Last November, CMS announced an expansion to their Recovery Audit Contractor program called the Prepayment Review Demonstration Project. Unlike previous RAC efforts that retroactively reviewed claims for billing accuracy and appropriateness, the new demonstration would switch tactics to “prevent improper payments before they are made.”
CMS initially scheduled the demonstration, expected to more than double the amount of reviewable claims to 2.7 million, to launch on January 1, 2012, and targeted 15 inpatient DRGs, including spinal fusion and cardiac implant procedures.
Read more »
Among the payment reforms under consideration by CMS and private payers, a methodology known as bundled payment has gained traction. Bundled payment programs seek to address one weakness of the fee-for-service payment system -- that physicians face little accountability for the cost of hospital-based patient therapy or care. Physicians consider cost less often than would be desirable when making cost-related decisions, such as which implant to use or when to discharge patients. Traditionally, hospitals cannot legally reward physicians for reducing costs associated with inpatient care.
However, the Center for Medicare and Medicaid Innovation (CMMI) recently released a bundled payment program in which participants can legally gainshare with physicians for episodes of care, during which the physicians keep costs below a pre-determined target. The goal is to provide hospitals with a mechanism for engaging physicians in cost control efforts. CMS benefits because participating hospitals must offer CMS a discount on services, and hospitals will come out ahead if they leverage the gainsharing to lower costs by more than the discount and/or grow volumes by tightening alignment with physicians. For a more detailed discussion of CMMI's Bundled Payment for Care Improvement Initiative, listen to the recording of our previous webconference and/or download the handout.
Read more »