Mac Care’s Post

As always Dr. Bricker provides explanation and insight to an industry that appears to not care about businness ethics. think about it Tim

good to know

A great video from Eric Bricker, MD explaining Medicare Advantage “risk adjustment” payments are created. Personally, I’ll die on the hill that it isn’t risk if you are getting paid extra for something. The basic definition of risk is the probably of something bad happening. To the plan, the risk is they will have to pay more for that person. But, with additional revenue and utilization management techniques that reduce access to care… I’m baffled why we continue to discuss “risk” for these payments.

To gain a better understanding of healthcare finance, listen to Dr. Brickers’ explanation of the coding process that drives payments to Medicare Advantage providers.

Medicare Advantage #RiskAdjustment Explained... Video is an Excerpt from a Training Session on #MedicareAdvantage. Medicare Advantage (MA) Payments to health insurance companies totaled $361B... up 200% from just 6 years ago.   MA is THE #Growth and #Profit Engine for #HealthInsurance Companies, so we MUST understand MA if we are going to understand healthcare finance. Learn: 1) What a Hierarchical Condition Category (#HCC) is. 2) What the Risk Adjustment Factor (#RAF) is. 3) How health insurance companies #maximize HCCs and RAFs to maximize their payments per beneficiary from #CMS (the Centers for Medicare and Medicaid Services). Sources at AHealthcareZ YouTube Channel.

Excellent summary of one of the most overlooked reasons why Medicare spending by the federal government is spiraling out of control. You will understand why hospitals (and insurance companies) are so focused on aggressive coding of patients.

#MedicareAdvantage beneficiaries are older, sicker, and often have more than one HCC or comorbidities. Medicare Advantage business makes more money the sicker their beneficiaries are. Proactively addressing patient health through preventative care has historically lacked sufficient incentives. It's difficult to quantify the value of preventing conditions that aren't immediately life-threatening or debilitating #PreventiveCare represents a paradigm shift and a moral responsibility for providers, emphasizing proactive health management and the well-being of our patients There is a glimmer of hope: #ValueBasedCare. Health systems are increasingly willing to incentivize #ValueBasedPayments by ensuring patients are treated holistically without gaps in care. This means that one patient, even if they need multiple types of care, can find rehabilitation or cure efficiently and effectively without waste. #PayForPerformance ensures that providers focus on quality and #outcomes, aligning incentives with what truly matters: patient health and well-being. By embracing value-based care, we can shift the focus from treating illness to maintaining health, while healthcare systems find ways to create new #revenue streams.

Bam! Eric Bricker, MD driving again to the organizing center of programmatic #failure in institutionalized #healthcare. In an exceedingly clear and relatable way, his failure analysis reveals the power of #incentives. One shouldn't avoid incentives because they are powerful. Quite the contrary. We must, however, get them right. In this case, Dr. Bricker explains the consequences of a method of #riskadjustment that promulgates the use and misuse of #HCC, most notably in additive combinations, to determine levels of #CMS payments to #medicaladvantage. If nothing else, business can optimize on well-defined #criteria, and it can produce winners of games with well-defined #rules. Business, however, rarely if ever can or should define its own rules. That's a completely different set of #values and skills. If #consumers and their stakeholders are going to define the rules of the game--collectively through #government, for example--they must get the models, methods, and measures right. Whatever the effect of incentives implicit in such rules at the outset, these rules must be #improved continually as lessons are learned about what they incentivize, intended or otherwise. It's impossible to imagine how objective criteria (rules) can be determined and continually improved without #evidence from the real world. If government R&D #funding or private sector IR&D focuses on producing evidence about medical conditions for which there (potentially) are lucrative treatments, it will always give outsized importance to conditions that can be treated through #acutecare (e.g., a "pill" or a "knife") for all the reasons revealed in Dr. Bricker's other posts. A science of #primarycare is needed to counterbalance the evidentiary hegemony of "sick care." #DPC and their early-adopter patient panels can be the #entrepreneurial insurgency that point to real-world #networks of support and long-term #trajectories for health in which "laboratories" of primary care science and its proper focus can be established. Ultimately, governmental methods can utilize this new bottom-up science to provide a healthier framework of incentives so that these DPC #innovations can "cross the chasm" to the majority of the population. Big business in healthcare then can do its thing and, with its de facto partners in big government, do the right thing.

A provider portal is a secure online platform that allows healthcare providers to interact with health insurance companies, healthcare payers, or other entities involved in the administration of healthcare benefits. These portals serve as a central hub for communication, information exchange, and transaction processing between healthcare providers and payers. . . . . . #MedicalBillingPros #HealthcareFinance #BillingSolutions #RevenueCycleManagement #HealthcareBilling #CodingandBilling #ClaimSubmission #InsuranceBilling #HealthcareAdmin #BillingAccuracy

Participating Providers: Bridging the Gap Healthcare institutions and practitioners who have contracted with health insurance companies are known as participating providers, or “in-network” providers. The terms and conditions for offering medical services to policyholders who are part of that specific insurance network are outlined in these agreements. These contracts cover a wide range of topics, such as costs, rates of reimbursement, and the scope of services to be rendered. Non-Participating Providers: Outside the Network Non-participating providers, sometimes referred to as “out-of-network” providers, do not have formal contracts with any particular insurance network, in contrast to participating providers. Rather, they are autonomous entities that set their own prices for healthcare services. #Healthcare #Providers #MedicalBilling #Credentialling #Contracting #RCM #Participating #NonParticipating