Reimbursement resource guide


Understanding some of the basics of health reform and reimbursement

Health reform and changes in reimbursement policy are critically important, but often complex. This Reimbursement Simplified Resource Guide strikes a careful balance—it explains some of the key issues of health reform and reimbursement in a way that non-experts can easily understand. But it also offers enough background and detail that readers get a full picture of the topic.

Accountable Care Organizations (ACOs)

With their focus on coordinated care and closer integration of providers, ACOs are beginning to change how health care is organized and reimbursed. Though the ACO movement was driven largely by the Affordable Care Act of 2010, private payers are also actively creating ACOs and ACO-like arrangements.


Both in Medicare and private payer ACOs, these organizations are “held accountable” for providing comprehensive health services to a specific population through a shared-services approach to reimbursement. The goal is to encourage physicians and hospitals to coordinate care by holding them jointly responsible for quality and cost.


How are they structured? How are they paid? How is their performance evaluated? The answers are here. Though these answers are based largely upon ACOs serving the Medicare population, this chapter also provides information about private sector ACOs.


Value-based Purchasing (VBP)

Value-based purchasing is a pay-for-performance program that affects a significant—and growing—percentage of Medicare reimbursement for medical providers. It ties reimbursement directly to how well a provider meets a specific set of quality and cost standards. This represents a significant shift in Medicare reimbursement: from volume to value.


Today, Medicare VBP has been expanded to include inpatient hospital services, as well as services that physicians provide Medicare patients. The Affordable Care Act (ACA) requires that VBP also be extended to nursing homes, home health care, and ambulatory surgery centers, among others. VBP is also part of a much broader trend in reimbursement among public and private payers that makes providers more financially accountable for the quality and cost of care they provide.


What are the basics of VBP? How is VBP for hospitals different than VBP for physicians? What is the private sector doing? This chapter provides answer.


Medicare Policies Affecting Imaging Services

Since 2005, Congress and the Centers for Medicare and Medicaid Services (CMS) have instituted a range of policies affecting the reimbursement and utilization of diagnostic imaging services, especially “advanced diagnostic imaging services,” such as MRI, CT, PET/CT and other nuclear procedures (including SPECT).


In general, these policies have been adopted in response to the growth in the utilization prior to 2006 and to the perception that some procedures were medically unnecessary. Although utilization has leveled-off or declined since then, this perception has persisted among many policy leaders. The result has been continued efforts to reduce or otherwise limit reimbursement and utilization.