Managing and Measuring Payer Performance
Healthcare providers should have a contract management system as the framework for managing the four components of the governance/communication processes―contract analysis and modeling, payment calculations, variance monitoring workflow, and payer scorecard and reporting.
Why Horizon BCBSNJ Likes Episode-of-Care Payments
Horizon Blue Cross Blue Shield of New Jersey’s episode-of-care program, believed to be the largest such program in the country, rewards physicians for successes but does not subject them to penalties. Horizon says that this arrangement creates better foundations for payer/provider relationships to move toward shared risk over time.
How South Shore Health System Protected Revenue During an EHR Transition
South Shore Health System created a formal revenue integrity department to mitigate revenue loss during its EHR transition and to monitor and track progress after implementation.
Understanding the Current State of MACRA
Hospitals and their employed physicians should take certain actions now to avoid penalties and ensure proper payment under MACRA, as well look at future education and staffing needs.
Finding Success with Provider-Sponsored Health Plans During Uncertain Times
Community Health Choice, a provider-sponsored health plan started by Harris Health System, has grown its marketplace membership from 300 enrollees to 150,000 over four enrollment periods. Despite uncertainty about the future of federal healthcare laws and the marketplaces, the health plan says that it may still experience growth in 2018.
Auditing for Stark Law Compliance
Compliance with the Stark Law requires involving legal, compliance, and other expertise on the front end of the process rather than auditing for problems later.
Why Health Plans Are Easing Preauthorization
In an attempt to build cooperative working relationships with physicians, some health plans are trying to reduce the burden of preauthorization.
DOJ Guidance on Compliance Effectiveness
New guidance highlights common questions that prosecutors ask when judging compliance program effectiveness.
Managing the ACA’s Nondiscrimination Provisions
The ACA prohibits discrimination in health programs or activities that receive federal financial assistance. Healthcare providers face the challenges of preventing language barriers that may impact certain patients based on race, as well as current litigation on gender identify.
Avoiding the Costliest Denials
Eligibility, outpatient medical necessity, and case management authorization continue to be three of the costliest denials. To avoid the negative effects of these types of denials, it is critical to implement an improvement process based on data.