Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions

The following questions were published in "Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions" from the Department of Health and Human Services.  For more detail on the these questions, there is a link to the full article at the end of this blog post.

What is an ACO?

• Doctors, hospitals, and other health care providers who voluntarily come together to provide high quality care to Medicare patients.

What is the Pioneer ACO Model?

1. The Pioneer ACO Model shows how particular ACO payment arrangements can best improve care and generate savings for Medicare.
2. It also tests alternative program designs to inform future rule making for the Medicare Shared Savings Program

When does the Pioneer ACO Model:

• Begin?
• January 1, 2012
• When does it end?
• 3 years from January 1, 2012.
• How many ACOs are participating?
• 32 Organizations

How is the Pioneer ACO Model different from the Shared Savings Program?

• To view the list of ways the Pioneer ACO Model differs from the Medicare Shared Savings Program, see the link at the bottom of the blog post.

How is it different from the Advance Payment Model?

• Only available to ACOs participating in the Medicare Shared Savings Program.

Can an ACO Participate in both the Shared Savings Program and the Pioneer ACO Model?

• No

How will payments to the Pioneer ACO work?

• Will follow a shared savings or losses experienced by Medicare for a specific set of beneficiaries.

What are population-based payments?

• Population-based payments are per-beneficiary per month payment amount intended to replace a significant portion of the ACO's fee-for-service (FFS) payments with a prospective payments.

How will beneficiaries be affected by the Pioneer ACO Model?

• Improves partnership between patients and doctors in making health care decisions.

Are beneficiaries required to participate in the Pioneer ACO Model?

• Competitive application review process

How did CMS select the ACOs participating in the Pioneer ACO Model?

• 160 letters of intent, 80 applications

To download the full PDF, please click the following link: Pioneer Accountable Care Organization (ACO) Model Program Frequently Asked Questions (FAQs).

For additional billing, coding and reimbursement resources, please click the following link: Medical Reimbursement, Inc. Resources Page.  

Are Medical Scribes Worth The Investment?

Are Medical Scribes Worth The Investment? A study was produced on whether or not scribes are worth the investment.  Two different hospital emergency departments were studied.

Some benefits of scribes:

• Can assist higher acuity emergency departments who struggle with long patient stays.
• Assist in decreasing the amount of patients leaving without being seen (LWBS)
• Assist with challenging EMRs (electronic medical record systems)

What does a scribe do?

• A scribe enters information into an EMR or chart directed by a physician or practitioner.

The study weighed the cost of the scribes' salaries against the return value as well as observed the following factors to see if a scribe was worth the investment:

• Patients per hour
• Relative value unit capture
• Number of billable patients
• Reduction in hours of coverage
• Number of down-coded charts
• Pulse oximetry and rhythm strip capture
• Length of stay for patients
• Door-to-doctor times

• The above factors were observed at two different hospitals. One hospital had an annual volume of 65,000 patients and the other hospital had an annual volume of 68,000 patients. 
• Overall, measuring the two hospitals against the parameters listed above, the hospitals showed improvements with the additional of a scribe.
• The cost for a scribe was about $20 an hour or they can also be measured at 20% productivity of the physician.

To view the full article as well as the percentages of improvements for the parameters, please click the following link: Are Medical Scribes Worth the Investment?

For additional billing and coding resources, please click the following link: Medical Reimbursement, Inc. Resources Page.

Documentation Costs Associated With An ICD-10 Mandate

MGMA produced a fact sheet on: "Documentation Costs Associated With An ICD-10 Mandate".  This fact sheet highlighted documentation costs for small, medium and large practices.

A "Small" Practice:

• Consists of 3 Physicians, 2 administrative staff.
• ICD-10 mandate for a small practice will cost an estimated: $83,290

A "Medium" Practice:

• Consists of 10 Providers, 1 full-time coder, 6 administrative staff
• ICD-10 mandate for a medium practice will cost an estimated: $285,195

A "Large" Practice:

• Consists of 100 Providers, 64 Coding Staff - 10 full-time coders, 54 medical records
• ICD-10 mandate for a large practice will cost more than an estimated: $2.7 million.

6 Key Areas that ICD-10 will impact:

1. Staff Education and Training
2. Business Process Analysis of Health Plan Contracts, Coverage Determinations and Documentation
3. Changes to Superbills
4. IT System Changes
5. Increased Documentation Costs
6. Cash Flow Disruption

To read the full article, please click the following link: Documentation Costs Associated With An ICD-10 Mandate

For additional billing, coding and reimbursement resources, please click the following link: Medical Reimbursement, Inc. Resources

Medicare Billing Rises at Hospitals With Electronic Records

The New York Times published an article: "Medicare Billing Rises at Hospitals With Electronic Records". The article discussed many key points on the impact of Electronic Health Records (or EHRs). The following are some points from the article:

• EHRs may be contributing to billions of dollars in higher costs for Medicare, private insurers & patients making it easier for the physicians to bill more for their services.
• In 2010, hospitals received $1 billion more in Medicare reimbursements than 5 years prior.
• For instance one hospital's reimbursements rose 43% in 2009, the same year they began their EHR.
• Another hospital discussed in the article had an increase in their paid claims by 82%.
• Because of the higher coding, this has prompted the attention of federal & state regulators as well as private insurers - they state that coding of E/M Services is vulnerable to fraud and abuse.
• One individual stated that  EHRs "can improve the quality of care, save lives and save money"

Some negatives of Electronic Health Records - EHRs are as follows:

• Automatically generated patient history
• Cut-and-paste examination findings from multiple patients - called "cloning"
• Boxes that allow doctors to review patients symptoms without a full exam being done.
• One individual was quoted stating: (the use of electronic records): "makes it faster and easier to fraudulent".

To download the full article, please click the following link: "Medicare Billing Rises at Hospitals With Electronic Records"

For additional billing, coding, and reimbursement resources, please click the following link: Medical Reimbursement, Inc. Resources Page

Emergency Room Visits Likely to Increase Under Obamacare

The National Center for Policy Analysis published a short article titled: "Emergency Room Visits Likely to Increase Under Obamacare".

According to the article, the following are two reasons why costs for the Emergency Room will increase:

• Around half of the insured will enroll in Medicaid and these patients typically seek care in the Emergency Room more often than those who are uninsured.
• There will be an increased demand for emergency rooms

Health Insurance Status
The Congressional Budget Office States the following:

• 32 million people who are uninsured will be able to obtain health insurance under the health care reform.
• About half of this 32 million will enroll in Medicaid and the State Children's Health Insurance Program.
• The health insurance exchanges to start in 2014 with implementation to begin in October 2013 will allow more members to obtain health insurance.

Emergency Room Use

• Many people think that the uninsured go to the hospital more than those with insurance and in this article, they state this is not the case.

Predicting Emergency Room Use Based on Change in Health Insurance Status

If the following 4 points are met:

1. Half uninsured obtain insurance
2. Newly insured enroll 50/50 in Medicaid & private plans
3. The newly insured are reflective of the current population
4.  The newly insured behave similar to those like them

• Under 18, the number of insured will climb to 22% from 18%
• Ages 18-44 ER visits will increase to 28% from 21%
• Ages 45-64 ER visits will increase to 28% from 19%

Predicting Emergency Room Use Based on Health Care Rationing

• Uninsured make almost two physician visits per year it is more than 3.5 for privately insured and 7.5 for Medicaid patients.
• It is estimated that the newly insured will attempt 3.6 additional physican visits
• After the above being said - this would be an increase of 39-41 million additional emergency room visits per year.

To download the full article with a chart, please click the following link: Emergency Room Visits Likely to Increase Under Obamacare.

For additional billing, coding, & reimbursement resources, please click the following link: Medical Reimbursement, Inc. Resources Page.

Detached ER Costs Criticized

The Journal Gazette published an article from Bloomberg News titled: "Detached ER Costs Criticized" highlighting claims that freestanding Emergency Room charges are excessive.

• The article discussed one patient's bill was nearly $2,000 ($700 out-of-pocket and $1,518 "facility fee") - this is about 5x what the patient would have paid to get similar care elsewhere.
• The Benefits of Freestanding Emergency Rooms:
• They offer 24-hour service, short waits along with board certified emergency specialists.
• They also may be helping out the overcrowded and understaffed hospital Emergency Rooms.
• The charges that come along with the free-standing ERs are closely related in amount to what you would pay at a hospital because the services are similar.
• Some states have required free-standing emergency rooms to accept all patients regardless if they can pay or not.  
• One individual quoted in the article said: "Many are glorified urgent-care centers, but they still bill ER charges."
• These unattached ERs as well as urgent-care centers will transfer patients to hospitals if they require more care than they can handle.  
• According to the article, expenses in a stand-alone ER are more than 10 times what the patient would pay if they went to a doctor's office or an urgent-care.

To view and download the full article, please click the following link: Detached ER Costs Criticized

For additional billing, coding, and reimbursement resources, please click the following link  Medical Reimbursement, Inc. Resources Page.

ICD-10 Transition to Impact Specialists More Negatively

EHR Intelligence published an article titled: "ICD-10 Transition to Impact Specialists More Negatively".

According to the article:

• Some specialties will be affected more than others
• ICD-10 will increase the number of codes from 14,567 to approximately 68,000 codes.
• Implementation costs range from $83,000 to $2.7 million per practice (according to the AMA)

Easy specialties for transition to ICD-10:

• Hematology
• Oncology

Most challenged specialties for transition to ICD-10:

• Obstetics
• Psychiatry
• Emergency Medicine (Poisoning)

The outcomes for this study were a result of a case study done by the emergency department at Illinois Health Connect.
 

To view the full article, please click the following link: ICD-10 Transition to Impact Specialists More Negatively

For additional billing, coding, and reimbursement resources, please click the following link: Medical Reimbursement Resources Page.