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The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) is the most significant change to Medicare physician reimbursement in a generation. Beyond substantially tying payment to physician performance, MACRA accelerates and amplifies a potentially even greater factor in the long-term health of a
provider organization: its public reputation.
In particular, most Medicare Part B clinicians will be subject to MACRA’s Merit-based Incentive Payment System (MIPS), which takes effect Jan. 1, 2017, and each year will publicly report clinician performance on a 100-point scale.
Senior leaders of provider organizations are increasingly focused on provider reputation because of its impact on:
Of particular concern is the fact that once a provider’s reputation is damaged, it is very difficult to repair. Public reputation can be thought of as a glass vase. Once it shatters, it is difficult if not impossible to piece back together in this world of pervasive online marketing and social media.
Payer reimbursement is more like a rubber ball in that bouncing back from a down year is more feasible. It is more difficult to reverse consumer perceptions stemming from news that a provider has earned, say, only 40 out of 100 performance points in MIPS than it is to rebound from temporary
Consumer awareness and use of provider ratings and reviews is high and growing. As far back as 2014, a survey found that 65 percent of consumers were aware of provider-rating websites and 36 percent had used a rating site at least once.1 Sites such as Healthgrades.com and
Vitals.com capture tens of millions of visits per month and publish quality indicators derived from a broad array of data sources, including the Centers for Medicare & Medicaid Services (CMS). This year, Angie’s List (100 million visits per month) granted free access to all consumer reviews,
including those of healthcare providers.2
CMS currently publishes quality metrics from the Physician Quality Reporting System (PQRS) on a named-provider basis on the Physician Compare website, where the data is also available as a free download for third parties such as Healthgrades. Furthermore, CMS is planning to fold those metrics into a
single 5-star rating for each provider’s 2016 performance, to be published by early 2018.3 Provider organizations such as Cleveland Clinic self-publish quality metrics or patient reviews of providers.
A provider’s public reputation does not yet override other selection factors, such as referrals from physicians or from friends and family members, out-of-pocket costs, and location.4 However, as adoption of high-deductible insurance plans grows, consumers are
increasingly paying more out-of-pocket for health care and are seeking to make more-informed choices. Many providers are concerned that the status quo may be disrupted, as it has been in other consumer-oriented industries such as automobiles, by the proliferation of ratings sites and the rising tide of provider
quality information being published by the likes of CMS.
The MIPS scoring system and the expected scope and quantity of MIPS measure data are likely to accelerate and broaden public reporting of provider performance. Each provider is rated on a continuous 100-point scale composed of four performance categories: quality (60 percent for 2017, 50
percent for 2018), advancing care information (25 percent), clinical practice improvement activities (15 percent), and resource use (0 percent for 2017, 10 percent for 2018). For many of the MIPS measures, providers earn points based on their performance relative to national peer benchmarks, meaning there are
effectively a limited number of points to go around.
Providers earning a score above an annual performance threshold set by CMS receive an incentive, whereas those scoring below the threshold are assessed a penalty. Each point below or above the threshold translates proportionally into financial impacts. The penalties assessed
nationally help fund the incentive pool for the higher performers, meaning the winners are effectively paid by the losers. The performance threshold is expected to increase annually as average MIPS performance improves nationwide.
The impacts on public reporting and, consequently, provider reputation are significant. First, within approximately 15 months of the end of the performance period, CMS will publish each provider’s MIPS score and component category scores to the Physician Compare website. Consumers will be
able to see how providers rate relative to each other on a 100-point scale and within each of the four MIPS performance categories. It is apparent that CMS chose a 100-point scale for MIPS because consumers easily understand how to interpret such a score from their experience with other forms of comparison
shopping, such as movies and hotels. CMS projects that about 600,000 clinicians will receive a MIPS score for the 2017 performance year.
Second, Physician Compare also will release the scores in a freely downloadable and structured format (such as an Excel document or text file), as is currently done for PQRS measure data. Third-party provider rating sites are currently hampered by low sample sizes, such as too few patient
reviews for a given provider. Hence, these sites will seek to enhance their provider ratings by incorporating MIPS scores that CMS has deemed to be statistically significant. This dynamic will greatly expand the reach and audience for MIPS scores, which will be much easier for consumers to interpret
than are current quality indicators, such as performance measure rates. A consumer is more likely to be influenced by seeing a score that is based on a 100-point scale and verified by Medicare than by reading a few patient reviews about that provider.
Third, CMS will publish national aggregate information about the MIPS score, including the national average score and the range of scores for all clinicians overall and in each of the four performance categories. This information enables provider-rating sites to more directly show how a
provider’s performance compares with that of other Medicare clinicians nationally, rather than limit the peer comparison group to only those providers for which a site is able to collect data on its own. For many providers, the MIPS score will be the first time their public reputation may be impacted by a 100-point
scale placed on a national comparison platform and distributed to an audience of potentially millions.
Fourth, one of the most impactful aspects of the MIPS score is that once a clinician earns a score, that score is tied to the clinician through the payment adjustment year (e.g., through 2019 for performance in 2017) regardless of where the clinician may subsequently be employed. Hiring organizations will
want to know a clinician’s MIPS score for preceding years to know what incentive or penalty the clinician is bringing along. Similarly, Physician Compare will continue to show that clinician’s most recent MIPS score even if he or she has switched organizations.
Providers will not learn their MIPS score until late in the year after the performance year (e.g., in late 2018 for the 2017 performance year). When providers learn of a bad score, the current year will be nearly over, meaning those providers then can focus only on improving for the following
performance year. These factors combine to mean that a provider could effectively need two or more years to reverse a low MIPS score in the public domain. During such a wide gap, a provider could lose market share to providers with higher scores yet not be able to change that score until the damage is
already done. Provider organizations are increasingly interested in ways to estimate their MIPS scores while there is still time to improve performance before reporting data to CMS.
Many providers are concerned that their MIPS scores will not accurately reflect their actual performance. For instance, data-capture issues in electronic health records may result in low scores even though clinicians are performing the work required to score well. Provider organizations are
optimizing their IT systems to improve the consistency between actual and reported performance with an eye towards maximizing MIPS scores.
Last, educating clinicians about the financial and reputational impacts of MIPS and what they can do is perhaps the most important preparation. Current knowledge and awareness of MIPS is low among clinicians, so increasing numbers of organizations are explaining to clinicians how the
MIPS score is important to their reputational health, not just their immediate financial health. And that’s good advice, indeed.
Tom S. Lee, PhD, is CEO and founder, SA Ignite, Chicago.
1. Hanauer, D.A., et al., “Public awareness, perception, and use of online physician rating sites,” JAMA, February 2014.
2. Gensler, L., “Angie’s List Is Tearing Down Its Paywall, Will Soon Be Free,” Forbes, March 3, 2016.
3. Centers for Medicare & Medicaid Services, “Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2016,” Nov. 16, 2015, pp. 718-19.
6 Patient Revenue Cycle Metrics You Should Be Tracking (and How to Improve Your Results)
Patient financial engagement is more challenging than ever – and more critical. With patient responsibility as a percentage of revenue on the rise, providers have seen their billing-related costs and accounts receivable levels increase. If increasing collection yield and reducing costs are a priority for your organization, the metrics outlined in this presentation will provide the framework you need to understand what’s working and what’s not, in order to guide your overall patient financial engagement initiatives and optimize results.
10 Ways to Reduce Patient Statement Volume (and Reduce Costs)
No two patients are the same. Each has a very personal healthcare experience, and each has distinct financial needs and preferences that have an impact on how, when and if they chose to pay their healthcare bill. It’s no longer effective to apply static billing techniques to solve the complex challenge of collecting balances from patients. The need to tailor financial conversations and payment options to individual needs and preferences is critical. This presentation provides 10 recommendations that will not only help you improve payment performance through a more tailored approach, but take control of rising collection costs.
Reduce Patient Balances Sent to Collection Agencies: Approaching New Problems with New Approaches
This white paper, written by Apex Vice President of Solutions and Services, Carrie Romandine, discusses the importance of patient segmentation and messaging specifically related to the patient revenue cycle. Applying strategic messaging that is tailored to each patient type will not only better educate consumers on payment options specific to their billing needs, but it will maximize the amount collected before sending to collections. Further, targeted messaging should be applied across all points of patient interaction (i.e. point of service, customer service, patient statements) and analyzed regularly for maximized results.
The Future of Online Patient Billing Portals
This white paper, written by Apex President Patrick Maurer, discusses methods to increase patient adoption of online payments. Providers are now seeking ways to incrementally collect more payments due from patients as well as speeding up the rate of collections. This white paper shows why patient-centric approaches to online payment portals are important complements to traditional provider-centric approaches.
Payment Portals Can Improve Self-Pay Collections and Support Meaningful Use
Increased electronic engagement between healthcare providers and patients provides significant opportunities for improving revenue cycle metrics and encouraging patients to access EHRs. This article, written by Apex Founder and CEO Brian Kueppers, explores a number of strategies to create synergy between patient billing, online payment portals and electronic health record (EHR) software to realize a high ROI in speed to payment, patient satisfaction and portal adoption for meaningful use.
Large Health System Drives 10% UP (Patient Payments) and 10% DOWN (Billing-related Costs)
Faced with a rising tide of bad debt, a large Southeastern healthcare system was seeing a sharp decline in net patient revenues. The need to improve collections was dire. By integrating critical tools and processes, the health system was able to increase online payments and improve its financial position. Taking a holistic approach increased overall collection yield by 10% while costs came down because the number of statements sent to patients fell by 10%, which equated to a $1.3M annualized improvement in patient cash over a six-month period. This case study explains how.
ICD-10: Managing Performance
With the ICD10 deadline quickly approaching and daily responsibilities not slowing down, final preparations for October 1 require strategic prioritization and laser focus.
Clarity Drives Collections
Read how Gwinnett Medical Center provides clear connections to financial information, offers multiple payment options for patients, and gives onsite staff the ability to collect payments at multiple points throughout the care process.
Orlando Health Gains Insight into Denials, Reduces A/R Days with RelayAnalytics Acuity
Read how Orlando Health was able to perform deeper dives into claims data to help the health system see claim rejections more quickly–even on the front end–and reduce A/R days.
Revenue Cycle Payment Clarity
To maintain fiscal fitness and boost patient satisfaction and loyalty, healthcare providers need visibility into when and how much they will be paid–by whom–and the ability to better navigate obstacles to payment. They need payment clarity. This whitepaper illuminates this concept that is winning fans at forward-thinking hospitals.
Streamlining the Patient Billing Process
Financial services staff are always looking for ways to improve the verification, billing and collections processes, and Munson Healthcare is no different. Read about how they streamlined the billing process to produce cleaner bills on the front end and helped financial services staff collect more than $1 million in additional upfront annual revenue in one year.
Wallace Thomson Hospital Automates to Maximize Limited Resources
Effective revenue cycle management can be a challenge for any hospital, but for smaller providers it is even tougher. Read how Wallace Thomson identified unreimbursed procedures, streamlined claims management, and improved its ability to determine charity eligibility.
7 Steps for Building and Funding Sustainability Projects
Before launching an energy-efficiency initiative, it’s important to build a solid business case and understand the funding options and potential incentives that are available. Healthcare leaders should consider taking the steps outlined in the whitepaper to ease the process of gaining approval, piloting, implementing, and supporting sustainability projects. You will find that investing in sustainability and energy efficiency helps hospitals add cash to their bottom line. Discover how hospitals and health systems have various options for funding energy-efficient and renewable-energy initiatives, depending on their current financial structure and strategy.
Key Capital Considerations for Mergers and Acquisitions
Health care is a dynamic mergers and acquisitions market with numerous hospitals and health systems contemplating or pursuing formal arrangements with other entities. These relationships often pose a strategic benefit, such as enhancing competencies across the continuum, facilitating economies of scale, or giving the participants a competitive advantage in a crowded market. Underpinning any profitable acquisition is a robust capital planning strategy that ensures an organization reserves sufficient funds and efficiently onboards partners that advance the enterprise mission and values.
Key Capital Considerations for Mergers and Acquisitions
The success of healthcare mergers, acquisitions, and other affiliations is predicated in part on available capital, and the need for and sources of funding are considerations present throughout the partnering process, from choosing a partner to evaluating an arrangement’s capital needs to selecting an integration model to finding the right money source to finance the deal. This whitepaper offers several strategies that health system leaders have used to assess and manage capital needs for their growing networks.
Trend Watch: Providers adapt as value-based care moves from hype to reality
Announcements from several commercial payers and the Centers for Medicare and Medicaid Services (CMS) early in 2015 around increased efforts to form value-based contracts with providers seemed to point to an impending rise in risk-based contracting. Rather than wait for disruption from the outside in, health care providers are now making inroads on collaborating with payers on various risk-based contracting models to increase the value of health care from within.
Yuma Regional Medical Center case study
Yuma Regional Medical Center (YRMC) is a not-for-profit hospital serving a population of roughly 200,000 in Yuma and the surrounding communities.
Before becoming a ZirMed client, Yuma was attempting to manually monitor hundreds of thousands of charges which led to significant charge capture leakage. Learn how Yuma & ZirMed worked together to address underlying collections issues at the front end, thus increasing Yuma’s overall bottom line.
Reforming with a New 50-Bed Acute Care Facility
Kindred Hospital Rehabilitation Services works with partners to audit the market and the facility’s role in that market to identify opportunities for improvement. This approach leads to successes; Kindred’s clinical rehab and management expertise complements our partners’ strengths. Every facility and challenge is unique, and requires a full objective analysis.
5-Minute Briefing on Revenue Integrity Through HIM WhitePaper Hospitals FS
As the critical link between patient care and reimbursement, health information enables more complete and accurate revenue capture. This 5-Minute White Paper Briefing shares how to achieve cost-effective revenue integrity by your optimizing HIM systems.
5-Minute Briefing on Accelerating Cash Flow Through HIM WhitePaper Hospitals FS
Speedier cash flow starts with better CDI and coding. This 5-Minute White Paper Briefing explains how providers can improve vital measures of technical and business performance to accelerate cash flow.
5-Minute Briefing on Reducing the Cost of RCM WhitePaper Hospitals FS
Qualified coders are getting harder to come by, and even the most seasoned professional can struggle with the complexity of ICD-10. This 5-Minute White Paper Briefing explains how partnerships can help improve coding and other key RCM operations potentially at a cost savings.
Providers Focus Too Much On Revenue Cycle Management
The point of managing your revenue cycle isn’t just to improve revenue and cash flow. It’s to do those things effectively by consistently following best practices— while spending as little time, money, and energy on them as possible.
Lucille Packard Children’s Hospital Stanford Case Study
How Lucile Packard Children’s Hospital Stanford increased payments received within 45 days by 20% and reduced paper submission claims by 70% by using ZirMed solutions.
Using Predictive Modeling To Detect Meaningful Correlations Across Claims Denials Data
The reasons claims are denied are so varied that managing denials can feel like chasing a thousand different tails. This situation is not surprising given that a hypothetical denial rate of just 5 percent translates to tens of thousands of denied claims per year for large hospitals—where real‐world denial rates often range from 12 to 22 percent. Read about how predictive modeling can detect meaningful correlations across claims denials data.
ZOLL and Emergency Mobile Health Care Case Study
Emergency Mobile Health Care (EMHC) was founded to be and remains an exclusively locally owned and operated emergency medical service organization; today EMHC serves a population of more than a million people in and around Memphis, answering 75,000 calls each year.
Maximizing Medicare Reimbursements White Paper
Since the Physician Quality Reporting Initiative (PQRI) introduction, CMS has paid more than $100 million in bonus payments to participants. However, these bonuses ended in 2015; providers who successfully meet the reporting requirements in 2016 will avoid the 2% negative payment adjustment in 2018, so now is the time to act! Included in this whitepaper are implications of increasing patient responsibility, collections best practices, and collections and internal control solutions.
Denials Deconstructed: Getting Your Claims Paid
Getting paid what your physician deserves—that’s the goal of every biller. Yet even for the best billers, achieving that success can be elusive when denials stand in the way of success, presenting challenges at every turn. Denials aren’t going away, but you can learn techniques to manage and even prevent them.Join practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, to: Discover methods to translate denial data into business intelligence to improve your bottom line, determine staff productivity benchmarks for billers, and recognize common mistakes in denial management.
Automation and Operational Improvement Drive Sustainable Results
Physician practices must improve organizational efficiency to compete in this era of reduced reimbursement and escalating administrative costs.
Revenue Cycle Management Resolves Migration Implementation Issues
Many healthcare organizations are pursuing next-generation health information systems solutions. Learn more about Navigant's work with University of Michigan Health System.
Partnering For Success – Provider Achieves Strength in Stability
The proper implementation of healthcare information technology systems is crucial to an organization’s financial health.
Building a Clinically-Integrated Network
As value-based payment models evolve, providers are challenged to maintain superior clinical outcomes while controlling costs.
Winning in the Post-Acute Marketplace
Read more about factors contributing to the changes in the post-acute marketplace and what it means for manufacturers, physicians, clinicians, patients, and post-acute facilities as they anticipate the transition to the second curve.
Building A Common Vision with Employed Physicians
HSG helped the physicians and executives of St. Claire Regional in Morehead, Kentucky, define their shared vision for how the group would evolve over the next decade. As well as, develop the strategic and operational priorities which refocused and accelerated the group’s evolution.
Practice Performance Improvement
The client was a nine-hospital health system with 14 clinics serving communities in a multi-state market with very limited access to care, poor economic conditions, high unemployment, and a heavy Medicare/Medicaid/uninsured payer mix. In most of these communities, the system was the sole source of care.
Though the clinics were of substantial size (they employed 98 physicians) and comprised of multiple specialists, the physicians functioned as individuals and the practices lacked any real group culture.
Clinical Integration Without Spending a Fortune
Clinical integration can be expensive, but it doesn’t have to be, as this four-step road map for developing a CIN proves. Does it have to cost millions to initiate a clinical integration strategy?
Contrary to popular belief, we have clients who have generated substantial shared savings and a significant ROI over time, without massive investments. Yes, some financial capital is required for resources the CIN providers can’t bring to the table themselves. But the size of that investment can be miniscule relative to the value it produces: improved outcomes and documentation for payers.
Adding Value to Physician Compensation
Today’s concerns about physician compensation are the result of the changing healthcare environment. The transition to value is slow, but finally becoming a reality. Proactive hospitals want to ensure that provider incentives are properly aligned with ever-increasing value-based demands.
This report focuses on the three big questions HSG receives about adding value to physician compensation; Why are organizations redesigning their provider compensation plans? What elements and parameters must be part of successful compensation plans? How are organizations implementing compensation changes?
Effective Revenue Cycle Management in Your Network
Revenue Cycle Management has become an even more complex issue with declining reimbursements, implementation of Electronic Health Records, evolving local carrier determinations (LCD), and payer credentialing [The emphasis on healthcare fraud, abuse and compliance has increased the importance of accuracy of data reporting and claims filing).
The efficiency of a medical practice’s billing operations has critical impact on the financial performance. In many cases, patient billings are the primary revenue source that pays staff salaries, provider compensation and overhead operating cost. Inefficiencies or inaccurate billing will contribute to operating losses.
Succeeding in Value-Based Care
This publication identifies and outlines the necessary characteristics of a fully-functioning clinically integrated network (CIN). What it doesn’t do is detail how hospitals and providers can participate in the value-based care environment during the development process.
One common misconception is that the CIN can’t do anything significant until it has obtained the FTC’s “clinically integrated” stamp of approval. While the network must satisfy the FTC’s definition of clinical integration before single signature contracting for FFS rates and contracts can legally start, hospitals and providers can enjoy three key benefits during the development process.
Therapy: Benefits at All Levels of Care
Nearly half of all Medicare beneficiaries treated in the hospital will need post-acute care services after discharge. For these patients, a stay in an inpatient rehabilitation facility, skilled nursing facility or other post-acute care setting comes between hospital and home.
Does Your Budgeting Process Lack Accountability?
With the proper process, tools, and feedback mechanisms in place, budgeting can be a valuable exercise for organizations while helping hold organizational leaders accountable. Having a proper monthly variance review process is one of the most critical factors in creating a more efficient and accurate budget. Monthly variance reporting puts parameters around what is to be expected during the upcoming budget entry process.
Cost Accounting: the Key to Cost Management and Profitability
Managing the cost of patient care is the top strategic priority of most hospital CFOs today. As healthcare shifts to more data-driven decision making, having clear visibility into key volume, cost and profitability measures across clinical service lines is becoming increasingly important for both long-range and tactical planning activities. In turn, the cost accounting function in healthcare provider organizations is becoming an increasingly important and strategic function. This whitepaper includes five strategies for efficient and accurate cost accounting and service line analytics and keys to overcoming the associated challenges.