Bridging the gap: improving behavioral health services in rural communities

Read this if your company is considering outsourced information technology services.

For management, it’s the perennial question: Keep things in-house or outsource?

For management, it’s the perennial question: Keep things in-house or outsource? Most companies or organizations have outsourcing opportunities, from revenue cycle to payment processing to IT security. When deciding whether to outsource, you weigh the trade-offs and benefits by considering variables such as cost, internal expertise, cross coverage, and organizational risk.

In IT services, outsourcing may win out as technology becomes more complex. Maintaining expertise and depth for all the IT components in an environment can be resource-intensive.

Outsourced solutions allow IT teams to shift some of their focus from maintaining infrastructure to getting more value out of existing systems, increasing data analytics, and better linking technology to business objectives. The same can be applied to revenue cycle outsourcing, shifting the focus from getting clean bills out and cash coming in, to looking at the financial health of the organization, analyzing service lines, patient experience, or advancing projects.  

Once you’ve decided, there’s another question you need to ask
Lost sometimes in the discussion of whether to use outsourced services is how. Even after you’ve done your due diligence and chosen a great vendor, you need to stay involved. It can be easy to think, “Vendor XYZ is monitoring our servers or our days in AR, so we should be all set. I can stop worrying at night about our system reliability or our cash flow.” Not true.

You may be outsourcing a component of your technology environment or collections, but you are not outsourcing the accountability for it—from an internal administrative standpoint or (in many cases) from a legal standpoint.

Beware of a false state of confidence
No matter how clear the expectations and rules of engagement with your vendor at the onset of a partnership, circumstances can change—regulatory updates, technology advancements, and old-fashioned vendor neglect. In hiring the vendor, you are accountable for oversight of the partnership. Be actively engaged in the ongoing execution of the services. Also, periodically revisit the contract, make sure the vendor is following all terms, and confirm (with an outside audit, when appropriate) that you are getting the services you need.

Take, for example, server monitoring, which applies to every organization or company, large or small, with data on a server. When a managed service vendor wants to contract with you to provide monitoring services, the vendor’s salesperson will likely assure you that you need not worry about the stability of your server infrastructure, that the monitoring will catch issues before they occur, and that any issues that do arise will be resolved before the end user is impacted. Ideally, this is true, but you need to confirm.

Here’s how to stay involved with your vendor
Ask lots of questions. There’s never a question too small. Here are samples of how precisely you should drill down:

• What metrics will be monitored, specifically?
• Why do the metrics being monitored matter to our own business objectives?
• What thresholds must be met to notify us or produce an alert?
• What does exceeding a threshold mean to our business?
• Who on our team will be notified if an alert is warranted?
• What corrective action will be taken?

Ask uncomfortable questions
Being willing to ask challenging questions of your vendors, even when you are not an expert, is critical. You may feel uncomfortable but asking vendors to explain something to you in terms you understand is very reasonable. They’re the experts; you’re not expected to already understand every detail or you wouldn’t have needed to hire them. It’s their job to explain it to you. Without asking these questions, you may end up with a fairly generic solution that does produce a service or monitor something, but not necessarily all the things you need.

Ask obvious questions
You don’t want anything to slip by simply because you or the vendor took it for granted. It is common to assume that more is being done by a vendor than actually is. By asking even obvious questions, you can avoid this trap. All too often we conduct an IT assessment and are told that a vendor is providing a service, only to discover that the tasks are not happening as expected.

You are accountable for your whole team—in-house and outsourced members
An outsourced solution is an extension of your team. Taking an active and engaged role in an outsourcing partnership remains consistent with your management responsibilities. At the end of the day, management is responsible for achieving business objectives and mission. Regularly check in to make sure that the vendor stays focused on that same mission.

Read this if you are a leader at a state Medicaid agency.

CMS has delivered nearly  $34 billion, later updated to $51 billion, in the past week to the healthcare providers on the frontlines battling the 2019 novel coronavirus

• The process in which CMS is implementing requests has reduced times of an accelerated or advance payment to four to six days. Previously the timeframe was three to four weeks. 
• To date, CMS has received over 25,000 requests from providers and suppliers for accelerated and advance payments. Of these, CMS has approved over 17,000 requests in the past week. 
• It should be noted that this funding is separate and distinct from the $100 billion provided in the Coronavirus Aid, Relief, and Economic Security (CARES) Act.

CMS issues new wave of infection control guidance based on CDC guidelines to protect patients and healthcare workers 

CMS has issued a series of updated guidance documents focused on infection control to prevent the spread of COVID-19 in a variety of inpatient and outpatient care settings.

• The updated guidance includes a number of updates, notably the option of providing home dialysis training and support services. These are designed to help some dialysis patients stay home during the pandemic.
• In particular, the guidance includes the establishment of Special Purpose Renal Dialysis Facilities (SPRDFs), which can allow dialysis facilities to isolate vulnerable or infected patients.
• For hospitals, psychiatric hospitals and CAHs, the updated guidance provides recommendations on screening and visitation restrictions, discharge to subsequent care locations, as well as staff screening and testing.

CMS acts to ensure US healthcare facilities can maximize frontline workforces to confront COVID-19 crisis 

CMS has temporarily suspended a number of rules in order for hospitals, clinics, and other healthcare facilities to boost their frontline medical staffs.

The CMS guidance focuses on reducing supervision and certification requirements so that practitioners can both be hired rapidly and perform work to the extent of their licensure. CMS guidance allows the following:

• Doctors can now directly care for patients in certain settings without having to be physically present.
• Nurse practitioners may now perform some medical exams on Medicare patients at skilled nursing.

CMS approves additional state Medicaid waivers and amendments to give states flexibility to address coronavirus pandemic

CMS continues to deliver regulatory relief to a number of new states in the form of waivers and state plan amendments.

• In total, CMS has now approved 49 emergency 1135 waivers, 26 state amendments, seven COVID-19 related Medicaid disaster amendments and the first CHIP COVID-related disaster amendment
• The COVID-related Children’s Health Insurance Program (CHIP) disaster amendment is for the State of Maine. 
• CMS has now approved COVID-related Medicaid disaster state plan amendments for North Dakota, Rhode Island, and Wyoming.

HHS authorizes licensed pharmacists to order and administer COVID-19 tests

On April 8, HHS released new guidance under the Public Readiness and Emergency Preparedness Act that authorizes licensed pharmacists to order and administer FDA-approved COVID-19 tests.

• The guidance allows pharmacists to order and administer COVID-19 tests to their patients will provide easier access to testing and will expand testing for healthcare workers and first responders. 

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team. 

Read this if you are a Chief Executive Officer, Chief Financial Officer, Chief Risk Officer, Chief Information Officer, or Controller.

While COVID-19 has forced many of us into a remote work environment, we also have to deal with the challenges that come along with it. The stark contrast between an office environment and one that potentially involves working in isolation can be a difficult adjustment. Office kitchen conversations have evolved into conversations with pets, our newest co-workers. A quick, in-person question has now turned into an email, phone, or video call. And job responsibilities expand as we try to not only juggle work but also ensure our children focus on school work―and don’t destroy the house. 

Not only has this forced environment caused social challenges, it has also opened the door for internal control challenges, as  internal controls designed to operate effectively in an office environment may not be ideal for a remote workplace. Even ones that are appropriately designed, may prove to be operating ineffectively in this new environment. Let’s take a look at some internal control challenges, and potential solutions, faced by working in a remote environment.

Establishing a remote control environment

Exercising appropriate tone at the top and establishing appropriate oversight can be challenging with a remote workforce. Ethics and governance policies play an important role in setting clear expectations about workplace behaviors. But, a workforce is much more apt to follow a leadership team’s example rather than a policy. All of those office conversations, even the conversations that are not work related, help set an expectation of appropriate and inappropriate behaviors. These conversations often happen naturally in the office via a quick conversation in passing in the hallway or a late-Friday happy hour with your department. However, these interactions do not naturally occur in a remote workplace. Leadership and department heads should make an active effort to maintain communication with their workforce. Some things to consider:

• Send out weekly emails to the entire department and possibly more personal, one-on-one videoconferences or phone calls between your department heads or managers and individual members of their teams.
• These department-wide emails should stress the importance of communication as well as continuing to produce high quality work and maintaining accountability. 
• One-on-one meetings should be used to check in with employees to ensure their work needs are being met. 

Employees will most likely have many suggestions to improve their new work environment, including suggestions on how to improve communication amongst team members. 

The power of video

Videoconferencing also provides a great opportunity to stay connected. Virtual happy hours simulate an in-person happy hour. This is a great way to check-in with team members and show that, although people are out of sight, they are not out of mind. Town hall-type meetings can also be explored. Your leadership team can solicit open discussion. Agenda items may include office status updates, technological considerations, and an opportunity for employees to openly discuss current challenges due to working in a remote environment. Employees are going to have anxiety about the current environment. These meetings can help put employees at ease.

Risk assessment

Internal control environments are constantly evolving. Employees leave. Software is updated.  Offered services and products change. The list goes on. However, it is unprecedented that an internal control environment has changed so rapidly. Given these unprecedented times, there is potential for higher risk of fraud, internally and externally. Those responsible for designing internal controls (control owners) should reassess your company’s environment. Although internal controls can be designed in a manner in which they operate effectively regardless of the circumstances, it is possible there are unintended changes to processes that have occurred. 

For instance, let’s say the employee responsible for reviewing loan file maintenance changes is now working an alternative work schedule due to personal obligations. This employee does not have the ability to make loan file changes; therefore, segregation of duties has never been an issue. An employee within loan servicing has agreed to take some of the employee’s responsibilities and is now reviewing some of the loan file maintenance changes, which has put this employee in a position to review some of their own changes. 

Furthermore, some internal controls that require employees be at a physical location to operate may also be compromised, such as inventory cycle counts. If these controls are unable to operate, control owners will need to consider the impacts on the affected transaction areas, and if there are compensating controls that can be designed to alleviate some of the control risk.

Control activities

Accounts payable and check signing

The accounts payable and cash disbursement process will most likely be upended as a result of your new remote environment. Bills received through the mail will need to be scanned to the accounts payable clerk for entry into the accounting system. Some offices have designated certain personnel responsible for checking mail on an infrequent basis, for instance, weekly. Check signing may also prove to be a challenge as blank check stock may be inaccessible. Electronic receipt of invoices and signing of checks, as well as the use of wire and ACH transfers, lend themselves as feasible solutions. Email approvals may suffice when multiple signers are needed to approve high dollar disbursements.

Segregation of duties

As mentioned above, it is possible processes have inadvertently changed, exposing certain internal controls to ineffectiveness. Segregation of duties may become difficult as employees shift to alternative work schedules or have other issues. Maintaining segregation of duties should be a top priority for control owners and is something that should be constantly assessed as circumstances change. Challenging times may make segregation of duties difficult and may force you to get creative by requesting employees perform duties they are not otherwise accustomed to performing.

Digital sign-offs

You should also consider the manner in which you document the completion of controls. Control owners should be cautious about the integrity of an employee’s initials simply typed onto a digital document, as any employee can perform this task. Digital signatures, which require an employee to enter credentials prior to signing, enhance the integrity of a sign-off and are often time stamped. Digital signatures may also “lock down” the document, prohibiting any changes to the signed document.

Timely review

Given the circumstances, it is not unreasonable that preparation and review may take longer than under normal circumstances. Even if additional time is granted for the preparation and review of documents, you should consider the implications this has on the transaction class as a whole. The longer it takes to complete a control, the greater the consequences may be if you identify an error. For instance, the impact of an incorrect change to a loan rate index can be substantial if not identified timely. If identified quickly, you can avoid consequences later.

Information and communication

For many companies that have moved from a paper to a digital environment, sharing of information should not be an issue. However, for those that still operate in a mostly paper environment, performing tasks and sharing information with team members may prove to be difficult. And, those without the capability of scanning and sending documents from home could compromise a specific internal control altogether. Being forced to work remotely may be the perfect excuse to move paper processes into a digital format.

Monitoring

Monitoring your internal control environment is of the utmost importance given these significant changes. Frequent conversations should be had with control owners to ensure changes to processes do not render controls ineffective. Identified gaps in internal controls should be addressed proactively. Provide control owners with the opportunity to discuss changes to control processes with Internal Audit or Risk Management so such departments can consider the impact of changes on internal control. This also gives these departments the opportunity to cover any resulting gaps.

Permanent changes

Once the remote workplace requirements end, the effects of working in such an environment will not. There are many benefits and efficiencies to be found in working remotely. As people have now been forced to work in such an environment, they will be more apt to continue to do so. Therefore, let’s take this opportunity to revise processes and internal controls to be “remote workplace” compatible. This will provide a long-lasting impact to your organization far beyond the pandemic. 
 

Read this if you are a leader at a state Medicaid agency.

Here is a summary of information we have gleaned from the Center for Medicare and Medicaid Services (CMS) Administrator Verma’s recent call.

CMS is implementing new rules and waivers that increase provider flexibility and free up resources to deal with a surge in COVID-19 patients. CMS is working with the provider community to provide clarity around specific changes that impact their operations.

• The rulemaking process has been dramatically expedited to accommodate recent and forthcoming regulatory changes
• CMS is in the process of working out details to administer CARES Act provisions, including further regulatory flexibilities, expansion of accelerated payment program, and $100 billion appropriated to reimburse eligible health care providers
• CMS clarifies that the 3-Day Rule Waiver for skilled nursing facilities applies throughout the country and to all patients, regardless of their COVID-19 status

Medicaid Substance Use Disorder Treatment via Telehealth, and Rural Health Care and Medicaid Telehealth Flexibilities Guidance

This informational bulletin is composed of two parts: Rural Health Care and Medicaid Telehealth Flexibilities and Medicaid Substance Use Disorder Treatment via Telehealth.

• The informational bulletin identifies opportunities for telehealth delivery for services to increase access to Medicaid services. It is composed of two parts, Rural Health Care and Medicaid Telehealth Flexibilities and Medicaid Substance Use Disorder (SUD) Treatment Services Furnished via Telehealth
• The bulletin provides SUD guidance around Medication Assisted Treatment (MAT), counseling, high risk populations, and other areas critical to providing SUD services.

Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit

CMS is issuing an electronic toolkit regarding telehealth and telemedicine for Long Term Care Nursing Home Facilities.

• The toolkit includes electronic links to sources of information regarding telehealth and telemedicine, including the changes made by CMS over the last week in response to the national health emergency.
• Much of the toolkit’s information is intended for providers who may wish to establish a permanent telemedicine program, but there is information here that will help in the temporary deployment of a telemedicine program as well.
• There are specific documents identified that may be useful in choosing telemedicine vendors, equipment, and software, initiating a telemedicine program, monitoring patients remotely, and developing documentation tools. 

CMS makes regulatory changes to help US healthcare system address COVID-19 patient surge

CMS has issued a number of temporary regulatory waivers and new rules to assist the nation’s healthcare system with improved flexibility.

• Increased hospital capacity. CMS will allow communities to take advantage of local ambulatory surgery centers that have canceled elective surgeries, per federal recommendations.
• Healthcare workforce expansion. CMS’s temporary requirements allow hospitals and healthcare systems to increase their workforce capacity by removing barriers for physicians, nurses, and other clinicians to be readily hired from the local community as well as those licensed from other states without violating Medicare rules.
• Paperwork requirements. CMS is temporarily eliminating paperwork requirements.
• Telehealth in Medicare. CMS will now allow for more than 80 additional services to be furnished via telehealth.

Additional COVID-19 FAQs for state Medicaid and Children's Health Insurance Program (CHIP) agencies

CMS released an update to the COVID-19 FAQs posted on March 18, 2020 related to emergency preparedness and response, eligibility and enrollment flexibilities, benefit flexibilities, cost sharing flexibilities, financial flexibilities, managed care flexibilities, fair hearing flexibilities, health information exchange flexibilities, and COVID-19 T-MSIS coding guidance. Notably:

• States that have CHIP disaster provisions in their state plans can activate these provisions. CMS considers a significant outbreak of an infectious disease to be a disaster. CMS also recommends that states that do not have disaster relief provisions in their CHIP state plans include language that a federal- or governor-declared emergency is considered an event that can trigger the disaster provisions.

States may not suspend use of their AVS, however CMS reminds states that they can rely on self-attestation of assets and verify financial assets using their AVS post-enrollment in Medicaid.

• CMS can help provide technical assistance regarding approaches states can use to rapidly scale telehealth technologies.
• CMS clarified and provided COVID-19 T-MSIS coding guidance.

For more information

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team. 

Per CMS, all state Medicaid agencies, including territories, are eligible for the increased Federal Medical Assistance Percentage (FMAP), provided they adhere to the conditions outlined in the Families First Coronavirus Response Act (FFCRA). 

Key takeaways:

• The increase in FMAP will be retroactive to January 1, 2020 and will be available to state Medicaid agencies through the end of the quarter in which the public health emergency for COVID-19 ends.
• This guidance answers some of the following questions for states, including:
  • How long the funding will be available and when it begins
  • What costs are matchable under the enhanced funding 
  • The specific conditions under which states are eligible to claim the funds 
  • What documentation and processes will be needed in order to gain full access to funding

Trump administration releases COVID-19 checklists and tools to accelerate relief for state Medicaid & CHIP programs

In order to assist states as part of the COVID-19 outbreak, the Trump administration has released a number of tools and checklists that constitute a federal authority toolkit to support states in applying for and receiving federal waivers and other key flexibilities for their program. 

Key takeaways:
The tools released today include:

• 1115 Waiver Opportunity and Application Checklist 
  Under this demonstration opportunity states may select from a variety of options to deliver the most effective care to their beneficiaries as a result of COVID-19.
• 1135 Waiver Checklist 
  CMS released a template that states can use to help develop their 1135 Waiver request to temporarily waive certain Medicaid program requirements.
• 1915(c) Appendix K Template 
  Appendix K is a standalone appendix that states can utilize during emergency situations to request an amendment to approved 1915(c) waivers.
• Medicaid Disaster State Plan Amendment (SPA) Template 
  CMS released a SPA template and instruction document dedicated to temporary changes to support COVID-19 response.

CMS issues FAQs on catastrophic health coverage and the coronavirus

A catastrophic health plan may not provide coverage of an essential health benefit prior to an enrollee meeting the deductible for that plan. In order to clarify treatment and coverage of COVID-19 for catastrophic health plans CMS has issued Frequently Asked Questions (FAQs).

Key takeaways:

• Catastrophic plans currently include coverage for the diagnosis and treatment of COVID-19 as they must cover the essential health benefits (EHB) as required by the Patient Protection and Affordable Care Act (PPACA).
• Issuers of catastrophic plans will be able to provide coverage for the diagnosis and treatment of COVID-19 for enrollees who have not yet met their deductible without CMS taking enforcing action.
• The FAQ document encourages states to take an enforcement approach and CMS does not “consider a state to have failed to substantially enforce section 1302(e) of the PPACA if it takes such an approach.”

Relief for clinicians, providers, hospitals, and facilities participating in quality reporting programs in response to COVID-19

CMS is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs.  

Key takeaways:

• The exceptions include pending dates for measure reporting and data submission for related programs. 
• For data submission deadlines in April and May of 2020, submission of those data will be optional, based on the facility’s choice to report.
• 2019 data submission
  • Deadline extended from March 31, 2020 to April 30, 2020.
  • Deadlines for October 1, 2019 - December 31, 2019 (Q4) 
  • Data submission is optional for inpatient rehabilitation and hospital-acquired conditions.

CMS releases telehealth toolkits for general practitioners and End-Stage Renal Disease (ESRD) providers

CMS has released two toolkits on telehealth which follow the broadened access to Medicare telehealth services under the 1135 waiver authority and Coronavirus Preparedness and Response Supplemental Appropriations Act.

Key takeaways:

• The toolkit consists of electronic links to sources of information pursuant to telehealth and telemedicine. 
• Generally directed towards providers, particularly ones who may be considering a permanent telemedicine program.
• CMS notes that most of the resources were established prior to the current COVID-19 crisis. As a result, there are likely references to rules and regulations whose requirements may have been waived for the duration of the outbreak.

Toolkits:

• General Practitioners
• End-Stage Renal Disease Providers

For more information

We’re here to help. If you have more questions or want to have an in-depth conversation about your specific situation, please contact the team. 

Here is a summary of information we have gleaned from recent CMS updates and guidance. 

COVID-19 stakeholder call - March 16 

CMS held a National Stakeholder Call on March 16, 2020 to update the healthcare community on the rapidly evolving COVID-19 situation, which was declared a national emergency by President Trump on March 13, 2020.

Key takeaways:

• Administrator Verma reaffirmed the goal of reducing administrative barriers in the way of healthcare workers and agencies and to support them as best CMS is able.
• Acknowledging that there were questions on testing, Administrator Verma outlined that there will be a ramp-up in testing in conjunction with state and local governments. 
• CMS is relaxing clinician enrollment requirements for Medicare and making the same option available to states in their Medicaid programs.
• The administration has been clear that it wants agencies to focus on infection control efforts. CMS is designing a streamlined template to evaluate infection control.
• CMS sends guidance to Programs of All-Inclusive Care for the Elderly (PACE) Organizations.

On March 17, 2020, CMS issued guidance to all Programs of All-Inclusive Care for the Elderly (PACE) Organizations (POs) on accepted policies and standard procedures with respect to infection control.

Key takeaways:

• POs will need to create, apply, and sustain a documented infection control plan that involves procedures to recognize, examine, regulate, and avert infections in PACE centers
• POs will need to work to prevent infections within each participant’s place of residence, as well as implement procedures to record and develop corrective actions related to incidents of infection.
• CMS provides guidance that recognizes POs may need to undertake strategies that do not traditionally comply with CMS PACE program requirements in order to provide benefits while guarding from COVID-19. Some examples of this may include telehealth services.
• President Trump expands telehealth benefits for Medicare beneficiaries during COVID-19 outbreak.

CMS is expanding Medicare’s telehealth benefits under the 1135 waiver authority and the Coronavirus Preparedness and Response Supplemental Appropriations Act.

Key takeaways:

• Under the new 1135 waiver, Medicare can pay for office, hospital, and other visits provided via telehealth across the country and including in patient’s place of residence starting March 6, 2020. 
• Medicare telehealth visits: These visits are considered the same as in-person visits and are paid at the same rate as regular, in-person visits.
• Virtual check-ins: Virtual check-in services can only be reported when the billing practice has an established relationship with the member.  
• E-visits: Such services can only be reported when the billing practice has an established relationship with the patient.  

CMS coronavirus partner virtual toolkit

CMS has released a virtual toolkit to help stakeholders stay up-to-date on CMS materials available on COVID-19. Here is specific guidance from the toolkit designed for states and health plans:

• Medicaid.gov 
• Medicaid and CHIP Disaster Response Toolkit 
• Medicaid Telehealth

CMS approves first state request for 1135 Medicaid waiver in Florida and Washington

The 1135 waiver allows Florida and Washington to modify certain Medicaid program requirements, policies, operational procedures, and deadlines applicable to each state’s administration of its Medicaid program during the period of the national state of emergency to prevent further transmission of COVID-19. 

Key takeaways from Florida’s waiver

• Provider participation flexibilities for Medicaid and CHIP Waiver of Service Prior Authorization (PA) Requirements for fee-for-service delivery systems
• Waiver for Pre-Admission Screening and Annual Resident Review (PASRR) Level II Level II Assessments for 30 Days
• Waiver to allow evacuating facilities to provide services in alternative settings, such as a temporary shelter when a provider’s facility is inaccessible
• Waiver to temporarily delay scheduling for state fair hearing requests and appeal deadlines (NOTE: CMS was unable to waive all of Florida’s requested authorities in this area)

If you have questions or would like more information, we are here to help. Please contact us. 

Editor's note: read this if you are a leader in an accountable care organization and interested in value-based contracting.

Accountable Care Organizations (ACOs) and value-based payments: an introduction

With the goal of slowing the rising cost of healthcare while maintaining the delivery of high-quality care, the Centers for Medicare & Medicaid Services (CMS) and private payers utilize a number of different provider payment models. The primary approach to address increasing healthcare costs has been to move away from fee-for-service payment models—which incentivize increasing the volume of care provided—to value-based payment models, which hold providers accountable for both the cost and quality of care they provide. The models have the potential to lead to reduced revenue for some providers, an outcome that can be avoided by successfully attracting larger patient populations. 

Value-based payment model options 

CMS has been a driver in this transition by moving physician reimbursement from being solely based on the Resource-Based Relative Value Scale (RBRVS) fee-for-service methodology to one that adds performance-based elements either through the Merit-based Incentive Payment System (MIPS) or Advanced Alternative Payment Models (Advanced APMs):

• Providers that are MIPS eligible will have up to 9% of their RBRVS-based payments adjusted for four categories: quality, cost, clinical practice improvement activities, and promoting interoperability.
• Providers in an Advanced APM may earn an incentive payment based on their participation in an innovative payment model―with more opportunity for incentive rewards being given to those who take downside financial risk. 

On the hospital side, CMS developed the Hospital Value-Based Purchasing (VBP) Program in order to move away from reimbursement based strictly on Diagnosis Related Groups (DRGs). The Hospital VBP Program rewards hospitals with incentive payments based on the quality of care they provide to Medicare beneficiaries. 

ACO value-based payment models are APMs that typically incorporate quality and the total cost of care for all services for a specific population, rather than just a specific clinical condition or care episode. Under the ACO model, CMS contracts with providers to assume increasing financial risk and reward opportunities while also being held accountable for their quality performance managing defined sub-populations they serve. These types of models are also employed by private payers.

How can ACOs succeed with payment models constantly changing?

ACOs should proceed with caution as they enter models with accountability for financial risk such as the newly finalized CMS Pathways to Success program and certain private payer commercial models. In order to be successful in any model, it is critical that ACOs have an adequate foundation in place and a provider network built to provide coordinated care. Some of the key elements for your success include:

• Population data: Data for the ACO members that is a comprehensive record of their recent health utilization and spending history is critical.
• Eligibility reporting: Require that eligibility files are provided on a monthly basis, and understand the way in which members are attributed or assigned. 
• Claims data: Ensure accurate and complete claims data will be provided by payers monthly for the ACO members.
• Financial/quality reporting: Ensure creation of infrastructure to generate reporting from the population data on a timely basis. Without timely reporting, the actual performance against benchmarks will not be known until it is too late to take any action.
• Actuarial support: Validating spending targets and performance settlement should draw on the expertise of a qualified actuary.
• Clinical documentation: Ambulatory clinical documentation categorizes patients based on the complexity of their diagnoses, which can be a predictor of future health care costs and used to identify at risk members for care management, disease management, and other programs. 
• Population health management tools: Establish capabilities around population health management, specifically data aggregation and analysis that results in actionable recommendations
• Audit capability: Verify the accuracy of payer financial and quality reports including the risk adjustment methodology.

Success in value-based payment models will require ACOs to understand changes to their population and quickly respond to address quality, utilization, and cost trends.