The Shift From Grouper to APC Reimbursement: Advice for ASCs and HOPDs

In 2008, when the Centers for Medicare & Medicaid Services (CMS) shifted its payment approach in the outpatient surgery industry from the nine-grouper methodology to APC-based reimbursement, many assumed that commercial payors would follow suit. But the majority of insurers continued to base reimbursement to ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs) on grouper-based methodologies. Their models remained enhanced or modified versions of the historical CMS ASC model, with a few differences such as mapping of CPT codes and additional groupers. The resistance to adopting an APC-based model was largely due to the high system and operational costs associated with making the switch. Continue reading

CMS’s Proposed OPPS Rules Generate Confusion and Anxiety

CMS’s new proposed rules related to the Bipartisan Budget Act of 2015 would severely inhibit hospitals’ ability to expand and modify outpatient service offerings around the country. Issued on July 6, the regulations have yet to be finalized and comments are being requested; however, hospital planning executives are understandably fuming about the restrictive and complicated rules, which would compromise their ability to conduct provider-based billing at outpatient sites located more than 250 yards beyond the hospital walls. Of particular interest is the direct comment by CMS that Section 603 was designed to curb hospital acquisition of physician practices and the current practice of providing the same services under a higher-cost model of OPPS. Continue reading

Pediatric Post-Discharge Follow-Up: How to Get it Right

This post was written by Clark Bosslet, Manager, and Shelby Jergens, Senior Consultant.

In an earlier post, we talked about five key benefits pediatric units realize when they adopt the practice of making post-discharge follow-up calls to patient family members. In this post, we’ll look at call strategies, tactics, and even provide a sample script to guide hospital staff as they incorporate this follow-up model into their standard discharge process. Continue reading

A Call Worth Making: 5 Benefits of Pediatric Post-Discharge Follow-Up

This post was written by Clark Bosslet, Manager, and Shelby Jergens, Senior Consultant.

The moment of discharge following a long-term stay in a pediatric inpatient unit is emotional and chaotic. It is a huge relief for families to take their child home, but it can also be nerve-wracking to leave the safety of the hospital. The verbal instructions and bundle of paperwork received at discharge provide reassurance, but as families settle back in at home, their recollection of these important details can become hazy. Many hospitals have found that the best way to reengage families with their child’s care plan and increase patient adherence is to have familiar nurses or other advanced practice providers (APPs) from the unit follow up by phone within a few days of discharge. This practice has several key benefits: Continue reading

In Healthcare, Data Drives Value

Much has been written and discussed about preparing and positioning for value-based care, with efforts under way across the health system to reduce costs, expand access to care, and improve outcomes. However, attempting to meet these demands without the requisite information, analytical competencies, and a clearly defined strategy for doing so will bury an organization. Health systems cannot and should not underestimate how data, and the insight it provides, is vital to an organization’s readiness for value. I recently shared some thoughts on this topic with Alison Lake Benadada of The Washington Post for her article How Data Can Inform Value-Based Healthcare. Continue reading