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Welcome to Global Integrated Reimbursement Services’ blog. The purpose of our blog is to allow access to a repository of issues that our company tracks regarding the reimbursement for pharmaceuticals, medical devices, diagnostics, biologics, and biosimilars. Also, it shows you how we can assist you in these areas.

UnitedHealth Group to Implement Bundled Payment Models

Posted by on Dec 21, 2016 in Payer Coverage, Payment System | Comments Off on UnitedHealth Group to Implement Bundled Payment Models

UnitedHealthcare, a subsidiary of UnitedHealth Group, followed in the Centers for Medicare & Medicaid Services (CMS)’s footstep by recently announcing that they would be adopting bundled payment models for spinal surgeries, hip and knee replacement surgeries in over 40 markets next year. When it comes to knee replacement and hip surgeries, some payors have seen a great increase in prices. To lower overall healthcare spending and improve care, CMS, the largest payor in the country, implemented the Comprehensive Care for Joint Replacement (CJR), a bundled payment model pilot for hip and knee replacements. “This model tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.” (CMS, December...

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Elimination of Medicare Appeals Backlog Ordered by 2020

Posted by on Dec 20, 2016 in Payer Coverage, Payment System | Comments Off on Elimination of Medicare Appeals Backlog Ordered by 2020

A federal judge recently decided that the Secretary of Health and Human Services (HHS) must eliminate the Medicare appeals backlog currently pending before Administrative Law Judges (ALJs) by Dec. 31, 2020. An appeal is the action a Medicare beneficiary or healthcare provider can take if they disagree with a coverage or payment decision made by Medicare, a Medicare health plan, or a Medicare Prescription Drug Plan. The appeals process has 5 levels; If one disagrees with the decision made at any level of the process, they can generally go to the next level. Once a level 3 appeal is filed with the ALJs, by law, the court has 90 days to make a decision. Over the past several years, those level 3 reviews have become increasingly delayed due to volume. HHS reported that appeal hearings at the ALJ level...

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CMS Releases Medicare Physician Fee Schedule for Calendar Year 2017. See What is New for Your Accounts…

Posted by on Nov 7, 2016 in Payment System | Comments Off on CMS Releases Medicare Physician Fee Schedule for Calendar Year 2017. See What is New for Your Accounts…

On November 2, 2016, the Centers for Medicare and Medicaid Services (CMS) released the final Medicare Physician Fee Schedule (MPFS) for 2017. The Final Rule updates payment policies and payment rates for services furnished by physicians and other practitioners in all sites of service under the MPFS. These services include but are not limited to visits, surgical procedures, diagnostic tests, therapy services, and specified preventive services. These policy changes and payment rates are effective as of January 1, 2017. Some key payment and policy changes summaries are presented below: Physician payment rates will increase in 2017: The CY 2017 MPFS conversion factor increased from $35.80 in 2016 to $35.89 in 2017. The CY 2017 MPFS conversion factor reflects a budget neutrality adjustment of -0.013%. The increase in fees will vary by codes. Do you want to know how your...

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Medicare Sets Goal of 80 Percent Medicare Traditional Payment to Alternate Payment Methods by 2018

Posted by on Jan 27, 2015 in Payment System | Comments Off on Medicare Sets Goal of 80 Percent Medicare Traditional Payment to Alternate Payment Methods by 2018

  Medicare has introduced several alternatives to the traditional payment system such as Accountable Care Organizations, Hospital Value-Based Purchasing, Hospital Readmission Reduction Program and other quality measured payment methods over the last few years. Currently, 20% of total Medicare payments are provided by these alternative payment methods. Medicare has set new goal dates and percent of use of these alternative payment methods as: • 2016 30% payment by alternative payment methods • 2018 50% payment by alternative payment methods Medicare plans to tie larger portions of the hospital payments (85%) to the value based and quality programs with a 90% increase in 2018. This is the first time Medicare has set goal dates and percentage amounts to change the traditional fee-for-service model. Medicare plans to change the traditional economic incentives to outcome based incentives. HHS has created the Health...

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