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Health insurance billing and reimbursement
An inside look to payment models in outpatient and inpatient settings guidelines
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WEEK 4 HIT 235 LESSON 2Term Definition
Advanced Alternative Payment Models (APMs) are risk-based
arrangements between physicians and payers, usually Accountable
Care Organizations; however, APMs may be administered by CMS or
by private payers. To satisfy the requirements of the Quality Payment
Program, physicians are required to demonstrate that they bear a certain
amount of financial risk and that they are using certified electronic
health record (EHR) technology. The APM category is designed to
encourage more participants in APMs by reducing the reporting burden
and creating new scoring opportunities for participants. Their base
payments on quality measures are comparable to those used in the
Advanced Alternative Payment Models MIPS category
(APMs)
e Continuity of Care Document (CCD) was created to bridge the gap
between two complementary but incompatible XMD document formats
to better serve the purpose of health information exchange. Another
Continuity of Care Document challenge to interoperability includes the EHR vendors’ protocols for
Excess Readmission Ratio (ERR)
PROVIDING HIGHER QUALITY AT A
Efficiency (in health care) LOWER
Expected Readmission Rate
Hospital Value-Based Purchasing
Program
Interoperability HIMSS (Health Information and Management Systems Society)
defines interop-erability as the ability of different information
, Term Definition
technology systems and software applications to communicate,
exchange data, and use the information that has
been exchanged. Some of the challenges to interoperability include the
diversity of heMIalth care services, the wide range of information
systems, and the numerous clini-cal domains with high levels of
information complexity. An example of information complexity is the
document structure used to share patient information at transitions of
care between providers.
MAP keys
The Medicaid program, which is jointly run by the states and federal
govern-ment, has also been shifting to value-based payment models
under Medicaid man-aged care programs. The process began in 2015
when the Medicare Access and CHIP Reauthorization Act of 2015
(MACRA) repealed the sustainable growth rate formula previously
used to pay physicians. This changed Medicare’s reward system to
value rather than volume and authorized HHS to implement initiatives
Medicare Access and CHIP aimed at improving care access for Medicare and CHIP beneficiaries.
Reauthorization Act of 2015 (MACRA) One major provision of MACRA was the Quality Payment Program.
Merit-based Incentive Payment System The Merit-based Incentive Payment System (MIPS) reimburses
(MIPS) physicians for cov-ered Part B Medicare services and rewards them for
improving the quality of patient care and outcomes. MIPS has four
performance categories:
● Quality—assesses the quality of care based on measures of
performance
● Promoting interoperability—assesses the promotion of patient
engage-ment and the use of electronic health records for the exchange
of information
● Improvement activities—assesses participation in activities that
improve clinical practice and support patient engagement
● Cost—assesses the cost of the care provided based on Medicare Part
B claims
Meeting requirements
● Measures that are consistent with the common clinical practices of
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