Regarding health care reform in Maryland:
I listened to a meeting in Washington with health care reformers facilitating a panel of stakeholders. This is the commanding point of this meeting------FEE FOR SERVICE WILL BE REPLACED BY ACO BY 2016 SO GET USED TO IT! The doctors on the panel stated it would be impossible to consolidate all health systems and develop payment policy that fast------ keep in mind that ACO targets Medicare and Medicaid first but will include private health plans as well! Think your choice of MEDICARE doctors will not be limited by this? REALLY?
THE 1% INTEND TO DO IT BY THE END OF OBAMA'S TERM BECAUSE THEY KNOW THE NEXT PRESIDENT MAY WELL DISMANTLE THIS!
'Consolidation. As most physicians become employed by a hospital or join an IPA for ACO participation, the healthcare landscape continues to grow more consolidated. Mr. Haley refers to the Patient Protection and Affordable Care Act that established ACOs formally as a "get out of jail free card" for systems to consolidate the market without as strict of antitrust review. This, in turn, can lead to rising costs.
Though some have argued that the higher costs associated with consolidation in healthcare are worth what consolidation is working toward — improved quality and eventually lower cost of care — Mr. Haley disagrees. "Over time — it doesn't matter what market it is — where there's a monopolist, costs go up," he says'.
ACO stands for Accountable Care Organizations. What neo-liberals are trying to do to US health care is allow corporations to determine what will make US health care affordable. Now, who among all the American people would think that US corporations would be the source of good cost containment policy that works in the public interest and not only for corporate profit??????NO ONE BELIEVES THAT....SO WHY ARE WE BEING SUBJECTED TO THIS GARBAGE?
NEO-LIBERALS WORK FOR WEALTH AND PROFIT AT THE EXPENSE OF LABOR AND JUSTICE. OBAMA AND CONGRESSIONAL POLS ARE NEO-LIBERALS AND NOT LABOR AND JUSTICE DEMOCRATS!
When I talk with Expanded and Improved Medicare for All advocates about ACO this is the overwhelming concern......the policy places in the hands of these health corporations the ability to profit the less they spend on health care.....it doesn't matter how they get there. So, if an umbrella group of health institutions develop a system that gets people out of the hospital as quickly as possible and not allow them back into the hospital as a re-admit no matter what------THE FEDERAL GOVERNMENT GIVES THAT HEALTH SYSTEM A BONUS! Now, health institutions have defrauded entitlements for these few decades by many means, but one of the major methods of fraud is the 'billing coding fraud'. This is where a doctor or health institution deliberately enters a billing code that makes a patient seem sicker than they are so the doctor/health institution can charge Medicare/Medicaid more money than it should. We lose tens of billions each year with this fraud. It also skews the medical data by making Americans look sicker than they actually are. Look below for an investigative article that shows this medical fraud.
What does that have to do with the ACO and the plan to pay a lump sum for a health condition and bonuses for keeping people out of the hospital? IF DOCTORS/HEALTH INSTITUTIONS CAN CODE PATIENTS SICKER THAN THEY ARE TO GET MORE MONEY-----THEY CAN CODE PEOPLE MORE WELL THAN THEY ARE SO THEY GET MORE MONEY. Now, having too much health care is not good but it doesn't kill you in most cases. Having too little and deliberate blocking of the ability to enter hospitals for followup will kill you and THIS IS HUGE!
This is what Obama and your neo-liberal in Congress is making of the health care system under the Affordable CAre Act. They are taking a system of payment that did indeed need reform----fee for service----and making a system that will be deadly in placing the motive for profit on steroids. Why are they doing this to doctors who like the fee for service system and who know that simply building auditing and oversight in the medical billing will end all this fraud? Because ACO makes doctors employees to the hedge funds that will own these mega-health systems and hedge funds do not want doctors profiting from fraud......they want to profit from the fraud. So, billing code fraud that once went to the doctor/health institution will now go to the umbrella corporation overseeing this health group!
NONE OF THIS HAS ANYTHING TO DO WITH QUALITY HEALTH CARE OR ACCESS TO HEALTH CARE.....IT ONLY SHIFTS HEALTH CARE FROM A PUBLIC SERVICE WITH PUBLIC GUIDELINES TO MEGA-CORPORATIONS WITH CEOs DETERMINING HOW PROFITS CAN BE MADE------SUCH AS THE GENERAL ELECTRIC CENTRICITY ACCOUNTABLE CARE ORGANIZATION.
All we need to do is get rid of these neo-liberals by running and voting for labor and justice in all primaries so we can reverse this bad policy and simply place Expanded and Improved Medicare for All in its place!
Below you see an article that shows where this policy leads......a business, in this case General Electric pretending that it knows how to make health care affordable. Remember, GE is notorious for being unscrupulous and a very bad corporate citizen!
Preparing for a Shift in Healthcare Reimbursement
To successfully navigate the move to greater accountability for patient care outcomes, healthcare organizations will require:
Strong governance models and change management strategies
Interoperable revenue cycle management and electronic medical record solutions
Standards-based health information exchange capabilities
For ACO insights from GE Healthcare customers, download the whitepaper: Accountable Care Organizations - Early Lessons Learned from Strong Revenue Cycle Performers
Accountable Care is not something that happens overnight. But early adopters like Healthcare Partneres, a Pioneer ACO organization, have shown that the accountable and integrated care models can be a success with thoughtful strategy and the right integrated information technology infrastructure.
Healthcare is shifting towards a reimbursement system that’s focused more on paying for quality than volume. Incentives are shifting towards more integrated care delivery, with a continued focus on managing populations of patients. Healthcare organizations today need to prepare for a world that involves more accountability.
The consensus on what ails the U.S. health system, as well as the availability of new technologies, has led to the creation of new models of delivery, such accountable care organizations (ACOs) and integrated health organizations. These healthcare models are designed to promote accountability, share risk and savings, and improve outcomes for the health of a defined population.
Meeting this challenge begins with a strong foundation in Healthcare Information Technology (HCIT) and appropriate technology solutions including revenue cycle management, electronic medical records and health information exchange. Starting with data capture and risk analysis, then sharing between locations and multi-vendor systems, and finally evolving to sophisticated care management and predictive analytics, HCIT helps make accountability an attainable goal.
What's Required Under Accountable Care Reimbursement Models?
Organizations that take on additional risk for managing a population of patients should consider how the following technologies can support their patient care goals:
An enterprise revenue cycle management with inpatient and outpatient integration
A high-functioning, up-to-date Electronic Medical Record (EMR) system with quality measurement and quality improvement capabilities that allow measurement at the physician level to support a continuous feedback loop
Standards-based health information exchange to link disparate partners and exchange info broadly in the community, since patients won't receive all their care within the accountable care organization
Informatics solutions to capture and analyze vast amounts of data
Patient engagement technologies such as portals that allow patients to contribute to their own clinical records, and engage in administrative functions like scheduling appointments and making payments
About Centricity Business
The advent of Accountable Care and evolving payment methodologies including bundled and episodic payments will highlight the gap in capabilities between "next generation" and "old generation" enterprise revenue cycle management systems.
Centricity Business is a proven, next generation healthcare revenue cycle management solution that supports traditional and accountable care reimbursement models for greater profitability, efficiency and enhanced quality of care. What differentiates Centricity Business in the market is enterprise-ready, high performance, and interoperable capabilities.
Our Financial Management and Business Intelligence solutions help you support various emerging payment methodologies associated with ACOs.
Download the complimentary ACO whitepaper using the form on this page and visit www.gehealthcare.com/centricitybusiness to learn more.
Medical Coding Fraud
April 21, 2012 by Laureen Jandroep Codingcertification.org
Medical coding fraud and other types of health care fraud are financial losses estimated to range from $70 to $240 billion per year, according to the National Health Care Anti-Fraud Association. So, what can be done? A major fraud and abuse prevention strategy for physicians is to ensure that all coding staff has been properly trained and continues to receive ongoing medical coding education.
Intentionally submitting incorrect coding and billing information is fraudulent behavior and punishable by fines. Therefore, anyone considering going into the medical coding field, should be familiar with some of the most common medical coding frauds. They include:
Double billing: If you submit a single billing code multiple times when the procedure was only performed once; or if a provider attempts to bill Medicaid and either a private insurance company or the patient for the same treatment.
Upcoding: This is when a code that has a higher reimbursement rate is submitted, when a lesser-reimbursed code is more appropriate.
Downcoding: This may not sound like fraud, but it assigns the patient a lesser diagnosis and sometimes shows fake patient improvement, allowing for extended hospital stays or allotment of recovery benefits that would not otherwise be granted.
Unbundling: Some single codes encompass multiple procedures. Billing separate codes for a procedure covered by one code is fraudulent “unbundling.”
Incorrect codes: Assigning incorrect codes is a misrepresentation of patient services.
Fraudulent Medical Coding Penalties
Under the government’s 1986 False Claims Act (FCA), those charged with fraud may be assessed fines of $5,500 to $11,000 per claim.
According to Taxpayers Against Fraud, a nonprofit public interest organization, since 1986, False Claims Act recoveries (both federal and state) total more than $28 billion. Another nonprofit group, the Government Accountability Project, in 2011, reported that the Department of Justice recovered a record-breaking $2.8 billion in False Claims Act Cases.
The bottom line – don’t engage in medical coding fraud.
Remember that all the paperwork was a major complaint of doctors in processing Medicare and Medicaid patients? ACO is worse. So, it heightens the environment for fraud, it increases paperwork, and we already know that patient medical records will be bought and sold for profit. Bonuses for keeping costs contained is what Affordable means in Affordable Care Act----not affordable to the consumer.
The ACA actually increases the paperwork and hands over to mega-corporations the ability to write how payments will be made. The problem with health costs in the US is too much paperwork and massive health industry fraud. So, the ACA is built to maximize the most expensive costs to health care. That's only if you look at it from a taxpayer position.....from a hedge fund ready for fraud and selling medical health record data....this is a gold mine!
2 of the Largest Problems With ACOs
Written by Heather Punke September 16, 2013 Becker's Hospital Review
Though accountable care organizations have grown more visible in the last three years — there are at least 488 commercial and Medicare ACOs spread throughout every state but Delaware — the model is still not fully refined, and plenty of challenges still face ACOs. Some stakeholders in the industry are not yet convinced ACOs will accomplish the triple aim of improved quality and patient experience and lowered costs.
According to Dan Haley, vice president of government affairs for athenahealth, there are two main issues holding back the success of the model.
Dan Haley from athenahealthExclusion of some physicians. The nature of the ACO model makes it difficult for small, independent physicians to get involved, and that drives independent physicians' wariness of ACOs. Compared to employed physicians, independent physicians are less likely to believe the shift to accountable care will improve care quality. Instead, they're more likely to believe ACOs will have a negative impact on profitability, according to athenahealth's 2013 Physician Sentiment Index.
Participating in an ACO requires physicians to spend time reporting on metrics and filling out more paperwork — putting a damper on the time independent physicians spend seeing patients. "The administrative burden of participating in an ACO is huge," Mr. Haley says. "These are hurdles that independent and small group physicians who want to spend their days in patient care, not administration, just can't jump. As it is designed, the ACO model excludes small practices and independent physicians."
Many ACOs are physician-led, but the model hardly appeals to all physicians, especially those in smaller practices. Though several independent physician associations have formed ACOs in the last three years, Mr. Haley says independent physicians in small practices still think of joining an IPA as similar to becoming employed by a hospital. "Physicians in IPAs decided to become business people," he says. "They're not caring for patients as usual, but instead decided to manage a larger care entity." This, according to Mr. Haley, is an unattractive option for physicians who want to remain independent focused on patient care.
Consolidation. As most physicians become employed by a hospital or join an IPA for ACO participation, the healthcare landscape continues to grow more consolidated. Mr. Haley refers to the Patient Protection and Affordable Care Act that established ACOs formally as a "get out of jail free card" for systems to consolidate the market without as strict of antitrust review. This, in turn, can lead to rising costs.
Though some have argued that the higher costs associated with consolidation in healthcare are worth what consolidation is working toward — improved quality and eventually lower cost of care — Mr. Haley disagrees. "Over time — it doesn't matter what market it is — where there's a monopolist, costs go up," he says.
Though overcoming these issues with ACOs may seem impossible, because they are ingrained in the very structure of the model, Mr. Haley suggests one possible solution: an Independent Risk Manager model. Currently, the IRM model is in proposal stage. It is a way for independent physicians to participate in accountable care without joining another organization in an ACO.
Through this modification of the ACO model, an outside company could create an information technology platform allowing independent physicians to participate in ACO-like shared savings with no upfront investment. "It would allow independent physicians to participate without going under an employment or IPA 'umbrella,'" Mr. Haley says.
An IRM would use claims data to identify physician practices caring for similar patient populations and then group those practices into networks to share risk. Under the model, the physicians would assume risk and accountability for care quality and efficiency.
Ultimately, as ACOs stand today, independent physicians do not have a viable option for participating in accountable care models while remaining independent, according to Mr. Haley. The IRM model, or something similar, could alleviate that problem and allow independent physicians to move away from fee-for-service reimbursement but still run their own practices.
"It's not about replacing the ACO model, but making shared savings work," Mr. Haley says.
You can see by the CENTRICITY ORGANIZATION by General Electric this is not about academic research and development of sound cost analysis, after all, all that need be done is look at Medicare payments over a few decades to average costs of procedure. This is a huge database for all kinds of medical procedures ready to be analyzed and median costs set for each procedure. SOUNDS EASY PEASY, RIGHT? Instead, Obama and neo-liberals are allowing all kinds of different corporations do their own analysis to come to there own decisions as to what is cost effective. IT IS CRAZY-----it is about corporations presenting their own plans. As the doctors on this panel stated-------you have one ACO making one billing plan and another ACO making another with any number of combinations and each of these billing ACOs will be attached to a mega-health system and all working to maximize profits for the umbrella hedge fund basically.
THE ONLY PROBLEM WITH MEDICAL BILLING HAS BEEN THAT THERE HAS BEEN ABSOLUTELY NO GOVERNMENT OVERSIGHT AND ACCOUNTABILITY FOR FRAUD -------BUILDING THAT WHITE COLLAR CRIMINAL SYSTEM IS THE SOLUTION!
ACOs and the Affordable Care Act
By Luke Sato, MD, CRICO, Ann Louise Puopolo, BSN, RN, CRICO, and Sue Cornacchio RN, JD, CRICO
Related to: Accountable Care Organizations
Section 3022 of the 2010 2010 Affordable Care Act required the U.S. Department of Health and Human Services (HHS) to establish a Shared Savings Program to facilitate coordination and cooperation among providers to reduce unnecessary costs and improve the quality of care for Medicare Fee-For-Service beneficiaries. Eligible providers, hospitals and suppliers could participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). HHS finalized the rules for the establishment of ACO programs in October 2011.
The Affordable Care Act also created the CMS Innovation Center to evaluate the impact of innovative models of payment and care service delivery for Medicare, Medicaid and CHIP beneficiaries with the ultimate aim of improving the U.S. health care system. The Innovation Center has been working in concert with the Medicare Shared Savings Program to test alternative ACO models, the Pioneer ACO model and the Advance Payment model.
ACOs are voluntary groups of doctors, hospitals, and other health care providers, that agree to assume responsibility for the care of a clearly defined population of Medicare beneficiaries attributed to them based on their use of primary care services. ACOs create incentives for providers to coordinate their efforts to treat patients, particularly those with chronic illnesses, across the continuum of care – including doctor’s offices, emergency departments, hospitals, and long-term care facilities. Coordinated care will help ensure that patients, especially the chronically ill, get the right care at the right time, with the goal of avoiding unnecessary duplication of services and preventing medical errors.
The goal of these new payment models is the transformation from a volume-based health care system to one more firmly based on achieving value for patients and providers. These new health care delivery approaches are aimed at providing:
Better care for individuals
Better health for populations
Lower cost growth
If the ACO succeeds in both delivering high-quality care or improved care and reducing the cost of that care below what would otherwise be expected, it will share in the savings it achieves for Medicare. 
ACO Financial Models
The three ACO financial models are summarized below:
Medicare Shared Savings Program  –
Currently, 116 organizations have been selected for participation, three are in Massachusetts,: Circle Health Alliance, Jordan Community ACO and Physicians of Cape Cod.
The Shared Savings Program (SSP) fulfills an Affordable Care Act obligation to establish a permanent program to build a path forward for groups of health care providers to become ACOs.
Under the SSP model, providers will share in any savings they achieve for the Medicare program. The length of the program is three performance years. ACOs can opt for one of two SSP payment models for the first agreement period:
One-sided model (sharing savings, but not losses, for the entire term of the first agreement) ACOs in the one-sided model will be eligible for a sharing rate of up to 50 percent.
Two-sided model (sharing both savings and losses for the entire term of the agreement) ACOs adopting this model will be eligible for a sharing rate of up to 60 percent.
Pioneer ACO Model
There are 32 listed Pioneer ACOs, five are in Massachusetts: Atrius Health, Beth Israel Deaconess Physician Organization, Mount Auburn Cambridge Independent Practice Association, Partners Healthcare and Steward Health Care.
The Pioneer ACO Model initiative designed to test the effectiveness of a particular payment strategy. It was specifically designed for organizations with experience providing integrated care across settings. There are five different payment arrangements offered in the Pioneer ACO model. These models vary the rules for shared savings, amount of risk and degree of capitation, but all are governed by the principles below:
The first two years of the Pioneer ACO Model are a shared savings payment arrangement with higher levels of savings and risk than in the SSP. All Pioneer ACOs must assume substantial 2-sided risk (bonus/loss) in the second year.
Starting in year three, those Pioneer ACOs that have earned savings over the first two years will be eligible to move to a capitated or population-based payment model. Population-based payment is a per-beneficiary per month payment and is intended to replace some or all of the fee-for-service payments with a prospective monthly payment.
Entities that have failed to average at least 2% savings in the first two years will retain their second year payment arrangements but CMS may terminate their contract after the third year.
Pioneer ACOs will be required to develop similar outcomes-based payment arrangements with other payers (such as insurers, employer health plans) so that more than 50 percent of the ACO's revenues will be derived from such arrangements by the end of year two.
Outcomes-based contracts are described as those that: (1) include financial accountability (shared savings and/or financial risk); (2) evaluate patient experiences of care; and (3) include substantial quality performance incentives.
By the end of 2012, Pioneer ACOs must attest and CMS will confirm that at least 50% of the ACO’s primary care providers have met requirements for meaningful use of certified electronic health records (EHR) for receipt of payments through the Medicare and Medicaid EHR Incentive Programs.
Advanced Payment Initiative – There are currently 20 ACOs participating in the Advanced Payment model. One, Harbor Medical Associates, PC is located in Massachusetts.
The Advanced Payment Initiative program was designed for certain eligible providers already in or interested in the SSP. It provides advance payments to physician-owned and rural providers for start-up expenses such as infrastructure, staff or IT systems. Advance payments would be recovered from shared savings achieved by the ACO.
CMS will measure ACO quality of care in four key domains:
Care coordination/patient safety
At risk population management
These quality measures will be reported through a combination of CMS claims and administrative data, web reported clinical quality measures, and patient experience surveys. These measures are aligned with the measures in other CMS programs such as the Electronic Health Records (EHR) and Physician Quality Reporting System (PQRS). Eligible ACOs will still be deemed eligible for the PQRS bonus, regardless of whether the ACO qualifies to share in savings.
Pay for performance will be phased in over the three year ACO period. In year one, ACOs will be paid for reporting quality measures. In years two and three ACOs will be paid for performance as well as reporting of quality measures. CMS will then use this information to establish national benchmarks for ACO quality measures.