters on care delivery, as well as billing and reimbursement, will not only be felt for the short term, but are likely to ripple through your organizations for at least several months and possibly more than a year.  We encourage you to check the Hurricane page on the CMS website frequently for updates.  Questions regarding claims can be directed to your Medicare Administrative Contractor on its toll-free number, which can be found here.  ICD-10 coding advice from the Centers for Disease Control and Prevention in the aftermath of the disasters is available here.

Read more updates: MiraMed eAlerts

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Hurricane Harvey wreaked havoc in southeastern Texas last week and created a public health crisis.  The tropical cyclone or what is called a category four hurricane caused unprecedented and catastrophic flooding in the southeastern part of the state.  It was the first major hurricane in the U.S. since Wilma in 2005, a category five hurricane with winds of up to 185 mph.

Harvey is the wettest storm on record in the contiguous United States and is “almost certain” to be at least the third worst storm in U.S. history when it comes to damage costs, according to Enki Research.  The firm’s current estimate ranges from $48 billion to $75 billion, with an average of $57 billion.  However, those numbers are subject to change with each passing day.  “The computer models we normally use to do estimates for hurricanes don’t work that well for this kind of a storm,” Chuck Watson, the director of research and development at Enki Research, said.

The resulting floods inundated hundreds of thousands of homes, displaced more than 30,000 people and prompted over 13,000 rescues.  Medical services and hospitals were taxed beyond capability, especially since many hospitals and medical facilities were closed and evacuated.

Though Hurricane Harvey pounded Texas with a national rainfall record for a tropical storm, crisis management coordination between the state and Texas hospitals ensured care was minimally interrupted.  The South East Texas Regional Advisory Council (SETRAC) claims that roughly 90 percent of healthcare facilities will return to full service by October, according to STAT News.

The outcome could have been much worse, considering the nature of the storm.  Houstonians pulled together and weathered the storm with great determination.  Addressing Harvey’s effects required a resourcefulness that no other catastrophe has necessitated.  The storm has challenged a comprehensive disaster plan the city and surrounding counties had prepared.  The devastation so far has been unimaginable.

The host of National Public Radio’s (NPR) show, All Things Considered, Kelly McEvers spoke with Darrell Pile, CEO of SETRAC which runs the catastrophic medical operations center which will offer a perspective of the medical challenges experienced during the storm.  This interview has been edited for length and clarity.

NPR Interview Highlights

While the storm has largely left Houston, the flooding continues.  What is the situation with the hospitals you are working with?

The flooding is devastating, and we have at least two reservoirs where water is having to be released and is, in fact, flooding neighborhoods as we speak and has placed three hospitals in harm’s way.

The three hospitals are monitoring the water coming from the two reservoirs very closely, and they could, depending on the flow of the water, find that they could become inaccessible to EMS agencies.  We are tracking that very closely.

The situation with residents in their homes—some are on the second floor of their homes—the evacuation process [for those neighborhoods] continues, and, as a result, it is unclear what the demands on the health care system may be.  However, most hospitals are up and fully functional, and we believe we can handle any new demands that happen today or tomorrow.

Has the catastrophic medical operations center ever handled anything like this?

No.  The phone lines at one point became inundated.  The amount of resources needed began to exceed what we had available.  The calls included patients needing dialysis who might be at home.  It included hospitals saying we need to evacuate.  One call was asking for 50 wheelchairs to be sent to a shelter.  We did not have 50 wheelchairs left.  Fortunately, our governor declared a disaster and the president declared a disaster and resources have been brought in from all over the state and all over the nation to help us.

How did you get those 50 wheelchairs?

I am not clear on how they ended up getting the 50 wheelchairs, but I can tell you, it can be accomplished just through one or two tweets to Houstonians.  Those with wheelchairs perhaps in their attic or stored [elsewhere] could bring an abundance of wheelchairs, perhaps more than you even need.  So there are methods to solve every problem.  It is just having enough people to make the calls or to be innovative and creative to solve the problems.  This community has come to the call.

A number of hospitals did evacuate, either prior to the storm or during. How difficult is it to evacuate a hospital?

It’s not as simple as pulling up a bus or a convoy of ambulances and moving patients from one hospital to another hospital.  My organization makes sure that the receiving hospital meets the need of every single patient they agree to receive.  As a result, the evacuation of a hospital might mean we must identify ten different hospitals to meet the unique needs of each patient.

Every day, three times per day, we have hospitals electronically advise us of beds that they have available and the type.  So a pediatric patient goes to a pediatric bed.

Moreover, we have also spent time making sure the receiving hospital is not in harm’s way so that the patient would not have to be evacuated twice.  We have worked with the [Texas] Department of State Health Services to also identify hospitals with beds available in cities such as Dallas or San Antonio or Austin or even further away so that a patient doesn’t move twice.

Some Houston hospitals added flood protections as a result of other devastating storms, including Allison in 2001. Have those worked?

Absolutely.  We had a situation where in prior storms, water came into a tunnel system that connects the Texas Medical Center hospitals.  [The tunnels] make it easier to go from one hospital to another hospital.  However, waters came in and flooded every hospital through that tunnel system.

The Texas Medical Center invested in submarine-type doorways, and when there is a risk of flooding, they now close those doorways.  So each hospital is compartmentalized.  As a result, this storm—even though flooding devastated our community, it did not devastate Texas Medical Center.  So, congratulations to the Texas Medical Center.

Do the hospitals have the staff they need right now?

I can imagine some of the hospitals have fewer employees available to staff the hospital.  Some members of their workforce have lost everything—their homes destroyed, their automobiles destroyed.

Tomorrow, we will be holding a meeting to discuss what our hospitals need.  And from there we will be identifying where we need to place nurses.  We have an abundance of nurses from throughout Texas who have offered to help.  We also have an abundance of physicians who have offered to help.  Now it’s a matter of making sure we place them in the proper facilities.

The Aftermath of Hurricane Harvey

Hurricane Harvey began with raging winds, but its legacy will be the seemingly endless stream of water that swamped parts of Houston and the surrounding area.  Harvey whipped up tons of water from the sea and hurled it down on the country’s fourth most populous city, drowning vast tracks of the landscape and battering it with almost a year’s worth of rainfall in less than a week.

Houstonians are strong and will rebound from Harvey’s devastation.  So will its hospitals and medical community.  The rebuilding process will not happen without the assistance of those within and outside the healthcare industry.  The American Hospital Association (AHA) has been supporting colleagues at the Texas Hospital Association as they work with hospitals and health systems, as well as local and federal agencies, to respond to the ongoing disaster.

Concerned citizens can help relief efforts in a number of ways:

Blood Donations: The American Association of Blood Banks (AABB) is urging eligible donors, especially those with type O-positive blood, to make donation appointments as soon as possible.  Those interested in donating may contact the following organizations to find a local blood drive and schedule an appointment:

Texas Hospital Association Assistance Fund: The Texas Hospital Association has established an assistance fund to help hospital employees who experienced significant property loss or damage.  Administrative services are being provided in kind, so 100 percent of donations can be used to assist individuals in need. AHA has contributed an initial $50,000 to get the fund started.

For more information or to make a donation, visit https://www.tha.org/Harvey/ReliefFund.  For additional details, visit www.tha.org/harvey.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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Don’t gamble on your risk adjustment HCC coding.

Learn about how to stay in compliance and maximize reimbursements

Rescheduled date – September 28, 2017 | 2:00 to 3:00 pm EDT

Register today: Webinar: HCC Coding and Auditing Strategies

Do you have risk-adjusted physician services contracts for your Medicare Advantage patients? Then read on…you may be leaving money on the table by missing proper codes and creating inaccurate HCC coding.

Don’t miss this opportunity to learn about risk-adjusted HCCs and the strategies that will keep you in compliance and make sure that you maximize the reimbursement due to you.

In this webinar, you will learn:

  • Trends affecting Medicare Advantage and the healthcare industry
  • What are risk adjustment HCCs and how are they reimbursed?
  • Why is risk adjustment important for compliance and reimbursement?
  • What are the HCC types and programs
  • How to calculating an ROI for properly identifying and coded HCCs
  • Strategies for HCC compliance and reimbursement improvement

Presenters:

Amber Broadwater – MBA, RHIA, LHRM, ICD-10 Trainer – Vice President of Client Services, Coding Division at MiraMed Global Services.

Phil C. Solomon – Vice President of Marketing Strategy and Thought Leadership at MiraMed Global Services and Publisher of Revenue Cycle News Blog.

Save Your Spot – Register today: Webinar: HCC Coding  and Auditing Strategies 

For more information, contact Phil Solomon at phil.solomon@miramedgs.com

 

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CMS Seeking Comments for Abandoning Cardiac Bundles and Limiting CJR Model

The proposed rule change posted to the Federal Register on August 10, 2017 indicates the Centers for Medicare and Medicaid Services (CMS) will rescind the regulations governing two mandatory bundled payment programs, the Advancing Care Coordination through Episode Payment Models (EPMs) and Cardiac Rehabilitation Incentive (CRI) Payment Models, which were scheduled to start in 2018.  It also proposes to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model, including:

  • Giving certain hospitals selected for participation in the CJR model a one-time option to choose whether to continue their participation in the model;
  • Providing technical refinements and clarifications for certain payment, reconciliation and quality provisions; and
  • Increasing the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track.

The August 14, 2017 edition of Cardiovascular Business published the article, “Cardiac Bundles to be Canceled by CMS,” that reported the same bundles have already been delayed twice since Health and Human Services Secretary Tom Price, MD, and CMS Administrator Seema Verma, MPH, took the reins at the agencies. Both have been critical of making bundled payments mandatory, with Verma saying in her confirmation hearing that new payment models should be expanded more gradually.

Price, an orthopedic surgeon, was the lead author of a letter to CMS in 2016 criticizing the mandatory cardiac bundles and the expansion of a joint replacement bundle, saying the moves would lead to providers consolidating and turning away Medicare beneficiaries. “Medicare providers and their patients are blindly forced into high-risk government-dictated reforms with unknown impacts,” he wrote. “Any true medical experiment requires patient consent. However, patients residing in an affected geographical area will have no choice about their participation.”

Some of Price’s concerns have been countered by research. An August 2016 analysis by Avalere Health, a leading Washington DC-based healthcare consulting firm, said that 85 percent of the hospitals required to participate in the cardiac bundles would not experience gains or losses greater than $500,000 per year. Institutions with spending already far above the regional average would face the heaviest losses.

The elimination of the cardiac bundles would remove a path for practices to qualify for the 5 percent bonus in 2019 under the APM track introduced by the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA).

On August 16, 2017, Becker’s Hospital CFO Report outlined eight things that are key components of the proposed rule change in their article, “CMS Cancels Cardiac Bundles, Scales Back CJR Model: 8 Things to Know.”

  1. CMS sent a proposed rule to the Office of Management and Budget last week. The title of the rule indicated CMS would cancel mandatory bundled payment initiatives for heart attacks, bypass surgery, and hip and femur fractures. Details on the changes were revealed on August 15, 2017 when the proposed rule was made public.
  2. The proposed rule would cancel the mandatory bundled payment program for heart attacks and bypass surgeries as well as the cardiac rehabilitation payment model, which is intended to test whether a payment incentive can increase the utilization of cardiac rehabilitative services.
  3. The proposed rule would eliminate mandatory bundling for hip and femur fracture treatment under the Comprehensive Care for Joint Replacement program.
  4. The cardiac bundled payment models and expansion of the CJR program are slated to begin Jan. 1, 2018.
  5. The proposed rule would scale back the existing CJR model. Under the proposed rule, the CJR program would be mandatory for hospitals in 34 of the 67 geographic areas chosen for the program. The CJR model would continue on a voluntary basis in the other 33 geographic areas. The proposed rule would also make participating in the CJR model voluntary for all low volume and rural hospitals in the 67 areas.
  6. “Changing the scope of these models allows CMS to test and evaluate improvements in care processes that will improve quality, reduce costs, and ease burdens on hospitals,” said CMS Administrator Seema Verma. “Stakeholders have asked for more input on the design of these models. These changes make this possible and give CMS maximum flexibility to test other episode-based models that will bring about innovation and provide better care for Medicare beneficiaries.”
  7. Ashley Thompson, the American Hospital Association’s senior vice president for public policy analysis and development, said the AHA is concerned cancellation of the bundled payment models could cause problems for provider organizations that have spent valuable resources to implement these programs.
  8. CMS will accept comments on the proposed rule until October 16, 2017.

Chris Garcia, CEO of Remedy Partners, said his organization had forecasted similar hurdles due to the bundles’ mandatory nature, as well as how complex cardiac care can be.

“We were not surprised that the mandatory models were running into trouble. Cardiac care is very complicated. So many specialists will touch a patient during a cardiac episode. We had heard from our cardiology partners and they said, ‘What are they talking about? This is crazy.’ The amount of effort CMS has put into the models so far was really the only surprising aspect to the proposed cancellation,” Garcia said.

The models were originally slated to begin in July 2017, but provisions of the final rule—including the start date—were delayed multiple times over the past year to give the new administration a chance to review them.

Those who are interested in commenting on the proposed rule that cancels the EPMs and CRI incentive payment model and to rescind the regulations governing these models must respond by 5:00 pm EDT on or before October 16, 2017.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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The Centers for Medicare & Medicaid Services (CMS) is pursuing changes that would cut 340B payment rates to hospitals and may impair safety-net hospitals’ ability to treat low-income patients.

The 340B program requires drug manufacturers to provide outpatient drugs to eligible healthcare organizations and covered entities at considerably reduced prices.  The long-standing Medicare policy allows CMS to pay up to six percent more than the average sales price in the 340B program.

The proposed Outpatient Prospective Payment System (OPPS) rule, posted recently on Federal Register, would reduce 340B Drug Discount Program payment rates, drastically cutting Medicare payments for drugs that are acquired under the 340B drug pricing program.  CMS has proposed updating the OPPS rates by 1.75 percent, which would pay hospitals 22.5 percent less than the average sales price for some drugs purchased under the 340B program.

Industry Groups Unhappy with OPPS Proposal

Industry groups immediately made their feelings known about the proposal and they weren’t happy.  “For 25 years, the 340B Drug Pricing program—which enjoys broad, bipartisan support—has been critical in expanding access to life-saving prescription drugs to low-income patients in communities across the country,” said American Hospital Association (AHA) Executive Vice President Tom Nickels.  “The patients who benefit from the much-needed 340B program are the ones who will have their access to care threatened.  Cutting Medicare payments for hospital services in the 340B program is not based on sound policy.  Additionally, this proposed rule punishes hospitals for a policy outside of CMS’ jurisdiction.  It is unclear why the administration would choose to punitively target 340B safety-net hospitals serving vulnerable patients, including those in rural areas, rather than addressing the real issue: the skyrocketing cost of pharmaceuticals,” Nichols said.

The AHA is not the only industry group angry with the proposal. The association 340B Health, a group with more than 1,300 hospitals that supports involvement in the 340B program, said most of its members would likely withdraw from the program if CMS cuts payments that would take away most, if not all, of their savings on Part B drugs.  “With the uninsured rate rising again and so much uncertainty about the healthcare marketplace, this is no time to cut reimbursement to hospitals that serve patients in need,” 340B Health CEO Ted Slafsky said in a statement.

Other healthcare executives agree. Bruce Siegel, CEO of America’s Essential Hospitals, said the proposal threatens hospitals’ ability to maintain critical services to patients and communities.  From the reactions of industry insiders, if they have their way, this proposal will not see the light of day and CMS will never institute the proposed OPPS policy changes.

Eight Keys to the OPPS Proposed Rule

In the proposed rule, CMS suggests changing how Medicare pays hospitals for drugs that are acquired under the 340B Drug Discount Program.  There are several important keys tied to the proposal that are highlighted in Becker’s Hospital CFO Report titled, “CMS releases OPPS proposed rule for 2018: Nine things to know.”  The following are some salient points of the proposed rule.

Payment Update

  1. CMS proposed updating the OPPS rates by 1.75 percent in 2018.  The agency arrived at its proposed rate increase through the following updates: a positive 2.9 percent market basket update, a negative 0.4 percentage point update for a productivity adjustment and a negative 0.75 percentage point adjustment for cuts under the ACA.
  2. After considering all other policy changes included in the proposed rule, except for the provisions related to 340B drug payments, CMS estimates hospital OPPS payments would increase by two percent next year.

Proposed 340B Program Changes

  1. CMS proposed paying hospitals 22.5 percent less than the average sales price for drugs purchased through the 340B program.  That is compared to the current payment rate of average sales price plus six percent.  Under the proposed rule, the current payment would continue for vaccines.
  2. Regarding the proposed 340B program changes, CMS said it “seeks comment on implementing this proposal in a manner that will bring down out-of-pocket drug costs for Medicare patients and allows providers to best meet their patients’ needs.”

Proposed Update to Inpatient-only List

  1. The Medicare inpatient-only list includes procedures that are only paid for under the hospital Inpatient Prospective Payment System.  Each year, CMS reviews the list to determine whether any procedures should be taken off of the list.  For 2018, CMS proposed removing total knee arthroplasty from the IPO list.  The proposed rule also seeks comment on whether partial and total hip arthroplasty should be removed from the list.

Hospital Outpatient Quality Reporting Program Changes

  1. For 2018, CMS is proposing removing six measures from the Hospital Quality Reporting Program for the 2020 payment determination and subsequent years.  The measures CMS is proposing to remove are:
    OP-1: Median time to fibrinolysis
    • OP-4: Aspirin at arrival
    • OP-20: Door to diagnostic evaluation by a qualified medical professional
    • OP-21: Median time to pain management for long bone fracture
    • OP-25: Safe surgery checklist use
    • OP-26: Hospital outpatient volume data on selected outpatient surgical procedures

Possible Revisions to Laboratory Date of Service Policy

  1. CMS said it is considering potential modifications to the laboratory date of service policy.  The changes would allow labs to bill Medicare directly for molecular pathology tests and advanced diagnostic laboratory tests excluded from the OPPS packaging policy and ordered less than two weeks following the date of a patient’s discharge from the hospital.  Under the current policy, if a test is ordered less than two weeks after a patient’s discharge date, the hospital must bill Medicare for the test and then pay the lab that performed the test.

Comment Period

  1. CMS will accept comments on the proposed rule until September 11, 2017.

Summary

On July 13, 2017, CMS released its proposed OPPS rule changes in a request for information (CMS-1678-P) for public review.  In doing so, CMS believes that enacting the OPPS rule change is the first step in an effort to start a national conversation about improving the healthcare delivery system, how Medicare can contribute to making the delivery system less bureaucratic and complex, and how CMS can reduce burdens for clinicians, providers and patients in a way that increases quality of care and decreases costs.  All of this with the intention of making the healthcare system more effective, simple and accessible while maintaining program integrity and preventing fraud.

CMS will respond to comments in a final rule on or about November 1, 2017.

____________________

Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at philcsolomon@gmail.com

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2:00 PM Today – Webinar: The Ins and Outs of HCC Coding for Better Reimbursement

by Phil C. Solomon July 31, 2017

Webinar: The Ins and Outs of HCC Coding for Better Reimbursement August 10, 2017 | 2:00 to 3:00 pm EDT Do you have risk-adjusted physician services contracts for your Medicare Advantage patients? Then read on…you may be leaving money on the table by missing proper codes and creating inaccurate HCC coding. Don’t miss this opportunity to […]

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25 Keys to a Patient-Centric Revenue Cycle

by Phil C. Solomon July 19, 2017

Optimizing your revenue cycle management process is a key component for addressing a multitude of industry trends such as changes in regulations, consumerism and new reimbursement structures. Today’s patient centric revenue cycle requires the right systems to drive performance; however, employing systems based solely on their robustness does not guarantee success.  Optimal financial performance is […]

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