Michael Westover’s Post

How the tides can turn. A single regulatory change regarding Medicare Advantage has eliminated Billions in healthcare profits. At a recent conference, a CMS employee explained that with budgetary constraints and seeing how much money Humana, etc. were making, it became an easy target of cuts. I'm witnessing a lot of pain in the local primary care landscape, particularly for those funded with high debt levels. Both Cano and Caremax are insolvent and many others are bleeding badly and may not be far behind. I expect healthcare multiples to decline long-term as they revert back to the mean after having soared (doubling in many sub-sectors) in recent years. This has been exacerbated by many PE funds simultaneously choosing to exit the sector after seeing firsthand the potential government risk. #healthcare #mergersandacquisitions https://lnkd.in/em5R5H-a

Thanks for posting, Leslie Boles, BA, CCS, CPC, CPMA, CHC, CPC-I, CRC - I think this one slipped under the radar and isn’t getting the attention it needs. Performing and billing services under Incident To is still wildly popular and, if done incorrectly, brings risks. As a reminder, Incident To services performed in the Office/Outpatient setting must be an integral part of the physician's services during the diagnosis or treatment of an injury or illness and, generally, must be furnished under the physician's direct supervision. Incident To services are billed under the physician's National Provider Identifier number as if the physician personally provided the services.

The November OIG Work Plan takes a closer look at Medicare Part B Payments for Incident-To Services—an area critical to compliance and program integrity. These services, billed under a physician's NPI, must adhere to specific requirements, including: ✔️ Being an integral part of a physician's diagnosis or treatment, ✔️ Delivered under direct supervision, and ✔️ Fully compliant with Medicare regulations. The OIG aims to determine if these payments meet Medicare requirements, with a focus on transparency and accountability in billing practices. 💡 Take Action: Now is the time to review your policies, documentation, and workflows to ensure compliance with Incident-To regulations and avoid unnecessary risks. How is your organization addressing these compliance priorities? Let’s collaborate and share insights! https://lnkd.in/eEy6qPA2 #HealthcareCompliance #MedicarePartB #IncidentTo #OIGWorkPlan #ComplianceLeadership

It's important to remember the challenges small business owners, including ACOs, face as they navigate the complexities of their operations. Anytime a business (in this case, a collection of physician practices) makes a significant shift in a product or service, it has to forecast the adoption and the corresponding revenue ramp. We’re asking ACOs to invest the effort, time, and capital to reinvent care models and abandon a straightforward FFS reimbursement model in favor of a complex shared savings formula. Upfront payments would create predictability that allows for the development of 3-5 year strategic plans, making significant investments toward those plans while balancing the needs of their board of directors. Full risk would be a step further, giving providers the freedom and responsibility to go all-in without the involvement of additional stakeholders. With the right funding support, ACOs can embrace new VBC programs like ours and reap their potential benefits, such as the envisioned outcomes and financial sustainability. #acos #valuebasedcare #valuebasedhealthcare #primacycare #aco #accountablecareorganizations https://lnkd.in/g5NwMFqR

A nice read for those #healthequitywarriors still trying to catch up with the latest alternative payment models (APMs).....How many acronyms do we have in healthcare? Clearly not enough! 🤣 #ACOReach #APMs #VBC #healthequity RISE

Interesting report on #PriorAuthorization rates in #MedicareAdvantage. Over 93% of PA’s are approved on first pass and 80% of denied requests that are appealed get approved on the second pass. #UHC shows the second lowest rate of PA friction. #KaiserPermanente, a fully integrated system with its own #healthplan, shows the lowest rate. #Humana’s PA rate is more than triple that of #UHC’s. #TripleAim #HealthcareCosts

Prospective payments were an important theme of conversation at NAACOS’ spring conference. Generally, I believe this is a good policy as it gives ACOs resources to invest in the infrastructure, like data and analytics tooling, to succeed in value-based care. Advanced payment can also level the playing field and motivate more providers to make the shift from volume to value. At a time when budgets are stretched, these resources can help fuel the transformation we need for the sustainability of our healthcare system.

Today, HMA released a new white paper, “Medicare Physician Fee Schedule Reform: Structural Topics and Recommendations to Strengthen the System for the Future.” It provides an in-depth analysis of the Medicare Physician Fee Schedule, including the history of its implementation, stakeholder perspectives on reform, major structural issues, and recommendations for improving the $90-plus billion payment system. Read more about the white paper: https://bit.ly/3KbsELj

🚑 What EMS Providers Should Know About the CMS GADCS Report The recently published CMS GADCS Report (Years 1 & 2) offers groundbreaking insights into the operations, costs, and revenues of ground ambulance services across the U.S. Whether you’re looking to benchmark your organization’s performance, understand national trends, or prepare for upcoming policy changes, this report is a must-read. Here’s what we cover in our latest blog: ✔️ Key findings on participation rates and operational insights ✔️ A breakdown of labor, vehicle, and facility costs ✔️ Policy implications that could shape future reimbursement rates 💡 Why this matters: Policymakers can use this data to set reimbursement rates, making it critical for EMS providers to stay in the know. 🔗 Read the full blog to learn more: https://lnkd.in/g29Gv-97 Let us know your thoughts—how does this data impact your operations? ⬇️

Sheer madness, indeed. Broken, outdated and unsustainable are other words that come to mind. In a payment system that: • Values fee for service over connection to quality and outcomes. See more patients, do more with less and create the provider burn out inferno we now see. • Extends no inflationary update in reimbursement. Every year, providers take a pay cut due to inflation alone. From 2002 to 2023, providers are operating at 26% below its accompanying inflation rate. • Requires budget neutrality. Every year there are winners and losers and everyone get a turn on both sides but nobody ever comes out ahead. • Creates uneven payment advantages through an outdated RVU system. All healthcare is not created equal in the eyes of the RVU system. It’s no wonder why every year the great MPFS debate starts in the summer and everyone holds their breath for the Final Rule each November. Real change starts at the foundation, through alternative payment models and outdated provisions and legislation being lifted and revised to confront the reality of CMS spending. #medicare #healthcarefinance #hfma