Health Systems Management Network, Inc has reviewed the new rule which is in the comment stage. The rule is 947 pages long and difficult to digest. In a recent article published this week in Modern Health Care written by Beth Kutscher and Adam Rubenfire, these two terrific writers have tried their best and succeeded in getting this digested for you as a Hospital or Physician practice. The entire point of the change that CMS has made is to change the criteria which is the basis for current payment. SGR will be eliminated and hopefully the reimbursement cuts that they represent. However, the new system based on “Quality Criteria” depends largely on performance. It is suggested by many that two paths will be offered, which have been based upon current experiences going on in various parts of the country. The payment options are in two categories: “The Merit based Incentive Payment System (MIPS) or a qualifying Alternative Payment Model (APM). The first alternative is based on outcomes of certain disease categories they can choose (six have to be chosen), most physicians will probably end up in the MIPS.

The physicians likely to be in one of the other programs are probably going to be part of a larger group which can invest additional help, such as, care coordinators, etc.

We are providing a link to one of the articles which is well done but lacks lots of the detail and a link to the actual new rule being proposed and strongly suggest looking at both. More importantly, the entire reimbursement methodologies are going to be based on the collection data between the time the rule goes into effect and its operational status in 2019. While this sounds like a long time off, it is a signal to begin looking at the issues in both small and large practices specifically Clinical Documentation and Coding. Hanging over everyone’s heads are the threats by CMS to assure that hospitals and practices are reporting on overpayments based on upcoding. That is now in effect.

Health Systems Management Network, Inc has advised many of its clients to begin independent reviews immediately on an ongoing basis done by very highly skilled and credentialed people who understand the differences in clinical settings and how procedures and encounters translate into claims. Part of this also includes looking carefully at denied claims, any practice outliers and doing prospective looks at documentation.

Heath Systems Management Network, Inc has been Academic Medical Centers, Smaller hospitals and Medical Practices of all sizes since 1987. Perhaps a brief discussion with our Senior Management team might be helpful; please do not hesitate to contact us.