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Payment Integrity and ACO Success

  • by Margaret Klasa DC, APN BC
  • Apr 27, 2017, 09:46 AM

Various payment models are the trend for the healthcare industry today and will be in the future as a result of the Accountable Care Act (ACA). Keeping the Triple Aim foundation of: improving the patient experience by increasing quality of care to patients, population health, and reducing per capita cost, being successful in all three areas of this initiative is no small feat. Out of the many payment models an ACO must show that the care given to the patient has achieved its quality measures for example, by reducing readmission's to the hospital, or better Diabetes Management, or reducing cholesterol levels and BMI. Evidenced based medicine is just one of the guidelines for Triple Aim and the measures will be assessed through the claims data, pharmacy claims data and the Electronic Health records. Having key healthcare staff communicate and educate patients will also assist in  population health with  following up calls after hospitalizations and reminding patients of medication changes, follow up appointments, and key issues to watch for in their recovery or improved health status.

Yet, in terms of cost to the delivery of this care, groups of providers and health systems are on their own to figure out the cost of doing business, or sharing in the cost and perhaps even getting a bonus if the group of medical providers comes in below the contracted payer’s price points for their patient population.

So how can an Accountable Care Organization (ACO) accomplish the Triple Aim and be successful?

Knowing what the industry charges is the key for the ACO group. Knowing what the Usual, Customary and Reasonable charges (UCR) are, as well as what Medicare computes for its various fee schedules  will be  key to arm the  ACO for the cost of doing business for each procedure as it relates to the payer contracted terms.

By using Context 4 Healthcare’s Accountable Care and Payment Integrity platform  your ACO will achieve a comprehensive transparent pricing model per zip code and procedure for UCR and Medicare that will cover all price points.

Let Context 4 Healthcare demonstrate how, contact us at (800) 783-3378.

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