GeBBS Healthcare Blog

Nitin Thakor, CEO, GeBBS Healthcare Solutions

Recent Posts

Billions of Dollars Flow into Private Medicaid Plans with NO Cost Oversight or Efficacy of Treatment Determined

Posted on Wed, Nov 07, 2018 @ 10:52 AM

Cost containment has become a leading factor in the delivery of healthcare. What are some of the issues that are contributing to these burgeoning costs? One of them is Medicaid. We spent over $576 billion on Medicaid programs in 2017, as reported by the Kaiser Family Foundation.

A recent article in Kaiser Health News noted that 75 million low-income Americans rely on private Medicaid managed care programs. These programs have grown rapidly since 2014, boosted by the influx of new beneficiaries under the Affordable Care Act (ACA). Many states eagerly tapped into the services of private insurers as one way to cope with the expansion of Medicaid costs under the ACA, which has added 12 million people to the rolls. Outsourcing these government-payer programs to private insurers has become the preferred method for handling Medicaid in 38 states.

In return for their fixed fees, these private insurers provide treatment within a limited network -- in theory -- allowing for more judicious, less expensive care. States contract with health plans as a way to lock in some predictability in their annual budgets. Participating states in these private programs are funneling nearly $300 billion annually into private Medicaid insurers.

Are these private Medicaid insurance companies -- who are now receiving hundreds of billions in public money — earning their fees?

Hard evidence is lacking that these private contractors improve patient care or save government money. When auditors, lawmakers and regulators examine the records, many conclude that private Medicaid insurers fail to account for the dollars spent, document the care delivered, or provide access to a sufficient number of doctors. Oversight is sorely lacking and lawmakers in a number of states have raised alarms even as they continue to pay billions. Another “fly in the ointment” is that these private plans get to keep what they don’t spend. That means profits can flow from greater efficiency -- or from skimping on care and taking in excess government payments.

What is the solution to cost containment on these government-funded private payer programs?

Independent outsourced auditors who have deep experience in auditing insurance claims and determining the efficacy and quality of medical treatments can be utilized to monitor these privately managed care plans.

These independent outsourced auditors will have the information technology solutions to deliver highly skilled professionals, robust audit processes, proprietary workflow engines, and world-class IT infrastructures.

They can deliver immediately audit workflow and operations management to ensure consistency throughout the managed care plan audit process that will monitor and report the true cost of medical treatments and the quality of care being provided to patients.

Let’s get the “fox out of the henhouse” and move toward a system that will contain costs, and more importantly, improve the patient care being delivered.

GeBBS Healthcare Solutions is a leading technology-enabled provider of revenue cycle management (RCM) and Government Payer solutions. GeBBS’ innovative technology, combined with its over 6,000-strong global workforce, helps clients improve financial performance, compliance, and patient satisfaction. Visit our website to see how our services can work for you.

 

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Tags: RCM Solutions, Revenue Cycle Solutions

The Age of Revenue Cycle Management Outsourcing Has Arrived

Posted on Thu, May 17, 2018 @ 02:13 PM

The RevCycle Intelligence e-newsletter reported recently that 80 percent of hospitals are vetting full revenue cycle management (RCM) outsourcing. The demand to outsource full RCM is up 86 percent from 2015 among hospitals and inpatient organizations. Approximately 80 percent of hospital leaders in a new Black Book survey of 709 C-suite executives, board members, and senior managers at hospitals and other inpatient organizations said they were vetting or considering outsourcing full RCM by 2019.

The survey revealed the demand for RCM outsourcing is significantly up because hospitals and inpatient organizations are looking to reduce costs and focus on value-based care initiatives. Nine out of ten hospitals are also considering partnering with a third-party vendor to allow hospital leaders and providers to prioritize value-based care implementation.

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The complexity of value-based care reforms and their impact on revenue have put pressure on hospitals to decrease inpatient volumes, achieve financial outcome goals and provide cost-effective care. RCM outsourcing is growing because it offers struggling hospitals immediate results.

This is precisely the time to engage with a partner who brings a deep understanding of the revenue cycle. GeBBS Healthcare Solutions provides tailored revenue cycle management solutions that cut through the complexity with technology, service capability and operational excellence.

GeBBS provides a broad portfolio of HIM and RCM solutions to thousands of physician and healthcare organizations nationwide. As hospitals and physician practices look for ways to contain costs and increase their revenue, RCM outsourcing is a valid strategy to achieve a financially healthier organization. It’s just a matter of finding the right partner with the right expertise and technology.

Walmart Reportedly in Early-stage Talks to Buy Humana

Posted on Mon, Apr 02, 2018 @ 02:00 PM

Here we go again! In my last blog I mentioned how companies like Amazon, Google, Apple, Uber, etc. will be driving innovations in healthcare delivery and costs over the next 10 years. Today, the Wall Street Journal (WSJ) reported that retail giant Walmart is in preliminary talks with health insurer Humana about developing a closer partnership, with one possibility being that Walmart might acquire Humana.

If you are a Humana customer right now, they strongly suggest that you use Walmart for your prescription coverage. If this deal comes to fruition it will have a significant effect on the healthcare industry and it could be good for consumers/patients, since Walmart seems committed to its “always the lowest price strategy.

Here are five interesting facts that the WSJ reported:

1. The two companies are discussing a variety of options, and it is not certain they will strike a deal. If they do reach an agreement, it would be Walmart's largest deal ever. Humana's current market value is about $37 billion.

2. If the potential deal, which would require regulatory and shareholder approval, closes, Walmart would be one of the largest health insurers in the country.

3. The talks between Walmart and Humana come amid a flurry of deals that could transform the business of managing healthcare, including CVS Health's proposed acquisition of Aetna for $69 billion and Cigna's proposed acquisition of Express Scripts for $54 billion.

4. Humana shares jumped 10 percent in after-hours trading March 29 after WSJ reported the preliminary talks. Shares of Walmart dropped 1 percent.

5. Walmart, which is a major drugstore operator in addition to being the world's largest retailer and has a current market value of $260 billion.

America’s largest companies continue “to think outside the box,” and they have their eye on the healthcare industry.

Finally, we are thinking out of the box..

Posted on Tue, Mar 06, 2018 @ 10:36 AM

Companies like Amazon, Google, Apple, Uber, etc. will be driving innovations in healthcare delivery and costs over the next 10 years. This will have a significant, positive effect on the industry and it will be good for consumers/patients.

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One of the major social determinants in population health management is how to get patients to their care delivery sites. Uber in a big grab for the medical transit market announced the launch of a new digital tool meant to book rides for patients who need assistance getting to and from their appointments. A healthcare provider can book a ride for patients and caregivers immediately, within a few hours, or with 30 days’ notice. The company is positioning itself as a cheaper and more reliable option than most non-emergency medical transportation. Their announcement included over 100 healthcare providers all across the US.

Amazon is also trying to disrupt healthcare. They made big news last month after announcing it would seek ways to address soaring healthcare costs for its own employees. The online shopping titan is focusing its industry-disrupting power on the broader healthcare sector.

The retailer has rolled out a line of private label over-the-counter medicines and is building a business selling a wide array of medical supplies to doctors, dentists and hospitals. Amazon says the efforts are part of its strategy to enhance the shopping experience for businesses and consumers. The company’s efforts in the healthcare field are being closely watched, especially after it announced last month that it is working with Berkshire Hathaway and JPMorgan Chase to better control costs and reduce spending on the health insurance they offer for the 840,000 people who work for them.

Some industry watchers also speculate that the firm may try its hand at selling prescription drugs in the near future, though they warn this would be a big lift since the drug industry is so highly regulated.

Apple has also joined the fray by launching medical clinics to deliver the “world's best healthcare experience” to its employees. The company is launching a group of health clinics called AC Wellness for its employees and their families this spring, according to healthcare industry sources familiar with the company's plans.

The company quietly published a website, acwellness.com, with more details about its initiative and a careers page listing jobs including primary care doctor, exercise coach and care navigator, as well as a phlebotomist to administer lab tests on-site. Apple’s new primary care group — a group of clinical staff that is run independently from Apple but is dedicated to Apple employees — will initially only serve Apple's employees in Santa Clara County, where its headquarters are located. Initially, it has two clinics in the county.

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Efforts Applauded, But Uphill Battle Unlikely to Produce Results

Posted on Mon, Jan 22, 2018 @ 09:30 AM

Four not-for-profit health systems recently unveiled plans to create their own generic drug company. Industry experts say they'll face an uphill battle to make a significant dent in one of the fastest-growing industry expenses and persistent problems: rising drug prices and drug shortages.

Modern Healthcare magazine reported last week that Intermountain Healthcare, Ascension, SSM Health and Trinity Health are working with the U.S. Department of Veterans Affairs to pool their capital and 450 total hospitals to fight back against drug companies that unexpectedly hike the prices of decades-old off-patent generic drugs with minimal competition. They also look to create a more reliable supply of generic drugs like saline and sodium bicarbonate that are vulnerable to shortages.

While the health systems didn't specify what drugs their new venture will make, they want to provide both sterile injectables and oral medication either through their own FDA-approved manufacturing facility or by contracting with existing manufacturers. Most hospitals have some compounding pharmacy capacity, but the initiative will not use hospital compounding facilities to produce products, Harrison said.

Industry experts have commented that while they applaud the effort and think it might be a step in the right direction, this endeavor is going to be a labor-intensive and costly to set up manufacturing efforts.

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Players across the health industry have discussed how to cope with dramatic price hikes of widely used drugs coupled with enduring drug shortages, but solutions have been harder to come by. Retail prescription drug expenses accounted for about 12% of total U.S. healthcare spending in 2015, up from about 7% through the 1990s, according to a recent report from the U.S. Government Accountability Office. Branded drugs with no generic alternatives, or single-source drugs, are the main culprit. A study from Blue Cross and Blue Shield Association found that patent-protected drugs make up 63% of total drug spending. This new endeavor cannot combat 63 % of total drug spending.

But even off-patent drugs are part of the drug price dilemma. Valeant Pharmaceuticals, for example, acquired the rights to the off-patent heart drugs nitroprusside and isoproterenol and increased their respective prices 30-fold and 70-fold over a three-year span. The Cleveland Clinic found that utilization across 47 hospitals it studied decreased utilization by 53% and 35% for nitroprusside and isoproterenol respectively, which took a toll on patient safety and outcomes.

The health systems are making a valiant effort, but it is very unlikely that their work will significantly affect the cost of drugs or any drug shortages.

It Didn’t Take Long!

Posted on Tue, Dec 12, 2017 @ 11:52 AM

Right on the heels of the Aetna-CVS merger story, Healthcare Finance News reported earlier this week that Humana is eyeing a deal with Walmart.

The $69 billion merger between CVS Health and Aetna, announced by CVS on Sunday, has spurred industry analysts to talk about a possible deal between Walmart and Humana, as the retailer feels the increased competition from an integrated pharmacy business and is currently in an arms race against on-line giant Amazon who is reportedly poised to enter the pharmacy business.

Humana has not responded to the merger rumors.

So far, the American Hospital Association has offered no comment on what an Aetna-CVS deal, and its analytically-boosted pharmacy health hubs, would mean as competition to providers, but their totally integrated business would be a juggernaut with which other pharmacy and health plans will have to compete.

The Healthcare Finance article reported that Moody's Investors Service was bullish about the Aetna-CVS deal, saying its diversified revenue stream, unsurpassed scale and reach in the industry had the potential to reshape the entire health plan market.

The merger does have the potential to reduce the cost of healthcare, due to Aetna's membership data, technology and strong Medicare Advantage growth, combined with CVS's pharmacy operations, including minute clinics and prescription drug programs. However, it remains to be seen whether or not the savings from these mergers will be passed on to consumers or go straight to the bottom lines of the merged giants.

Another thing to consider is what will be the long-term effect on the healthcare industry when almost all of the pharmaceuticals and health plans are controlled by three or four seamlessly integrated giant companies. Will they pass their benefits and cost savings on to consumers or will they exploit their nearly monopolistic advantages for company gains?

“Blurring the Lines” – UnitedHealth Group Buys Davita Medical Group

Posted on Thu, Dec 07, 2017 @ 11:50 AM

In another example of the blurring boundaries in the healthcare industry, UnitedHealth Group, one of the nation’s largest insurers, is buying Davita Medical Group, a large physician group with a roster of 30,000 doctors. It seems that every day we are reading about more healthcare companies seeking to tighten their vertical integration by “blurring service lines” in the healthcare marketplace. Aetna/CVS, Humana/Walmart (rumored) and now UnitedHealthcare Group through their Optum subsidiary is buying DaVita Medical Group.

DaVita Medical Group serves approximately 1.7 million patients per year through nearly 300 medical clinics featuring primary and specialist care. The Group also operates 35 urgent-care centers and six outpatient surgery centers. UnitedHealth Group provides healthcare insurance

coverage and benefits services, while their Optum subsidiary provides information and technology-enabled health services to 115 million consumers in 35 states.

The agreement, entered into on December 5, 2017, calls for Optum to acquire DaVita Medical Group for approximately $4.9 billion in cash. The transaction is expected to close in 2018. According to their press relea
se, DaVita Medical Group will become part of Optum’s OptumCare division, which works with more than 80 health plans to serve consumers through 30,000 affiliated physicians and hundreds of care facilities.

Here is another example of “blurring the lines” with close integration of healthcare services: insurance provider, healthcare medical services provider, and information and technology-enabled practice management services. This acquisition and vertical integration will certainly strengthen the combined companies’ position in the marketplace, but will any cost saving benefits derived from this vertical integration be passed on to the consumers/patients of these combined companies? Let’s hope that happens.

Join the Fight to Prevent Cuts to 340B Hospitals

Posted on Tue, Nov 21, 2017 @ 11:49 AM

Following is a plea from AHA Chairman Gene Woods, and I would urge everyone in the healthcare industry to respond to his plea by contacting their congressional representatives. Our hospitals are already hurting from lower inpatient volumes and the movement to value-based care. This unnecessary cut will hurt them even further. As Mr. Woods points out, the 304B program does not cost the federal government a dime, and this is not the time to “pile on” further cuts to our already cash-strapped hospitals.

Mr. Wood’s Message:

The 340B program enables hospitals that serve many low-income and uninsured patients to buy prescription drugs from drug manufacturers at discounted costs and use the savings to provide a range of comprehensive health services to their local communities.

This program has played an important role in helping hospitals stretch already scarce federal resources to expand access to care, enhance community outreach programs and offer unique health services like free vaccines, clinical pharmacy benefits and smoking cessation classes.

However, without further action, the Centers for Medicare & Medicaid Services will cut Medicare payments to many of the hospitals that participate in 340B by nearly 30%—even though the program does not cost the federal government a dime.

Cuts that severe would dramatically threaten access to care for many patients in communities across the country, including our most vulnerable patients. That's why the AHA has filed a lawsuit to prevent these cuts, and reengaged with Congress to enlist its help protecting this important resource for our patients and communities.

Right now, it's important that we work together to assure that both the Court and Congress understand that the savings generated through the 340B discount program make a big difference for our communities and help our friends, neighbors and family so they can have access to the level of care they deserve. Please join our efforts now by urging your representative in Congress to cosponsor H.R. 4392, a bill to prevent these significant cuts from taking effect.

Gene Woods, AHA Chairman

Yes, It’s Time to Encrypt PHI Data!

Posted on Fri, Aug 14, 2015 @ 08:00 AM

Although employee negligence and lost/stolen devices continue to be major causes of data breaches, criminal attacks are now the leading cause of breaches in healthcare.

What are these cyber criminals doing to get access to the data, and what is causing the breaches in our healthcare organizations? Ponemon’s report says that 88 percent of these breaches came from phishing to get a foothold into a network. The attackers try to compromise employees who have elevated privileges that will give them access to sensitive systems and critical data.

Stronger technical controls like encryption and bio-access security devices will prevent damages from most of these attacks. These criminal are not looking for gall bladder surgery data; they are looking for financial information they can use to rob unsuspecting patients.

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Two things need to take place immediately; we need to begin to encrypt all stored PHI and we need to improve the security measures that protect access to that data.

Even though data processing speed sometimes suffers as a result of encryption, the justifications for not encrypting data are quickly going away. Safe and secure are better than fast.

Secondly, we must take the human element out of PHI data access. Bio-access security systems must be employed that will thwart unsuspecting healthcare workers from falling prey to sophisticated “phishing expeditions” by professional hackers.

Tags: Business Process Outsourcing (BPO), Healthcare IT Solutions / EHR

Top 10 Reasons Why You Should Outsource Your Revenue Cycle Activities

Posted on Thu, Mar 19, 2015 @ 12:12 PM

In today’s healthcare environment of shrinking reimbursements, due to governmental mandates and Medicare policy changes, the importance of maintaining a healthy revenue cycle is second only to providing the best patient care possible. Without an adequate margin there can be no medical mission.

One way to ensure your revenue cycle remains as healthy as possible is to enlist the help of a healthcare BPO company to assist with -- or handle completely -- your revenue cyclegebbs outsourcing medical billing activities. These organizations are expert at keeping your revenue cycle fine-tuned and optimized to its maximum performance level, much like a highly-trained
mechanic can do for your automobile. There are literally dozens of advantages that third party revenue cycle companies can provide, such as onshore and offshore medical coding and offshore medical billing. Here, in my opinion, are the top 10 reasons why healthcare financial professionals should consider outsourcing.

  1. You will see an increase in your reimbursements and collections.

  2. Your labor costs for revenue cycle maintenance will be reduced.

  3. Requires no capital investment.

  4. You get immediate access to highly-skilled and expert personnel that will mitigate risks from frequently changing governmental regulations.

  5. Staff members will be freed up to work on other critical financial issues.

  6. You will receive daily, detailed financial reports upon which you can take immediate action.

  7. Your revenue cycle will be easier to track and manage.

  8. It’s an uncomplicated solution that works from day 1 of implementation.

  9. No additional staff, training or office spaces are required.

  10. You get immediate peace of mind that you are doing everything you can to maximize your revenue cycle.

Tags: Business Process Outsourcing (BPO), Revenue Cycle Management (RCM), Medical Coding, Affordable Care Act, Insurance Billing Solutions, Offshore Medical Billing, Offshore Medical Coding, Medical Billing BPO, Offshore Revenue Cycle Management, Remote Medical Coding, Medical Coding BPO