2016 PAC-Related Medicare Alternative Payment Models

Access and our contracted strategic consultant, Avalere, have created a national map for use with leadership, staff and Board to assist in explaining the many Medicare PAC Pilot activities occurring.

Access Innovations is participating in a Model 3 Bundled Payment Pilot with 12 PAC providers in Ohio indicated by blue dots. The April 1st Comprehensive Care for Joint Replacement Model (CJR) is the first CMS mandatory model, profoundly signaling Medicare’s planned migration to bundled payment is upon us. All our Access strategies are designed to address changes in PAC payment.

Please feel free to call Bryce Henson, Director of Development, if you need more information, at 614-345-5001 x 208.

Medicare Mandatory Joint Bundles: April 2016

Comprehensive Care for Joint Replacement (CJR)

CMS has released its final rule for Comprehensive Care for Joint Replacement (CJR) which puts which puts 790 hospitals on notice that hip and knee replacement reimbursements from Medicare will be tied to cost containment and high standards for patient care. CMS will test the initiative at those hospitals from April 1, 2016, through Dec. 31, 2020. Under CJR, participating hospitals will be held accountable for patient care from a hip or knee replacement procedure (the two most common inpatient surgeries for Medicare patients) through 90 days post-discharge. The CJR Model would initially be implemented in 75 geographic areas and, unlike other existing bundled payment programs would be mandatory for hospitals in those areas. Hospitals may be the only risk-bearing entities under CMS’ CCJR proposed model, but there are major implications for post-acute care (PAC) providers.

Based on review of the CJR program, our Access consultant, DataGen, compiled the top seven things PAC providers need to know about and act on to be successful partners in this and other emerging payment models.

Access Innovations: CMS Model 3 Bundled Payment Pilot

Access Innovations, a CMS Model 3 Bundled Payment Pilot, allows us to begin working under the value based payment methodology currently offered by CMS. A new payment model, it’s designed to coordinate care, improve quality and improve efficiency. Our Pilot offers fiscal analytics based on past Medicare claims data, care redesign resources such as evidence based guidelines and outcomes driven programming, a care coordinated model for up to 90 days of monitoring and tracking to community discharges, and progressive participation profiling as a roadmap for the future.

With twelve core providers, our initiative is allowing us to develop the infrastructure design necessary for clinical and payment modeling of the future.

Contracting Updates

This time of year we are working with each Plan on upcoming 2016 changes including:

  • Medigold – will be revising their episodic payment methodology to shorter episodes, and a new quality design in which more highly Star rated SNFs will receive an increased rate. They are actively reviewing their network, advising 1 and 2 Star SNFs may be terminated from their network.
  • United Health Care – will be focused predominately on 4 or 5 Star sites for new contracts.
  • Medical Mutual of Ohio – is launching their 2016 new Medicare Advantage Plan in Ohio. You will be receiving updated information on their Plan, including new electronic marketing flyers for use with your hospitals and MD referral sources.

We will keep you posted as we continue to review each Plan and changes for 2016.

Revenue Cycle Tips & Tricks

Attention Members:

Please remember to send an email to service@access-advantage.com after importing claims to Zirmed. You will receive a confirmation email with the following response: “Access Advantage has received your claims submission request. We are currently reviewing coding specifications to assure clean claim submission to payer. Please allow 24-48 hours for AA review. Please check ZirMed in 48 hours (or two business days) to verify claims submission to payer and review that your claims upload is complete. If additional information is needed prior to submission we will be in contact with you.”

Medical Mutual Room and Board Revenue Code

Per Medical Mutual of Ohio, room and board must reported with a Revenue Code 120. Claims with a Revenue Code 110 are likely to be denied by the payer.

Transportation changes for Molina and United Healthcare MyCare members

Molina Healthcare has a new vendor, Secure Transportation, which will take over services currently provided by Logisticare for Medicaid members on November 1, 2015. MyCare Ohio and Medicare members will start services on January 1, 2016.

Secure Transportation will contract with medical transportation providers throughout Ohio to provide quality “door-to-door” transportation to our members.

November 1 Changes to Facility Transportation for United Healthcare MyCare Members

UHC MyCare Ohio transportation for United Healthcare MyCare Ohio members residing in your facility will no longer be handled by Cooperative Health Partners (CHP). UHC contracted facilities will now be able to arrange transportation through their contracted provider or provider of choice. Transportation providers will then bill UHC directly for reimbursement of those services. This includes MyCare Ohio member hospital discharges, trips from a SNF to physician, recurring trips from SNF to dialysis or chemo, and facility to facility transports.

Click here for more information