Archive for the ‘Healthcare Administration’ Category

Infographic: 5 Ways to Support Your Advanced Practice Providers

February 24th, 2020 by Melanie Matthews

Advanced practice providers (APPs) are becoming increasingly valued in healthcare delivery, seeing a 55 percent increase in number within the past 10 years alone, according to a new infographic by VITAL WorkLife.

The infographic examines how healthcare organization can best support this integral role.

Positioning for Value-Based Reimbursement: Leveraging Care Management for Clinical and Financial Outcomes While others wait for the healthcare industry to complete its transition to value-based reimbursement, Bon Secours Medical Group has already aligned itself with payment reform, leveraging its care team and providers and automating workflows to enjoy immediate rewards from its patient-centered approach.

Positioning for Value-Based Reimbursement: Leveraging Care Management for Clinical and Financial Outcomes describes how this 600-provider medical group has primed its providers to employ a broad mix of team-based care, technology and retooled care delivery systems to maximize quality and clinical outcomes and reduce spend associated with its managed patients.
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Infographic: U.S. Statistics on Surprise Medical Billing

February 21st, 2020 by Melanie Matthews

Out-of-network charges typically expose patients to higher cost-sharing when they use services and may lead to balance billing—in which healthcare providers bill patients directly, often at an unexpectedly higher rate. In the past two years, one in five insured adults had an unexpected medical bill from an out-of-network provider, according to a new infographic by Kaiser Family Foundation.

The infographic examines unexpected and “surprise” medical billing trends across the United States.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: 2020 Medicare Physician Fee Schedule: Chronic Care Management

January 24th, 2020 by Melanie Matthews

The Centers for Medicare and Medicaid Services’ final 2020 Physician Fee Schedule contains specific changes to the chronic care management program, according to a new infographic by Navigating Cancer, Inc.

The infographic outlines the top-level CCM changes.


Healthcare Trends & Forecasts in 2020: Performance Expectations for the Healthcare IndustryGiven the powerful patterns disrupting healthcare, what will it take to succeed as a high-velocity healthcare organization in the coming year?

Healthcare Trends & Forecasts in 2020: Performance Expectations for the Healthcare Industry, HIN’s 16th annual business forecast, is designed to support healthcare C-suite planning as leaders continue to strive to improve healthcare quality and access and reduce costs as the industry continues its move toward a value-based system.

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Infographic: Strategic Pricing Factors for a Healthcare Provider

January 10th, 2020 by Melanie Matthews

Price is an increasingly important factor as consumers shop for product network benefits and choose healthcare services. Providers need a pricing strategy that is responsive to this new reality, according to a new infographic by BDC Advisors.

The infographic highlights essential factors to consider when determining a pricing strategy.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: 5 Steps To Creating a Healthcare Culture of Accountability and Performance Excellence

November 20th, 2019 by Melanie Matthews

Many healthcare organizations fall short when it comes to creating and successfully implementing strategic and tactical initiatives. A lack of clear leadership accountability, insight into performance metrics, transparency and progress tracking cause many to lose sight of tactical actions that drive results, according to a new infographic by MedeAnalytics Inc.

The infographic provides five steps to create a culture of accountability and performance.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

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Infographic: Violence Against Nurses: The High Cost of Patient Care

November 15th, 2019 by Melanie Matthews

Nurses are often subject to physical and verbal abuse while they’re taking care of patients, according to a new infographic by Rave Mobile Safety.

The infographic examines risk factors and trends in violence against nurses, the cost to healthcare providers, both legal and business.

With health coach support on two fronts, PinnacleHealth Systems is changing the patient engagement conversation—both among its staff of clinicians and its most disengaged patient population.

Dual Approach to Patient Engagement: Activating High Utilizers and Coaching Clinicians describes PinnacleHealth System’s two-pronged strategy for prioritizing patient engagement within its culture, and elevating key quality and clinical metrics in the process.

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Infographic: The Broken Healthcare Referral System

November 13th, 2019 by Melanie Matthews

Across the healthcare industry, it is generally agreed that in-network care coordination is important. However, with 19.7 million clinically inappropriate network referrals occurring each year, contradictions in referral behavior remain a concern, according to a new infographic by Evariant.

The infographic pinpoints shortcomings of the current healthcare referral system and highlights opportunities to solve these obstacles.

The release of the Centers for Medicare and Medicaid Services’ care coordination toolkit provides further evidence that care coordination is an integral part of the current healthcare delivery landscape. Whether part of the primary care office, emergency department or health plan, care coordinators are having a positive impact on both the clinical and financial outcomes for healthcare organizations.

2019 Healthcare Benchmarks: Care Coordination is a comprehensive analysis by the Healthcare Intelligence Network of care coordination settings, strategies, targeted populations, supporting technologies, results and ROI, based on responses from over 75 healthcare organizations to the May 2019 Care Coordination survey.

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Infographic: Key Strategies for Developing Successful Consumer-Driven Ambulatory Businesses

November 6th, 2019 by Melanie Matthews

To build a successful consumer-driven ambulatory care business in a value-based market, health systems must retool their ambulatory approach by investing time and resources in six key business strategies, according to a new infographic by BDC Advisors.

The infographic examines these six strategies.

2019 Healthcare Benchmarks: Patient EngagementThe perennial challenge for healthcare organizations as they continue to develop and refine programs aimed at improving healthcare quality while reducing costs is engaging patients in these initiatives. Actively engaged patients have been shown to have lower costs and improved outcomes.

In fact, a recent study released by Humana on its wellness rewards program, Go365®, found that high-engaged members had lower healthcare cost increases than members with low or medium engagement. These highly engaged members paid a per member per month average of 22 percent less in healthcare than low-engaged members, had 35 percent fewer emergency room visits and 30 percent fewer hospital admissions than low-engaged members and had 11 percent more preventive doctor’s office visits than low-engaged members.

2019 Healthcare Benchmarks: Patient Engagement is the third comprehensive analysis by the Healthcare Intelligence Network of programs aimed at improving patient engagement, including how patients are identified for patient engagement interventions, populations presenting the most significant challenges, program components and results and ROI, based on responses from over 50 healthcare organizations to the October 2019 patient engagement survey.

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Infographic: Healthcare Revenue Cycle Trends

October 14th, 2019 by Melanie Matthews

Electronic health record adoption challenges are still outweighing benefits, according to a study on the impact of EHRs, consumer self-pay, and IT budgets on revenue cycle operations by Navigant Consulting, Inc. and HFMA, highlighted in a new infographic.

The infographic explores: the struggles health systems face to optimize available EHR functions and upgrades; consumer self-pay concerns; revenue cycle IT budget growth; and more.

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS SuccessA laser focus on population health interventions and processes can generate immediate revenue streams for fledgling accountable care organizations that support the hard work of creating a sustainable ACO business model. This population health priority has proven a lucrative strategy for Caravan Health, whose 23 ACO clients saved more than $26 million across approximately 250,000 covered lives in 2016 under the Medicare Shared Savings Program (MSSP).

Profiting from Population Health Revenue in an ACO: Framework for Medicare Shared Savings and MIPS Success examines Caravan Health’s population health-focused approach for ACOs and its potential for positioning ACOs for success under MSSP and MACRA’s Merit-based Incentive Payment System (MIPS).

Get the latest healthcare infographics delivered to your e-inbox with Eye on Infographics, a bi-weekly, e-newsletter digest of visual healthcare data. Click here to sign up today.

Have an infographic you’d like featured on our site? Click here for submission guidelines.

Guest Post: 6 Barriers to Automating Prior Authorization

October 3rd, 2019 by April Todd

Automating prior authorizations could save the healthcare industry $417 million annually.

Prior authorization has been used for decades as an important check to ensure prescribed medical treatment is safe and appropriate. In recent years, however, it has become regarded by many as a frustrating, time consuming barrier to care.

Much of the frustration has to do with the fact that the overwhelming majority of prior authorizations are conducted using manual processes that can take days, and, in some cases, weeks, delaying patient care. Prior authorizations are also a financial burden on providers and plans. So much so that the industry could save $417 million annually if these transactions were automated, according to the 2018 CAQH Index.

In spite of the widespread frustration, the number of prior authorizations increased by 14 percent in 2018 over the previous year.

Increasing automation seems like an obvious solution, especially when there has been a federally-mandated standard for automating part of the process for more than a decade. But that just is not happening fast enough.

A recent CAQH CORE, an organization formed by the industry to develop common business rules to support healthcare transactions, white paper, identified six factors that have slowed end-to-end automation of prior authorization:

  1. Data is inconsistent

    Health plans use codes to communicate status, errors and next steps for prior authorizations—including the need for clinical documentation to prove medical necessity. But today, these requirements differ across (and within) health plans, and providers can’t easily identify what information is required. This lack of uniformity— and use of overly generic codes— limit adoption of the standard prior authorization transaction by providers.

  2. No federally mandated standard for “attachments” or clinical documentation

    As part of standard prior authorization requests, providers are asked to include “attachments” or clinical documentation. However, there is no national standard or uniformity for the supporting clinical documentation. This creates a sense of uncertainty about investments in various solutions, and results in workarounds that providers are asked to support.

  3. Lack of integration between clinical and administrative systems

    Electronic prior authorization requests typically require the use of practice management systems (PMS) and data from electronic health record (EHR) systems. But integration between PMS and EHR systems is limited. This forces most providers to retrieve clinical information from the EHR and manually enter it into the prior authorization request. This is not only an obvious source of human error, but also a frustrating drain on productivity and efficiency.

  4. Limited vendor products that support electronic prior authorization

    Only 12 percent of vendor products support electronic prior authorization, according to the 2017 CAQH Index. For all other electronic transactions, vendor support is between 74 percent and 91 percent.

    Some vendors indicated that, while their systems do currently support prior authorization, this functionality is not part of the core product offering. That is, prior authorization functionality may be available in some vendor systems, but only in a premium configuration.

  5. State requirements for manual intervention

    Some state legislatures have mandated that certain steps of the prior authorization process be handled manually. For example, in both Colorado and Rhode Island, health plans are required to give providers an opportunity to speak directly by phone or in person with a qualified medical professional before issuing an adverse determination. Some of these manual requirements are in place because a phone call or written letter may be a more trusted mode of receiving communication regarding determinations.

  6. Lack of provider awareness

    Many providers are unaware that HIPAA requires health plans to offer the standard prior authorization request to conduct prior authorizations electronically. Greater demand from providers can incent broader use of the standard and encourage development of vendor products to support its exchange.

How Do We Get to Automation?

Currently, there is a groundswell of support from a diverse group of stakeholders to improve the prior authorization process. The Department of Health and Human Services, federal and state policymakers, providers and health plans, industry coalitions and standard-setting organizations are all motivated to resolve the administrative burden associated with prior authorization—creating an unprecedented opportunity to find alignment and implement solutions.

So, Where Do We Start?

To reduce the prior authorization burden, it is important for all stakeholders to participate in developing standards that support automation, and follow them. CAQH CORE’s participating organizations, which encompass 75 percent of insured lives, have developed two sets of operating rules that are already addressing several of the challenges identified above. By adopting the Phase IV and V CAQH CORE Operating Rules, and participating in CAQH CORE’s prior authorization pilots, healthcare stakeholders can help accelerate the move toward automation of prior authorization.

This renewed spirit of collaboration is the pathway to reducing the prior authorization administrative burden. It is imperative for all stakeholders to actively encourage and participate in this collaborative momentum toward a more automated prior authorization end-to-end workflow.

April Todd

April Todd

About the Author: April Todd leads CAQH CORE, an initiative of CAQH that was formed to drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability and align administrative and clinical activities among providers, payers, and consumers. CAQH CORE is industry-led—representing more than 75 percent of insured Americans, including health plans, healthcare providers, vendors, government entities, and standard setting organizations. Five phases of CAQH CORE Operating Rules and Certification Test Suites have been issued to date.