Nalashaa Healthcare Blogs
The proposed rule is currently titled ‘Reducing provider and patient burden’. However, the proposed rules do not promise any reduction of burden for payers. Payers must make sure their systems are updated, along with their workflows to be compliant with the proposal once it does become a rule. As burdens go, here are a few…
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The COVID-19 pandemic is still at large, operating in waves and through transmutation. It appears that its effects are destined to linger for many years to come. While most of these effects have been devastating, the pandemic has had one profound positive effect on the healthcare industry. Federal agencies such as the ONC, FDA and…
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The healthcare industry is currently undergoing a radical change driven by patient centricity and the quest for the seamless access and exchange of electronic Patient Health Information (ePHI). Healthcare Information Technology (HIT) and the capabilities it offers for healthcare and payer organizations will determine the success of this vision. The interoperability of healthcare systems and…
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The new CMS mandate for Electronic Prior Authorization (ePA) requests focuses on the NCPDP SCRIPT version 2017071 standard for four electronic Prior Authorization (ePA) transactions. The PA initiation request/response, PA request/response, PA appeal request/response, and PA cancel request/response and prescribers will be required to use this standard when performing ePA transactions for Part D-covered drugs…
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In the previous blogs, we have defined the Transparency of Coverage rule’s compliance requirements and their corresponding solutions. Now that the expectations from the solution is set, here we are looking at the implementation. Let’s cut straight to it. The implementation approach will depend on various technological factors such as cloud platforms, identification of the right source system with respect to data elements, data quality, etc. Without further ado, let us take a close look at the various dimension required to implement a solution to comply…
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The outbreak of the COVID-19 pandemic presented a unique challenge for care providers. They were handed the daunting task of identifying patients who needed medical attention the most. The burdensome aspect of this challenge was the level of data accuracy needed. One wrong move and the consequences severely affected patient mortality rate. Care providers have always been strapped…
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The healthcare industry is currently undergoing a tectonic shift towards a patient-centric care model to pursue Value-Based Care (VBC). To unearth the ‘value’ in care delivery, care providers must tap into incoming patient data to induce ‘well-informed’ clinical decisions. With this, the fascination for data has grown significantly over the last decade in the US healthcare industry. However,…
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As the dates set for public disclosure requirements, Jan of 2022, draws close with every passing day, it is best for everyone involved if health plans got themselves aligned with these requirements. Compliance would ensure faster delivery of quality care, resulting in reduced visits to the hospital, thereby healthier members. Disclosure requirements for public files…
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The Department’s guidelines on ensuring transparency in coverage are quite elaborate on the context and objective of disclosing information. Our previous blogs outline the disclosure requirements for both the Participants, Beneficiaries, or Enrollees, and the public. However, when disclosure requirements are converted into solutions, complexities arise. Currently, health plans do not have the required information in one place. Even if they do, their Enterprise Data Warehouse (EDW) would…
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Since the past couple of years, the CMS began its journey to instill interoperability into the healthcare ecosystem and trying to bring about a culture of patient-centricity into the picture. The Interoperability and Patient Access final rule aimed to address the existing drawbacks hampering interoperability and thereby improve the quality of care. However, it missed…
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Back in May 1, 2020, The Centers for Medicare & Medicaid Services (CMS) introduced the Interoperability and Patient Access Final Rule. The rule aimed to improve healthcare quality provided by improving patients’ access to their healthcare information. By adopting the patient-first approach, CMS believed it would help patients make informed care decisions. While Interoperability and…
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Cost is one of the key elements that profoundly influences the efficiency of care delivery operations. Care providers don’t just incur costs when acquiring resources for care delivery. Expenditure is incurred for enabling it also. Healthcare technology is a foundational aspect of enabling care delivery and among the essentials. With the healthcare industry transitioning to…
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Provider expectation from HIT vendors has grown exponentially. These expectations encompass data security to application performance and the manageability of IT resources and systems. The good news is, HIT vendors have many avenues to explore to overcome the barriers that prevent care providers from realizing the potential of their technological choices. In this blog, we look at those areas…
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Patient engagement was initially only a methodology to ramp up the extent of patient satisfaction. With the improvement of healthcare technology, many benefits of patient engagement such as patient safety, transaction efficiency and better-quality care outcomes began to rise to the top. As the healthcare industry aligns itself to ‘patient-centric care’ patient engagement is set to play a leading…
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Access to healthcare is undoubtedly one of the most important factors in leading a well-rounded, healthy life. Although access alone is not enough, healthcare must also be easy to comprehend given that people from all walks of life need to access it. To ensure people are kept in the loop about their healthcare coverage options…
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Successful reimbursements supplement successful care outcomes. In simple words, when clinicians get paid for their services regularly, the frequency of the medical services amplifies. On the downside, there is no sure-fire way to ensure the quality of care with flawless reimbursements. This is mainly where reimbursement models are undergoing a radical change. Recent CMS regulations have introduced a plethora of changes…
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EHR systems rose to prominence at an exponential rate since the beginning of the ‘meaningful use’ days in 2009. However, the multitude of contextual changes, mainly driven by perennial regulatory updates, have impeded innovation in EHR development. EHR vendors must restart their innovation engines in the face of evolving reimbursement models, improvements in interoperability standards, rising consumerism and clinician…
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It has been reiterated time and again by the CMS that member engagement is crucial to both the health plans and members. To the health plans, engaging with members contributes to their shared savings, when their members choose a low-cost, high-value service post-consultation. To members, engagement with a payer results in proactive and well-informed healthcare decisions. Keep An Eye Out For These Roadblocks The…
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Health Plans are in pursuit of ensuring that members get to choose the best healthcare service which results in better care quality and outcomes. To do so, they are expected to come up with innovative and effective member engagement strategies. As the term suggests, Member engagement is about interacting with members the right way and at the right time. To gauge the right time and right way, or rather to get the context of the engagement right, Health Plans must keep an…
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The US healthcare industry is undergoing a tectonic shift towards Value-Based Care (VBC). Changing reimbursement models and HHS regulations are the two primary forces energizing the circumstances. Care providers are caught in this crosswind of a radical industry-wide change. Healthcare Information Technology (HIT) is the buoy that can help them stay afloat and advance towards…
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Member engagement is the new trend, taking the healthcare ecosystem by storm. Health Plans are now compelled to make themselves more approachable with enhanced member experience. By definition, member engagement is the interaction health plans have with their members. Traditionally, this interaction was limited to collecting premiums and reimbursing claims. With the onset of mobile applications, however, interactions between…
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The healthcare industry is witnessing a cultural shift, and aligning business goals along member-centricity. This shift is propelled by both member expectations as well as the plethora of rules and regulations. One such rule is Transparency in Coverage, requiring organizations to divulge cost-sharing details with those concerned, promoting better care decisions. Back in November 2020, ‘The Departments’ released a set of new requirements…
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The benefits of cloud computing in healthcare need no introduction. Many healthcare facilities in the United States have sampled the power of the cloud. Those who have exhibited excellence in personalized care have also managed to trim operational expenses in the process. As care providers explore healthcare cloud computing in further detail, patients have become acclimatized with quick…
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The healthcare revenue ecosystem is always on the move to achieve operational excellence, to offer personalized policies, proactive care programs, and preventive healthcare measures of the best quality. One way to achieve operational excellence is through continually improving the analytics culture, ensuring the data flowing in is utilized the right way to pull off business…
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With the onset of consumerism in healthcare, health plans must be prepared to make adjustments or modifications to IT systems and business processes to include the oncoming set of rules and regulations. Back in November 2020, ‘The Departments’ released a set of new requirements under the Transparency of Coverage rules. ‘The Departments’ consist of the…
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Data is the octane that powers the revenue-generating engines of all businesses on Earth. The CMS and ONC understand the possibilities of digitizing and storing high-quality data well, and this explains the ardent push towards a ‘patient-centric’ transformation of US healthcare. Establishing a partnership among patients and care providers is the goal, and it puts the onus on the providers…
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The healthcare industry is going through a makeover where organizations are pushed towards patient-centricity. With the rapidly surging volume of data and care information available online, regardless of the accuracy, patients are demanding access to optimized healthcare delivery. To keep patients satisfied and to stay ahead of the competition, it is high time health plans…
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Descriptive analytics ensures payer organizations are aware of trends in their workflows and key performance indicators (KPIs). Once a deviation within these trends is identified and addressed, stakeholders may need to be updated on the possibility of undesirable events in the future. This is where predictive analytics comes in. It gathers data to come up with event predictions and can notify payers whether their healthcare data management strategies would grant them desirable results. Predictive Analytics in Action The exponential increase in data…
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Payer organizations deal with data, day in and day out. It is not enough that payers fulfill their roles in the healthcare revenue ecosystem through claim management, credentialing, code entry, billing, and so on. They need to identify their shortcomings as an organization and address them to achieve higher efficiency, and this is done with the…
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Clinicians are currently playing the role of superheroes protecting humanity from a vicious enemy, the COVID-19 pandemic. There appears to be another silent adversary wearing our warriors down. Unfortunately, this enemy exists in the administrative systems that we created to support healthcare and well-being in the first place. Clinician burnout continues to affect healthcare professionals at a growing rate, and COVID-19…
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On December 13, 2016, the 114th United State Congress passed the 21st Century Cures Act with an intention to make it big in the face of U.S Healthcare. While it is designed to accelerate preventive care, health IT development and clinical research, it also intends to encourage data fluidity in the healthcare ecosystem. Recently, through the Cures Act Final Rule, released on May1, 2020, it brought…
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Telehealth services have been the guardian angel of both care providers and patients since the outbreak of the pandemic in 2019. They served as a lifeline for patient triaging and to deliver non-emergency care to chronically ill patients. Care providers’ and patients’ response to telehealth strategies and the extended support for care plans is a shining example of how global communities have adapted…
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From member enrollment, eligibility checks, and provider network management to billing and collection, healthcare payers are involved in handling and reporting sensitive healthcare data. The healthcare payer process is drawn out and cumbersome, with human errors resulting in penalties and loss of revenue, and must be automated at all costs. Besides the obvious benefits of report automation, it provides an excellent opportunity for all external stakeholders to view and analyze data efficiently in a customized manner. Payer Challenges in Absence…
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The COVID-19 pandemic has delivered punishing blows to chronic disease management. Patients enduring pulmonary diseases, hypertension, diabetes, and mental health conditions were among the most impacted. To hold the fort, care providers must utilize remote care platforms and contextually designed engagement to their fullest. But where exactly is the locus of control in Chronic Care Management during the…
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Today, data is everywhere and in many forms. The processing power to crunch huge amounts of data and get analytical insights is exponentially increasing. Cloud technologies are boosting the effective utilization of data at a rapid rate. Low-cost storage and on-demand scalability are taking data handling capabilities to new heights. But there is a flip side…
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When Deepmind’s AlphaGo defeated Lee Sedol, a top professional Go player, in the year 2016, deep learning (DL), a subset of machine learning (ML), became the buzz word instantly all over the world. After the demonstration of AlphaGo’s DL capabilities, businesses began to assess long term strategies to make serious commitment towards AI/ML implementations. Since then, the experimentations and use cases of implementation of AI/ML…
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Since the Meaningful Use initiatives of 2009, Healthcare Information Technology (HIT) development has been driven by continually evolving healthcare regulations. The Interoperability and Patient Access Final Rule & the 21st Century Cures Act Final Rule, released in 2020, continue this trend. HIT’s role in improving care outcomes and managing the pandemic is far too important to…
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The ONC issued a final rule on March 9th, 2020, to hold entities who interfere with, prevent, or materially discourage the access, exchange, or use of electronic health information (ePHI), accountable. It was the Information Blocking final rule, and it affected healthcare providers (Hospitals, SNFs, LTCH, Mental Health Centers, and more), ‘Certified Health IT’ developers, (Certified EHR developers), and HIEs. The…
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Although at the beginning of the 21st century, many businesses had started to focus on data, the COVID–19 pandemic has forced organizations to develop and adapt to a must–have data-driven culture at all levels. Data was once a business byproduct for many organizations. Now, data itself is a key driver for decision making in most businesses. Increasingly, many future business decisions will rely on data insights the company gets from its internal and external sources. When the pandemic hit, world economies and organizations went into panic mode because…
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The 2019 Physician Fee Schedule introduced three new CPT codes (#99453, #99454, and #99457) to enable hospitals and home health agencies to qualify for CMS reimbursements. The CMS’s proposed 2021 Physician Fee Schedule, released in August 2020, adds further clarity to how care providers can use the new CPT codes with the existing ones covering…
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ICD-10-CM has been used to document inpatient hospital procedure coding since October 1, 2014. It was introduced as an update to ICD-10. The year 2020 introduces two new changes to the coding system. In this blog, we cover the changes in detail. In July 2020, the CMS released the 2021 ICD-10-CM Official Guidelines for Coding and Reporting.…
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Millions of citizens in the United States rely on the accuracy of Electronic Health Records (EHR) to make crucial decisions about their well-being. EHR systems are the conduits that host, exchange and retrieve patient health records for clinicians, patients and other dependent institutions that are an integral part of the care continuum. When the integrity…
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Consumer satisfaction is paramount to the success of the product or service delivered by a business playing the field in the consumer segment. With increasing competition in the healthcare industry, this key performance variable is crucial to how your patients see you as a care provider. The CMS and the ONC continue to push for…
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We are witnessing a rise in the use of AI/ML concepts and technologies in healthcare. Today, algorithms are already outperforming radiologists at spotting malignant tumors and guiding researchers to construct cohorts for costly clinical trials. There is also an increasing number of investments being made around AI/ML use cases and proofs-of-concept across the healthcare industry. …
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The health of your organization is directly dependent on the health of the members enrolled with it. A holistic view of your members gives you a complete status of their health, enabling you to decipher future patterns in their healthcare. Such levels of visibility are vital to your profitability/prosperity/growth/organic growth. With excellent insights from the…
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Innovations in technology are constant in every industry, and healthcare is no exception to this trend. Healthcare IT (HIT) systems have taken center stage in improving the value of care through meaningful use and the seamless interoperability of patient health information initiatives by the CMS and ONC. HIT vendors must now constantly adapt to regulations without compromising on…
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The Centre for Medicare and Medicaid Services (CMS) has introduced a final rule to update the Inpatient Rehabilitation Facility (IRF) Prospective Payment System (PPS). The IRF PPS was introduced to cover all the capital costs that IRFs are expected to incur in furnishing intensive inpatient rehabilitation services. The final rule advances the CMS’s vision and…
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The outbreak of COVID-19 has sent shockwaves through the healthcare ecosystem, disrupting many vital healthcare services. Most individuals tested positive for COVID-19 now find themselves in the middle of financial turmoil. Others are gripped by confusion and panic, putting a grinding halt to ‘normal life’ as we know it. Care providers are currently caught in…
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Medical researchers and clinicians seek answers to two evocative questions in their line of work. The first one is, “Why do people suffer from a health problem”? The other is, “What exactly determines recovery?” The hunt for these answers has led to the birth of new healthcare domains such as pharmacokinetics, which reveals how medicines interact…
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The 21st Century Cures Act Final rule was introduced on May 1, 2020. It institutes crucial changes to the definition of Certified Electronic Health Record Technology (CEHRT). This means the current standards that define the format of the structured data which EHR systems use are set to change. We will now take a look at…
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The progress of healthcare technology was primarily driven by the innovative spark of HIT vendors. All great ideas from their research labs and development centers have become a standard in the healthcare industry today. A fine example of this is the integration of data analytics and business intelligence tactics into the Electronic Health Record (EHR)…
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Title IV of the 21st Century Cures Act is dedicated to the enablement of easy access to patient health records for care providers, patients, and payers. Interoperability, transparency in reporting, and preventing all efforts directed to blocking access to patient health records a.k.a information blocking make up the nucleus of this section. With the release…
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Let’s Start with The Bad News COVID -19 has spread to almost every nation in the world since it was first detected in the Wuhan province in China. The United States has over one million cases with 70,000+ deaths and counting. The seemingly ‘intelligent’ behaviour of the virus that causes its meteoric spread before showing…
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The first of this two-blog series on patient-focused healthcare underlines how the US healthcare ecosystem has a lot to be desired from the patient’s perspective. It speaks of how the changing context of the industry is transforming the traditional way of how patients are treated, injecting personalized outreach into the equation. Technological evolution is pivotal…
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The goal of a healthcare delivery system that comprises trained professionals, institutions and resources are to meet the health needs of people. The value of care outcomes lies in the ability of clinicians and doctors to understand patient needs and help restore fitness. Its nature makes it a highly specialized system designed to match the…
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As consumers, we have very distinct and specific preferences. From food to clothing and lifestyle accessories, every choice of an individual is a carefully considered action. Some of the biggest names in e-commerce, hospitality services, consumer electronics and even automotive insurance are now focussing on ‘the individual’. This begs the question. Why should healthcare continue…
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Electronic Health Record (EHR) systems have transformed the way doctors and physicians review patient health records. The dawn of EHR systems also gave federal bodies like the CMS an effective tool to promote value-based care by using EHR data as a reference to determine care quality. EHR vendors continue to evolve their products based on…
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The Comprehensive Care For Joint Replacement (CJR) model was designed to make participant hospitals accountable for both the quality and cost of Lower Extremity Joint Replacements (LEJR) procedures. Hip and knee replacements are two of the most commonly carried out LEJR procedures. With the CJR model, the CMS intended to reward participant hospitals for coordination…
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Artificial Intelligence (AI) has been a prodigious prospect for the healthcare industry for a long time. AI entails the collection of gargantuan amounts of unstructured data. Developers then need to figure out a way to design an algorithm to sift through all this data and make sense out of it. This exercise yields patterns that…
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Home health agencies can now report the costs of Remote Patient Monitoring (RPM) services to Medicare for Reimbursement. The latest update to the 2019 Physician Fee Schedule, the RPM reimbursement final rule introduces vital changes in the form of new CPT codes, vastly improving the prospects for telehealth technology. In 2017, the Centre for Medicare…
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The Center for Medicare and Medicaid Services (CMS) has finalized the hospital price transparency rule. The mandate directs care providers to provide patients with a consolidated list of their standard medical services with their costs before admission. The latest attempt from the CMS to standardize healthcare pricing, the hospital price transparency final rule is more…
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Citizens of the United States have always been in the dark about the cost of their treatment until the moment they receive the bill for it. This ambiguity can be burdensome, often elevating the stress levels of the patient who is already experiencing the unpleasantries of their medical condition. The Department of Health and Human…
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Providing caregivers with mobile functionality increases their frequency of accessing critical patient records. They can use it when performing a wide variety of tasks. From simple tasks like giving out prescriptions to the management of emergencies and complex surgical procedures, mobile devices are always handy during a busy day at the office, doctors say. Unlike traditional…
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The Invaluable Potential of a ‘Mobile Moment’ The rapid and prolific growth of mobile apps can be attributed to one special term that usually doesn’t get the credit that it deserves, ‘Mobile Moment’. In simple terms, a Mobile Moment can be defined as ‘any instance in which a user pulls out a mobile device with…
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On August 2, 2019, the CMS introduced the Long-term Care Hospital (LTCH) Prospective Payment System Final Rule which established highly specific requirements for eligible professionals (EP) from CY 2020. It further advanced the utilization of the Certified Electronic Health Record (CEHRT) based on the requirements of the Medicare and CHIP Reauthorization Act (MACRA), Merit-based Incentive…
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The Elephant in the Room The Centre for Medicare and Medicaid Services (CMS) is going all guns blazing to integrate patient engagement and the interoperability of health information systems with the care continuum. This explains the tall order of proposed rules that the CMS is releasing proactively. Yet, patients who depend on the services of Post-Acute…
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“Great service does not happen by chance, it happens by design”. Every service is made memorable and satisfying with pleasant interactions. It is human nature to appreciate courteousness, which eventually translates to brand loyalty. This is why industries across the world are diverting their focus on customer experience. It is a consumer-driven world out there…
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The Cancer Care Burden The estimated expenditure for cancer care in the United States was $147.3 billion in 2017. In 2016 alone, the estimated number of cancer survivors was 15.5 million and it is set to increase to 20.3 million by 2026. These statistics point to the effectiveness of cancer research and care in the current…
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The Structural Changes in the Second Draft of TEFCA The Office of the National Coordinator for Health Information Technology (ONC), released the second draft of the Trusted Exchange Framework and Common Agreement (TEFCA) for comments, in April 2019. This draft contains important updates to the fundamental structure of TEFCA and the terms and conditions that…
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Let the Games Begin! Computer games and the baby boomer generation have been sworn enemies since these games were released in the second half of the 1980s. American parents fiercely crusaded against the rise of the budding computer gaming industry, calling game developers out for inducing gameplay addiction, promotion of violence and more. With a…
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Understanding the Internet of Medical Things (IoMT) Internet of Medical things or IoMT refers to a system of medical devices that interface with software applications and the internet, with the sole purpose of collecting healthcare data. IoMT can be regarded as a subset of the Internet of Things (IoT) devices, which comprise all web-enabled devices…
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ICD-11 is the latest iteration of the International Classification of Diseases (ICD). It is preceded by ICD-10 and comprises of work completed over 10 years, involving over 300 healthcare industry experts from 55 countries. It was accepted by the members of the World Health Organization in May 2019 and is set to be the official…
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The Quest for Harmonization of Healthcare Quality Reporting Standards The year 2018 was busy and fruitful for the CMS and ONC, the two federal agencies that are responsible for the improvement of healthcare standards of all American citizens. From the release of the Trusted Exchange Framework and Common Agreement (TEFCA) to the announcement of the…
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The Importance of Predictive Models in Clinical Trials Every year in the United States, close to 1.7 million people are diagnosed with cancer for the first time. This makes the recruitment of patients to test the efficacy of potentially life-saving experimental cancer drugs, extremely important. While the efforts from research facilities and hospitals have been…
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Ballistocardiography: Under the Hood Piezoelectric sensors are devices that convert changes in pressure, strain, temperature, and acceleration into electrical charge. These sensors can be embedded in common objects such as a chair or a bed to provide a graphical representation of heartbeat-induced micro-movements of the human body. This method of monitoring the vital statistics of…
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Understanding Clinical Quality Language (CQL) How Healthcare Quality Measures Work The Center for Medicare and Medicaid Services (CMS) employs Clinical Quality Measures (CQMs) to measure the quality of healthcare services provided by eligible professionals, eligible hospitals, and critical access hospitals. Healthcare providers are required to report CQMs electronically (eCQM) by using the data extracted from…
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Currently, the treatment for cancer comprises of a combination of procedures including surgery, chemotherapy, radiation therapy and immunotherapy. Traditionally, these types of treatments have targeted only the type and size of the cancer. While this approach is currently used across most hospitals globally, it is not necessarily the best one. Recent advancements in clinical research…
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Understanding the Epidemic The illegal use of opioid drugs came into focus for the first time in the year 1999. Pharmaceutical companies had begun to recommend opioids for treating patients who suffered from chronic pain in both acute and post-acute care settings. It did not take very long for the dramatic proliferation of opioids as…
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Changes in New York Workers Compensation Regulation: To improve healthcare participation of the providers in the New York State workers compensation system and to improve the condition of injured workers/employees’ access to timely and quality medical care, the New York State Workers Compensation Board (WCB) has decided to adopt Form CMS-1500. This Form is already…
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The Centers for Medicare and Medicaid Services (CMS) has unveiled the Data Element Library (DEL), which is a centralized resource for CMS, allowing the public to view specific types of data that CMS requires post-acute care facilities to collect as part of the health assessment of their patients. Post-acute care settings are currently grappling with…
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The Office of the National Coordinator (ONC) for Health Information Technology has proposed a rule to put into practice the key provisions in the 21st Century Cures Act. The proposed rule breaks down the existing barriers to important data exchange needed to empower patients by giving them access to their own health care. This whitepaper talks about the scope and impact that the proposed rule aims for.
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The new rule laid down by Medicare has included Health and Safety Standards for Home Infusion Therapy and new rules and regulations to administer Infusion Therapy. A considerable amount of change has also been made in the payment system of Infusion Therapy to overcome the issues previously faced by it.
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Medicare has recently adopted a major technological change; Remote Patient Monitoring device, which is a method of healthcare delivery that uses the latest advances in information technology to gather patient data outside traditional healthcare settings.
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The Trusted Exchange Framework and Common Agreement has been initiated by the US Government to streamline data exchange by building a network of Health Information Networks under the management of ONCHIT. The common agreement may include a common method for authenticating trusted health information network participants and a common set of rules for trusted exchange. There are a basic set of principles and terms and conditions proposed in TEFCA to mitigate the challenges faced in data exchange.
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CMS is fixated on reshaping the ACA market that in its 2020 Payment Notice, they proposed a reduction to exchange user fees and potentially eliminates auto re-enrollment and “silver loading,” for which CMS is currently open for feedback.
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The Centers for Medicare and Medicaid Services released the Final Rule of the 2019 Medicare physician fee schedule (MPFS). It mainly includes adding physical and occupational therapists as eligible clinicians for 2019 MIPS performance year.
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Pharmacy Benefit Managers (PBMs) are professionals that administer prescription drug plans for payers, employers, and CMS programs with the goal of lowering prescription drug costs, improving convenience, and ensuring patient safety for payers and their beneficiaries. PBMs reduce prescription drug costs and improve quality for patients, employers, unions, and government programs by: Engaging patients to…
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The technological capabilities have changed the shift from volume to value-based care. The combination of value-based delivery with actionable intelligence and new care delivery models, and value-based payment with new reimbursement models with selected provider networks have pushed providers and payers to operate across a transparent, administratively simple, shared ecosystem. Nalashaa can help in mitigating…
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Utilization Management is an integral part of the US healthcare ecosystem used by health insurers or Pharmacy Benefit Managers (PBMs) to evaluate the appropriateness, medical necessity, and efficiency of healthcare services rendered to patients. Utilization Management aims to: Improve the quality of service at the right cost, in the right setting Address the clinical activities of…
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Headlines on opioid epidemic are engrossing the United States. There are tremendous impacts of opioid overdosage across the care continuum with no single solution. Impacts of Opioid Crisis The opioid epidemic is affecting the United States economy adversely. Opioid over-prescribing is shrinking the number of eligible workers (Krueger, 2017) The Hardest Hit workgroup is between…
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Areas where technology helps providers cope with the new changes Identity Management EMPI solution to detect duplicate records Duplicate records provide a splintered view of patient’s medical history, leading to unnecessary services/tests putting the patient at risk. In addition, many denials are due to the inability to identify patients correctly based on the data provided.…
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The CMS provides issuers with a number of review tools to check their plans for errors in the QHP application that would result in correction notices following submission. Issuers should run each of the below tools, as applicable to their issuer type (e.g. SADP/QHP) before uploading materials to HIOS or SERFF to identify and rectify…
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CMS finalizes the calendar year 2019 and 2020 payment and policy changes for Home Health Agencies and Home Infusion Therapy suppliers. The 374-page rule sets out conditions for home health agencies to be able to participate in federal Medicare and joint federal-state Medicaid programs. Finalized Calendar Year (CY) 2019 Medicare payment updates Finalized quality reporting…
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The Patient Protection and Affordable Care Act (PPACA) and applicable regulations assert that health plans, including SADPs, must meet a number of standards in order to be certified as a QHP. With so many criteria to be met, let us discuss a few guidelines for payers to ensure a seamless QHP certification. QHP Accreditation Things…
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The Affordable Care Act (ACA), defines QHP as an insurance plan certified by the Health Insurance Marketplace which provides Essential Health Benefits (EHBs), follows established limits on cost-sharing, and meets other requirements outlined in the application process. QHPs offer the core set of benefits, including preventive services, mental health, and substance abuse services, emergency services, prescription drugs and,…
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In the previous section we discussed the technologies available to enhance a PHM solution, and how it helps the healthcare industry. Current PHM solutions aim to achieve PHM goals by helping physicians identify care gaps, prevent medical errors and improve patient outcomes. However, there are challenges associated with most PHM solutions. Some of the current…
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Healthcare organizations need to have technological capabilities within their care delivery processes to effectively use data to manage the cost and quality of care. To pursue more aggressive risk-based reimbursement models, these capabilities need to be expanded strategically and proportionately. In the previous post, we discussed the benefits of having a supreme Population Health Management Strategy.…
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Population Health Management is the systematic process of patient data gathering, analyzing and managing patient’s data in the health care system. The changes in the healthcare industry are impacting traditional hospital reimbursement models. Before the introduction of the Patient Protection and Affordable Care Act, hospitals were reimbursed based on the volume of procedures through models like fee-for-service.…
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The data being made available through Blue Button 2.0 initiative provides opportunities to leverage this data for meaningful purposes. Depending on the motivation of the user of these systems, the purpose and approach may differ.
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Blue Button 2.0 is creating a data-centric ecosystem for Medicare beneficiaries. By facilitating access to patient health history, it has the potential to drive down Medicare spending and improve health outcomes.
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