While Alaska and parts of California still pay more than other states, they’ll also see smaller decreases. Big cities like Chicago, Miami, and Houston, which typically have higher payment rates, will also face Medicare cuts in 2025 of more than 16%. 

Before we jump on the table for details by state, let us quickly share some factors affecting Medicare payment for mental health therapy in 2025. 

Factors Influencing the Medicare Reimbursement Rates for MHT in 2025

Medicare reimbursement rates for mental health therapy services in 2025 are shaped by a variety of factors, from legislative actions to economic conditions. 

Here are the key elements influencing these rates:

1. Conversion Factor Adjustments
2. Legislative Actions
3. Economic Factors
4. Medicare Advantage (MA) Plans
5. Quality Payment Program (QPP)
6. Inflationary Pressures
7. Other factors

Let’s have a quick look at these factors now.

1. Conversion Factor Adjustments

The conversion factor, a key component in Medicare’s payment system, has decreased by 2.83% for 2025, down to $32.3465. This marks the fifth consecutive year of reductions. The decrease is due to the expiration of a temporary adjustment and a 0% baseline update, which does not account for inflation in practice costs.

2. Legislative Actions

Congress plays an important role in determining Medicare’s payment rates. If lawmakers fail to intervene, providers, including mental health therapists, may face further payment cuts. Legislative action helps stabilize and increase reimbursement rates for mental health services.

3. Economic Factors

The Medicare Economic Index (MEI) predicts a 3.5% increase in the cost of providing services in 2025. However, due to budget neutrality rules, this increase does not result in higher reimbursement rates, leading to a financial strain for providers.

4. Medicare Advantage (MA) Plans

Medicare Advantage plans are seeing an average reimbursement increase of 3.7% for 2025. In contrast, traditional fee-for-service Medicare is experiencing cuts. This difference underscores a growing trend toward shifting reimbursements from traditional Medicare to MA plans.

5. Quality Payment Program (QPP)

The QPP continues to shape reimbursements by rewarding physicians who meet performance metrics. Those involved in Advanced Alternative Payment Models (APMs) may see higher payments compared to providers under the standard fee-for-service model. This shows a shift toward value-based care in 2025. 

6. Inflationary Pressures

The absence of an inflation adjustment within the current reimbursement framework puts pressure on healthcare providers. Consequently, as costs rise, many mental health therapy practices face financial challenges in delivering care.

7. Other Factors (Not Entirely Applicable in 2025)

Geographic reimbursement variations, impact of fee schedule area, differences in CPT codes can affect reimbursements. But mental health therapy reimbursement rates will drop in 2025 mainly because of new laws, economic challenges, and the reasons mentioned earlier.

Medicare Reimbursement Rates for Mental Health Therapy by State and Areas in 2025

The table outlines the reimbursement rates for CPT Code 90791 (Mental Health Therapy) across various states and counties in the US. It shows the percentage change in reimbursement rates for 2024 and 2025.

But first, let us share the key observations across states:

• The national reimbursement rate for CPT Code 90791 drops from $195.46 in 2024 to $166.91 in 2025, showing a -14.63% decrease.
• This national decline is consistent across most states, with the exception of a few where local factors might affect reimbursement.
• While most states see a similar decline, some regions, such as Alaska and certain counties in California, experience slightly higher reimbursements for mental health therapy relative to the national rate but still face similar percentage declines.
• Major urban areas like Chicago, Miami, and Houston tend to have higher rates, but also see large reductions in reimbursement rates, often surpassing 16% in decline.

Jump on the table below for more details by state:

Mental health therapy payment rates are dropping across the US from 2024 to 2025. This could be happening because of budget cuts, new healthcare rules, or rising costs of mental health care. While some areas still pay more than others, payments are going down almost everywhere in the country.

Schedule FREE Consultation to Get Paid More

Dealing with lower insurance payments can be tough for mental health providers. BellMedEx helps therapists get paid more and on time with improved medical billing and revenue cycle management. Get in touch with us today to learn how we can help your practice succeed.

One of those challenges is to handle your finances the right way. If you have a lot to do by yourself, things can sometimes get a bit messy. This can lead to poor revenue cycle management and lower profits.

Outsourcing your tasks to a healthcare RCM company, like BellMedEx is a smart choice! If you do this, you can save your energy and focus on what really matters, like giving great medical care and making sure patients are happy.

Lots of healthcare providers hire other companies to help with their work, like handling medical bills, sending in claims, and managing denials. Outsourcing your healthcare operations has many great benefits!

Here are some great reasons why outsourcing healthcare can help lower medical costs.

8 Reasons Why Healthcare Outsourcing Reduces Medical Costs?

Here are reasons that demonstrate how can you improve your revenue and how can you reduce your costs with healthcare outsourcing:

1️⃣ Cutting-Edge Tech at Affordable Prices

When healthcare groups outsource their admin tasks to a special third-party company, they can use the latest technology and skills without spending too much money. These companies spend a lot of money on the newest AI-powered diagnostic tools, telemedicine platforms, cloud computing, and other cool stuff. Things that would cost a lot for one medical practice to do all by itself.

The vendors offer these cool services at prices that are easy to pay for their clients. By helping many places, they get the most out of their investment in these technologies. The economies of scale make the costs feasible.

This helps small clinics and solo doctors give their patients the exciting benefits of high-tech medicine. Things like talking to doctors online, quick lab tests, and easy access to your health records. Without outsourcing, these services may be out of financial reach.

Also, getting help with regular tasks like billing, scheduling, and medical coding can save money. The vendors have smart workers and good ways to minimize expenses.

Strategic outsourcing allows healthcare firms to reallocate more resources to providing real care to patients. All while enabling access to leading-edge solutions that improve outcomes, experience, and affordability. It’s a win-win scenario for facilities, clinicians, and most importantly, patients.

2️⃣ Zero Maintenance Costs Guarantee Maximum Savings

If you run things yourself, you have to buy and take care of costly stuff like machines, software, furniture, and work areas. This ongoing maintenance costs a lot and can use up your resources fast. Every healthcare place has to deal with this cost when they run things on their own.

But if you let someone else handle these tasks, you can say goodbye to those maintenance costs for good! You don’t have to buy any software, hardware, or furniture. The outsourcing partner will take care of everything you need to get the job done well. You don’t have to stress about keeping costly equipment or spending money on workstations and spaces anymore.

If you cut out these maintenance costs, you’ll save a lot of money that will help your profits grow. You can use the money you saved from maintenance and equipment to make patient care better, buy new technology, invest in healthcare marketing, or offer more services.

3️⃣ Top-tier Data Security

One big reason is that outsourcing partners can provide great data security that follows HIPAA rules, and it’s a lot cheaper than creating it ourselves.

Making a data security system that follows HIPAA rules requires special skills and some money. Outsourcing partners located overseas have massive scale advantages that let them spread these fixed costs across many clients. They focus a lot on security because that’s their specialty. The end result is enterprise-grade systems that include disaster recovery, access controls, and sophisticated encryption.

It’s just too expensive for one American healthcare provider to handle this kind of data security all by themselves. Getting the right IT tools, having smart security folks, and sticking to rules can take a lot of time and energy away from their main job of helping patients. Outsourcing transfers that heavy lifting to partners who can do it better and cheaper.

Patients today really want their personal information to be kept safe and private. Outsourcing keeps things safe and lets American providers spend more time taking care of patients instead of stressing about technology. It’s a nice way to improve healthcare and save some cash too!

4️⃣ Cut Down Real Estate Costs

When a practice tries to manage every aspect of patient care in-house, they need more physical space for staff, equipment, and supplies. As more people need help, we also need bigger offices and clinics. Buying or renting this extra property can be tough on your wallet.

Outsourcing takes away the stress of needing to buy more property. Partners take care of things like billing, scheduling, and medical transcription remotely. Providers avoid ballooning real estate costs since outsourcing firms staff their own offices. This helps save a lot of money each year on rent or mortgage payments!

No need to fix up or make the current buildings bigger. Outsourcing certain administrative and clinical services allows practices to see more patients without adding new exam rooms or nursing stations. This makes the best use of the space that is already there without having to pay for renovations or new buildings.

5️⃣ Unbeatable Labor Costs

Outsourcing helps save money by letting healthcare facilities find skilled workers from around the world for much less than they would pay locally. Hiring and retaining top medical talent is incredibly expensive in the US – from salaries to benefits to training and more.

Outsourcing lets small and large scale healthcare practices work with talented people from countries where things cost less. So facilities can have complex tasks like billing coding, medical transcription, and imaging analysis done with precision for much less. The outsourcing provider takes care of all the HR management and operations for the healthcare provider.

6️⃣ Smooth Revenue Cycle Management

Think about being a caring healthcare worker who really loves helping patients feel better. But while you’re busy helping people and keeping them healthy, you also have to deal with the tricky and time-consuming process of revenue cycle management (RCM). This important part of healthcare can easily turn into a hassle, taking your attention away from what really matters – giving great medical care.

Managing money in a business can be tricky. It needs special skills and careful focus on every little thing. If you make a small mistake when sending in a claim, it can cause insurance companies to say no, reject it, or pay you less money. As a result, healthcare providers often struggle with cash flow issues, making it hard for them to keep their practices running and growing.

Luckily, there’s a way to make things easier for healthcare workers so they can focus on what really counts – taking great care of patients. By outsourcing revenue cycle management to specialized firms, healthcare providers can tap into a wealth of expertise and streamlined processes tailored to maximize reimbursements.

These medical billing outsourcing companies have a team of experts who focus on handling medical billing and coding. They know all the rules and guidelines really well. They make sure every claim is sent in perfectly, so there are no mistakes or rejections.

When healthcare providers let these experts handle their revenue cycle management, they can feel confident that their claims will be processed quickly and correctly. This means they will get paid on time and receive the most reimbursement possible from insurance companies. This helps reduce money worries and creates a better way to work. It lets healthcare providers buy new tools, offer more services, and give better care to their patients.

7️⃣ Personalized Services According to Your Needs

Healthcare is a fast paced field, with fast growing technology, regulations and changing needs as a practice. Healthcare providers have to keep changing to keep up with these updates.

Keeping up with the latest stuff can also cost more money for new changes and upgrades. Outsourcing companies always keep an eye on the newest market trends and make sure they are affordable for healthcare providers.

They can help you with your needs as you grow in any part of managing money coming in. Working with different healthcare providers at once helps keep costs low. So they offer these services for really low prices.

8️⃣ Better Focus on Core Tasks

Doctors and hospitals in the United States have a tough job. They need to give great care to patients but also keep the costs down. This is not an easy task because the healthcare world gets more complicated every year. We need to keep investing and changing to keep up with new technologies, rules, and what patients need. For one healthcare group, this can feel like a lot to handle.

Outsourcing key services is an elegant solution to help alleviate these pressures. Specialized outsourcing partners are dedicated to staying on the cutting edge of industry best practices. They put a lot of effort into training, technology, and making things better so healthcare workers can focus on their jobs. By leveraging their scale across multiple clients, outsourcing firms can offer these services at a fraction of the cost of building similar capabilities in-house.

Healthcare providers can tap into this expertise on-demand. Outsourcing partners are quick and adaptable, changing their services to fit what each client needs and wants. They work closely with the client, helping them with new ideas and growth every step of the way. This personalized approach allows healthcare companies to access world-class capabilities that would otherwise be out of reach.

Conclusion

Healthcare is a challenging field as you have to manage more than one task at the same time. As a healthcare provider this scatters your focus, depriving the core tasks. With outsourcing you can improve the quality of your services while reducing the costs.

If you’re looking for a trustable outsourcing partner for your medical office, who improves the quality of your tasks while decreasing the costs, BellMedEx is your go-to medical billing outsourcing company!

That’s why I’ve put together this handy guide on the top healthcare payer companies in the USA. Whether you are trying to change your insurers or just simply want to be well informed, this blog post will get you inside information about payers that just kill it on provider satisfaction, claims processing, and ease of doing business altogether.

So, grab a cup of coffee—or if that is not your style, then tea—and let us dive together into the world of the healthcare payers. By the time you are done reading this, you will know way better what companies you should consider for your practice. Let’s begin!

What is a Healthcare Payer?

A healthcare payor, also written as a healthcare payer, is an organization that covers the expenses of healthcare services its members receive from credentialed healthcare providers. These payors can be government and private insurance providers, such as Medicaid and Medicare (government programs) and other commercial insurers.

Payors offer patients various health plans. A slight difference between a payor and a health plan is that the health plan includes all the details about covered treatment procedures and their costs, while the payor is the entity responsible for processing patient enrollment, services, and payments.

Insurance payors pay both healthcare providers for services rendered to their covered patients and patients if they receive services from out-of-network providers with the consent of their insurance provider. In the latter case, the patient pays healthcare providers out-of-pocket for services received and then submits claims, in the form of a superbill, to their insurance payor to receive payment for covered care services.

Top 5 Best Healthcare Payors Companies in the USA

Choosing the best healthcare payor in the USA requires careful consideration of several important factors. Healthcare providers need a partner that ensures reliable reimbursements, comprehensive insurance coverage, and a long-term, trustworthy relationship.

Below is a list of the top-rated healthcare payors, known for their excellent services, timely payments, and commitment to both providers and patients.

1⃣ Kaiser Permanente

Kaiser Permanente is a trusted name among the best healthcare payer companies in the USA. It provides reliable coverage and high-quality care. With over 12 million members across the U.S., they have built a strong reputation. For healthcare providers, teaming up with Kaiser has some great benefits you might not find elsewhere.

First, because Kaiser has so many members, providers get a steady flow of patients. This means more chances to grow your practice and have consistent income. Plus, Kaiser’s closed network makes it easier for providers to work together and share patients. You can coordinate care smoothly with other professionals in the network.

Another bonus is predictable payments. Kaiser has set schedules for reimbursements, so you know when and how much you’ll get paid. This helps you plan your practice’s budget without surprises.

Kaiser has been around for over 75 years, so they bring a lot of experience to the table. Working with them means you can build long-term relationships and see your practice grow. Their focus on patient-centered care is something that aligns with most providers’ goals – offering quality care and good health outcomes.

Kaiser also invests in new tools and technology to help healthcare providers. You’ll have access to the latest resources, which can help take your practice to the next level and offer your patients the best treatment available.

And, with Kaiser’s big presence in states like California, partnering with them gives you the chance to reach more patients in popular markets. You’ll have access to a larger group of people who rely on Kaiser for their healthcare.

For healthcare providers, Kaiser Permanente is a great partner. They offer financial stability, the chance for growth, coordinated care, and tools to improve your practice. With their focus on both patients and providers, Kaiser is a smart choice for healthcare professionals.

So, if you’re looking for a trusted, reliable partner, Kaiser Permanente might be just what you need!

Click Here To Get Credentialed with Kaiser Permanente

2⃣ United Healthcare

United Healthcare is known as one of the best healthcare payer companies in the United States for good reason. With an expansive network of providers and innovative programs for members, United Healthcare makes it easy for doctors and hospitals to provide quality care.

Their vast network includes over 1.5 million physicians and 6,200 hospitals across the country. This gives members exceptional access to care, whether they are at home or traveling for work. Providers can trust United Healthcare to give their patients flexible coverage options at fair rates.

UnitedHealthcare offers affordable health plans that allow members to see in-network doctors with lower out-of-pocket costs. Programs like UnitedHealth Wellness also help patients better manage their health with resources focused on prevention. For providers, this means patients that are more engaged in their care.

With Oxford Health Plans, United Healthcare provides flexible products to meet diverse member needs. Virtual visits let patients conveniently access care through their phone or computer. This innovation makes life easier for both patient and physician.

Optum, United’s technology division, is another advantage for providers. Optum’s data analysis and research helps doctors improve quality and efficiency. By partnering with United Healthcare, physicians get tools to deliver better individual care and strengthen the healthcare system overall.

At the end of the day, United Healthcare’s provider-focused approach means doctors can devote their energy to patient care. Their programs give physicians useful support to better serve members. For these reasons, United Healthcare is regarded nationwide as a leading health payer that providers can trust.

Click Here To Get Credentialed with United Healthcare

3⃣ Elevance Health

Elevance Health is a top-tier healthcare payer for providers across the United States. With a presence in 14 states, it offers access to millions of members through renowned affiliates like Blue Cross Blue Shield and WellPoint. This extensive reach and strong reputation make Elevance Health a reliable partner for providers seeking growth and stability.

What draws providers to Elevance Health are the variety of coverage plans, timely reimbursements, and supportive partnerships. Medicaid, Medicare, and commercial options give providers access to diverse patient populations and needs. Prompt payment for services maintains robust cash flow. Resources, training, and tools help deliver quality care and ease administrative duties.

Elevance Health also focuses on improving patient outcomes. This aligns with providers’ goals of offering excellent care. Through investments in programs and technologies, Elevance Health assists providers in upholding stringent care standards.

In 2021, Elevance Health covered nearly 6 million members and earned over $43 billion in premiums. By the end of 2022, its membership had surged to nearly 46 million, solidifying its position as one of the leading payers in the industry. As of September 30, 2024, Elevance Health is providing coverage to approximately 45.8 million members, continuing its impressive growth and market presence.

For providers seeking reliable volume, administrative relief, and shared objectives, Elevance Health is an ideal payer partner. With comprehensive plans, expanding membership, and a dedication to service quality, Elevance Health offers robust support for providers across diverse specialties and care settings. Its national presence and locally-focused affiliates give providers the best of breadth and depth in a single payer relationship.

Click Here To Get Credentialed with Elevance Health

4⃣ Oscar Health

Oscar Health is known for its low claim denial rate—just 7%! This means healthcare providers can count on getting paid quickly and fairly for their services. Doctors, hospitals, and clinics can trust Oscar to reimburse them promptly, which is a huge relief in an age when denied claims and delayed payments are common.

Joining Oscar Health is easy, too. The provider credentialing process is simple and smooth. Once you’re in the network, you can focus on what you do best—caring for patients—without worrying about payment issues. This makes it easier for you to spend less time on paperwork and more time helping people heal.

Oscar Health values strong relationships with its providers. They only partner with the best to give their 1.65 million members top-quality care. This shared focus on providing excellent care makes Oscar Health a great partner for healthcare professionals.

Oscar Health is a leader in offering accessible, high-quality insurance nationwide. But what really sets them apart is their streamlined processes and timely reimbursements. Doctors can confidently join Oscar’s network, treat their patients, and receive prompt payment for their services.

If you’re looking for a supportive payer partner, Oscar Health is a smart choice for healthcare providers!

Click Here To Get Credentialed with Oscar Health

5⃣ HCSC (Health Care Service Corporation)

When it comes to healthcare payers, providers need partners they can rely on. Partners with comprehensive networks, efficient claims processing, and timely reimbursements. Partners that make it easy to deliver quality care. In the vast healthcare insurance landscape, one payer stands out—HCSC.

As a licensee of the Blue Cross Blue Shield Association, HCSC offers providers access to an extensive member base across 5 states. Over 20 million lives are covered, opening doors to grow practices. This gives providers a wealth of resources to enhance patient care.

Processing power matters as well. HCSC is lauded for its smooth claims handling and quick payments. Fewer administrative headaches mean more time for what matters—patients. Strong finances also offer stability healthcare providers can count on.

When choosing payers to work with, providers need more than claims paid. They need responsive partners invested in better care. With its robust network, operations, and support, HCSC checks all the boxes. For providers looking for security, efficiency, and collaboration, HCSC is a payer that truly understands their needs.

Click Here To Get Credentialed with HCSC

How to Select the Best Healthcare Payer for Your Medical Practice?

Choosing the right healthcare payers is crucial for healthcare providers. It impacts everything from financial stability to the quality of care provided. Below are some key factors to consider when selecting the best healthcare payers for your practice:

Payer Mix Optimization

Understand Your Patient Population ➜ Look at the health needs of your patients. Identify the main health challenges they face and choose payers who specialize in covering those needs. A payer with a history of effectively managing specific conditions is key.

Diversify Your Payer Mix ➜ It’s important to have a balanced mix of payers—insurance companies, government programs (like Medicare and Medicaid), and self-pay options. This balance helps reduce financial risk and ensures a steady flow of revenue.

Payment Timeliness & Financial Stability

Payment History ➜ Make sure the payer has a good track record of making timely and accurate payments. Quick payments help maintain a consistent cash flow and keep your practice running smoothly.

Understand Reimbursement Rates ➜ Review the reimbursement rates offered by different payers. Ensure that the rates are fair and cover the costs of the services you provide, so you’re not underpaid.

Quality of Care & Patient Outcomes

Commitment to Quality ➜ Partner with payers that support quality care. This includes programs for preventive care, chronic disease management, and patient education. Payers who focus on patient health outcomes are valuable long-term partners.

Patient Satisfaction ➜ Check patient satisfaction ratings and reviews. Providers should partner with payers known for high levels of patient satisfaction. Happy patients are more likely to stay and recommend your services.

Administrative Support & Technology

Administrative Support ➜ Evaluate the payer’s administrative support in terms of claims processing, billing assistance, and customer service. A payer with strong support will reduce the administrative burden on your practice.

Leveraging Technology ➜ Look for payers that offer advanced technology solutions, like EHR integration, data analytics, and tools for managing population health. These technologies improve efficiency and patient care, making your practice more effective.

Contract Terms & Bargaining

Contract Review ➜ Carefully review contract terms, especially around payments, dispute resolution, and termination clauses. Ensure everything is clear and favorable to your practice.

Negotiation ➜ Don’t hesitate to negotiate better rates, payment schedules, and other terms. A well-negotiated contract will secure better financial health for your practice and avoid potential issues later on.

Regulatory Compliance & Risk Management

Compliance Check ➜ Ensure the payer is compliant with healthcare regulations like the Affordable Care Act, HIPAA, and other state or federal requirements. Compliance is essential to protect your practice from legal issues.

Risk Management ➜ Look into the payer’s risk management strategies. A good payer will have systems in place for handling disputes, preventing fraud, and managing any financial risks that could affect your practice.

As a healthcare provider, do you feel the pinch of not getting your full Medicare reimbursement rates?

The Centers for Medicare & Medicaid Services (CMS) sets fixed reimbursement rates as per the Physician Fee Schedule, but providers often fall short.

Even though rates are set by the Physician Fee Schedule, with updates like the recent 2.93% increase to the 2024 Conversion Factor, simply being enrolled isn’t enough to guarantee full payment.

But worry not. We understand this financial stress.

Therefore…

In this blog, we’ll break down reasons for lower Medicare payments and give actionable steps to increase Medicare reimbursement rates.

You worked hard—now get fully paid!

What Is Medicare Reimbursement?

“Medicare Reimbursement” is the payment sent from the federal Medicare program to doctors, clinics, hospitals and other healthcare providers to compensate them for the medical care and services provided to patients enrolled in Medicare. It helps cover some of the costs incurred by providers for treating Medicare beneficiaries.

Medicare provides healthcare coverage to patients 65 years of age or above and patients with particular disabilities, even if they are below the age limit. The federal health insurance program covers expenses for the patients who receive care services from healthcare providers.

For example, a healthcare practitioner provides care services to Medicare beneficiaries in a private practice and submits claims to insurance providers (Medicare) for the services provided. Medicare will review these claims and pay the healthcare provider according to a particular reimbursement rate. Medicare’s payments to healthcare providers are called Medicare reimbursements.

This amount can be affected by various factors, including medical specialty, economic trends, legislative budgets, geographic location, performance of practice and quality of care, and physician’s fee schedule. However, Medicare reimbursement rates are predetermined, but these factors can cause providers to receive less payment than the allowed amount.

Medicare Physician Fee Schedule

Medicare Physician fee schedule is a table showing reimbursement rates updated annually by the Centre of Medicare and Medicaid Services (CMS) based on input from healthcare providers, medical societies, and other stakeholders. This schedule ensures fair compensation by standardizing payments across medical specialties and geographic locations.

The fee schedule evaluates the value of care services, the location of providers, and the costs of operating healthcare practice and determines how much Medicare will reimburse healthcare providers.

For each year, CMS proposes changes for the following year’s schedule—now for the year 2025. Healthcare providers can submit their feedback on the proposal in a specific allowed comment period. After closing the comment period, CMS reviews their feedback and decides on a new physician fee schedule. Then, the updated fee schedule will be released in November, 2024 and take effect from January 1, 2025.

Staying updated on the Physician fee schedule allows providers to align their charge amount for healthcare services and get maximum reimbursement from Medicare.

Effective Strategies to Increase Medicare Reimbursement Rates

Here, we guide you on how to increase Medicare reimbursement rates, though they are fixed. Applying these proven strategies can help healthcare enterprises boost their revenue by getting the maximum reimbursement from Medicare.

1). Reducing Medical Coding Errors

One of the most effective strategies for improving Medicare reimbursement rates is reducing medical coding errors. Inaccurate coding can lead to significant financial losses for healthcare providers, affecting their reimbursement rates from Medicare.

Why Accurate Coding Matters?

To maximize reimbursement, accurate medical coding is essential. Here’s why:

Correct Codes Ensure Appropriate Payment ➜ Providers must use precise codes for procedures and diagnoses to get the payment they deserve.

Avoid Revenue Loss ➜ Mistakes in coding can result in lower payments or delayed Medicare reimbursements, which can hurt the provider’s cash flow.

Common Coding Mistakes to Avoid

Here are some common mistakes made by medical coders that can reduce reimbursement, along with tips on how to avoid them:

Failure to Code to the Highest Level of Specificity

Coders sometimes fail to select the most specific codes for a patient’s diagnosis or procedure. This may happen due to lack of knowledge or familiarity with certain codes.

Why It Matters: If a code doesn’t fully capture the patient’s condition, Medicare may reimburse at a lower level, assuming the treatment was less complex.

Solution: Coders should ensure they’re well-versed in CPT and ICD-10 codes and are thorough in reviewing the patient’s records to select the most accurate code.

Inaccurate or Missing Modifiers

Modifiers provide additional details about a procedure or service, influencing the reimbursement amount. Incorrect or missing modifiers can lead to underpayment.

Example: If a patient receives care twice on the same day, coders must use Modifier-76 (Repeat procedure by the same physician). Without it, Medicare may only pay for the first service.

Solution: Ensure the correct use of modifiers to reflect the services provided fully. Consult AMA guidelines for accurate modifier application.

How Coding Mistakes Lead to Lower Reimbursement

To put it simply, when medical coders don’t capture the full scope of services provided, Medicare pays less. Let’s look at an example:

Scenario: A Medicare patient visits a clinic with severe back pain. The provider offers a comprehensive set of services: diagnosis, x-ray, chiropractic treatment, and a follow-up care plan.

What Happens: If coders only use codes for a routine check-up, Medicare will reimburse based on that lower level of service, leaving the provider underpaid for the care actually given.

Solution: Coders must accurately document and code all services rendered, ensuring they reflect the full extent of care provided.

Best Practices for Reducing Coding Errors

Here are some best practices for coders to avoid mistakes and help providers increase reimbursement:

Ongoing Education: Regular training on the latest CPT and ICD-10 codes is vital.

Detailed Review: Always double-check patient records for the most specific and accurate codes.

Modifier Accuracy: Make sure modifiers are used correctly to capture all aspects of a procedure or service.

Audit Regularly: Conduct regular audits of coding practices to identify and address errors before they affect reimbursement.

2). Leveraging Merit-Based Incentive Payment System (MIPS)

However, the Medicare reimbursement rates are fixed, but providers can get maximum reimbursement in the shape of additional earnings by meeting performance standards in quality care and improving healthcare activities at practice. In this way, they can easily maximize their revenue by leveraging MIPS.

In addition, the merit-based incentive payment system (MIPS) is another component for practices to consider when increasing their earnings. Medicare uses this program to adjust payments using composite performance scores. Through the MIPS program, eligible practitioners may receive a bonus amount, a payment penalty, or no payment adjustment.

Medicare considers four performance categories for counting the final MIPS score. This score determines the payment adjustment applied to Medicare Part B claims. The categories are:

Quality

Eligible clinicians must report on six quality measures, including one outcome measure. But, they must select one high-priority measure if an outcome measure is not available. For this purpose, AAPM&R (The American Academy of Physical Medicine and Rehabilitation) has created a quality measure guide to help them with the most applicable measures.

Improvement Activities

Eligible practices must attest to completing four activities at least 90 days each. However, those who live in small or rural areas have to complete only two. The AAPM&R created an improvement guide to help members explore activities that are most applicable to the specialty.

Promoting Interoperability

Promoting Interoperability is the MIPS performance category that promotes patient engagement and electronic exchange of information using certified electronic health record technology (CEHRT). The performance category is worth 25% of your MIPS Final Score for 2024.

Cost

The cost category determines a practice’s performance and covers 30% of the final MIPS score. It replaces the Medicare Value Modifier Program for eligible clinicians.

Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost (TPCC) measure the cost category. MSPB evaluates Medicare costs prior to, during, and after the hospital stay of patients, and TPCC evaluates Medicare Part A and Part B costs associated with any beneficiary over a year.

Who is not eligible for MIPS?

There are three types of healthcare providers who are excluded from MIPS eligibility:

• Providers who enroll in Medicare for the first time during a performance year are not eligible for MIPS until the next performance year.
• Providers participating in an APM, as defined by MACRA, are not eligible for MIPS.
• Clinicians who bill less than $90,000 in Medicare beneficiaries in a particular period OR provide care for less than 200 Medicare patients a year are excluded from MIPS.

3). Improving Reimbursement Through Detailed Documentation

Using poor quality, unclear, incomplete documentation, or missing documents that providers submit to Medicare can cause rejected or denied claims, which leads to less or no reimbursement. Healthcare providers must comply with detailed documentation to build a strong foundation for claims and consider all the billable aspects to get full payment on time. Experts at Medicare thoroughly review all the documents related to claims. Therefore, a slight mistake can cause providers to face losses.

Here are a few points discussed that clearly highlight the importance of effective documentation in maximizing Medicare reimbursement.

• Detailed and accurate documentation results in correct coding and fewer rejections or denials. It leads to better coding, which improves the chance of being reimbursed appropriately by Medicare for services provided. 
• Thorough documentation helps coders to understand it better and apply appropriate codes. In this way, documentation can play a major role in maximizing reimbursement and the practice’s overall revenue growth. 
• Document procedures should be as accurate and detailed as possible because reimbursement can be affected by even the smallest missing detail.

A properly documented medical record can facilitate practices with effective revenue cycle processes, boost payment, reduce hassles in claim processing, and ensure appropriate reimbursements. Healthcare practices are required to improve their documentation skills to get full benefits from care services provided in the shape of maximum reimbursements; here are steps to follow on how they can improve:

Standardization: They should focus on clear and concise communication while using industry standards and documenting procedures that are easily understood by readers of the medical records. 

Regular Review: Providers should follow a simple process by reviewing previous records and encounters and aligning them with current EMRs.

Peer Support: Peer-to-peer documentation support can increase standardization and productivity as clinicians can understand the ins and outs of documentation quite well. 

Continued Education: The clinician should never stop the learning process. Adhering to ideas for improvement helps them keep up to date and increase documentation compliance. 

4). Regular Auditing and Compliance Checks

One of the most important strategies to maximize Medicare reimbursement is regular auditing and staying informed and up-to-date with the latest rules and regulations and CMS requirements. Medicare and Medicaid are constantly evolving and adopting new changes with current and updated trends. Therefore, healthcare providers must stay updated on any changes that may affect reimbursement rates.

Staying updated with these complex programs might be challenging for providers as these regulations vary by state. However, healthcare providers can stay informed by regularly reviewing Medicare reimbursement guidelines and ensuring that they are submitting accurate claims and receiving full reimbursement for the services they provide to Medicare patients.

Furthermore, healthcare providers should be aware of external audit outcomes to reduce the risks of rejected and denied claims that may lead to low reimbursement. Providers should perform internal audits by their in-house teams or outsource third-party auditors to demonstrate compliance with risk adjustment regulations to reduce the risk of penalties and fines.

5). Using a Claim Management Software

Effective claim management is a crucial factor for optimizing Medicare reimbursement. Sometimes, healthcare providers take the burden and fail to manage a high volume of claims, and it becomes challenging for them to submit these claims to Medicare. Also, it becomes a headache for them to keep track of records and ensure that each claim is processed properly and correctly.

By using claim management software effectively, healthcare practices can streamline the process of claim submitting and identify errors quickly to avoid any unpleasant result, i.e., rejection or denial of claims. This will ultimately improve the revenue of practices by getting properly reimbursed.

6). Outsourcing Billing Services

After following all the procedures, if providers fail to maximize their Medicare reimbursement rates, the ultimate solution is hiring a third-party medical billing company to do all of the work on their behalf. One of the reliable billing companies in the US is BellMedEx, providing billing services and supporting providers in optimizing their reimbursement rates.

The experts and professionals at the billing company can lessen the burden from providers’ shoulders by providing them with result-oriented services, for example, medical coding, compliance management, and claim management, which can prove extremely helpful in maximizing Medicare reimbursement rates.

After outsourcing the third-party billing services, the experienced staff at the company can ensure accuracy and alignment with CMS guidelines and requirements. We suggest this is one of the easiest ways to maximize reimbursement and grow healthcare practice’s revenue.

What’s Next for Medicare Reimbursement? My Take on the Future

When it comes to Medicare reimbursement, there’s a lot on the horizon for healthcare providers. The landscape is definitely shifting, and those who stay ahead of the curve will be the ones who can really capitalize on these changes.

In my opinion, the future of Medicare reimbursement is all about adapting to new trends, especially as CMS (Centers for Medicare & Medicaid Services) continues to refine its approach.

So, what can providers expect in the coming years? Let’s break it down.

Focus on Quality Over Quantity

One major trend I see coming is the shift from the volume of services provided to the quality of care delivered. CMS seems to be heading in this direction with its value-based payment model, and I honestly think it’s a good thing for both patients and providers.

Instead of rewarding providers for simply seeing more patients or performing more procedures, they’ll be incentivized based on how well they actually take care of those patients.

What does this mean for reimbursement rates?

Well, providers who deliver better care can expect higher reimbursement. It’s that simple. A quality reporting program like MIPS (Merit-based Incentive Payment System) is a prime example of how CMS is linking reimbursement to performance metrics. The better your practice does in terms of patient outcomes and quality, the more you’ll get paid.

And it’s not just about seeing patients faster or getting through more appointments. Care coordination and patient engagement are going to become even more important. If you’re collaborating with other providers, sharing information, and really involving patients in their own healthcare decisions, you’re going to see better outcomes—and better reimbursement as a result.

Embracing Technology

Another big factor that’s shaping the future of Medicare reimbursement is the adoption of new healthcare technologies.

I honestly believe that practices already using things like EHRs (Electronic Health Records), telehealth, and remote patient monitoring are going to have a serious edge moving forward.

CMS is pushing for the adoption of these technologies because they know how much potential they have to improve care and efficiency. Think about it: telehealth has become a game-changer, especially with how it helps providers see more patients remotely and manage care more effectively. Plus, remote patient monitoring means you can keep an eye on your patients’ health without them having to come into the office all the time.

The way I see it, practices that embrace these tools now will be better positioned to meet the evolving standards set by CMS and, in turn, secure higher reimbursement rates in the future. It’s all about staying ahead of the technology curve.

Imagine a patient arriving at the Emergency Room with severe abdominal pain. In a traditional healthcare setting, they might face long wait times, unnecessary paperwork, and clashes between departments. But with lean healthcare, the patient is quickly triaged and directed to a dedicated care team following standardized procedures to minimize delays.

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Overview of Lean Healthcare

The concept of “lean” originated in manufacturing, with the term coined by John Krafcik in 1988. James Womack and colleagues later defined lean more broadly in 1996 as a “systematic approach to identifying and eliminating waste (non-value-added activities) through continuous improvement by flowing the product at the pull of the customer in pursuit of perfection.”

The Triple Aim of US Healthcare was created by the Institute of Health Improvement (IHI). It provides a helpful framework, pushing healthcare systems to simultaneously improve patients’ experience, population health, and per capita costs.

While lean has proven models, each organization must modify these models to suit their own context. Establishing a mindset of constant improvement at all levels is necessary for success. When done correctly, lean healthcare methods can greatly transform care delivery.

Waste Categories Used in Lean Healthcare

In lean healthcare, waste is anything that does not help make the patient’s care and experience better. Lean principles aim to find and remove wasteful elements, making operations easier and improving efficiency in healthcare.

The concept of waste in lean healthcare is often categorized into eight types:

Defects

Errors can happen in medical procedures due to wrong diagnoses or faulty medical equipment that need fixing. These problems can raise costs, harm patients, and slow down medical care. For example, if a patient is diagnosed incorrectly, it can result in the wrong treatment. This may lead to serious health complications and higher medical costs.

Overproduction

If we make more medical equipment and medicine than we need, it creates waste. This waste can include unnecessary diagnostic tests or treatments that are not needed for patient care. For example, doing too many blood tests for a patient when they are not needed wastes resources and incurs more healthcare expenses.

Waiting

If patient care is delayed because of more waiting time for consultation, test results, medical equipment, or doctor availability, this issue can cause long stays of patients in hospital territory and neglect care about patient satisfaction. For example, a patient in the Emergency Room (ER) waiting for many hours to see a doctor may feel discomfort.

Non/Underutilized Talent

Not using the skills and knowledge of medical staff well can cause many problems for healthcare practices. Because of mistakes and low spirits, healthcare workers cannot achieve their best. For example, a nurse trained specifically in wound care might be tasked with recording daily patient visits and discharges, rather than focusing on the specific needs of patients.

Transportation

Transportation is considered the unnecessary movement of patients, staff , or other medical material within healthcare practice. Moving patients between departments without a good reason can be a waste. For example, moving a patient many times for tests can increase the chance of errors and cause more discomfort.

Inventory

Having too few or too many healthcare supplies and medications can hurt patient care. Having too many medical supplies or medications can result in more items getting expired. On the other hand, not having enough can lead to long waits for patient care. For example, having too much medical stock that expires before all items are used can cause money loss. Also, delays in treatment due to inventory shortage can have serious effects or even lead to death.

Motion

Staff may lose time and work less efficiently because of extra physical movement. This can cause poor patient care and wastage of time. For example, a nurse hired for checking patients’ Blood Pressure (BP) spends too much time locating the BP apparatus instead of helping the patient with their worries. In that case, this can disturb the overall productivity of staff.

Extra or Over-Processing

Doing extra work that is not needed, like unnecessary tests, can raise medical costs and slow down patient care without helping anyone. For example, duplicating the same patient information in different treatment forms can lead to more mistakes and extra work for staff.

The annual cost of waste in the US healthcare system is estimated at almost $750 billion, which includes unnecessary services, excessive administration costs, and inefficient delivery.

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Six Principles of Lean Healthcare

Focusing more on better teamwork and working together is very important when using lean healthcare principles. Healthcare practices should improve their use of lean principles. They need to look for ways on finding areas to improve and use data to help them. Using lean healthcare ideas can help your clinic create a stable and balanced environment that offers high-quality, waste-free care.

1). Value

It is important to understand what is valuable for treating patients from their point of view. This principle is about finding and providing healthcare services that can help improve patient care and make patients happier. Focusing on what patients need in healthcare can remove unhelpful activities and improve the overall experience for patients.

2). Value Stream Mapping

Value stream mapping shows all steps in a process to find and remove waste. We can look at the whole process from when patients arrive to when they leave. This helps healthcare providers make everything work better and ensure patients move through the system easily.

3). Flow

This principle helps all healthcare processes work well without any problems. It can also highlight the ongoing flow of patients, their information, and medical supplies or medications. By removing all delays and problems, healthcare practices can make wait times shorter and improve healthcare services.

4). Pull

A pull system is a way of providing healthcare services based on what patients need, instead of having set appointments or pre-planned schedules. This principle helps prevent making too much and makes sure all resources are used properly and effectively, which leads to better care for patients and better management of resources.

5). Perfection

Always try to improve all healthcare processes. This principle emphasizes the importance of ongoing evaluation and improvement. It encourages all healthcare providers to always look for ways to enhance quality, reduce errors, and increase efficiency.

6). Respect for Everyone

It is important to recognize and value the contributions of all healthcare staff to keep quality care. This principle aims to create a helpful work environment where all staff can share their ideas to improve processes. When healthcare organizations keep a good culture, they can improve patient care and make staff happier.

Do You Know ➜ What is Lean Six Sigma?

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Lean Six Sigma is a powerful approach used in healthcare to make processes better and increase patient happiness. It is a combo of two different approaches: Lean, which works to remove waste and make operations more efficient, and Six Sigma, which seeks to lower mistakes and enhance quality. Lean uses tools such as the 8 Wastes and the PDCA cycle. Six Sigma uses the DMAIC method to define, measure, analyze, improve, and control processes.

Similar to a thriving garden where each plant contributes to the ecosystem, Lean and Six Sigma work together to help healthcare practices provide better services. They improve performance, reduce waste, and make sure the quality is always up to the mark.

Lean Methodologies and Implementation in Healthcare

Lean methodologies and how to use them are important for better patient care, making operations work better, and cutting down on waste. Here are different methodologies that are used to make the healthcare system better.

1). Value Stream Mapping (VSM)

Value stream mapping is a useful tool that healthcare organizations can use to make patient care better. It shows a clear picture of the whole process of giving care to patients, from beginning to end. This covers all tasks, like ordering supplies and administering medicine. The map helps teams find problems, waste, and things that do not work well so they can fix them. This simple process lowers costs and waiting times and makes care better.

2). Kaizen (Continuous Improvement)

Kaizen is a process of constantly looking for ways to improve. It involves everyone in an organization working together to make small, incremental changes on a daily basis. The goal is to eliminate waste and streamline processes.

In healthcare, Kaizen can help make the movement of patients in a clinic better. A team plans every part of the patient journey, starting from checking in, to seeing the doctor, and ending with checking out. They find problems or slow parts in each stage and think of ideas to make the process easier. This could be as easy as moving furniture around or adding signage. Kaizen means making small changes all the time, not big changes all at once.

3). Just In Time (JIT)

The Just In Time (JIT) method means getting supplies and materials only when you need them, rather than stocking up in advance. The goal is to avoid overproduction and excess inventory, which can cause waste. With JIT, you make or order just what is required, just when it is required. This helps save money and improve efficiency.

4). Root Cause Analysis (RCA)

Root Cause Analysis is a way to solve problems in healthcare. It helps find the main reasons for issues. It means looking into problems to discover the real reasons why they happened. The purpose of RCA is to discover ways to stop problems from happening again.

5). Kanban (Card You Can See)

Kanban is a way to see and manage work as it goes through different steps. It uses cards or signals to show tasks or work items that go through different steps from beginning to end. The goal is to visualize workflow, limit work-in-progress, and maximize efficiency. Think of a Kanban board with sticky notes moving across columns to understand when something is ready to be worked on, in progress, or completed.

6). Poka-Yoke (Error Proofing)

Poka-Yoke is a lean methodology that helps stop mistakes before they happen. It focuses on building quality into processes by adding simple fail-safes that make errors nearly impossible. The goal is to design systems where the next logical step is the correct step. This eliminates the need for expensive defect detection and inspection processes down the line.

7). Heijunka (Production Leveling)

Heijunka is a lean methodology that aims to smooth out the flow of work over time. It involves leveling the mix and quantity of production across a time period. The goal is to eliminate unevenness, overburden and waste. Heijunka creates a steady predictable pace so operations can work at an optimal volume. This helps reduce variability and stress on the system.

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What is 5S Methodology in Lean Healthcare?

The 5S methodology is a lean approach that aims to improve workplace efficiency, safety, and organization in healthcare settings. It consists of five Japanese principles, each starting with the letter “S”:

1

Sort (Seiri 整理) — Identify and eliminate unnecessary items from the workspace, keeping only essential medical supplies and equipment.

2

Set in Order (Seiton 整頓) — Arrange and label all necessary items in a systematic and logical manner for easy access and retrieval.

3

Shine (Seiso 清掃) — Maintain a clean and hygienic work environment by regularly cleaning and sanitizing medical equipment, workstations, and patient areas.

4

Standardize (Seiketsu 清潔) — Establish and implement consistent procedures and standards for tasks such as inventory management, equipment sterilization, and patient intake processes.

5

Sustain (Shitsuke 躾) — Continuously review and improve the established standards through regular audits, training sessions, and encouraging staff to adhere to and enhance the 5S practices.

Examples of Lean Healthcare

The following are some easy examples of how lean healthcare can help improve healthcare practices and make managing tasks easier:

Example #1 ➜ Reducing Wait Times in the Emergency Room

Have you ever had to wait for hours in the emergency room before being seen? Lean healthcare can help reduce those long wait times. Hospitals use a method called Value Stream Mapping to map out the entire journey a patient takes from walking in the door to being discharged. By streamlining the processes in the emergency department, hospitals can cut down on wasted time by up to 30%, leading to happier patients.

Example #2 ➜ Faster Patient Discharges

Getting discharged from the hospital can often be a long, frustrating process with lots of paperwork and communication issues. Lean healthcare uses a method called Kaizen, which means “continuous improvement.” A team of healthcare workers reviews the discharge process, identifies inefficiencies, and makes changes like pre-discharge planning and electronic documentation. This can reduce the overall discharge time by 20-40%, freeing up beds for new patients more quickly.

Example #3 ➜ Faster Lab Test Results

Have you ever had to wait a long time for lab test results before your doctor could diagnose you or give you medication? Lean healthcare helps labs use a “Just-In-Time” approach, where they schedule tests based on demand rather than doing big batches. This way, they can speed up their processes and get results back 20-30% faster.

Example #4 ➜ Reducing Hospital-Acquired Infections

Nobody wants to go to the hospital and catch an infection! Lean healthcare uses Root Cause Analysis to identify the sources of hospital-acquired infections. Hospitals can then implement strategies like better equipment sterilization and improved hand hygiene to cut down on these harmful infections.

Pros and Cons of Lean Healthcare

Lean healthcare has many advantages if you can implement it in your healthcare practice. However, it also has some disadvantages that can be tackled by implementing correct strategies.

Pros of Lean Healthcare

The main benefit of lean healthcare is that it removes waste and improves all medical processes. This makes operations more efficient. You can do this by cutting out extra steps, organizing patient movement, and making work processes simpler.

Various lean methods help find and remove activities that do not add value, which can lower operational costs effectively. You can lower these costs by cutting down on inventory costs, waiting times, and using resources more efficiently.

A good and balanced workplace is made by helping employees to notice and fix problems themselves. This can affect how happy people are with their jobs and make them work harder.

Using lean healthcare methods helps make sure your patients receive care quickly and effectively. This can make patients happier and improve results.

Using clear processes and good practices can help lean healthcare lower the chances of mistakes and make patient safety better.

Cons of Lean Healthcare

Using lean methods means making big changes in culture and showing dedication in healthcare practices. But, resistance to change and not having support from healthcare staff can make it hard to implement things successfully.

It can be hard to see how lean initiatives affect things when they are complicated. Keeping a complex system running needs better data gathering and examination.

Focusing more on efficiency can sometimes cause people to ignore important human factors. But, not having this element can lead to staff tiredness and lower the quality of care.

It can be hard to manage and keep lean healthcare practices working well for a long time. So, it is important to keep checking and putting these ideas into practice to maintain them in healthcare.

Small healthcare practices might find it hard to manage resources. This is because starting lean processes can take more time, training, and money.

Conclusion

Are you keeping an eye on the current state of your practice? Lean healthcare allows you to concentrate on cutting waste and streamlining procedures to improve operations. This may result in patients receiving better care. Putting the patient first raises the standard of care and increases the flexibility of your medical business. By maximizing patient flow, it may maintain profitability while enhancing service delivery.

Optimize Patient Care with BellMedEx’s Lean Healthcare Solutions

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Thanks to BellMedEx, our billing reimbursement is at its highest!

Dr. Esther

Counselor, Mental Health Clinic

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As the sun rises and sets, so does the journey through health’s trials.

I mean, as we age, we really do face healthcare challenges along the way.

And when intense care is needed, a skilled nursing facility (SNF) is usually the best choice. However, you have options — a short stay to recover or a permanent move from the SNF to a nursing home.

Therefore, knowing the daily rates for each guides smart decisions.

Medicare pays SNFs different daily rates compared to nursing homes. Rates change every year, with important updates in 2024. The Centers for Medicare & Medicaid Services (CMS) say there will be a 4% increase in daily rates for skilled nursing facilities (SNF) in 2024. This means about $1.4 billion more will be spent.

These SNF costs are projected to climb up to 4.1% in 2025, thus raising the possibility of further price escalations.

So it is important for SNF staff to know about rate changes to bill correctly.

Skilled Nursing Care Rates By Location

The price of skilled nursing care can change a lot based on where you are. This difference in rates allows Medicare beneficiaries to move to another area or state to find more affordable care while living in a nursing facility or nursing home. Picking a place with cheaper prices can help seniors make their benefits last longer.

Skilled Nursing Facility Rates By State

The costs of skilled nursing facilities change based on where they are located. So, some states have SNFs that charge a lot, while other states have SNFs that charge less. The table below shows the average monthly costs of nursing homes.

What Are The States With The Most Affordable Nursing Home Care?

Here is a list of top 10 states with the most affordable nursing home care.

Nursing Home Costs in the U.S. Cities

How Can You Differentiate Between A Skilled Nursing Facility And A Nursing Home?

“Skilled nursing facility” and “nursing home” are words that people often use the same way, but they actually mean different types of care places with important differences. The main differences are in how long you stay, the care you get, the services available, and how you pay.

Duration of Stay:

Skilled Nursing Facilities (SNFs) are meant for short visits. They help people who are recovering from all illness, injury, or surgery. These facilities give short-term medical help and rehabilitation services. They assist patients in getting back their independence so they can go home or move to a long-term care facility if necessary.

In contrast, Nursing Homes are places for long-term care. They help people who need support with daily activities because of long-term health issues or aging problems.

Level of Care:

SNFs provide more medical care and supervision than nursing homes. They have trained healthcare workers, like registered nurses, practical nurses, physical therapists, occupational therapists, and speech therapists. These experts work as a team to give complete medical care, rehabilitation help, and skilled nursing services that are designed for each patient’s unique needs.

Nursing homes, on the other hand, mainly offer basic medical care and help with daily activities like bathing, dressing, eating, and moving around. Nursing homes usually have licensed nurses, but they do not have as many different types of medical specialists as skilled nursing facilities (SNFs).

Services Provided:

Along with skilled nursing care, SNFs provide various services to help patients recover and rehabilitate. These services can include care after surgery, taking care of wounds, managing pain, giving medicine through IV, physical therapy, help with daily activities, and speech therapy. SNFs also offer 24-hour emergency services and special equipment to help with recovery.

Nursing homes, in contrast, provide long-term care for people who need help with daily activities, taking medicine, and basic health care. They might provide fun activities, help for social needs, and transportation services to improve the lives of residents.

Payment Methods:

Medicare usually pays for SNFs for a short time if the patient meets specific requirements, like being admitted from a hospital within a certain period. Nursing home care, on the other hand, is often paid for through a combination of private funds, long-term care insurance, and Medicaid (for those who qualify based on income and asset levels).

Some places may provide both skilled nursing and long-term care services, making it hard to tell the difference between SNFs and nursing homes. However, understanding the differences between these two types of care facilities can help people and their families choose the best care option for their needs and situations.

Medicare Coverage For Skilled Nursing Care Facilities

Medicare coverage for skilled nursing care facilities is based on two main things: where the facility is located and how long you stay there. Additionally, patients need to follow specific rules from Medicare to qualify for coverage.

For example, Medicare Part A pays for up to 100 days of care in a shared room during each benefit period. This is for when a skilled nursing facility meets Medicare’s requirements. A benefit period starts when you enter a hospital or skilled nursing facility and ends when you have been out of the facility for 60 days in a row.

To qualify, you must have a qualifying hospital stay of at least 3 days before going to the skilled nursing facility. You must also need daily skilled care like intravenous medications or physical therapy. In addition, a doctor must confirm that you need skilled care within 30 days after you are admitted. You can get coverage for a maximum of 100 days each time you use your benefit period.

Requirements for Medicare Coverage of Skilled Nursing Facilities

1⃣ The patient needs to stay in the hospital for at least three days to get important medical care. This stay is for situations that need skilled nursing care afterwards.

2⃣ A doctor must give a prescription that shows the patient needs daily skilled nursing care or therapy. This care should be done by, or with help from, qualified professionals or technical staff, making sure that the services follow Medicare standards.

3⃣ The skilled nursing facility (SNF) needs to be approved by Medicare. This certification shows that the facility follows important health and safety rules set by the government.

4⃣ The patient must be transferred to a participating skilled nursing facility within 30 days of being discharged from the hospital. This requirement is crucial for maintaining eligibility for coverage.

5⃣ The patient must be enrolled in Medicare Part A, which covers inpatient hospital stays and certain skilled nursing facility services.

6⃣ The services provided in the skilled nursing facility must be deemed medically necessary and appropriate for the patient’s condition, as determined by their healthcare provider.

7⃣ Patients might need to have regular assessments to make sure they still qualify for skilled nursing services. This includes progress evaluations by healthcare professionals.

8⃣ Medicare usually pays for skilled nursing care for up to 100 days in each benefit period. The first 20 days are fully covered, but for the next 80 days, there is a copayment required. In 2024, the coinsurance is about $204 each day.

9⃣ The patient needs skilled nursing care every day. This care can include things like taking care of wounds, giving medicine through an IV, or helping with rehabilitation.

The need for skilled nursing must be clearly justified based on the patient’s medical condition and treatment plan, ensuring that the care provided aligns with their health needs.

What is a Benefit Period in Skilled Nursing Facility?

A benefit period refers to the way Medicare measures your use of hospital and skilled nursing facility (SNF) services. It determines how much coverage you will receive from Medicare Part A for inpatient care. 

Each benefit period begins the day you are admitted as an inpatient to a hospital or SNF. The benefit period ends when you have not received inpatient care in either a hospital or SNF for 60 consecutive days. At that point, if you need to be admitted again, a new benefit period will begin.

During each benefit period, Medicare Part A provides coverage for your inpatient care according to certain limits:

• For hospital care, Medicare Part A covers up to 90 days. You pay a deductible for days 1-60 and a coinsurance amount for days 61-90. 
• For SNF care, Medicare Part A covers up to 100 days. You pay nothing for the first 20 days. For days 21-100, you pay a daily coinsurance amount.

For example, let’s say you are admitted to the hospital for 5 days due to pneumonia. This starts your benefit period. Two months later, you fall and break your hip, requiring another hospital stay of 4 days. This is still the same benefit period because less than 60 days passed between your hospital stays.

After your hip heals, you transfer to a SNF for rehabilitation for 30 days. Those SNF days also apply to the same benefit period. In total for this benefit period so far, you have used 9 hospital days and 30 SNF days. If you need more inpatient care, your coverage will depend on how many benefit days you have left.

Skilled Nursing Care Billing Tips

Skilled nursing facilities can use these important billing tips to help prepare and submit claims for Medicare beneficiaries accurately and correctly:

Understand Utilization Days: It is important to know that the last day of care—this could be the day you leave the hospital, the day of death, or the first day of a leave of absence (LOA)—is not counted as a utilization day for billing. This means facilities should not charge for these days.

Discharge Policy: If a patient covered by Medicare leaves but comes back before midnight on the same day, Medicare does not count this as a discharge. So, billing should reflect the patient’s continuous stay, because it impacts the total days used.

Accurate HIPPS Rate Coding: Make sure that the HIPPS rate code matches exactly with the assessment that was submitted and accepted by the state where the skilled nursing facility is located. Any mistakes can cause claims to be denied or payments to be delayed.

Clear Documentation: Keep clear and correct records of all services given. This includes daily notes, care plans, and any changes in a patient’s condition. Good documentation helps show why services billed to Medicare are needed.

Ongoing Training for Staff: Provide regular training for your billing staff to ensure they know the latest Medicare rules, coding updates, and compliance needs. This active method can greatly lower mistakes and improve the accuracy of claim submissions.

Claim Submission: Submit claims on time to prevent delays in getting your money back. Learn the specific deadlines for submitting documents as required by Medicare to follow the rules.

Keep Updated on Policy Changes: Check for updates from Medicare and other important organizations about changes in policies, billing rules, and payment rates. Being informed will help your facility adjust and follow the rules.

Consolidated Billing In Skilled Nursing Facilities

Under consolidated billing, Medicare requires Skilled Nursing Facilities (SNFs) to submit a single consolidated bill for most Medicare Part A services provided to patients during their covered stay. This applies regardless of whether the services are provided directly by the SNF or by an outside entity. The services included in the consolidated bill are:

• Nursing care
• Therapy services (physical, occupational, speech-language)
• Medical supplies
• Certain physician services

However, some services are billed separately under Medicare Part B coverage. These include:

• Certain dialysis services
• Certain types of chemotherapy and radiotherapy
• Services provided by outside suppliers with specialized Medicare certification (e.g., ambulance services)

It is important for SNFs to know which services go in the consolidated bill and which ones should be billed separately. If you don’t do this, your claims might be denied. For instance, if a skilled nursing facility includes ambulance service costs in the main bill by mistake, the claim might be rejected. This is because ambulance services need to be billed separately under Part B.

SNFs need to make sure they bill correctly to prevent problems with getting paid by Medicare. It is very important to understand the rules for consolidated billing. This helps to follow the law and keep things running smoothly.

Factors that Affect the Cost of Skilled Nursing Care

There are several factors that determine how much a patient should pay for skilled nursing care. These factors include:

• The state and region where the facility is located
• Whether the facility is a luxury senior living community
• The choice between a private room and a semi-private room
• The length of the patient’s stay
• The type of care required by the patient
• The patient’s insurance benefits

But worry not! Because this BellMedEx guide covers 17 proven strategies to achieve medical practice revenue growth in record time. You might already be using some of them, so evaluate which ones are going to maximize practice cash flow.

Schedule a FREE consultation with our practice growth specialist if you feel overwhelmed or need help implementing any of these strategies.

For now, let us learn how to increase revenue in medical practice.

1. Build Solid Online Presence to Grow Your Practice

A robust online presence for any medical practice is important to increase its revenue and attract new patients. In fact, 43% of patients in a Software Advice survey said that they’ll go out of network provider with positive online reviews.

A clear, well-designed healthcare website serves as the foundation for a solid online presence. But you should also expand your practice’s online reach to major review sites and social media platforms.

As a holistic, omnichannel practice growth company, BellMedEx offers healthcare SEO solutions to help practices build solid online presence. We help you reach more patients with increased organic visibility for your healthcare facility.

Here are a few ideas on how to stand online for the sake of increasing medical practice revenue:

• Develop a practice website with helpful content and patient testimonials.
• Launch business profiles on major review sites like Google Reviews and Yelp.
• Create and update social media profiles for your practice.
• Respond promptly to patient reviews and comments, addressing concerns.
• Use digital marketing strategies to improve online visibility.

Pro Tip: Regularly monitor online reviews and feedback using solid reputation management tools to stay on top of competition.

2. Optimize Medical Billing Workflows & RCM

As a healthcare provider, your job is to provide quality care. But you might already know you must work on your billing to improve your practice’s revenue cycle.

Then why not give your best to optimize billing workflows and RCM to ensure fast and timely reimbursements. Efficient billing systems reduce errors and denials, which can otherwise lead to costly delays in payments.

Enforce regular billing cycles, invoice promptly, and offer various payment methods to boost patient satisfaction. Regular audits and partnering with reliable billing services like BellMedEx can remove billing errors, ensuring a smoother medical revenue cycle.

Let us summarize how you can optimize your billing cycle for practice growth:

• Start using EHR software integrated coding functionalities.
• Train practice staff on accurate coding.
• Ensure prompt invoicing payers after patient visits.
• Offer diverse payment options for fast patient payments.
• Automate repetitive billing processes.
• Conduct regular audits for error correction.

Pro Tip: Regularly review your billing processes and partner with a professional billing service to increase revenue in medical practice.

3. Improve Patient Satisfaction and Retention

Patient satisfaction drives more patients and medical practice revenue growth. You should optimize the entire patient journey from scheduling appointments to follow-up care to increase patient retention and satisfaction.

Satisfied patients are more likely to recommend your practice, enhancing your reputation and attracting new patients. Effective communication methods and personalized care contribute to a positive patient experience.

And it leads to increased referrals and a stronger reputation. That is why you must always improve and maintain the highest level of healthcare services at your practice.

Let us give you a few more ideas on improving patient care:

• Improve appointment scheduling systems.
• Streamline patient intake procedures for efficiency.
• Ensure timely follow-ups on lab results and treatments.
• Enhance clarity and support in your communication methods.
• Invest in staff training and professional development.
• Get and act on patient feedback to improve care quality.

Pro Tip: Use patient feedback surveys to gain insights into improvement opportunities and address patient concerns.

4. Negotiate Better Payer Contracts

At BellMedEx, we consistently helped many healthcare practices increase their revenue by carefully reviewing and negotiating payer contracts. Many healthcare practices overlook this proven practice growth strategy, considering its complexities. But insurers are often open to negotiating terms with high-performing medical groups.

Highlight factors such as low readmission rates, strong clinical outcomes, and effective delegation of care to negotiate better terms. Emphasize your contribution to improving health plan outcomes, as these align with key healthcare quality measures like HEDIS.

Demonstrating your practice’s positive impact on patient care and cost-efficiency can strengthen your position in negotiations.

Engaging with healthcare consultants like BellMedEx provides additional leverage for win-win negotiations.

Let us quickly summarize on payer contract negotiation:

• Assess and review current payer contracts for improvements.
• Highlight your practice KPIs and outcomes during negotiations.
• Engage with legal experts and consultants for support.

Pro Tip: Keep detailed records of your practice’s performance metrics to use as leverage during contract negotiations.

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5. Expand Your Healthcare Service Offerings

Expanding your service offerings attracts a broad patient base and opens new revenue streams for your practice. You can introduce services based on current market demands and shifting patient needs. This helps enhance patient loyalty and increase revenue in medical practices.

For example, integrating behavioral health services can help many people fight mental health concerns. You can offer direct pay pricing options to those without insurance. Adding roles such as physician assistants can also help capture patients seeking convenient care alternatives.

Keeping an eye on medical advancements and patient needs can help your practice grow its revenue and remain competitive in the market.

Let us summarize these care service diversification ideas now:

• Assess patient needs and community trends for new service ideas.
• Welcome a new team member to expand healthcare services.
• Stay updated on medical advancements.
• Integrate new treatments into your practice.
• Evaluate current service offerings and adapt accordingly.

Pro Tip: Conduct market research and patient surveys to identify the most valuable services to add, ensuring new offerings align with patient needs and practice goals.

6. Do Not Sit On Your Denied Claims

The number one problem with denied claims is that they become long-term headaches when they start piling up. Inefficient claims management impacts a medical practice’s revenue negatively, with denied claims often leading to substantial financial losses.

Claims that remain in accounts receivable (A/R) for over 50-60 days create cash flow issues. And they incur administrative costs of approximately $120 per appeal. With around 11% of claims typically denied, this can add up substantial expenses.

Let us give you ideas on optimizing the denial management process so as to improve profitability without raising rates in healthcare:

• Implement clear workflows for claim submission.
• Analyze and categorize denied claims to identify issues.
• Address the root causes of denials such as coding errors or eligibility issues.
• Develop a robust claim tracking system for your practice.
• Invest in staff training or external claim management consultants like BellMedEx.

Pro Tip: Regularly review and update your claims management processes to reduce denied claims, increasing medical practice’s revenue fast.

7. Go Heavy on Online Practice Reputation Management

Managing your practice’s digital reputation helps attract and retain patients. Online reviews play a significant role in a patient’s decision-making process.

Effective online review management helps streamline the collection of patient feedback. It also enables you to respond to reviews efficiently and uplift their digital presence.

A robust online reputation management strategy involves getting positive reviews from satisfied patients and addressing negative ones.

Here are a few ideas on improving your practice online reputation for an increased medical practice revenue:

• Encourage patients for positive reviews on platforms like Google and Yelp.
• Address negative reviews promptly and resolve any issues immediately.
• Update your practice’s website with relevant content.
• Engage with patients through social media and local business directories.

Pro Tip: Regularly audit your practice’s online presence and review analytics to identify improvement opportunities for maximum practice revenue growth.

8. Start Offering Telehealth Services

Telehealth has revolutionized patient care by providing remote access to medical services. Offering after-hours virtual visits helps expand patient reach and improves convenience. It also helps address physician shortages and improve care continuity, particularly in underserved or rural areas.

Telehealth services allow practices to offer consultations, follow-ups, and even mental health services remotely, thereby attracting new patients. Offering telehealth services is one of the best strategies to achieve medical practice revenue growth.

Here are a few things to consider when implementing telehealth at your practice:

• Provide remote consultations and follow-ups.
• Choose reliable, HIPAA-compliant telehealth software.
• Promote telehealth options to existing and potential patients.
• Integrate telehealth services into your existing practice management systems.
• Evaluate the performance and patient feedback on telehealth services.

Pro Tip: Regularly assess and upgrade your telehealth technology to ensure it meets patient needs and regulatory standards.

9. Consider Hiring a Practice Growth Consultant

Hiring a practice growth consultant like BellMedEx can provide valuable insights into your medical practice’s performance and profitability. These consultants offer expertise in various aspects of practice management, from administrative to marketing strategies.

They can conduct thorough evaluations to identify inefficiencies, recommend improvements, and help develop a unique value proposition. Investing in a consultant helps optimize billing practices, helping your medical practice revenue grow fast.

Here’s how to make the consultation effective:

• Research a consultant with experience relevant to your practice’s specialty.
• Schedule a FREE evaluation to assess your practice.
• Ask your consultant to run a detailed billing audit.
• Develop a clear and compelling value proposition.
• Regularly review and update your practice’s strategies based on feedback.

Pro Tip: Be open with your consultant’s feedback and actively participate in the development of practice growth strategies.

10. Ensure Efficient Appointment Scheduling

Efficient appointment scheduling is key to maximizing patient access and increasing healthcare practice revenue. There are many benefits of an online appointment system, for example it reduces barriers for patients and allows for more convenient scheduling.

Offering features such as online booking, text reminders, and an optimized patient portal helps elevate the patient experience. And it also reduces administrative burdens. Using tech for scheduling helps improve patient retention, reduce no-shows, and increase practice revenue.

Let us share some tips when ensuring effective appointment scheduling:

• Streamline scheduling with online appointment booking solution.
• Use automated text or email reminders to reduce no-shows and late arrivals.
• Optimize your patient portal for easy access and appointment.
• Integrate telemedicine scheduling to offer remote consultation.

Pro Tip: Monitor appointment scheduling metrics and patient feedback to refine your processes and address booking issues.

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11. Improve Your Patient Collection Strategy

Effective patient collection strategies help increase practice revenue and manage financial risks. Optimizing collections is important also because a significant portion of revenue comes from patient co-pays, particularly in high-deductible insurance plans.

Train your practice staff to handle patient inquiries effectively. And regularly evaluate your collection strategies to ensure your practice achieves optimal revenue collection and maintains a positive patient experience.

• Implement point-of-service collections to get payments faster.
• Design clear, informative patient statements.
• Develop follow-up programs patients’ outstanding balances.
• Offer flexible payment arrangements for some patients.
• Utilize secure, HIPAA-compliant online payment portals.

Pro Tip: Analyze patient collection KPIs like rate of bad debt, cost per encounter, rate of net collection, and more to adjust your strategies accordingly.

12. Invest in Tech and Leverage Data Analytics

Investing in technology and leveraging data analytics helps streamline operations and improve patient outcomes, making your practice more profitable.

Data analytics provides healthcare providers with comprehensive insights into patient care. And it enables more informed decisions that enhance treatment effectiveness and operational efficiency.

For example, predictive models can help identify high-risk patients and tailor interventions, reducing unnecessary costs. Also, integrating electronic medical records (EMRs) and other digital tools reduces overheads and boosts healthcare practice revenue growth.

To achieve this practice growth strategy:

• Use a robust EMR system to streamline patient record management.
• Leverage data analytics tools to analyze patient health outcomes.
• Invest in predictive analytics to identify high-risk patients.
• Automate routine administrative tasks to increase staff productivity.

Pro Tip: Regularly review and update your technology to stay current with advancements in healthcare IT.

13. Encourage Your Patients for Referrals

Encouraging patient referrals is a solid strategy for growing your medical practice’s revenue. Satisfied patients are willing to share their positive experiences with others, making referrals a breeze.

To capitalize on this, proactively request referrals. And develop systems to make it easy for patients to recommend your services. Here’s how:

• Provide referral cards and digital referral links during patient visits.
• Create an easy-to-navigate referral program with clear incentives for patients.
• Use social media and email campaigns to encourage patient referrals.
• Offer a referral bonus or recognition program for staff.
• Monitor referral sources to analyze referral strategies.

Pro Tip: Personalize your referral requests by highlighting specific aspects of the patient experience that could resonate with new patients, such as unique services.

14. Reduce No-Shows and Late Cancels

Reducing no-shows and late cancellations improves operational efficiency and maximizes revenue in medical practice. Missed appointments result in revenue losses along with inefficient use of practice resources and staff time.

The solutions? You might go for automated reminders and virtual visit options. Virtual visits remove barriers such as travel and time off work, making it easier for patients to keep appointments. And a streamlined scheduling system includes clear cancellation policies and convenient rescheduling options.

To achieve this strategy:

• Use automated appointment reminders via SMS and email.
• Offer virtual visit options and establish a clear cancellation policy.
• Provide easy rescheduling options for patients.

Pro Tip: Analyze patient no-show analytics data to identify patterns and adjust your reminder schedule or appointment availability accordingly.

15. Delegate Care in Your Practice as Appropriate

Effective delegation helps your practice be more profitable and efficient. You can outsource non-medical tasks, such as administrative duties and billing so physicians can focus on patient care. But delegation is a different set of skills you must work on.

For example, you can focus on the 5 R’s of delegation; Right Task, Right Circumstance, Right Person, Right Directions, and Right Supervision to ensure smooth delegation. This approach optimizes staff utilization, operational efficiency, and patient satisfaction.

Here are more tips to effectively delegate care:

• Ensure clear communication and proper training for staff when delegating.
• Delegate care as much as appropriate (don’t over do it).
• But outsource all your non-care tasks from coding to administrative work.
• Start evaluating the performance of delegated tasks.

Pro Tip: Create a detailed delegation plan for your practice needs and provide ongoing feedback to ensure efficiency.

16. Train and Motivate Your Practice Staff

The performance of your medical practice staff directly influences patient satisfaction and practice revenue. A motivated and well-trained team provides high-quality patient interactions and practice growth. Investing in your staff’s growth and well-being creates a more engaged workforce, improving patient care and increased revenue.

Regular training and professional development opportunities ensure that staff members are knowledgeable and efficient.

Here’s how you can increase staff engagement for practice growth:

• Provide regular training and development opportunities for all staff members.
• Go for motivational strategies such as positive feedback.
• Consider increasing or adjusting business hours to satisfy patients.
• Conduct 1:1 meetings to understand staff concerns and provide support.
• Develop a positive work environment.

Pro Tip: Use staff feedback to identify improvement areas and tailor your training and motivational strategies to increase overall performance.

17. Offer After-Hours Care (Physical & Online)

Offering after-hours visits is one of the best strategies to achieve medical practice revenue growth because it accommodates patients outside traditional office hours. You can offer physical and virtual visits to capture revenue that might otherwise be lost.

After hours visits are also convenient and flexible, helping patients schedule appointments whenever they want. Offering after-hours visits can also get facility visits, increasing revenue in medical practices from after-hours care.

Here are essentials tips for efficient after-hours care:

• Ensure you have enough, willing staff to cover after-hours shifts.
• Promote your after-hours services through social media, website, and more.
• Use telemedicine and online appointment booking to streamline the process.
• Offer flexible scheduling options to reduce wait times and increase patient satisfaction.

Pro Tip: Conduct a survey or analyze patient data to determine the need for after-hours services.

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Thanks to BellMedEx, our billing reimbursement is at its highest!

Dr. Esther

Counselor, Mental Health Clinic

Top Features

✓ New Revenue Opportunities
✓ Maximum Profits
✓ More Patient Volume

Two principal electronic systems have dropped anchor: the Electronic Medical Record (EMR) and Electronic Health Record (EHR).

At first glance, the two appear lashed together under a similar banner. However, the distinction between the EMR and EHR is as clear as an azure sky meeting a cobalt sea.

But what exactly are EMR and EHR, their differences, and how do they impact healthcare delivery? Let’s read.

An EMR typically includes a wide range of patient information, such as:

• Patient Demographics: Basic information like the patient’s name, date of birth, address, and contact details.
• Symptoms and Diagnoses: Detailed documentation of a patient’s symptoms, diagnoses made by physicians, and implemented treatment plans.
• Medication Management: A record of current medications, dosage instructions, and potential allergies.
• Analytics and Reporting Module: Analytical reports to assist providers track KPIs, identify areas for improvement, and make informed decisions.

Detailed Breakdown of the Components of an EMR System

Electronic Medical Records (EMRs) have transformed the healthcare industry by offering a digital platform to manage patient information. Understanding the core components of an EMR is important for making informed decisions when choosing the right system for your practice.

Here’s a breakdown of the essential functionalities that define a robust EMR:

1. Analytics, Dashboards & Reports

Dashboards: Provide real-time access to crucial patient health data, presented in an easy-to-understand format. This empowers healthcare providers to make quick and informed decisions during urgent situations, routine check-ups, or managing chronic conditions like diabetes.

Customizable Reports & Dashboards: Allow creation of personalized views tailored to specific needs. You can design reports to quickly review a patient’s medical history, compare it to their current status, or track trends over time.

Advanced Reporting: Facilitates the generation of detailed reports for various purposes. These reports can be used for patient case tracking, analyzing referral conversion rates, assessing staff performance, monitoring inventory, and gaining insights into various aspects of your practice.

Data-Driven Decisions: By offering a clear view of your data, EMRs empower data-driven decision making. This can lead to improved communication within your practice, a more conducive work environment, and ultimately, enhanced care delivery methods.

2. Patient Charts

Centralized Repository: EMRs eliminate the need for paper charts, offering a secure and digital solution for storing all essential patient information. This includes registration details, consultation notes, treatment records, surgical history, medication documentation, and more – all accessible within a single platform.

Additional Information: Clinical charts can encompass other elements such as:

• Chief Complaint (CC): A concise term capturing the primary reason for a patient’s visit.
• History of Present Illness (HPI): Provides a detailed narrative of the illness progression, from initial symptoms to the current state of health.
• Review of Systems (ROS): Utilizes a standardized set of questions to identify potential issues and diseases across different organ systems.

Enhanced Features: EMR systems may offer additional functionalities to streamline chart management, such as:

• Auto Save: Ensures information is automatically saved, eliminating the risk of data loss.
• Day Notes: Allows for quick documentation of daily patient encounters.
• Encounter Summaries: Provides a comprehensive overview of each patient visit.
• Flowsheets: Offer a visual representation of a patient’s health status over time, allowing for easy tracking of vital signs or other key metrics.
• Patient Vitals: Enables efficient recording and storage of vital signs like temperature, blood pressure, and heart rate.
• Preventive Screening Tools: Provides checklists and questionnaires to facilitate preventive care measures.

3. Clinical Workflows

Digital Patient Journey: EMRs enable the management of the entire patient care journey using a digital system. This includes registration, check-in, check-out, and post-treatment details.

Improved Team Communication: Streamlined workflows facilitate better communication and collaboration among healthcare teams, leading to improved care coordination and overall patient outcomes.

Data-Driven Optimization: By providing insights into staff efficiency and patient health trends, EMRs enable data-driven strategies to optimize clinical operations. These insights can be used to identify areas for improvement and implement innovative approaches to enhance healthcare delivery.

4. Collaboration Tools

Secure Messaging: EMRs often integrate secure messaging platforms that allow patients and doctors to communicate easily. This can be used for various purposes, including addressing questions, scheduling appointments, requesting prescription refills, or sharing health information.

Virtual Interactions: Some EMRs offer features like screen sharing, video conferencing, and the ability to send photos and documents. This empowers doctors to provide more comprehensive virtual consultations, improving patient engagement and satisfaction.

5. Electronic Prescriptions (E-Prescribing)

Improved Medication Management: E-prescribing allows doctors to review a patient’s medication history before prescribing new medications. This minimizes the risk of errors, drug interactions, and adverse reactions.

Enhanced Features: E-prescribing functionalities may include:

• Benefit Verification & Formulary Checks: Ensures medications are covered by a patient’s insurance and avoids prescribing medications that may interact with existing medications.
• Clinical Decision Support: Provides real-time guidance to doctors based on best practices and patient-specific factors.
• Dose Calculators: Assists healthcare providers in calculating the correct medication dosage based on the patient’s age, weight, and other factors.

Electronic Prescribing of Controlled Substances (EPCS): Allows for the secure electronic prescribing of controlled substances.

Here’s the list of key components of an EHR:

• Patient Demographics: Basic patient information like name, date of birth, address, and contact details.
• Medical History: A detailed record of a patient’s past illnesses, surgeries, allergies, immunizations, and medications, incorporating information from different healthcare providers.
• Symptoms and Diagnoses: Documentation of presenting symptoms, diagnoses made by various physicians throughout the patient’s healthcare journey, and treatment plans implemented across different care settings.
• Lab Results: Electronic copies of laboratory test results, X-rays, imaging scans, and other diagnostic reports from various facilities.
• Progress Notes: Notes and observations documented by physicians and other healthcare professionals during patient encounters.
• Insurance Information: Detailed representation of current insurance coverage helping providers verify eligibility and proceed accordingly. 
• Medication Management: A comprehensive record of current medications, dosage instructions, and potential allergies, incorporating information from different providers.
• Preventive Care Records: Documentation of vaccinations received, screenings performed, and upcoming preventive care recommendations.

Detailed Breakdown of the Components of an EHR System

An EHR system consists of various functional components working together to deliver a seamless experience for both patients and healthcare providers. Here’s a breakdown of some key components:

1. Patient Management

• Facilitates capture, storage, and retrieval of up-to-date patient information, including demographics, insurance details, past medical history, emergency contacts, and a unique medical record number.

2. Clinical Component

• Equips care teams with decision support tools to deliver quality care.
• Allows for electronic documentation of patient interactions, including history & physicals, operative notes, nursing care plans, and medication orders.

3. Secure Messaging and Alerts

• Integrates secure messaging and alerting solutions to streamline communication flow between healthcare providers.
• Enables real-time alerts for critical situations, facilitating prompt intervention and improved patient outcomes.

4. Financial Dashboards

• Integrates RCM functionalities to enhance revenue collection and financial performance.
• Provides financial insights to healthcare providers through easy-to-use dashboards.
• Offers reports on clinical and financial metrics, aiding informed decision-making about practice operations.

5. Revenue Cycle Management (RCM)

• Offers real-time data for informed financial decisions and improved patient care sustainability.
• Integrates RCM functionalities to enhance revenue collection and financial performance.

6. Clinical Data Repository

• The core component, storing all patient clinical data (demographics, medical history, medications, allergies, lab results, imaging reports).
• Utilizes standardized data formats for easy exchange between different EHR systems and healthcare applications.
• Crucial for providing a single source of truth for clinicians and generating reports to track patient trends and improve care delivery.

7. Clinical Decision Support System (CDSS)

• A computer-based system that provides clinicians with information and tools for better decision-making.
• Integrates with EHRs, utilizing patient data, clinical guidelines, and research evidence to generate recommendations.
• Offers functionalities like alerts, order sets, clinical scoring tools, and evidence summaries.
• Aims to improve quality of care by reducing errors, promoting adherence to guidelines, and offering evidence-based support.

8. Order Entry System (OES)

• Allows electronic ordering of tests, medications, and other patient services.
• Integrates with EHRs, enabling selection from pre-built options or entering custom orders.
• Electronically transmits orders to the appropriate healthcare provider or department.
• Tracks order status for improved workflow efficiency.

9. Patient Portal

• A secure online platform giving patients access to their medical records and communication channels with providers.
• Enables patients to view medical history, lab results, imaging reports, and other relevant information.
• Facilitates secure messaging with providers for inquiries, appointment requests, prescription refills, and bill payments.
• Empowers patients to be more informed participants in their healthcare journey.

10. Reporting System

• Generates reports on patient data for various purposes.
• Offers population health reports (disease prevalence, healthcare service utilization), quality improvement reports (patient outcomes, guideline adherence), regulatory compliance.

EMR Vs. EHR: The main differences explained

The difference between an Electronic Health Record and an Electronic Medical Record comes down to scope.

The EMR represents a siloed set of patient information from a single medical practice. This detailed record reflects care administered by that provider alone – think of the files kept by a primary care physician. This localized record reflects the work of an individual provider, such as a family doctor. For example, an EMR may include details of annual checkups, diagnosed conditions, and prescriptions.

The EHR, on the other hand, paints with a broader brush — incorporating records from multiple providers to form a more comprehensive picture of a patient’s medical history. For instance, the EHR may include specialist referrals and hospital visits in addition to primary care.

So while the EMR offers an in-depth view of care from a single practice, the EHR stitches together a quilt of medical encounters from across providers.

Since EMRs and EHRs are interchangeably used however, when selecting either software, it’s crucial to consider your clinic’s specific requirements to ensure optimal functionality and compatibility.

Let’s dive into the key differences between EMRs and EHRs:

1). EMR vs EHR – Scope of Information:

EMR (Electronic Medical Record): An EMR serves as a digital version of a traditional medical chart, focusing on a patient’s medical history within a specific healthcare provider’s practice (doctor’s office, hospital department, etc). It primarily includes information collected during a patient’s encounters with that specific provider.

EHR (Electronic Health Record): An EHR offers a more comprehensive view. It acts as a centralized repository, storing and integrating a patient’s medical information from various healthcare providers throughout their lifetime. Think of it as a complete picture, incorporating data from doctors, specialists, hospitals, and other healthcare settings a patient has visited.

2). EMR vs EHR – Accessibility:

EMR (Electronic Medical Record): EMRs are typically accessible by authorized personnel within the specific healthcare provider’s practice where the information was generated. Sharing information with other providers often requires manual intervention or specific data exchange protocols.

EHR (Electronic Health Record): EHRs are designed for broader accessibility, ideally allowing authorized healthcare providers across different healthcare systems to access a patient’s complete medical history with their consent. This fosters better care coordination and collaboration between specialists involved in a patient’s treatment.

3). EMR vs EHR – Focus:

EMR (Electronic Medical Record): EMRs primarily focus on documenting a patient’s medical history within a single practice. This includes details like symptoms, diagnoses, treatments, medications, and lab results collected during their visits to that specific provider.

EHR (Electronic Health Record): EHRs take a more holistic approach, aiming to provide a complete picture of a patient’s health. They not only incorporate information from various providers but may also include preventive care records, immunization history, and social determinants of health that can influence overall well-being.

EHR and EMR in Healthcare: Why EHR is better?

When it comes to managing patient records in the healthcare industry, electronic records systems have become increasingly popular. While both EMR and EHR offer digital solutions, there are distinct advantages to using EHR. One of the main benefits is the ability to share information between different healthcare providers, making it easier to coordinate care and avoid errors.

Here are the top reasons that give EHR a superlative edge over the EMR system:

Enhanced Care Coordination

Though EMRs assist independent practices in monitoring patients, EHRs allow for advanced coordination between doctors. Having access to complete records, providers can team up to plan first-rate care.

EHRs present clear advantages in terms of comprehensive patient histories and enhanced care coordination between providers. Armed with a patient’s complete records across multiple sites of care, physicians can better collaborate on treatment plans, reviewing the same information to deliver superior coordinated care.

However, EMRs retain merits for smaller, independent practices. Their lower price points and simpler implementation make EMR adoption realistic for clinics lacking resources. Within their own patient population, EMRs help identify trends and inform treatment decisions.

Improved Communication

EHRs synthesize big data across institutions to optimize treatment, whereas EMRs digitize charts economically for private practices.

Electronic health records offer patients and doctors alike a glimpse into the whole picture of one’s wellbeing. Through EHRs, patients can see their test results, message their doctors, and make choices about their care with eyes wide open. For physicians, EHRs unlock a wealth of knowledge to provide the best treatment. They can see what other doctors have prescribed, results of past procedures, and patterns that point to better solutions. EHRs are best suited for large hospitals and integrated health systems, where cooperation and coordination are most valued.

Electronic medical records, on the other hand, are useful for small practices where simplicity and low cost are priorities. EMRs do a fine job of digitizing patient charts and prescriptions, freeing up space in cramped medical offices.

Reduced Risk of Errors

EMRs may remedy the inefficiencies of paper files for small practices, but EHRs remedy the perils of fragmented care. Once a patient’s medical information is gathered from every portal they’ve passed through, doctors using EHR gain an omniscient perspective that allows them to make the right choices and avoid potentially fatal mistakes.

For a private physician’s office, an EMR offers a more organized system than paper files. Doctors can easily pull up digital charts, lab results and prescription histories for more efficient visits. This consolidated access benefits small clinics with limited staff and infrastructure.

However, larger hospitals and health networks gain more from comprehensive EHRs. With patient data integrated from various offices, labs and pharmacies, EHRs give different providers a shared understanding of each case. This reduces misdiagnoses and mistakes caused by fragmented paper trails or poor penmanship. EHRs also enable doctors to spot health patterns not visible within just one practice’s EMR dataset.

Personalized Patient Care

EHRs give doctors a complete view to shape care around patients as individuals. EMRs work fine for standalone clinics, yet they don’t have the whole story for personalized medicine.

While both EMRs and EHRs digitize patient information for providers, EHR systems offer more robust data and care coordination benefits, healthcare experts say.

EHRs give authorized providers a comprehensive view of a patient’s medical history across multiple care sites to enhance treatment personalization. Access to a patient’s complete health profile allows physicians to craft tailored care plans addressing their unique needs, risks and conditions.

An EMR, containing data siloed within one facility, provides less insight for personalized medicine. However, for independent clinics, EMR systems can efficiently digitize their patient records and medical workflows.

For larger integrated delivery networks and accountable care organizations, EHR systems better suit their needs for data fluidity across care settings to deliver high-value customized care.

Informed Decision-Making

Though EMR helps small clinics work better, EHR’s broad access to a patient’s history gives doctors a fuller perspective to make wiser choices about care.

EHR’s broad access to patient history grants providers a valuable, more holistic perspective. With medical, lab, pharmacy and other records integrated from multiple sources, physicians gain a fuller understanding of the patient’s health profile. This comprehensive view allows for more informed decision-making regarding diagnoses and treatment plans.

Yet EMR still has merits, especially for small or solo practices where clinical data sharing across organizations is less critical. For these providers, digitizing and organizing patient records can improve workflow efficiency, billing processes and compliance with regulations.

Improved Quality of Care

EHRs assemble a wide-ranging outlook by merging records across doctors. This facilitates preventive care through screening prompts and medication monitoring regardless of which physician a patient visits. EMRs focus more narrowly on the daily operations of private practices.

EHRs create a broader view by integrating records across providers. This aids preventative care through screening reminders and medication monitoring regardless of where a patient seeks treatment. EMRs have a narrower focus on office workflows for individual practices.

Small clinics may find EMRs more affordable and customized to their needs. But when it comes to big picture care coordination, EHRs have the upper hand.

Future Trends of Electronic Records in the Medical Domain

Electronic Medical Records (EMRs) and Electronic Health Records (EHRs) have revolutionized healthcare by enabling secure, digital management of patient information. But the future holds even more exciting possibilities, with a focus on improved information gain, interoperability, and leveraging the power of big data.

Here are the top future trends of EMR/EHR:

Interoperability Policies and Incentives:

• Ongoing regulations will ensure EHR systems seamlessly exchange data between different healthcare providers. This fosters a more holistic view of a patient’s health and eliminates duplicate testing.
• Government initiatives like Meaningful Use will financially incentivize healthcare organizations to adopt interoperable EMR/EHR systems, further accelerating data exchange.

Cloud-Based Security with Encrypted Access:

• Cloud computing offers scalability, remote accessibility, and automatic backups, making it the preferred platform for future EMR/EHR systems.
• Emphasis will be placed on robust security measures like encryption to safeguard sensitive patient data from cyberattacks, phishing attempts, and unauthorized access.

Standardization and Open APIs:

• Standardized data formats will ensure seamless information exchange between different EHR systems, regardless of vendor.
• Open application programming interfaces (APIs) will allow third-party developers to create innovative healthcare applications that integrate seamlessly with existing EMR/EHR systems, empowering patients with a wider range of tools to manage their health.

Robotic Process Automation (RPA):

• RPA automates repetitive tasks like data entry, reducing human error and improving data accuracy within EMR/EHR systems. This frees up healthcare professionals to focus on patient care.
• Integration of RPA with existing EMR/EHR systems will be streamlined, offering healthcare providers a practical solution to improve system efficiency and reduce manual workload.

Telehealth Integration:

• EMR/EHR systems will integrate seamlessly with telehealth platforms, enabling secure and efficient remote patient care.
• This integration will allow for real-time data exchange during virtual consultations, improving care delivery and patient engagement.

The Rise of AI, Voice Recognition, and NLP:

• Artificial intelligence (AI) will play a crucial role in analyzing vast amounts of patient data stored in EMR/EHR systems.
• AI-powered voice recognition will enhance data entry speed and accuracy, allowing doctors to focus on the patient during consultations.
• Natural Language Processing (NLP) will enable EMR/EHR systems to understand and interpret clinical notes, improving data searchability and facilitating better clinical decision-making.

Blockchain Technology for Enhanced Security:

• Blockchain technology offers a secure and tamper-proof way to store and manage patient data in EMR/EHR systems.
• This technology eliminates the need for expensive integrations between different healthcare providers, allowing authorized personnel to access patient records securely from any location.

Big Data, 5G, and 6G for Faster Analytics:

• The explosion of healthcare data from wearables, sensors, and EMR/EHR systems necessitates big data analytics for meaningful insights.
• Advanced analytics can identify trends, predict potential health risks, and personalize treatment plans for patients.
• The advent of 5G and the development of 6G technologies will provide the high-speed data transmission needed for real-time processing and analysis of large datasets.

Wearable Devices and Data Integration:

• Wearable devices will play a bigger role in healthcare, offering a continuous stream of patient health data. These devices enable you to actively track patient health metrics from their every-day activities to health condition, and medication routine, etc.
• EMR/EHR systems will integrate data from wearables, providing a more comprehensive view of a patient’s health and enabling proactive care interventions.

Real-Time Data and Analytics for Clinical Decision Support:

• EMR/EHR systems will leverage real-time data analytics to provide clinical decision support (CDS) to healthcare professionals at the point of care.
• This real-time data will empower doctors to make more informed decisions, potentially leading to improved patient outcomes.

By embracing these future trends, EMR/EHR systems will evolve into powerful tools for data-driven healthcare. This will ultimately lead to a more efficient, cost-effective, and patient-centered healthcare experience.

MIPS decides how much money Medicare will pay doctors for seeing people on Medicare. It looks at things like how healthy doctors keep their patients, how good a job they do taking care of illnesses, and what patients say about their doctors.

In 2024, MIPS scores will matter a lot. Doctors will get points for things like keeping patients healthy, properly managing diseases, and having good patient reviews. If a doctor scores well, Medicare pays them more. If they score poorly, Medicare pays them less.

This article explains MIPS in 2024 including who must participate, how scores are calculated, and how pay is adjusted based on those scores. For doctors, MIPS scores translate directly to how much they get paid, so performing well in MIPS is important business for them.

Introduction to QPP and MIPS

The Quality Payment Program (QPP) and the Merit-based Incentive Payment System (MIPS) work together to improve healthcare quality and outcomes.

The QPP was created by Medicare to reward high value, high quality care. MIPS is one part of the QPP that measures clinician performance across quality, cost, improvement activities, and promoting interoperability. MIPS scores determine payment adjustments under QPP.

So in simple terms, MIPS scores lead to QPP incentives. By participating in MIPS, clinicians can earn positive payment adjustments by scoring well. The higher the MIPS score, the higher the Medicare payment. This encourages clinicians to deliver better care. MIPS and QPP aim to tie Medicare payments to value and quality, rather than just quantity of services.

What is QPP?

The QPP stands for Quality Payment Program. It was established under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

The QPP dominates value over volume in delivering healthcare services. Its primary purpose is to improve Medicare by helping providers focus on care quality and the one-on-one patient relationships that lead to better health outcomes.

For example, under the QPP, a primary care physician is rewarded for spending more time with patients to fully understand their health conditions and provide preventative care, rather than simply treating illnesses as they arise.

The physician receives incentives for achieving better outcomes, like reducing avoidable hospital admissions, rather than being paid based on the number of office visits and procedures performed. This encourages the physician to focus on quality care.

The Quality Payment Program (QPP) consists of two major tracks:

• The Merit-based Incentive Payment System (MIPS)
• Alternative Payment Models (APMs)

What is MIPS?

The Merit-based Incentive Payment System (MIPS), established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), came into effect on January 1, 2017.

The way Medicare pays doctors these days depends a lot on how they measure up according to MACRA. MACRA takes a look at doctors individually or in their group practices and grades them on four areas:

Quality Measures – Are patients getting good, high-quality care?

Cost Measures – How much does it cost the doctor to provide that good care?

Health IT Use – Is the doctor using technology properly in the office to keep records and share information?

Practice Improvement Activities – Is the doctor constantly working to make the practice run more efficiently?

Doctors who score the best in these areas according to MACRA standards get paid more by Medicare. Those who don’t score as well may face lower payments.

MIPS acts as a catalyst for transforming the healthcare industry from fee-for-service to pay-for-value. Under the traditional fee-for-service model, providers are paid based on the quantity of services performed, regardless of outcomes. MIPS, on the other hand, ties Medicare payments to the quality of healthcare service provided by the provider to the patient and cost-efficiency.

So this would not be wrong to say that MIPS strives to transform Medicare into a purchaser of ‘Quality’ rather than ‘Quantity’.

Here’s how MIPS scoring works:

With MIPS, the idea was to take the Physician Quality Reporting System, which measured the quality of care through various metrics, the Value-based Payment Modifier, which adjusted Medicare payments based on performance, and the Electronic Health Record Incentive Program, which provided rewards for using electronic health records, and roll them all together into one consolidated program that would be easier for physicians and clinics to participate in.

Eligible clinicians are scored on four weighted performance categories: quality (30%), cost (30%), promoting interoperability (25%), and improvement activities (15%) of the total score. Based on their composite performance score, clinicians receive positive, negative, or neutral adjustments to their Medicare Part B reimbursements.

MIPS Reporting Options

There are three MIPS reporting options for eligible clinicians:

1. Traditional MIPS

This is where most physicians report on certain measures of quality, resource use, clinical practice improvement activities, and advancing care information. Based on how you score, you may earn a bonus, face no change in pay, or get a small penalty.

2. Alternative Payment Model (APM) Performance Pathway (APP)

This is for doctors already in approved Alternative Payment Models set up by Medicare. These are special programs where doctors take responsibility for both the cost and quality of care for their patients. Medicare evaluates just two categories for these doctors: quality of care and cost of care. The requirements are more flexible for doctors in these models.

3. MIPS Value Pathways (MVPs)

This pathway ties measures and activities together around a specific medical condition or procedure. The idea is to align what doctors report more closely with how they actually practice medicine. Medicare is still developing many of these MVPs with input from doctors and medical experts. Doctors can choose to report through an MVP once they are ready if they think it suits their practice better.

Eligibility and Participation in MIPS Program

If you are an individual clinician who bills Medicare Part B, such as a physician, nurse practitioner, or physician assistant, you can participate in MIPS.

Eligibility is determined based on specific criteria set by Medicare, including providing care for more than 100 Medicare patients or billing more than $30,000 to Medicare Part B during a 12-month determination period. First-year Medicare providers and those meeting the low-volume threshold are exempt from participation.

Here are some participants of MIPS:

• Physicians (MD/DO, DDS, DDM, DPM, Optometrists, and Chiropractors)
• Osteopathic Practitioners
• Physician assistants
• Nurse practitioners
• Clinical nurse specialists
• Nurse midwives
• Clinical psychologists
• Dieticians/nutritional professionals
• Clinical social workers 
• Certified nurse-midwives
• Certified registered nurse anesthetists
• Physical or occupational therapists
• Speech-language pathologists
• Qualified audiologists

Clinicians can choose their pace of participation, starting any time between January 1 and December 31 of the performance year, allowing flexibility to adapt to the Medicare Quality Payment Program (QPP).

There are 5 participation options: individual, group, virtual group, subgroup, and APM Entity. Use the QPP Participation Status Tool to view your eligibility status, which informs you of your participation options. You can also learn more about how QPP determines eligibility and the eligibility determination period and snapshots.

How to Check Your Participation Status for the Quality Payment Program of CMS?

First, get your 10-digit National Provider Identifier (NPI) code . You’ll need to enter that, along with which year you want to check – this year or maybe last year.

Once you’ve got that sorted, visit QPP’s Participation Lookup tool and look for where it says “check your participation status.” Click on that.

If you’ve never signed up for their QPP account, you’ll have to register for one. But if you already have an account, just log right in. Either way, you’ll end up on a page showing whether they’ve included you as one of the doctors getting bonuses or penalties under this here Quality Payment Program of theirs.

MIPS Categories and Scoring

MIPS includes four performance categories that are scored to calculate a composite performance score. Each category contributes a different percentage to the total score.

MIPS assesses performance scores in four categories:

1). Quality

Weight: Typically, this category contributes 30% to the overall MIPS score.

Scoring and Methodology: Healthcare providers must report on six measures of their choice, and scores are given based on performance benchmarks established by CMS (Centers for Medicare & Medicaid Services). Providers can earn up to 10 points per measure.

2). Cost

Weight: Usually accounts for 30% of the total score.

Scoring and Methodology: CMS calculates the score based on claims data, so no additional reporting is required from providers. Cost performance is evaluated through measures that assess the total cost of care during the year or hospital stay. The score reflects the resources used to care for patients and is compared against historical benchmarks and peer performance.

3). Improvement Activities (IA)

Weight: Generally makes up 15% of the MIPS score.

Scoring and Methodology: Providers select from a list of over 100 activities and report their participation. Activities vary in weight (medium or high), and providers must accumulate a set number of points to earn the total score for this category. This improves clinical practice, including care coordination, beneficiary engagement, and patient safety. There are high and medium-weighted activities, and clinicians choose the activities that best fit their practice.

4). Promoting Interoperability (PI)

Weight: Typically contributes 25% to the overall score.

Scoring and Methodology: This category focuses on using certified electronic health record technology (CEHRT) to manage patient care. Providers must report on e-prescribing, health information exchange, patient access, etc. Scores are based on performance for each measure. Clinicians must fulfill several objectives and measures, like e-prescribing and health information exchange.

Rewards for MIPS Performance Scores

The MIPS system is designed to reward high-performing clinicians to improve the overall quality of healthcare:

• Above 75 Points: Clinicians with an MIPS performance score above 75 typically receive a substantial positive payment adjustment. As of the most recent guidelines, this could be as high as 9% of their Medicare Part B reimbursements.
• Below 75 Points: Those scoring below 75 may receive a minor positive adjustment, no adjustment, or even a negative adjustment, depending on their specific score relative to the performance threshold.

MIPS Penalties and Bonuses

• Penalties: Clinicians scoring significantly below the threshold risk may receive a penalty, which decreases their Medicare reimbursements.
• Bonuses: Additional incentives, such as the exceptional performance bonus for top performers, further enhance the positive adjustments for the highest scorers.

Incentives for Participating in an Advanced APM

Advanced APMs offer a different set of incentives aimed at encouraging providers to take on more risk and responsibility for patient outcomes:

• 5% Incentive Payment: Participants in qualifying APMs can receive a lump sum incentive payment of 5% of their estimated Part B covered professional services for the previous year.
• Exemption from MIPS: Providers sufficiently involved in an Advanced APM are exempt from the MIPS reporting requirements and payment adjustments.

These frameworks are part of a broader move towards value-based care, where providers are financially incentivized to improve the Quality and efficiency of healthcare rather than the volume of services delivered.

MIPS Payment Adjustments 2024

The CMS sets the performance threshold for 2024, and clinicians’ final scores determine the payment adjustments they will receive. Providers can see positive, negative, or neutral payment adjustments depending on their MIPS final score.

For 2024, an MIPS performance score above 75 could reward providers with up to a 9% increase in Medicare reimbursements, reflecting their commitment to high-quality care.

Conversely, scores below the threshold may result in penalties, reducing Medicare payments. The program is designed to be budget-neutral, which means penalties fund the bonuses. For example, if Dr. Jones gets an 80 and gets a bonus, but Dr. Smith gets a 70 and gets penalized, it’ll balance out for Medicare’s budget.

➜ Check out this CMS User Guide to learn more about MIPS Payment Adjustments 2024 and MIPS Performance Score.

The Importance of Certified EHR Technology (CEHRT) for MIPS Reporting in 2024

If you’re going to run a medical practice these days and get proper compensation from Medicare for your services, you’re going to need an electronic health records system that’s up to snuff. Medicare calls these certified electronic health record technologies or CEHRT.

CEHRT refers to electronic health records systems that fulfill the specific requirements laid out by Medicare and Medicaid and the Office of the National Coordinator for Health Information Technology. These requirements ensure that the systems help doctors provide high-quality care, keep patients’ information private and secure, and can exchange information with other systems.

CEHRTs are key to getting scored right in Medicare’s Merit-based Incentive Payment System. MIPS evaluates how well doctors care for their patients, and having a CEHRT that meets Medicare’s standards is critical to getting a good MIPS score. A good MIPS score means better pay from Medicare.

CEHRT is essential in MIPS for several reasons:

Data Capture and Sharing

One of the primary ways in which CEHRT is used in MIPS is through its ability to capture and share data across various healthcare systems. This is essential for ensuring that patient data is easily accessible to healthcare providers, regardless of where they are located. With CEHRT, patient data can be shared in real-time, allowing for faster and more accurate decision-making.

To illustrate the importance of CEHRT in MIPS, let’s consider an example. Say a patient visits their primary care physician for a routine check-up, and the physician identifies a potential health issue that requires a specialist’s attention. With CEHRT, the primary care physician can quickly and easily share the patient’s medical records with the specialist, who can then make an informed decision about the patient’s care.

Of course, with the sharing of patient data comes concerns about security and privacy. CEHRT is designed with built-in security features to safeguard patient data, and it must meet certain interoperability and functionality requirements to ensure that data can be easily shared among various healthcare systems.

Calculating Metrics

CEHRT is pretty handy for the Merit-based Incentive Payment System. It’s because it gathers up all your patient information and then crunches the numbers to measure your performance. It looks at things like how many of your patients with diabetes got their blood sugar tested or how many ladies came in for their mammograms. The computer tallies it all up automatically so you don’t have to do it yourself with paper and pencil.

With the CEHRT figuring the metrics for you, reporting for MIPS becomes a breeze. You just review the calculations, make sure they look right, and then send them off. The MIPS agents use those metrics to evaluate how you did over the year and determine your MIPS score. A good score means you get a bonus in your Medicare payments. The CEHRT streamlines the whole MIPS process so you can focus on doctoring instead of pushing paper.

Proper Reporting Efficiency

Without CEHRT, medical practices won’t be able to properly report the necessary measures to CMS and qualify for the MIPS incentive payments. CEHRT is essential for MIPS because it provides an efficient way to collect and report the data that demonstrates a practice is providing high-quality care.

Using an electronic health record system, physicians and their staff can easily track things like patient outcomes, care coordination, patient safety and patient satisfaction. At the end of each performance year, they can then compile all this data to report to CMS and show they have earned the MIPS incentive payments.

Supporting Improvement Activities

MIPS rewards physicians based on four performance categories, one of which is Improvement Activities. This measures how providers are improving care through activities focused on patient safety, care coordination, population management, and more.

To receive credit for the Improvement Activities performance category, clinicians must attest that they have completed certain activities using CEHRT. This could involve providing patient access to EHRs, sharing information electronically with public health agencies, participating in a quality improvement registry, and so on. CEHRT offers the functionality and interoperability required to successfully carry out these improvement initiatives.

Without certified EHR systems, practices would struggle to meet the criteria for this important MIPS component.

Ensuring Compliance and Maximizing Scores

With a CEHRT system, providers can seamlessly track quality measures and report data to Medicare. This takes a huge compliance burden off their shoulders. No more manual chart reviews or spreadsheet gymnastics. The CEHRT system does that heavy lifting for them. Ultimately, this frees up time for patient care while ensuring accurate MIPS reporting.

The CEHRT optimizes and maximizes MIPS scores too. It can uncover care gaps in patient panels and suggest appropriate interventions. Providers using CEHRT often have higher scores on quality measures than those without. The system provides built-in clinical decision support that facilitates evidence-based care. This directly translates into more MIPS points.

Optimize Your MIPS Scores with BellMedEx

As a medical billing company, we offer a comprehensive Physician Billing Service that not only handles full service billing with RCM and denial management, but also optimizes a physician’s MIPS scores.

How do we do this, you ask?

Well, our process ensures that physicians gain MIPS positive reimbursements and bonuses by staying up-to-date with the latest regulatory requirements, tracking performance data, and submitting accurate and timely reports.

In addition, our EHR system is specifically geared towards MIPS reporting, providing physicians with a reliable and efficient tool to help them comply with MIPS regulations.

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Need Help In Choosing The Best Reimbursement Model For Your Practice?

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“Reimbursement”.

It’s a fancy ten-dollar word for plain old payment.

But in healthcare, it means everything.

Reimbursement in the medical world translates into a provider or healthcare facility collecting payments from the big government programs like Medicare and Medicaid or from private insurance companies for the healthcare services provided.

The way it works is the hospitals, labs and other caregivers send a bill after treating patients. The insurance company or agency reviews the charges and pays a negotiated amount.

Without a steady flow of reimbursement checks, even the best hospitals and doctors would close up shop before long.

However…

In healthcare, there are many reimbursement models to know. As a doctor, understanding each is key to picking what fits you best.

Take Fee-For-Service Reimbursement, for example. With this model, you bill for each service you provide and get paid accordingly. It’s simple but may not fit if you want steady income. Capitation Reimbursement, on the other hand, pays you a set amount per patient no matter what. You get the same pay whether patients come in or not. This guarantees income but risks leaving you short if patients need a lot of care.

This article aims to outline the major healthcare reimbursement types so you can weigh the pros and cons for your practice. The goal is to help you pick a system that lets you earn a good living while also providing the best care.

1). Fee-For-Service Reimbursement Model

Best Suited For: Healthcare providers who prioritize a high volume of services and procedures, as it allows them to be reimbursed for each individual service provided.

Fee-For-Service (FFS) is the traditional medical reimbursement model that pays doctors for each and every service they provide to the patient.

A patient walks in with a bum knee, that’s one fee. Doc orders an x-ray to see what’s the matter, that’s another fee. Gives some advice or a brace, another fee. It’s like a car mechanic – you pay for the parts and labor by each little thing.

The physician would then bill the insurance for the patient’s consult, the x-ray test, the exams, any medicines.

It’s a straightforward reimbursement model but could lead to over-testing and over-treating. Lots of volume but not always what was best for the patient. The more services a doctor provided, the more they’d make, even if it was more than medically necessary.

PROS

CONS

Full Access to Care: Patients can receive full access to care options they require if they can pay for the services. Autonomy in Treatment: Patients have the freedom to choose their healthcare providers and the type of treatment they want. Unlimited Choice: There is an unlimited choice of non-experimental treatments available. Direct Compensation: Providers are directly compensated for each service they provide. Straightforward Billing: The billing process is straightforward, making it easier for providers to get paid for services rendered.

Costly Healthcare: The FFS model is often blamed for spiraling healthcare costs. Incentive for More Services: There’s a risk of unnecessary medical procedures as providers are incentivized to offer more services to earn more money. Barriers to Quality Care: The model can create barriers to quality care and hinder care coordination. Complex Bills: Patients may receive long and confusing bills due to unbundled payments for each service.

2). Global Reimbursement Model

Best Suited For: Healthcare providers and facilities that offer comprehensive care packages, as it simplifies billing for multiple services under a single payment.

Let me break it down for you plainly: “Global Reimbursement” model is when the doctor gets a single payout for a bunch of procedures, not a pile of payments for each one. It can be applied to services done in one sitting or stretched over some time frame.

Take knee surgery for example. That includes the initial visit, the surgery itself, follow ups for 6 months after – the whole treatment package. Here the doctor will bill the global bundled code, and get paid the global fee.

Here if the doctor tries to manipulate Medicare by billing the services all split up, despite getting paid for all those services in a single payout – the doctor’s practice might face “unbundling” charges in return.

PROS	CONS
Simplified Billing: Providers deal with a single, comprehensive bill for all services rendered during an episode of care. Predictable Revenue: Providers can predict their revenue as they receive a predetermined amount for a patient’s care. Encourages Efficiency: This model incentivizes providers to deliver care efficiently to stay within the budget.	Financial Risk: Providers assume more financial risk if the costs of services exceed the fixed payment. Potential for Reduced Care: There’s a risk of providers reducing the quality or quantity of care to stay within budget. Complexity in Implementation: It can be complex to implement due to the need to define the scope of services included in the global fee.

3). Cost-based Reimbursement Model

Best Suited For: Healthcare providers serving high-need, low-income populations, where it ensures sustainability by covering actual costs.

The Cost-based Reimbursement model is one way Medicaid pays certain providers based on their actual costs of caring for recipients. Rather than a set fee-for-service, providers submit their real expenses for caring for Medicaid patients. These expenses are audited and then used to determine payment.

*Note: Interestingly, not all services delivered are eligible for cost-based payment because it is limited to allowable costs that are directly related to the provision of healthcare services.

Say a rural health clinic spends $100,000 last year on nurses, supplies, and facilities to care for Medicaid patients. The clinic submits detailed cost reports to Medicaid showing the $100k in expenses. Medicaid audits these costs and determines they are justified. Since Medicaid wants to ensure continued access for low-income individuals in rural areas, they agree to reimburse the clinic $90K – enough to cover most of their actual costs for serving this vulnerable population. This cost-based payment gives the clinic the support it needs to keep its doors open and provide essential care.

PROS	CONS
Fair Compensation: Providers are reimbursed based on the actual costs of the services provided, ensuring fair compensation. Coverage of Costs: It allows for the coverage of all costs incurred by the provider, including indirect expenses.	Complexity: The model can be complex due to the need to accurately account for all costs. Limited Incentive for Efficiency: There is less incentive for providers to be cost-efficient since reimbursement is based on costs incurred.

4). Capitation Reimbursement Model

Best Suited For: Healthcare providers and organizations aiming for cost control and efficient care delivery, particularly in managed care settings.

Some organizations that provide health care and certain other medical services receive a fixed payment amount each month for each person who has signed up to get care from them. These prepaid sums are called “Capitation Reimbursements”.

Typically, an insurance outfit will figure how much they will pay the provider every month. They review this number each year to make sure it’s still right. The idea is that people in these plans can see their doctors whenever they need to. At the same time, the doctors know they’ll get at least a minimum payment each month.

Another benefit is that medical costs are capped. In theory, this helps make sure they don’t go up faster than the economy.

For example, say an HMO gets $200 per month for each plan member. If the HMO has 5,000 members, they would get $1 million each month. The HMO would use this money to pay its doctors, clinics, and hospitals for the care provided to members. If costs of care go up, the HMO may ask the insurance company to increase the monthly capitation rate.

PROS	CONS
Efficiency and Cost-Control: Encourages providers to focus on preventive care and cost-effective treatment strategies. Reduced Overhead: Simplifies billing and reduces bookkeeping overhead for providers. Predictable Income: Offers providers a fixed amount per patient, making income predictable.	Potential for Under-Service: May lead providers to offer fewer services to stay within budget. Cheaper Services: Could incentivize the use of cheaper drugs or services. Population-Based Rates: High population areas might result in lower capitation rates, affecting income

5). Bundled / Episode-Based Reimbursement Model

Best Suited For: Healthcare providers focused on coordinated care and efficiency, particularly for procedures with well-defined episodes of care.

The bundled reimbursement model is a bit of a hybrid between the fee-for-service and capitation reimbursement model.

This reimbursement methodology is a sort of middle ground between paying fee-for-service, where providers get paid for each little thing they do, and capitation, where they get one lump sum per patient no matter what. With bundled payments, they get a single payment to cover a whole episode of care.

So for a knee replacement, the hospital, surgeons, and physical therapists would split up one bundle for that operation and all the associated care.

For example, say a man named John needs a knee replacement. The hospital and doctors will get a single bundled payment to cover the surgery, hospital stay, physical therapy, and follow up care for the next 90 days. If John has complications or needs extra services, the providers have to eat those costs. But if John recovers quickly and doesn’t need as much care, the providers get to keep the difference. The incentive is for them to work as a team to give John excellent, efficient care.

It’s an interesting approach, getting these providers aligned and collaborating instead of working in silos. And it flips the incentives too – volume goes down, efficiency goes up.

PROS	CONS
Incentivizes Quality and Efficiency: Encourages providers to deliver high-quality, coordinated care within a budget. Promotes Collaboration: Fosters collaboration among providers across different settings to improve care coordination. Predictable Costs: Provides a single, comprehensive payment that covers all services in a patient’s episode of care, making costs predictable.	Complexity: Can be complex to implement due to the need to define the scope of services included in the bundle. Financial Risk: Providers may face financial risk if the costs exceed the bundled payment amount. Potential for Reduced Services: There’s a risk of reducing services to stay within the fixed payment, which could affect care quality