Payment Safeguards For Provider Managed Care Arrangements

Author:Ms Karie Rego
Profession:Sheppard Mullin Richter & Hampton
 
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As California transitions faster than other parts of the country into more and more managed care payment arrangements, the challenges and pitfalls related to payment increase. Thus, providers must identify risks and implement safeguards to protect payments.

New coding issues can require additional attention. Even though in some ways coding is simpler than traditional fee-for-service, in other ways there is a complicated learning curve and the potential of increased government scrutiny. Medicare Advantage, new ACO arrangements and many commercial contract payments are based on the patient's diagnosis.

As California transitions faster than other parts of the country into more and more managed care payment arrangements, the challenges and pitfalls related to payment increase. Thus, providers must identify risks and implement safeguards to protect payments.

New coding issues can require additional attention. Even though in some ways coding is simpler than traditional fee-for-service, in other ways there is a complicated learning curve and the potential of increased government scrutiny. Medicare Advantage, new ACO arrangements and many commercial contract payments are based on the patient's diagnosis. However, the rules for determining one diagnosis over another are newly evolving with regard to outpatient services, having traditionally been used only to determine inpatient payments. Further, once the diagnosis is determined, the provider will need to consider best practices for evidencing treatment and follow-up...

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