Sylvia Trujillo MPP JD’s Post

Hey all! As promised, we've posted a more in-depth article focused on the new Advanced Primary Care Management codes proposed in the 2025 Medicare Physician Fee Schedule Proposed Rule that was released by #CMS last week. (Was it only last week?? Feels like a lifetime ago...) Headlines: * The new monthly APCM codes are NOT based on time spent by practitioners or clinical staff, opening the door for use of AI tech to automate certain care coordination/management functions. * The codes provide a reimbursement opportunity where time requirements for CCM/PCM are not met. * The APCM codes are another step towards preparing primary care physicians for the shift to value-based care -- BUT, proposed reimbursement rates combined with requirements for implementation could hamper adoption. Please share your thoughts in the comments when you have a moment! I also strongly encourage all stakeholders -- vendors of care management services, PCP practices, etc. -- to submit comments to the Proposed Rule by no later than September 9th. We've seen CMS reference specific comments in their Final Rule as reason for changes to their original proposal. We're happy to help! https://lnkd.in/eV4CxPmg

Check out Carrie Nixon's post below on the newly proposed Advanced Primary Care Management Codes from the 2025 Medicare Physician Fee Schedule Proposed Rule! #CMS #caremanagement #digitalhealth #healthcareinnovation

The prior authorization (PA) process has evolved into a significant bottleneck in healthcare, raising critical concerns for providers, patients, and insurers alike. Does prior authorization delay care? Absolutely. The American Medical Association reports that 94% of providers confirm these delays, often impacting timely treatment. This inefficiency compromises patient outcomes, with 51% of patients abandoning necessary care altogether. Such delays undermine the primary objective of healthcare—saving lives and improving quality of life. Is PA still doing its job, or are providers doing it for them? Initially intended to ensure appropriate care and cost containment, PA has now shifted its focus, overburdening providers with administrative tasks. Providers spend an average of 14 hours weekly navigating PA requirements. These bureaucratic hurdles detract from their primary role—delivering care—and increase frustration among clinicians and patients alike. Has the system crossed the line into care prevention? Yes. While insurers argue that PA ensures medically necessary care, the process often results in delayed or denied treatments, leading to worsened conditions and higher costs in emergency settings. The reliance on outdated methods like faxes in 2024 further highlights the inefficiencies. The PA process requires urgent reform. Streamlining approvals through AI and automation can alleviate the burden, ensuring timely care without sacrificing cost management.

Exciting news for healthcare providers! Proposed changes to Remote Patient Monitoring (RPM) coding could revolutionize reimbursement by 2025. The American Medical Association's May CPT Editorial Panel meeting will discuss crucial updates, potentially expanding RPM coverage and flexibility. Currently, RPM services are billed under four CPT codes, but upcoming changes may introduce significant enhancements. Key proposals include: 1. Introducing a new code covering 2-15 calendar days of collected data, easing billing for shorter monitoring periods. 2. Revising codes to reduce minimum care management times, promoting flexibility and provider reimbursement. 3. Enhancing interactive communication code allowances, encouraging more patient engagement. These changes are anticipated to drive higher RPM adoption and program flexibility, benefiting both patients and providers. If approved, Medicare and private payers may follow suit, expanding coverage and potentially improving patient outcomes while reducing healthcare costs. Stay tuned for updates post the AMA meeting in May! #HealthcareInnovation #RPM #HealthcareCoding #MedicalBilling

We often hear about prior authorization, but few know about retro authorization. I recently learned about it and wanted to share my knowledge with you. In healthcare, authorization plays a crucial role in ensuring seamless patient care and reimbursement. However, many professionals confuse prior authorization with retro authorization. Let's break down the key differences: - Prior Authorization: Obtaining approval from the payer BEFORE providing treatment or services, ensuring necessary care is covered and reimbursed, reducing financial burdens on patients. - Retro Authorization: Obtaining approval from the payer AFTER treatment or services have been provided, often used in emergency situations or when prior authorization was not obtained. Key takeaways: - Prior authorization is proactive and patient-centric, ensuring coverage before care is delivered. - Retro authorization is reactive, seeking approval after care has been provided. Understanding the difference is crucial for healthcare professionals, administrators, and patients alike. Let's work together to streamline the authorization process and prioritize patient care! #healthcare #authorization #priorauthorization #retroauthorization #patientcare #reimbursement #healthcaremanagement

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Independent private practice is under attack Here's what CMS did: -2.9% payment reduction for independent practices +3.7% payment increase for Medicare Advantage +2.9% payment increase for hospitals The good news? Despite obvious headwinds, there's never been a better time to jump The right tech The right partners The right education The right information The right distribution channels It's all out there The best news? Higher earning potential Greater satisfaction Better outcomes Reduced costs Remember that triple, or quadruple, or however many aim they used to talk about? It already exists It's called independent physicians Time for CMS to catch up P.S. Here's one free resource that pulls back the curtain on the business of healthcare so you can get on the path to practicing your way and thriving Check it out here: https://buff.ly/47NeASx See you out there!

Independent, private practice healthcare is under attack CMS and commercial insurance networks are waging a war on independent, private practices. But why? Commercial insurance carriers want to acquire these practices or force them into the arms of large health systems. Either outcome is a win. If the insurance carrier owns it, they can route more patients to their owned physicians and bypass the MLR (look it up). If a large health system buys the practice, the insurance carrier will collude to negotiate a higher price for services which makes the MLR pie bigger. The "How" is quite simple... pay these practices less and increase the administrative burden. Frustration and surrender will soon follow. And why is CMS waging war on independent docs and private practices? Large health systems and insurance carriers spend lavishly in D.C. to curry favors from elected and non-elected officials. When these businesses get annual taxpayer-funded fee increases, the money needs to come from somewhere. And if we, as patients, think healthcare is bad now... wait until all the independent physicians and practices are gone. P.S. direct contracting between independent doctors/practices and self-insured employers is an answer to the mess that CMS and insurance networks are creating.

🌟 Understanding MIPS and MACRA in Healthcare 🌟 In the dynamic landscape of healthcare, staying abreast of regulatory changes is key. Two significant initiatives in this realm are MIPS (Merit-Based Incentive Payment System) and MACRA (Medicare Access and CHIP Reauthorization Act). But what exactly are they and why are they important? Let's delve in: 🔍 What are MIPS and MACRA? MIPS: MIPS is a quality payment program under Medicare that evaluates eligible clinicians based on four performance categories: Quality, Promoting Interoperability, Improvement Activities, and Cost. MACRA: MACRA, enacted to shift Medicare payments towards value-based care, established MIPS as one of its key components. It aims to improve healthcare quality, promote interoperability, and control costs. 💡 Why are they important? 1- Quality Improvement 🔩: MIPS encourages clinicians to focus on delivering high-quality care by incentivizing performance in various quality measures. 2- Financial Incentives 💵: Participation in MIPS can result in financial rewards through positive payment adjustments for high-performing clinicians. 3- Patient-Centered Care 👨⚕️: By promoting interoperability and patient engagement, MACRA and MIPS foster a healthcare system centered on patient outcomes and satisfaction. 4- Adaptation to Value-Based Care: MACRA's emphasis on value-based care shifts the focus from volume to value, aligning payment incentives with quality and cost-effectiveness. 🚀 Embracing Change for Better Healthcare Adapting to MIPS and MACRA requirements is essential for clinicians to thrive in today's healthcare landscape. Leveraging technology and data analytics can streamline reporting and improve performance in MIPS categories. Continuous education and collaboration within healthcare teams are vital to navigating these regulatory changes effectively. 🚀 In conclusion, MIPS and MACRA represent significant steps towards achieving higher-quality, cost-effective healthcare. Embracing these initiatives not only ensures compliance but also fosters a culture of continuous improvement and patient-centered care. Let's embrace the change and work together towards a healthier future! 💪🏥 #Healthcare #MIPS #MACRA #ValueBasedCare #QualityImprovement

In the evolving world of value-based care, Value-Based Enterprises (VBEs) offer the legal and operational flexibility to align incentives between providers and payers. Understanding the different risk models under the Stark Law exception and the Anti-Kickback Statute (AKS) safe harbor is crucial for compliance and success. The below infographic is a breakdown of the three key risk models under each legal framework, highlighting when the VBE or the participating physicians must bear financial risk: Key Distinctions Between VBE Risk and Physician Risk: In full financial risk models, the VBE as a whole assumes risk for the patient population, with physicians participating without individual financial risk unless there are separate agreements in place. In meaningful or substantial downside risk models, the individual physicians must take on a portion of the financial risk, ensuring their incentives are aligned with the overall goals of the VBE. In no financial risk or care coordination models, neither the VBE nor the individual physicians must bear downside financial risk. Participating physicians, however, can be rewarded through incentives tied to care quality, patient outcomes, or cost reduction efforts. Each of these models offers unique opportunities and challenges for healthcare organizations, and understanding where the financial responsibility lies—whether with the VBE or the individual physicians—is critical to structuring compliant and effective arrangements.