Reimbursement

As the struggle to halt healthcare costs continues, Maryland has uniquely managed to contain hospital reimbursement.

Provider consolidation, lower Medicare and Medicaid reimbursements, and post-recession stress will combine to increase healthcare costs by 8.5% in 2012, according to a new study.

The Center for Studying Health System Change's visits to 12 metropolitan communities found that hospitals are using their clout to command high payment rate increases from private insurers.

Comparative effectiveness research will take a more prominent role in payer policies as the Patient-Centered Outcomes Research Institute drives research efforts.

Real-time, on-site claims processing will become as common as point-of-service transactions in other industries.

There's a large gap in private insurer inpatient payment rates among regions, with Miami-South Florida averaging 147% of Medicare rates, while San Francisco came in at 210%

The goal of Comparative Effectiveness Research appears to be something that everyone can agree on

Controversy continues to swirl around Medicare's two-year-old policy of not paying for what it considers preventable hospital-acquired condtions. CMS has decided for now not to expand its list of 12 serious adverse events for which it does not reimburse hospitals.

There seems to be a growing consensus among healthcare stakeholders that despite new reforms, something still has to give in the way care is delivered. Episode-based payment may be a viable solution. It is an intermediate step between fee-for-service, which historically leads to overuse or underuse of services depending on reimbursement, and capitalization, which moves all the risk to the provider.

In a move toward accountable care, the Blue Cross and Blue Shield Assn. (BCBSA) has established a policy that denies acute care hospitals reimbursement for certain never events.

A health plan's approach to provider reimbursement is rooted in the need to move from traditional fee-for-service models to a payment model that accounts for providers adhering to best practices.

Proactive fraud detection programs should identify bogus claims before the money is paid out

Coordination of care helps decrease costs and ensures effect use of resources

If more patients are covered by Medicaid, hospitals stand to become unstable under reimbursement of 88 cents on the dollar

State of the Industry survey results

MedPAC reports 2009 MA payments will be 14% above fee-for-service rates.

The shortage of oncologists and the increasing numbers of cancer survivors combine to produce a classic case of demand exceeding supply

Payment structure among stakeholders must be equitable in order to avoid contract disputes and provide the highest quality of care to consumers.

Payer initiatives will encourage consumers to make educated choices, especially since prices can vary so dramatically.

CMS will begin demonstration projects to further test the promise of P4P by bundling payments for certain services as single case-rates

Study finds CT colonoscopies to be as effective as standard ones. This may prompt further coverage by health plans, as well as encourage more individuals to be screened for colon cancer.

Insurers follow updated CMS rules regarding financial responsibility for egregious medical mistakes, do not pay list and never events

There is more focus on linking payment with quality, whether as pay for performance, value-based purchasing or restructured employee benefits packages that modify out-of-pocket expenses based on quality of providers, according to experts.

More than 650 hospitals have pledged to adopt the Leapfrog Group's policy on "never events"-rare medical errors that should never happen to a patient.

Virtually everyone agrees that properly incentivizing physicians-particularly rewarding the high-level performers-is critical to changing the direction of the U.S. healthcare industry. No single stakeholder can effect much of a change alone, however; if the industry is going to change, it will be with help from every direction and demographic.

As health plans elect to cover a new FDA-approved vaccine that protects girls and women against strains of the human papillomavirus (HPV), parents might wonder if it will be mandated by states as a routine immunization for girls at a certain age.

Just like the rest of healthcare, dental and vision ancillary benefit providers are adopting cost-sharing strategies that offer options to employees but demand more skin in the game. With less financial responsibility on the shoulders of employers, ancillary benefits have become more flexible, varied and are more closely tied to the overall health of individuals, who are assuming more risk for their health.