So Long, Fee-for-Service Reimbursement

On June 5, 2012, CMS announced another new data initiative. If you are a provider, this one should be important to you – CMS intends to transform its approach to data analytics: “The initiative will help guide the agency’s evolution from a fee-for-service based payer to a ‘value-based purchaser of care’ that links payments to quality and efficiency of care, rather than sheer volume of services.” To run the initiative, CMS created an oversight group titled the Office of Information Products and Data Analysis. The goal of the new entity is making data management and information sharing a core CMS function. CMS is charging this new data-savvy group with oversight of current data functions, including the Chronic Condition Warehouse (CCW), the Medicare Current Beneficiary Survey, the Medicaid Analytic Extract, the Research Data Assistance Center, and other important initiatives. Read the CMS Fact Sheet for more.

My Take

My daughter reminds me that I rant and no one pays attention – or at least she doesn’t!  Even so, there are times when I just have to rant, and this is one of those cases.  I have to say, “I told you so.” CMS has made it as clear as possible that we in healthcare are going to have to document in support of our actions. Now they will have a data czar and team focused on the information we create via our requests for payment.  Not only will these folks oversee current data initiatives, but CMS also expects they will begin new studies, including the Medicare Geographic Variation Trend Data. Any organization thinking they can hide by not creating data or by creating vague data had better rethink their strategy.

Studies like this will identify these facilities as outliers by geographic location among other parameters. The data initiatives are making fee-for-service obsolete. Care trends and outcomes can be mapped and compared by diagnosis and service against your claims. Now CMS wants to know not only what you did by why you did it.  A conference call today with compliance colleagues revealed an anecdote from an auditor: unless the record said specifically the ‘patient failed conventional therapy (etc.),’ use of the cyber-knife (substitute any relatively new procedure) is being denied. Wouldn’t it be nice to have an expanded diagnosis/service code set that included the information that the patient failed conservative therapy? New ways to report what we do could be the key to avoiding audits/denials driven by the in-depth data analysis these new guys are going to do.  Never overlook the need to level the playing field with your payers. Otherwise, you will lose as the rules change.

Barbara Aubry is a Regulatory Analyst with 3M Health Information Systems.

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