Author: Jason Crosby

Supreme Court Sides With Hospitals in Multi-Billion-Dollar DSH Formula Dispute


Today, the Supreme Court released their decision regarding a hospital lawsuit against the Department of Health and Human Services (DHHS).  Several hospitals had joined together to sue DHHS regarding a previous rule change in the calculation of disproportionate share hospital (DSH) payments which began in 2014. The DSH payment change had reduced payments significantly to PPS hospitals. The Supreme Court has ruled in favor of the hospitals that this change violated the Medicare Act since it was not subject to public comment and the established rule-making process for government agencies.

The estimated impact of this decision is estimated in an additional $4 billion in DSH payments owed to hospitals for payments made since the 2014 rule change.  Additional details can be found here.

At present, DHHS has not commented on the ruling. SHP will continue monitoring the developments on how DHHS will be reissuing corrected payments based on the Supreme Court ruling and will keep you posted.

Primary Care First: Why CMS’ Latest Program Truly Matters

The Centers for Medicaid and Medicare Services (CMS) released yet another voluntary payment model intended on restructuring financial reimbursement for primary care services. At face value, Primary Care First furthers many of the underlying concepts utilized in CPC+ by generally offering upfront Per-Member-Per-Month (PMPM) payments to providers while theoretically undercutting the financial pressure for primary care physicians to push volume of appointments over meaningful time spent with patients. Primary Care First intends to upend market realities that straightforward Fee-For-Service reimbursement pressures put on providers to drive focus towards patient outcomes.

Just another CMS pilot? Maybe. It’s worth looking into this long stream of programs and initiatives CMS has unveiled aimed at re-prioritizing primary care, to clear up time for patients with complex chronic ailments. This simultaneous effort to increase patient health outcomes and reduce total costs of care may seem like just another theoretic framework doomed, waiting to face harsh practical realities to an untrained eye.  Though this multiprong effort intending to liberate a primary care office from the many inefficient entanglements’ providers face, simply trying to get paid for providing care, there is a more impactful lesson here. So, what makes Primary Care First different than any other lofty so-called “Re-design”? Nothing.

Nothing except for a potentially brand new medical framework to prove your ability to offer effective care coordination that actually reduces readmissions, unnecessary ED utilization, and simply shows your personalized care plans works better for your patients than your competitor down the street. Nothing except for the capability to pivot PMPM success from CMS to your local employer and payors, with data, infrastructure, and legal means to do so. Nothing except for a temporary breath of financial fresh air to contemplate your own practices to see how you can meet patients on their terms, rather than in the terms of a Medicare Fee Schedule. Nothing except another source of profitable information your Clinical Integration Network can bring to the negotiating table. How so?

In order to change our current circumstances, we need to change the conversation. So, how can we change the conversation? Easy, develop something new to talk about, that is worth talking about, and then talk about it, a lot.

Something new to conversate with your local self-insured employer groups may be your recent successes in reducing avoidable admissions amongst your highest acuity patients. Something new to conversate with a large local employer may be your home-grown lower-back pain “clinic” that you integrated into your practice that created a pathway toward therapeutic rather than surgical care, when appropriate.

See a trend here?

Something new to conversate with your regional Medicare Advantage payors may be your successful annual wellness visit in which an NP captures over 80% of your patients on a yearly basis, funneling them to their PCP when necessary with a practical team-based care model. They’d certainly be interested in hearing how you developed a pathway to document HCC coding for 80% of your eligible patients. The thinking is simple, do not undervalue how swiftly you can position recent action into conversation, and bring that conversation to those that need it most. With a bit of disciplined strategic discussion and transparent action, primary care practices are perfectly positioned to dovetail any population health success in quality, clinical outcomes, and financial savings with CMS to interested parties down the street. Those who struggle to see this, will likely continue to face new disrupting competitors showing up unannounced with proven evidence at succeeding in reducing non-value adding health costs by providing technologically-advanced personalized team-based care that patients, employers, and providers all desire.

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Insurance Plans Piloting Primary Care Programs

Healthcare operations continue to stride forward in new directions; Forbes published an article this week detailing how BCBSGA, UHC and Aetna are running pilot programs where they are directly employing providers that circumnavigate the existing healthcare delivery systems.  From the plans’ perspective; exerting more control on the delivery system has led to reportedly positive impacts; including improved quality metrics and reduced cost.  While this is certainly an admirable objective and a focus of the overall healthcare model being rolled out today from CMS to all other payers; there is no universality in measuring these objectives and how the health plans are meeting these goals is a matter of self-analysis and reporting.

What is particularly concerning about this is that health plans have full knowledge of the provider rates that they have established in every market giving them a significant competitive advantage to ensure that they are driving patient volume to their own physicians and clinics.  From a regulatory perspective regarding anti-competitive rate setting; it will be fascinating to follow any legal challenges that health plans may face in the coming years based on the redirection of services away from established providers in their markets.

While this is not something that we anticipate will be rolled out anytime soon; it is imperative to monitor the developments and understand the impact that it could have on your business as plans push into this new realm.

Medicaid and CHIP Managed Care Network Adequacy

In mid-November 2018, the CMS, under the direction of the Trump administration, proposed highly anticipated modifications to managed care regulations that were put in place back in 2016. These modifications would grant states more flexibility in determining network adequacy standards for Medicaid managed-care plans, with intentions of aligning Medicaid regulations more closely with Medicare Advantage standards. Simply stated, the intent was to generally increase the privatization of Medicaid Managed Care and limit federal financial involvement.

Given that Medicaid Managed Care Organizations behave similarly to self-insured employer groups, states vary in the levels of financial risk taken when contracting with participating provider networks. This relationship creates a unique opportunity for provider networks to either solidify their network by aligning with other existent contracts, or more realistically, a chaotic scenario involving a misaligned blend of Medicaid, Medicare Advantage, and commercial participation within a provider network, or even individual physician office. This brings the all-too-familiar patient confusion, revenue cycle difficulties, front-office misunderstandings, and overall provider enrollment nightmares.

Of the many aspects of the proposed rule, that will soon be publicized as a final rule, include:

  • Pass-Through Payments – This proposal expands states’ authority to direct payments from plans to providers in states transitioning towards Medicaid managed care from traditional Fee-For-Service models. The proposal is a three-year period that permits states to require payments that equate Fee-For-Service reimbursements to ease the financial transition for provider organizations and healthcare facilities.
  • Testing Value-based payment reform – This proposal permits increased authority at the state level to offer value-based payment models potentially reflecting value-based methodologies used in Medicare Advantage and commercial markets. It is noteworthy that this does not directly mimic Medicare Advantage frameworks which reduces much-needed value-based synchrony but offers regional flexibility for provider groups to actively negotiate mirroring value-based contracts with a traditionally siloed payor class such as a CMO plan.
  • Provider Network Adequacy – Currently, states enforce network adequacy standards that include time and distance standards for various provider specialties. Many argue this deters telehealth and telemedicine capabilities that could allow networks to include distant professionals. This proposal eliminates this requirement completely and replaces it with quantitative network adequacy standards that may include loosely defined provider-to-patient network ratios. Completely removing the time and distance rules for even primary care providers caused significant concern with provider organizations, which is likely to be addressed in the final rule. Additionally, states would now maintain the authority to define “specialists” in terms of network adequacy standards.
  • Rate Ranges – The proposed rule allows rate to vary only by beneficiary or service characteristics, unlike the current reliance on the level of Federal Financial Participation (FFP). Importantly, this rule modifies the stipulation that payment modifications must be delivered based on sound actuarial principles. This means any revisions and underpaid reimbursement due to a variety of rate-related issues could be simply denied.
  • Coordination of Benefits (COB) – As managed care enrollees are often covered by multiple sources (Dual eligibility in Medicare Advantage, specialized behavior/dental care, etc). Currently, the proposal offers states the flexibility to route claims as they chose rather than the existent policy that leverages Medicare’s claims routing methodology.

Further Information provided by The Centers for Medicare and Medicaid Services can be found here.

Let’s Talk About How We Utilize the Department of Insurance

As the payer market in Georgia has consolidated through mergers/acquisitions; one of their key goals was increased efficiencies that they could leverage through size. Unfortunately, their provider partners have seen the exact opposite: consolidation has taken significant power out of the local state markets and placed it into national warehouses; whether that is claims appeals/provider loads and credentialing/etc. This national consolidation has slowed payer response and accountability to resolve issues.

Newly elected Insurance Commissioner Jim Beck recognizes that payers need increased accountability in Georgia and has, therefore, convened a stakeholders committee representing providers around the state; to identify the top four issues facing providers for the Insurance Commissioner to address with payer.

One of those key issues is provider credentialing and the typically slow processing of network loads; which is a statewide issue and a key focus of the complaints that they receive. It is evident that the payers in the state are not sufficiently meetings the challenges of provider credentialing.

Despite the universality of this issue, Commissioner Beck’s team shared that less than 10% of the overall complaints that their office receives are from physicians/hospitals. The DOI is simply not hearing from enough providers in this state to hold payers accountable to provider issues; in fact, medical complaints still represent the smallest percentage of insurance complaints received. Thus, the lack of complaints fails to trigger the additional scrutiny available from the DOI over payer activity.

The DOI’s resources are going to be devoted to the bulk of complaints that they received; therefore, SHP encourages our providers to ensure that they are utilizing the Department of Insurance complaint process. By appropriately reporting the myriad of payer issues, we believe that Commissioner Beck’s team will have a clearer picture of ongoing payer issues, thus direct their resources more actively in our assistance.

The DOI link is listed below in order to submit a Provider Complaint; including using the portal for electronic submission to DOI.

Tips for Creating Engaging Content


In the age where Buzzfeed listicles dominate and memes have replaced words, it’s difficult to figure out how to create blog content that will keep a reader engaged past the title. The good news? We have some tips on how to hook those readers in and keep them coming back for more.

1. The acronyms are actually important.
The digital age is filled with talk of the almighty SEO, or Search Engine Optimization. The lofty air surrounding SEO engagement is actually pretty vital to a blog or really any digital marketing campaign. Keywords lie at the heart of SEO optimization. They’re the main points of your content and will help Google guide potential readers to your site. This is not to say that you need to throw a million keywords in your blog so that the actual points are muddled with Google-nonsense. The reason why someone clicked on your post was because they were interested in the title and/or topic, so make sure you deliver on that promise.

2. Images, Images, Images
Unfortunately, most people won’t stick through text-heavy content. To get people to keep reading, come up with creative subtexts, organize the information into bullet points or lists, provide links to other sources, and include those images and/or videos. In this article by The Guardian, research shows that videos are the way of the future, so partner with YouTube and start cranking out interesting clips to accompany your blog posts.

3. Give your readers something in return.
Sure, the information that you’ll be providing is a gift enough, but sometimes creating even more engaging content means providing the readers with something tangible. Perhaps for a share, your reader can download some cool treat (i.e. white paper, ebook, video) that relates to the blog content? Creating contests will also help boost your fan base. People love to compete, and what better way to get your business out in the virtual sphere than by having people share your information for a prize?

4. Grammar is actually important!
Play with words to make your copy more lively and fun to read. Know when to be direct and when it’s proper to be passive. Depending on your company, some topics should be said in a more approachable manner with suggestions rather than rules. As we’ve been doing, use the second person to talk directly to the reader. Yes…you! Keep your tone of voice in mind when creating content as well. Nothing will put a reader off more than an unfriendly or rude tone.

5. Literally engage your readers.
Listen to what your audience is saying about a particular product/trend/whatever your business does, then try to get them to respond on your blog. Ask questions. Be inviting. Encourage comments.

6. And your point is?
Throwing out lots of jokes and using fancy jargon may be great for some circles, but when it comes to getting people to engage with your content, stick with what appeals to a broader population. If your witty title talks about how to create engaging content, for instance, than what follows that heading should be all about that topic. (Are we doing okay?) It’s also a good idea to follow current trends. Entrepreneur says it best, “Specific triggers get more people to share our content, spreading our message, gaining traction, winning customers and beating the competition.”

Written by Jeremy Miller with Boost by Design.

The Life Cycle of a Resume


When recruiting for a job, companies look for many things before they even pick up the phone to call you for an interview.  Most people think that when you, the potential job candidate, submit a resume online, it gets screened by either a computer program or human, and then you are either called or the resume is put in the rejected pile. However, there is much more to the recruitment process than you think.

Let’s start at the very beginning. The candidate finds your job posting. Something about what you have written interests them. They think… “This is perfect for me” or “I can do that.” They then put together their resume, write a cover letter, and hit the send button.

I am sure most candidates assume that the recruiter begins reading their cover letter before they even look at a resume. That really is not the case; in fact, it is more likely than not the cover letter will never even be read. Oh yes, as recruiters we highly encourage the candidate to write a cover letter, but in all honesty, on average per job opening we receive about 250 resumes with a cover letter attached. Odds are we are not going read the cover letter; we are going to go straight to the resume. Only about 23% of the cover letters sent are read. We ask that you submit cover letters because if it comes down to you and another candidate, we will look at the cover letter and check to see who would be a better fit.

Next, either the computer app recruiter’s use, scans for key words in a resume and then flags it as something you must see or you personally go through each resume. It takes an average 5-7 seconds for a resume to be scanned, either by a human or a computer. That is right, I said seconds. It takes longer for you to make a sandwich. Although it only takes a few seconds to scan the resume, it only takes about 1 second to notice a grammatical error or typo in a resume. It is like a spotlight is shown on this one tiny mistake, and it then blinks at you over and over again.

I understand, when you are young and creating an email address, you think… “I will be creative with it, it is going to be”  Now, that is great when you are 11 years old; however when you in your 30’s sending out resumes, it is not so professional and the recruiter will not take you seriously. So there goes the resume….in the rejected pile.

Last, but not least, social media is here to stay. As recruiters we are going to see if you have an online presence. We want to see if you are someone we want representing our company by what you post. If you just post about your family and pets, then odds are we are going to pick up the phone and call you for an interview. If you post how much you hate your job and co-workers, we will probably send your resume to the rejected pile. 1 out of 4 recruiters will reject you based on your online presence.

Before you hit the send button on your phone, computer, or tablet, think to yourself…Is my resume grammatically correct/no typos; Does my cover letter sell me and what I have done and what I will do for the company; Should I change my email address that I have had since I was 11 yrs. old; Are my social media accounts set to private and how do I look if an employer should look at my profile? But above all, remember you are a professional; therefore, your first impression should be as a professional.

Written by Karyn Koch.

Medicare: Limited Enrollment Through March 31


Medicare Advantage (MA) plans have continued in popularity with over 22 million enrollees for 2019 according to CMS, an increase of over 32% since 2015. While beneficial, is still a confusing product for most.  As a result, most on Medicare will stay with a plan simply out of the intimidation of the process. Thankfully, due to the 21 Century Cures Act, you have an extended time frame for enrollment this year. You now have until March 31, 2019 to change your Medicare Advantage (MA) plan, or switch to ‘traditional’ Medicare and purchase a Part D prescription plan (You cannot change Part D plans during this 1st quarter time frame). This time can best be served by more education of the plans in your area, as some markets can have up to a dozen plans to select from. According to CMS, these changes will take place the first month after the plan receives your request.

As you investigate the many offerings in your area, first review your current insurance coverage and what you may need in the coming year or gaps that currently exist. Do not get lured simply by the low premiums, while attractive, may not be the solution you need. Some plans will also come with other appealing options such as gym memberships or dental coverage. However, they can also change annually and limit your provider network / selection. Be sure to stay focused on the entire coverage of services, including your providers, hospital, and prescription needs.

Click here for more information.

Gossiping vs Venting in the Workplace


Everyone has a friend/colleague that we like to discuss things with such as work or other colleagues in the workplace.  We like to discuss the good, bad, and ugly of our workplace stresses, frustrations, and annoyances with our friend/colleague…does this mean we are gossiping or is it just venting? This is a grey area for most, so hopefully this will give you some guidance of when venting can become gossip.

Venting is commonplace in the workplace; in fact it is inevitable. At times we need that friend/colleague with whom we can share our frustrations with and that is absolutely ok.  In fact, many would say venting can be a healthy release of stress and frustration for some. When we vent or a colleague vents their annoyances or stressors constantly, please keep in mind this can spread negativity and be disruptive to your co-workers just as much as gossip. But like all things, we should always think before we speak.

One of the most important things to think about when venting is to choose someone who can be objective about whatever you are saying. The second thing would be to tell someone who is going to keep it confidential. Most of us process our feelings by talking them out with someone or we need help figuring out how to respond. Venting is totally appropriate during these times.  A good friend/colleague should be someone you can rely on to be honest with you good or bad.

It is very easy for us to get in the habit of venting about every little perceived grievance in the workplace. Be mindful that this can create a workplace reputation for you as a complainer. You can minimize the impact you are having on your fellow teammates by not venting any frustrations at work itself but go to lunch with your friend/colleague or discuss it after hours. Venting is not something you would want to do in an open space, say near the copy machine, because someone will overhear you and can misconstrue what you have said and then turn that into gossip.

Now here is the grey area when workplace venting can be perceived as workplace gossip. You should start by asking yourself some simple questions: is the information you are sharing yours to share, why would this person need to know this information, and is it true? Keep in mind, even if something is public domain, it doesn’t always make it right to repeat it.  The second question is slightly harder for us to qualify. If you are sharing information about someone as a warning to not repeat their mistake or to help see things clearer, then it is not gossip. However, if this information is being shared for no other reason than to share information that is hurtful or not flattering, then not only is it a bad habit to share; it is gossip. Even if you are stating a fact, that doesn’t mean it isn’t gossip.

Whether you are gossiping or venting about work, please balance the negative with the positive and come up solutions. If you or your colleague only focus on the negative things about work, you are never going to be happy with yourself or your job. Start coming up with solutions to things you feel are impacting the company negatively and voice your solutions so you can be a part of the change and not the problem.

If you are tempted to vent or gossip, please think before you speak. Think what the repercussions could be as to what you are saying. We are human, and we will continue to fall in the grey area. Hopefully, these steps and questions you will ask yourself will help you to stay in the venting category as opposed to the gossip category.

Written by Karyn Koch.

CMS Overhauls ACO Programs Towards Quicker “Pathways to Success”


As 2018 came to a close, the Centers for Medicare & Medicaid Services (CMS) released substantial adjustments to the Medicare Shared Savings Program (MSSP), most of which are arguably the most impactful since its inception. “Medicare can no longer afford to support programs with weak incentives that do not deliver value,” CMS Administrator Seema Verma emphasizes. The final rule particularly targets MSSP Track One ACOs, the vast majority in the market, as data on their ACO cost performance ‘does not move the dial’ as substantial as ACO participants who took performance-based financial risk.

To further encourage risk, CMS reduced the shared savings rate to 40% for those ACOs that do not assume risk, previously known as Track One MSSP ACOs. All other ACOs that acquire financial risk will keep the 50% shared savings rate.

The bold “Pathways to Success” initiative will implement the most substantial adjustments representing CMS’ lessons learned these past six years:

Timeline Within the new program, new “low-revenue” ACOs will have only three years to remain in a one-sided risk model whereas existing one-sided ACOs will only have a single year to take on additional risk.  All other new ACOs will have two years to take on risk.  Those ACOs strategically avoiding MIPS and/or those ACOs who did not emphasize the seriousness of their commitment to the program will no longer have a free pass.

Quality: Pathways to Success increases accessibility to telehealth services to boost convenience for patients and providers, including services delivered at a patient’s residence, as difficult as that may prove to be.  Many Telehealth enthusiasts appreciate another incremental step towards broadly supported Telehealth services even if the reimbursement expansions may only be available to ACO participants who take significant financial risk.

Beneficiary Engagement: To further drive improved health outcomes, Pathways to Success allows ACOs to offer new incentive payments for beneficiaries who participate in their care by obtaining primary care services and adhering to necessary follow-up care plans.  With care coordination resources provided by most ACO’s, the theory of ‘getting them in the door’ and thus having actionable data, will permeate the necessary communication and care most go without today.

Though CMS themselves predicts 109 ACOs will leave the program due to these changes by 2028, the estimated savings is estimated at $2.24 billion over the next decade.  Most ACOs and provider organizations are rightfully scrutinizing the details of this verbose rule, despite the short deadline for a July 1, 2019 start date, with applications due by February 19, 2019.  With 3-Day SNF waivers, gift cards available for patient reward, and telehealth reimbursement carrots dangled to provider organizations by CMS, it’s a quick turn likely to push more entrants into the MIPS program.  However, the savviest of groups may recognize the potential advantageous economics of the SNF Waiver that eases and expedites the referral process to a nursing home without the currently required three-day inpatient stay.  Only ACOs participating in MSSP performance-based risk tracks are eligible to obtain these waivers that very well can directly impact your daily census.  Though CMS limits waiver use to patients prospectively attributed to the ACO, the minimal reduction in red tape is enticing depending on your unique patient population and market needs.  Many particulars of the Final Rule will continue to further split providers into financial risk takers, taking the form of ACO members and MIPS-Composite score focused MIPS participants, while continuing to complicate and catalyze healthcare payment reform in 2019.

Meanwhile, the message is clearer now than ever before.  Get on the Fee For Value train before your wallet and patients are left at the station…

Posted in ACO