GeBBS Healthcare Blog

CMS Will Only Adjust Medicaid Rules – Not Drastically Change Them

Posted on Tue, Nov 20, 2018 @ 05:00 AM

After much ballyhoo and for years of promising a major overhaul to the cost-prohibitive Obama-era managed care rules, the CMS has issued a proposed regulation that makes smaller changes – not the drastic “gutting” that had been promised -- to the standards states meet when running their Medicaid plans.

The proposed rule issued Thursday would give states some new flexibility in setting rates for their managed care plans and ensuring insurance companies have adequate provider networks. There still no oversight on how private insurance companies managing these state plans use the money for patient care and the profits they can reap.

The agency estimates that the changes it's proposing would cut states' administrative costs by $27 million, or 120,000 hours less in clerical tasks.

The new proposed rule doesn't affect the key linchpin of the Obama-era rulemaking, which set a federal medical-loss ratio (MLR) of 85%. That means all insurers must spend at least 85% of their Medicaid revenue on medical care and other activities that improve quality.

The Trump-era CMS has said it supports the 85% MLR provision because it believes it will help control spending in the program.

The new rule focuses on states' secondary concerns. For instance, the Obama rulemaking required states to develop and enforce minimum travel time and distance standards for providers. Medicaid directors have complained this policy wouldn't improve network adequacy, noting that there's no guarantee a provider or specialist practices within certain distance of a patient.

The proposed rule would allow states to use quantitative standards to judge plans' networks. That could include data such as how long it takes for a patient to get an appointment or provider-to-patient ratios.

CMS has said they believe that this change would enable states to choose from a variety of quantitative network adequacy standards that meet the needs of their respective Medicaid programs in more meaningful and effective ways.

It seems to me the more things change the more they stay the same.

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

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.


If you liked our blog please like, share, and comment!


Tags: RCM Solutions, Revenue Cycle Solutions

Two Couples Break-Up on Valentine’s Day

Posted on Wed, Feb 15, 2017 @ 02:50 PM

By Nitin Thakor, GeBBS President & CEO

Cigna ended its merger agreement with Anthem on Valentine’s Day and said it will seek $13 billion in damages from Anthem on top of the $1.85 billion break-up fee outlined in the deal. The planned $54 billion merger was blocked by a federal district court last week on anti-competitive grounds. Cigna said the reason for the break-up was that the potential alliance cannot and will not achieve regulatory approval and was calling off the deal in the best interest of its shareholders. Industry analysts are projecting that Anthem will not pay the break-up fee without a fight.


Also ironically on Valentine’s Day, another merger went sour. Aetna and Humana announced they had terminated their $37 billion merger following a U.S. district court judge's ruling against the deal.

In this case, Aetna will not seek an appeal and instead will pay Humana $1 billion to terminate the agreement. Aetna will also pay Molina Healthcare a break-up fee to end their agreement. Aetna had agreed to sell Molina some of its Medicare Advantage plans to win court approval for the Humana deal.

What does all of this mean?

While both mergers were blocked for different reasons, there is at least one conclusion that can be drawn from both. Industry analysts are saying that the courts have been quick to embrace the flexibility and creativity of the Obama administration’s antitrust enforcers in terms of defining product markets.

With a new administration in power, all of that could change. It’s anyone’s guess which way it will go. President Trump’s actions have not matched any previous administrations. He’s been very surprising in many different ways.

My guess is that the fast pace of enforcement we saw under the Obama administration appointees will slow, but I don’t think it will disappear. Consolidation in the insurance industry isn’t going away. It’s very likely that the mega-mergers will slow down, but larger companies may decide to pick off smaller competitors farther down the chain. More importantly, in my opinion, this will be the impact of the planned repeal of ACA. Let’s wait and see what Congress and the President are able to accomplish with this and how they plan to reconfigure the provision of health insurance and healthcare services.

Tags: Best Practices, RCM Solutions, Revenue Cycle Solutions

What Will Be the Effects of Merger Mania on the Delivery of Healthcare?

Posted on Fri, Jan 20, 2017 @ 05:00 AM

By Nitin Thakor, GeBBS President & CEO

A Healthcare Finance News article last year quoted a New Jersey hospital executive as saying: “Big is going to be better; small is not going to survive.” Time will tell if he is right, but most industry analysts agree that the coming year will be full of acquisitions and mergers as hospitals, health systems, information technology companies, software firms, medical practices and other healthcare service providers seek to discover whether or not bigger is indeed better in the new world of the Affordable Care Act (ACA) -- and whatever evolves from its planned repeal and replacement.


A prime example is United Health’s recent announcement that their Optum unit would buy Surgical Care Affiliates for about $2.30 billion, creating a comprehensive ambulatory care services platform, including primary care, urgent care, and surgical care services. Surgical Care and its affiliates serve about one million patients per year in more than 30 states and operate 205 surgical facilities, including ambulatory surgery centers.
Not all provider realignments will be associated with mergers and acquisitions, some will come as partnerships to support better clinical integration and improved care delivery. The new CMS value-based payment reimbursement models create incentives to focus on prevention and the need for hospitals and healthcare systems to work together more efficiently.  Even if health reforms, such as the new Quality Payment Programs under the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015, weren’t enacted, pressures in the private marketplace would have driven healthcare providers in this direction.
There is no doubt that market forces, including the enactment of ACA and other reimbursement issues, began the mergers and acquisition movement and continue to drive its mania. Healthcare is moving from being hospital-centered to population-health centered. Managing this transition requires providers to operate multiple local delivery centers to hold down costs and provide healthcare at a local setting.
Mergers also offer the opportunity to produce a cost savings, both in back office functions -- such as purchasing, revenue cycle and IT -- and ultimately enhance healthcare delivery through improved, standardized clinical protocols.
Only time will tell whether or not bigger is indeed better in the new world of whatever evolves from the planned repeal and replacement of the Affordable Care Act.

Tags: Best Practices, RCM Solutions, Revenue Cycle Solutions

AHA President and CEO Asks President-Elect Trump For "Steady as She Goes" Effort on Healthcare

Posted on Tue, Dec 20, 2016 @ 11:00 AM

By Nitin Thakor, GeBBS President & CEO

AHA President and CEO Rick Pollack recently sent a congratulatory letter to President-elect Donald Trump and asking him to go slowly on changes to our healthcare delivery system, particularly when it comes to the Affordable Care Act (ACA). This is good advice since healthcare represents a significant portion of the U.S. economy and essential public services. Pollack explained his case in terms that abrupt changes could lead to significant instability for patients, providers, insurers and others.


However, he was not so cautious when it came to Stage 3 Meaningful Use and M&A mergers. Pollack urged the President-elect to cancel Stage 3 of Meaningful Use, standardize the M&A merger review process, and reform the RAC program.

Pollack's letter highlighted five areas of concern for hospitals: reducing the regulatory burden; enhancing affordability and value; continuing to promote quality and patient safety; ensuring access to care and coverage; and continuing to advance healthcare system transformation and innovation.

In my opinion, much of what Mr. Pollack asked for makes perfect sense. It is my sincere hope that President-elect Trump will understand the consequences of abrupt changes to any financial system. He has already softened his stance on cancelling ACA on Day One of his administration. There are many things wrong with the ACA and reform is needed. I am hopeful that thoughtful men and women of goodwill will come up with a new plan that includes more participation of the private sector and the ability to sell health insurance across state lines.

This will provide a replacement plan that continues to provide a mechanism for individuals to obtain affordable insurance coverage, with realistic deductible amounts. Everyone who works in healthcare knows that the regulatory burdens faced by hospitals and physicians are substantial and unsustainable.

I remain hopeful that thoughtful reform can be accomplished, and we look forward to working within this new healthcare delivery system.

Tags: Revenue Cycle Management (RCM), Healthcare Revenue Billing, Best Practices, Insurance Billing Solutions, Medical Billing BPO, RCM Solutions, Revenue Cycle Solutions

Beware of Secondary Injury to Your Wallet after an ER Visit

Posted on Tue, Dec 13, 2016 @ 03:00 PM

A recent article in US News and World Reportexplained a little known fact of which most patients are completely unaware. A trip to the emergency room could cause a secondary injury to a patient’s wallet. Even if a patient goes to a hospital included in his or her health insurance network, if the emergency room physician who treats the patient is not part of the health insurance network, the patient will be responsible for a separate and unexpected bill.


Is this a big problem?

Research conducted by Yale University found that roughly 2 of 10 in-network visits involved a doctor not in the patient's insurance network. Going to an in-network hospital does not mean all your charges will be covered.

There is some slight hope in these situations. If you are attended by an out-of-network doctor, it doesn't necessarily mean financial calamity. That can depend, in part, on the patient's insurance coverage. And, some states like New York have laws that offer some protection against surprise bills, although the extent of that protection varies.

There are limited options to rectify the unexpected charges. Patients can ask that the claim be processed again as in-network care since the patient had no way of knowing the doctor was out of network or they can try to negotiate a lower bill.

In recent years, especially since the creation of the Affordable Care Act's public insurance exchanges, insurers have formed networks of doctors and hospitals, in part, to gain some leverage for negotiating reimbursements.

When the medical treatment is an emergency situation, you don’t always have time to question the physician’s insurance network coverage. However, if you have time, it’s a good thing to make sure your attending physician is part of your health network.

Tags: Revenue Cycle Management (RCM), Healthcare Revenue Billing, Insurance Billing Solutions, Medical Billing BPO, RCM Solutions, Revenue Cycle Solutions

The Importance of Revenue Cycle Management in an Evolving Healthcare Delivery Environment

Posted on Tue, Dec 06, 2016 @ 06:00 AM

At the recent Becker's Hospital Review 5th Annual CEO + CFO Roundtable healthcare experts seasoned in the revenue cycle management (RCM) process discussed how their organizations and companies are working to stay ahead of the financial curve.  As hospitals evolve into a value-based care delivery environment, RCM becomes even more critical.


The Roundtable highlighted the fact that hospitals are striving to cut costs and that has paved the way for revenue cycle management to come center stage, with organizations throughout the nation making it a top priority. Each year, the United States spends $2.7 trillion on healthcare. Of that figure, $400 billion goes toward claims processing, payments, RCM management and bad debt, a 2009 McKinley & Co. study found. Additionally, the study also found 15 cents of every U.S. healthcare dollar goes toward revenue cycle efficiencies.

As patients become increasingly responsible for their healthcare dollars and margins get tighter due to shrinking reimbursements, the need for an end-to-end RCM process reaches a critical tipping point.

An end-to-end revenue cycle management process must be comprehensive and include everything from payor credentialing to complete billing and collections services. One of the Roundtable participants, a large healthcare system, had tried using an outside software solution, but allowed each member hospital to apply the solution in its own manner. They achieved only mixed results.

An experienced outsource provider of RCM solutions will have the management expertise in all facets of the revenue cycle and knowledgeable people to provide and manage an all-inclusive solution. Their billing experts will be well versed in all Medicaid state plans, managed care plans, government-funded programs, third-party insurance, and Medicare billing rules. They will also have the expertise to follow industry-standard key performance metrics and integrate best practices, so you will achieve the RCM results you desire.

An effective, end-to-end RCM outsourced solution will also include an HIM management component. This will provide an in-depth innovative solution that will allow you to successfully resolve your RCM challenges, while enhancing your overall business operations. A well-qualified outsource company will form a partnership with your hospital to optimize your RCM processes by leveraging their people, processes and technology to ensure your success.

Tags: Health Information Management (HIM), Revenue Cycle Management (RCM), Offshore Revenue Cycle Management, RCM Solutions, Revenue Cycle Solutions

How to Survive in a Value-Based Healthcare Delivery Environment

Posted on Thu, Oct 06, 2016 @ 11:00 AM

Black Book™, well-known for its accurate, impartial customer satisfaction surveys in the services and software industries, recently conducted its annual revenue cycle management outsourcing and software/technology user poll. They survey the clients of RCM vendors to provide insight into their customer experience in the functional areas of Billing, Charge Capture, Mid Process Coding, Claims Management, Reimbursement, Insurance and Payer Management, Payment Resolution and Collections, and collectively for end-to-end RCM software/technology and outsourced managed services.


Black Book’s most recent survey found that RCM solutions are in current replacement mode or assessment by 85% of provider organizations, hospitals and physician practices. The reason for this surge is that providers are trying to cope with the impacts of a value-based healthcare delivery environment. Healthcare providers are seeking to optimize their fiscal operating environments with better RCM solutions to improve payer connectivity, using advanced analytics that enhance the patient experience. 94% of health organization CFOs surveyed believe transformed revenue cycle management processes will allow them to become more efficient and positively impact their organization’s financial health.

If your organization has not embraced an end-to-end revenue cycle management solution that includes everything from payor credentialing to complete billing and collections services, you need to do so immediately to cope with the effects of the new value-based healthcare delivery system.

A comprehensive, business process outsourcing (BPO) company can provide RCM solutions that will provide expertise in multi-specialty collections and billing to deliver an all-inclusive RCM solution with billing experts that are well versed in all Medicaid state plans, managed care plans, government-funded programs, third-party insurance, and Medicare billing rules. They will be able to follow industry-standard key performance metrics to measure success and integrate best practices, so that you get the full value of proven experience and expertise.

A comprehensive RCM package should include:

System and Process Implementation -- PMS/EMR Implementation (optional); development of provider dictionaries, chargemaster(s), procedure code dictionaries, and clearinghouse set up.
Scheduling, Eligibility Verification, and Pre-Authorization -- Patient schedules reconciliation, eligibility verification and pre-authorization/pre-certification, including copay/co-insurance estimates.
Data Entry -- Patient demographic and financial information; charge entry into PM system; coding and billing edits.
Full Range of Certified HIM Clinical Medical Coding Services -- Validation of procedure codes to documentation and accurate PT/ICD coding that are ICD-10 ready, along with coding compliance audits.
Claims Submission -- Daily file submission; claim edit correction; reconciliation of claims.
Accounts Receivable (A/R) Management -- Status, aged receivables projects and ongoing denial management; credit balance resolution.
Customer/Patient Access Solutions -- Outbound and inbound phone center – make soft collection calls; pre-bad debt management; self-pay patient calls; incoming inquiries, patient updates and payments; and statement production (DMA).

GeBBS Healthcare Solutions, a leading offshore RCM provider, has just been named for the third year in a row to Black Book™ Market Research’s list of the top 20 outsourced revenue cycle management services. We can help you survive in the new value-based healthcare delivery world.

Tags: Revenue Cycle Management (RCM), Offshore Revenue Cycle Management, RCM Solutions, Revenue Cycle Solutions