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2016 Healthcare Claims Processing

Medicare Regulations Are Changing Come 2016. Apex EDI’s OneTouch® Healthcare Claims Processing Service Makes Change Easy

With the advent of 2016 just around the corner, we’re sure many of you are already aware of the coming Medicare Physician Fee Schedule (MPFS) regulation update this January. If not, here’s a quick look at just a few of the policies that will be affected by the new 2016 payment rules:

    Home Health Value-Based Purchasing

    Driven by mandates in the Affordable Care Act, Value-Based Purchasing incentivizes providers to increase the quality of their care. In fact, the amount of incentives participating agencies receive is directly proportional to the quality scores they earn. The program has been piloted through various disciplines within the medical industry, and beginning January 1, all Medicare-certified home health agencies operating in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee will move to a Value- Based model.

    The “Two-Midnight” Rule

    After considerable debate, the controversial “Two-Midnight” Rule CMS first introduced in 2013 will officially go into effect. In essence the rule clarifies that in terms of Medicare payments auditors must assume a hospital stay was legitimate and necessary as long as the stay spanned two midnights. (Stays under the two-midnight mandate will now be billed as outpatient observation care; a key difference in terms of healthcare claims processing.) According to CMS, this illustrates the “long-standing emphasis on the importance of a physician’s medical judgment in meeting the needs of Medicare beneficiaries.”

    End-Stage Renal Disease Quality Incentive Program

    Like the Value-Based Purchasing initiative discussed above, the new End-Stage Renal Disease rule will tie the incentives dialysis facilities receive to the quality of the dialysis care their patients actually receive. Quality of care will be determined with respect to measures such as infection rates, safety violations and overall patient experience. In fact, facilities that fail to meet a “total minimum performance” requirement will be penalized with a reduction in their rates.

    New Physician Payment System

    This change is garnering attention because it’s the first final rule issued since the sustainable growth rate formula was repealed by the by the Medicare Access and CHIP Reauthorization Act of 2015. The new rule covers quite a bit of ground, but most notably, also begins a new period of physicians and practitioners being paid according to merit. Like many other agencies, physicians will receive payment incentives for providing high-quality, while those who fail to meet standards may be subject to payment reductions. Also included is the institution of two new, separate billing codes for advance care planning services provided to Medicare beneficiaries. Formerly all advanced care planning has been coded under a single “Welcome to Medicare” visit. This change allows for Medicare coverage of more in-depth discussions.

While regulation change can seem confusing, rest assured that with Apex EDI’s OneTouch® electronic healthcare claims processing, we’ve done the heavy lifting. In all the ways possible, our real-time eligibility verification, patient statements delivery, and electronic remittance advice (ERA) will take regulation changes into account— ensuring that the process for collecting payments come January 1 is as simple and secure as always.

For more information on the 2016 regulation changes visit https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-10-30-2.html.

Posted in: Healthcare Claims

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