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Provider Reimbursement Strategies for 2014

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Understanding reimbursement models for 2014, including Accountable Care Organizations (ACO's), Private Payer Models, and Health Care Reform Initiatives.

Understanding reimbursement models for 2014, including Accountable Care Organizations (ACO's), Private Payer Models, and Health Care Reform Initiatives.

Published in: Health & Medicine, Business

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  • 1. PROVIDER REIMBURSEMENT STRATEGIES FOR 2014 Michael P. James, J.D., M.B.A., CSSGB Phone: (517) 377-0823 (313) 965-9038 Email: mjames@fraserlawfirm.com www.linkedin.com/in/MichaelJamesLaw Fraser Trebilcock Davis & Dunlap, P.C. One Woodward Avenue, Suite 1550 Detroit, Michigan 48226 www.fraserlawfirm.com Phone: (313) 237-7300 Fax: (313) 961-1651 Fraser Trebilcock Davis & Dunlap, P.C. 124 W. Allegan Street, Suite 1000 Lansing, Michigan 48933 www.fraserlawfirm.com Phone: (517) 482-5800 Fax: (517) 482-0887 © 2013 Fraser Trebilcock Davis & Dunlap, P.C.
  • 2. Shifting Landscapes Under Health Care Reform
  • 3. Physician Landscape Accenture predictive modeling. Accessed 12/3/13. http://www.accenture.com/usen/outlook/Pages/outlook-online-2011adapting-new-model-physicianemployment.aspx
  • 4. Reimbursement Landscape 2011 2000 National Health Expenditures National Health Expenditures Government Government 64.5% 35.5% 55% Private 45% Private Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/tables.pdf Accessed 12/3/13. (see Historical; NHE Web tables, Table 5).
  • 5. Reimbursement Landscape Evolving Reimbursement Models under HCR      Fee-for-Service Bundled Payments/Episode of Care Payments Partial or Full Capitation Care Management Fees Shared Savings  One-Sided  Two-Sided
  • 6. Riding the Wave of Change How do you address these shifting landscapes to continue to drive profits?
  • 7. Medicare Shared Savings Program (MSSP)  MSSP designed to improve beneficiary outcomes and increase value of care by promoting:     Accountability for patient population; Coordination of care for services; Investment in infrastructure; and Redesign of care processes.
  • 8. What Are ACOs?  ACOs are the vehicles through which providers/suppliers participate in the MSSP.  A legal entity designed to manage and coordinate care for Medicare fee-for-service beneficiaries under the MSSP.
  • 9. What Are ACOs? Fundamental Principles of ACOs Reduce Growth of Beneficiary Expenditur es Improve Care for Beneficiari es Enhance Health in its Population
  • 10. Types of ACOs Integrated Delivery System Model ACO CMS Health System ACO Hospital Physicians Skilled Nursing Facility Etc.
  • 11. Types of ACOs PHO Model ACO CMS PHO ACO Hospital Independent Practice Assn.
  • 12. Types of ACOs Independent Practice Association Model ACO CMS IPA ACO Physician Physician Physician Physician
  • 13. Types of ACOs Group Practice Model ACO CMS Group Practice ACO Hospital Specialists
  • 14. ACO Membership 5% of Members = 45% of costs 15% of Members = 35% of costs 80% of Members = 20% of costs
  • 15. Utilization Management  Predictive Modeling for Last 2 Years of Life:        Medical homes Home Calls Care Plans Navigators ER / Hospital Hospice Multiple Chronic Diseases:      Medical Home Care Plans Team Care Navigator ER / Hospital
  • 16. Utilization Management  Chronic Disease:      Medical Home Care Plans Team Care ER / Hospital All Others:     Medical Contact & Education Care Plans ER / Hospital
  • 17. Payment Evolution      Insurance License. Claims Processing. Alignment of Fee Structures. Incentive to Move from Volume to Value. Quality Monitoring Systems.
  • 18. Risk Sharing Culture of Restructuring More Patients in System Reduce Capacity of System
  • 19. Michael P. James, JD, MBA, CSSGB Fraser Trebilcock Health Care Reform www.mihealthcarelaws.com Fraser Trebilcock Davis & Dunlap, P.C. One Woodward Avenue, Suite 1550 Detroit, Michigan 48226 www.fraserlawfirm.com Phone: (313) 237-7300 Fax: (313) 961-1651 Phone: (517) 377-0823 (313) 237-7300 Email: mjames@fraserlawfirm.com www.linkedin.com/in/MichaelJamesLaw Fraser Trebilcock Davis & Dunlap, P.C. 124 W. Allegan Street, Suite 1000 Lansing, Michigan 48933 www.fraserlawfirm.com Phone: (517) 482-5800 Fax: (517) 482-0887 © 2013 Fraser Trebilcock Davis & Dunlap, P.C.