Reimbursement resource guide

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Medicare’s drive to improve value in health payment and delivery continues. New payment models, such as accountable care organizations and bundled payments, are being used widely, and pay-for-performance programs continue to be added to fee-for-service reimbursement systems. This Reimbursement Simplified Resource Guide explains some of these Medicare reimbursement policies, along with recent developments.

Accountable Care Organizations (ACOs)

Since they were introduced in 2010, ACOs have become a centerpiece of Medicare’s efforts to change the financial incentives underlying health care payment and delivery. The goal is to encourage physicians, hospitals, and other providers to coordinate care by holding them jointly responsible for quality and cost. Medicare ACOs now cover some 10.5 million beneficiaries and come in new models and new payment tracks. Read more.

Bundled Payments

A bundled payment covers all the services a patient receives during a specific episode of care, often including the services of hospitals, physicians, nursing homes, and other providers. The Centers for Medicare & Medicaid Services (CMS) is introducing bundled payments for some high-cost, high-utilization conditions. The purpose is to encourage greater coordination among provides and more integrated patient care. Read more.

Medical Imaging

Since 2005, Congress and CMS have instituted policies affecting the reimbursement and utilization of diagnostic imaging services, especially “advanced diagnostic imaging services.” This includes MRI, CT, PET/CT and other nuclear procedures (including SPECT). Such policy issues have continued to evolve, presenting challenges and opportunities for imaging.

MACRA

The 2015 Medicare Access and Chip Reauthorization Act (MACRA) dramatically changed how physicians fees are updated annually. The new method introduced financial incentives for better quality and value for all physicians, and created special incentives for those who join advanced alternative payment models.

Pay-For-Performance

The efforts by CMS on value-based payment are focused heavily on Medicare fee-for-service programs. This includes several long-standing payment policies—including value-based purchasing, the preventable readmissions reduction program, and the hospital-acquired conditions reduction program—that directly link payment for providers to the quality and cost of services they provide.