Contexture’s Post

Happy to be part of work from the National Association of ACOs and AHCA/NCAL on policy changes needed to increase participation by long-term care providers in value-based care arrangements. We came together last year to organize roundtables to test ideas and develop recommendations that are included in a paper we're making public today. Our recommendations include: Alignment - Because ACOs are historically centered around primary care, the method that Medicare uses to assign accountability to providers doesn't work well for post-acute care. There are ways to make that better. Financial Benchmarks - Institutionalized patients are inherently sicker and more costly. Therefore, how we set financial spending targets, which is based on patients' historic spending, needs to better account for these patients. Quality Measurement - Here too, special considerations need to be made for different provider types because what is used in Medicare ACO programs is designed for traditional physician office settings. Data Access - Accountable care relies on providers receiving timely, actionable data on their patients in order to identify care needs and effectively intervene. Here too are ways to make the process better for post-acute care providers. Nested bundles - Improvements can be made to pay for episodic care by better leveraging relationships ACOs have today with their post-acute provider networks. Read the full paper here: https://lnkd.in/evxZBzvc https://lnkd.in/eaVeu6-d

Great reminder from CTAC on the value of Advance Care Planning to Medicare Advantage Medicare Star Ratings. And always important - how we can support the voice of individuals to be the center of all healthcare plans. https://lnkd.in/gzq9wkgC

In the News: A record number of second-quarter disputes between hospitals and payers involved Medicare Advantage plans, and 30% of disputes failed to reach a timely agreement, meaning tens of thousands of patients were left without in-network coverage, according to a recent Becker's Healthcare article. Check it out here: https://hubs.li/Q02Gz2KY0 #hospitalfinance #medicareadvantage #patientoutcomes #RCM #coverage #hospitalrevenuecycle #hospitalrevenue #hospitalmargins #beckershealthcare #revenuecyclemanagement

The Medicare Advantage (MA) program is experiencing significant changes, and providers must adapt to maintain strong performance, particularly in relation to the Star Ratings system. Originally introduced by the Centers for Medicare & Medicaid Services (CMS) to measure the quality of care delivered to MA members, achieving high Star Ratings is becoming more challenging as the focus shifts toward clinical outcomes and health equity. Providers play a critical role in this transformation. Their ability to deliver high-quality care, manage chronic conditions, and ensure effective documentation directly impacts the Star Ratings of the health plans they work with. One key area for providers to focus on is improving clinical measures, which now carry more weight in determining Star Ratings. By aligning care practices with updated clinical guidelines and improving outcomes in areas like medication adherence, preventive screenings, and chronic disease management, providers can significantly contribute to better ratings. Building stronger partnerships with MA plans is another critical step. Providers who consistently meet performance targets related to healthcare effectiveness, such as through Healthcare Effectiveness Data and Information Set (HEDIS) measures, help drive better Star performance for their partners. These partnerships often include incentive structures, like bonus payments, which reward providers for achieving high standards of care and member satisfaction. Provider collaboration is also essential in the shift towards value-based care. As MA plans move more members into value-based contracts, providers must be equipped to handle risk-sharing arrangements that reward them for delivering better outcomes at lower costs. This approach not only improves patient care but also ensures providers are financially aligned with the goals of the value-based care. #MedicareAdvantage #HealthcareProviders #PatientOutcomes #StarRatings #ValueBasedCare #NPIDataServices #VBCRiskAnalytics #RAFScoreCalculator #HealthcarePayers

*Administrative Burden and the Cost of "Initial" Denials* A recent survey revealed provider organizations are urging CMS to address Medicare Advantage (MA) plans' claim denial practices, which are significantly impacting their financial health. Providers spent around $20 billion in 2022 on claim denials, with private plans being notably costlier. The survey, which included 516 acute care hospitals, found a 15% initial denial rate across payer types, with over half being eventually paid. The report highlights the extensive administrative burden and financial strain this places on healthcare providers, urging CMS to implement stricter regulations on MA plans to improve transparency and reduce unnecessary delays in payments. basys.ai Jie Sun John L Brooks III James Roosevelt Mohammad Elias https://lnkd.in/eHieuqkr

The Medicare Advantage program is undergoing its biggest shifts in more than two decades. Payers can take steps now to mount a strategic, agile response as the changes unfold. An increased emphasis on clinical and health equity measures, while staying strong on member experience, is critical to secure 4+ stars and to bolster the overall Medicare Advantage strategy. #MedicareAdvantage #healthcarepayers #StarRatings #CMS #patientexperience

Major shifts in Medicare Advantage are taking place, including a crucial component of a new regulation—the extension of the two-midnight benchmark rule to MA plans. Our latest blog, “New Medicare Advantage Rule: Implications for Healthcare Providers and Patients,” unpacks the game-changing rule from the Centers for Medicare & Medicaid Services (CMS). Learn what it means to health systems and hospitals moving forward here: https://hubs.li/Q02Rzdxp0 #RCMblog #revenuecyclemanagement #rcm #HealthcareFinance #MedicareAdvantage #HealthcarePolicy #CMS #CMSUpdates #HealthcareInnovation #revenuecyclemanagementsupport #healthcare #healthcarercm #healthcarelegislation

🚨 Rule alert! 🚨 This morning, the Centers for Medicare & Medicaid Services (CMS) released the proposed CY 2025 Medicare OPPS Rule, which is packed with interesting proposals that touch on #HealthEquity, including: 🏥 For the ASCQR Program, CMS is proposing to adopt the Facility Commitment to Health Equity (FCHE) measure beginning with the CY 2025 reporting period/CY 2027 program determination. 🩺 The Screening for Social Drivers of Health (SDOH) measure beginning with voluntary reporting in the CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. 📊 The Screen Positive Rate for Social Drivers of Health (SDOH) measure beginning with voluntary reporting in the CY 2025 reporting period, followed by mandatory reporting beginning with the CY 2026 reporting period/CY 2028 payment determination. 🗓️Comments are due in 60 days! You can read more about the rule here: https://lnkd.in/eyMs8Wjx #socialdeterminants #cms #medicare

The fact that CMS is intervening as a means to sustain healthcare services lets you know the affects of this breach will leave ripples for a long time. It’s time to pull up your sleeves to do what you can to help your organizations stay above water. #medicare #medicalbilling #aapc #reimbursement #medicalbillingandcoding

The Centers for Medicare & Medicaid Services (#CMS) has just announced a long-awaited final rule that brings crucial reforms to prior authorization processes. This new rule slashes patient care delays and introduces electronic streamlining for physicians to obtain the necessary prior authorization to prescribe the appropriate medications and procedures that patients desperately need. The changes outlined in the rule are expected to result in significant cost savings for physician practices, estimating a whopping $15 billion over the next decade per the Department of Health and Human Services (#HHS). Streamlining the prior authorization process electronically with time limitations on urgent and non-urgent requests will reduce hospital admissions and #readmissions linked to delays in prior authorization requests for critical medications and procedures. By doing so, we're not only saving valuable time but also improving overall outcomes for patients. Imagine a #healthcare system with instant response and transparency on medication prescriptions and procedure requests that will inform the physician-patient decision-making process. #priorauthorization #clinicalinformatics #clinicalexcellence #valuebasedcare #cmsdevelopment #healthinnovation #physicianburnout Link: https://lnkd.in/g9_9qj_3