A recent letter addressed to the acting Centers for Medicare and Medicaid Services (CMS) administrator, Elizabeth Richter, by Representative Scott Peters of California and Representative Bobby Rush of Illinois, expressed concern over reimbursement methodology as it concerns radiopharmaceuticals (a group of pharmaceutical drugs with radioactive isotopes used in diagnostic and therapeutic agents).

Miami, FL -- (SBWIRE) -- 04/22/2021 -- Nuclear medicine studies organ anatomy and evaluates its function to optimize a doctor's ability to find the best possible treatment plan. Diagnostic radiopharmaceuticals are necessary drugs to enable all nuclear medicine imaging studies to properly diagnose and determine the severity of a disease.

Roughly 20 million Americans benefit from nuclear medicine exams in any given year, but there are still roadblocks in federal payment programs that are preventing coverage.

Two United States Congressmen have brought their concern forth to the CMS, calling the payment policies "flawed" for diagnostic imaging drugs.

In the letter, the two representatives write, "The nuclear medicine industry is developing exciting new drugs to provide precision imaging for hard-to-diagnose diseases such as Alzheimer's disease, Parkinson's disease, cardiovascular disease, and prostate, breast, and neuroendocrine cancers," and that "The flawed reimbursement policy utilized by the Centers for Medicare and Medicaid Services threatens patient access to these cutting-edge innovations by creating a disincentive for hospitals to use the most appropriate diagnostic drugs."

Diagnostic radiopharmaceuticals must be approved by the Food and Drug Administration (FDA), but since 2008, CMS has treated them as a supply "ancillary to" the packaged procedure and after three years of a pass-through payment period, has "policy packaged" their cost into procedure amounts through the Ambulatory Payment Classification (all in hospital settings).

In December of 2020, CMS issued the Final Rule for 2021, which rejected the recommendations of its Advisory Committee and stakeholders from the provider and patient community in order to unpackage diagnostic radiopharmaceuticals.

Both representatives are asking that Richter meet with them to discuss the issue and hopefully the potential of policy change from CMS.

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

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Last month, CMS announced improvements for 2022 Medicare Advantage and Part D payments, adding the finishing touches to a phase-in of a new, divisive payment system spanning several years focused solely on encounter results for plan risk scores.

Miami, FL -- (SBWIRE) -- 10/15/2020 -- Previously, CMS trusted reports sent via its Risk Adjustment Processing System (RAPS) mechanism to supplement encounter details in the estimation of payment but claimed that the approach would be discontinued by 2022.

Risk ratings reflect the projected medical costs of a patient and are used in tailoring discretionary contributions to the Medicare Advantage schedule. The sicker a person is, generally, the higher the risk score, thus, the higher the payout received by an MA plan. In 2012, CMS started gathering experience data, or data based on claims data produced in a practice or hospital setting by a provider, supplier, or provider. As reported by insurers, these details may be inaccurate or unreliable, so risk ratings may reduce federal benefit premiums if based solely on the data.

As mandated by the 21st Century Cures Act, CMS will fully transition to this risk adjustment measurement model by 2022. The use of encounter data to determine payments has been steadily growing since 2016, when it comprised 10% of a risk score. Last year, 25% of risk improvement ratings were tailored to encounter data, and that figure soars to 75% in 2021. Encounter data will be the single deciding factor for risk management estimation in 2022.

About CareOptimize
CareOptimize provides healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

For more information on this press release visit: http://www.releasewire.com/press-releases/release-3.htm

The basic concept of value-based medicine is simple to understand. Providers are paid for the value they produce compared the volume of patients seen. Affordability inspired value-based care, which strongly led to the Affordable Care Act. Nowadays, value-based coverage is one of the few services that have political support nearly across the board. When implemented successfully, clinicians are empowered to take care of the whole person, resolving the risk factors so important to patients' quality of life.

Miami, FL -- (SBWIRE) -- 09/16/2020 -- Many value systems continue to be built on a fee-for-service foundation, where doctors are being limited in what they are able to do with the traditional billing and coding methods. These systems too frequently calculate procedures versus outcomes (for example, blood pressure tests versus actual progress and reducing hospitalization). It is not clear whether determined actions will result in the genuinely desired outcome of less costly, more sustainable healthcare, and those actions say nothing about real patient experiences.

A primary care doctor, on average, sees around thirty patients a day. At $80 a visit, this produces roughly $600,000 annually. In addition to trying to keep patient visits brief, there is still a huge amount of paperwork that needs to be filled out. The provider hopes to take home a fraction of what specialists receive after covering the costs of operating the practice. There's little gain from value-based insurance payouts, irrespective of their PCP performance.

What if those patients were assumed "full" risk by the doctor, who took greater responsibility for them? Things change dramatically. Assuming payor arrangements were resolved, that same provider could have nearly $12 million (about $500 per patient per month), about twenty times the income. There is always the risk the $12 million will be used up, and the doctor will suffer a loss. Primary care is worth more than five percent ($600,000 of the $12 million) of total costs the doctor receives in the fee-for-service setting since PCPs would redefine the use of "downstream" services. To reduce spending the other 95 percent of preventable, avoidable, and unsustainable care, it all becomes how patient well-being can be maximized. Working with patients is about motivating them to do what's needed to have a positive impact.

About CareOptimize
CareOptimize provides healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

For more information on this press release visit: http://www.releasewire.com/press-releases/release-3.htm

As of January 1, 2021, providers who serve Medicare patients will be required to consult a Clinical Decision Support Mechanism (CDSM) and obtain a determination as to whether the test conforms to the Appropriate Use Criteria (AUC) before the test can be administered. Advanced diagnostic imaging services are crucial tools for ensuring accurate diagnoses and planning suitable treatment.

Miami, FL -- (SBWIRE) -- 08/06/2020 -- As of January 1, 2021, providers who serve Medicare patients will be required to consult a Clinical Decision Support Mechanism (CDSM) and obtain a determination as to whether the test conforms to the Appropriate Use Criteria (AUC) before the test can be administered. Advanced diagnostic imaging services are crucial tools for ensuring accurate diagnoses and planning suitable treatment.

What is an Advanced Imaging Service?

Examples of CDSM imaging services are CT (Computed Tomography), PET (Positron Emission Tomography), Nuclear Medicine, and MRI (Magnetic Resonance Imaging). Any time any of these services are ordered, providers are required to consult the CDSM and receive a determination whether or not the order follows AUC guidelines.

Will This Affect Me?

All physicians and other providers who treat Medicare patients and any facility that furnishes those services in a physician office, hospital outpatient department, ambulatory services department, or independent diagnostic testing facility will be required to adhere to the regulation. Right now, the program is in the testing phase, so no payment consequences will result from not following the recommended workflow. Fines or other punitive measures will not be levied during the 2020 educational and operational testing period. Providers should take this time to familiarize themselves with the process, however, as any practitioner who treats Medicare Part B beneficiaries will be required to abide by this rule from January 1, 2021 on.

What Do I Need to Do?

The CDSM is a tool within your certified EHR. (All CEHRT systems should be on the 2015 certfied version.) This tool must be enabled to be incorporated into the workflow.The institution of this requirement will fundamentally change the workflow for ordering and subsequently performing these services. Ideally, this consult should be done at time of ordering, so the test will not be denied later. Embedding the AUC requirement into your workflow will ensure you are following prescribed guidelines and avoiding any payment penalties.

CareOptimize is ready to help any practitioner with any questions about this new rule. Our value-based experts can assist with:

- Ensuring your workflow is adjusted to accommodate the AUC requirement
- Enabling the tool within your EHR

This update is provided by CareOptimize. We provide healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

For more information on this press release visit: http://www.releasewire.com/press-releases/release-3.htm

The Centers for Medicare & Medicaid Services (CMS) recently called for a greater national commitment to value-based care, based on Medicare claims data showing the effects of COVID-19 on Medicare beneficiaries. Value-based reimbursement links payments to patients’ health outcomes and quality of care. It’s been the direction healthcare is heading, and the pandemic has only accelerated the movement and highlighted the benefits to patients and practices with a comprehensive, well-implemented value-based program.

Miami, FL -- (SBWIRE) -- 07/14/2020 -- The Medicare population as a whole is more vulnerable because of age and the propensity for chronic conditions. The CMS data revealed what has long been implicit: health outcomes worsen even more when the Medicare beneficiary comes from a lower income racial and ethnic minority group.

According to CMS, well over 100,000 Medicare beneficiaries have been treated at hospitals for COVID-19, which equates to 175 COVID-19 hospitalizations per 100,000 Medicare beneficiaries. Medicare and Medicaid (dual-eligible) beneficiaries also saw considerably high rates, with more than 450 hospitalizations per 100,000 beneficiaries. Dual-eligibles also exhibited a higher infection rate than those only enrolled in Medicare, and COVID-19 rates are higher in dual-eligible populations across all age, sex, and race/ethnicity groups.

While Value Based Medicine is a new concept for many, CareOptimize and Analitico are well poised to assist practices with the process of transition. They have been working in the value-based space for more than 15 years and have seen the opportunities it presents to practices both large and small. They work directly with full-risk centers that epitomize the most extreme use of Value Based Medicine. In addition to guaranteeing the most comprehensive care coordination that can actually bring in revenue and promote cost savings, CareOptimize ensures every healthcare dollar is wisely spent, leading to greater savings and better outcomes – the perfect value-based mix.

Value-based models rely on care coordination and require a greater amount of data capture and analytics. The right data platform produces information that can be shared across the healthcare continuum to move programs forward. Analitico is a robust, user-friendly tool that ceaselessly compiles and analyzes information from various sources of data, translating it into actionable solutions to complex regulatory ventures. The rules engine easily and efficiently exposes gaps in quality measures and coding, putting information at the point-of-care in a standardized checklist for opportunities, resulting in higher scores and revenues.

To learn more about Analitico, please visit https://careoptimize.com/analitico/.

About CareOptimize
CareOptimize provides healthcare management consulting services and products, managed care solutions, value-based expertise, Nextgen EHR utilities, MIPS consulting, and more. CareOptimize has helped numerous healthcare organizations succeed for more than a decade. For more information, please call 855.937.8475.

For more information on this press release visit: http://www.releasewire.com/press-releases/release-3.htm

Miami, FL – 05/07/2020 – The COVID-19 pandemic has fundamentally changed the way healthcare providers provide their services, requiring them to respond to previously unforeseen challenges. CareOptimize continues to track the pandemic closely and its far-reaching consequences. As changes arise, the CareOptimize COVID-19 Insights webinars continue to highlight them.

Miami, FL -- (SBWIRE) -- 05/08/2020 -- This week, the CareOptimize COVID-19 Insights returns with a new episode. Topics include the ongoing changes by CMS, current loans and grants, telehealth opportunities, and how more and more states are opening for elective surgeries. The episode will be published on the CareOptimize YouTube channel at https://www.youtube.com/careoptimize and the CareOptimize website: https://careoptimize.com/insights/.

About CareOptimize
CareOptimize provides healthcare management consulting services and products and has assisted numerous healthcare organizations to succeed for more than a decade. It provides managed care solutions as well as products like coding modules, next-generation EHR utilities, MIPS consulting, and more. For more information, please call 855.937.8475.

For more information on this press release visit: http://www.releasewire.com/press-releases/release-3.htm

Miami, FL – 04/08/2020 – The COVID-19 pandemic has radically changed the way healthcare providers offer their services, forcing them to adapt to unprecedented challenges. In response to these changes, CareOptimize recently launched its weekly COVID-19 Insights webinar series.

Miami, FL -- (SBWIRE) -- 04/09/2020 -- The COVID-19 Insights webinar covers a broad range of topics, including the ongoing regulatory updates being released by the Centers for Medicare & Medicaid Services (CMS), how to improve revenue under existing circumstances, and more. Episode two of the webinar was published last week and focused on several different provider models and how they are managing:

Premier South Atlanta is a three-location, fee-for-service primary care provider in the Atlanta metro area. Patient visits have dropped, so they've switched to telemedicine and chronic care management to keep up revenue.

Sunrise Cardiology is a two-provider, fee-for-service specialty group. Their patient load is also markedly lower, and they have switched to telemedicine to help.

CareMax Medical Centers are eight medical centers in South Florida serving high-risk, low-income seniors in a global capitation model. The centers are integral parts of their communities and offer complete wellness and medical services. Because so many depend on the centers for social, wellness, and medical needs, CareMax was faced with the unique challenge of continuing to serve their members while ensuring they stay at home.

To help, many initiatives have been put in place at CareMax, including weekly communication with every member for wellness checks, virtual visits with the extra benefit of safely transporting tablets to patients' houses for the visit, food deliveries to ensure patients are getting necessary nourishment, virtual wellness classes on a Facebook Live feed, and a Call CareMax First campaign urging patients to call their centers first before going to a hospital.

A new episode of the COVID-19 Insights webinar is published every Thursday at 2PM Eastern time. All episodes are available on the CareOptimize YouTube channel: https://www.youtube.com/careoptimize.

About CareOptimize
CareOptimize provides healthcare management consultin g services and products and has assisted numerous healthcare organizations to succeed for more than a decade. It provides managed care solutions as well as products like coding modules, next-generation EHR utilities, MIPS consulting, and more. For more information, please call 855.937.8475.

For more information on this press release visit: http://www.releasewire.com/press-releases/release-3.htm