CMCS Connections

The ACA: an Opportunity for an Improved Healthcare System By Rochelle Bailey he Affordable Care Act (ACA) is within our sight and implementation deadlines are quickly approaching. Federal requirements will mandate changes to provider payment methods, employee/employer benefit relations, expand funding for fraud and abuse prevention, and will create limitations on insurance company control. CMCS is looking forward to leading our partners into the new era of healthcare with cutting edge systems technology, new data analytics, and processes we've been perfecting for over a decade. The experienced and innovative leadership of CMCS will ensure successful navigation into the era of healthcare reform, and prepare our partners for what may otherwise seem like an overwhelming task. T ACA Examples ( from healthcare.gov) • Hospital Value-Based Purchasing program (VBP) offers incentives for hospitals to improve quality of care. • Physician formed "Accountable Care Organizations" will improve quality of care through care management, coordination, and reduction in avoidable readmissions. • Physician payments will be tied to quality of care goals starting in January 2015; physicians who provide higher value care will receive increased payments. N e t work E ducat i on a n d Su pport The various health plans that CMCS supports are strategizing to accommodate the increase in member populations. However, some may not be well prepared to cope with the management of care for a large influx of members with chronic conditions or who were previously without healthcare benefits. CMCS is a unique company: unlike the traditional Third Party Administrator (TPA), we offer local onsite medical management, claims processing and benefits administration, quality management and exceptional customer service. Our experience with riskbased managed care, including Medicaid and commercial entities, has given us the expertise needed for the upcoming ACA provisions. CMCS has developed a business strategy for our partners including new methodologies for efficient service, increased data reporting/analytics and quality management services. Work has begun to implement the new rules and regulations required by the ACA legislation to ensure continued efficient service to all of our customers. The emphasis on the Healthcare Effectiveness Data and Information Set (HEDIS) or quality-based reimbursement will create a greater need for our quality education and data analytics services. CMCS has developed materials and quality management reports to assist the provider offices in meeting quality standards which are tied to Pay-for-Performance programs (P4P). CMCS connections 2 Program Integrity • Funding to curb fraud and abuse will be available to increase efforts to track and investigate provider and member behavior. • Increased funding to help prevent waste in federal programs, like Medicaid, Medicare and CHIP. • Insurance companies will be required to justify premium increases to be eligible for new grants. • The Program Integrity Committee, which CMCS has convened, currently reviews aberrant billing practices and potential member fraud issues for our health plan customers. Medicaid & Healthcare Acce s s E xpan sion The ACA will also provide new funding to support construction and expansion of community health center services. Additionally, in 2014, if your employer does not offer insurance, you will be able to buy it directly in an Affordable Insurance Exchange. Workers meeting certain requirements who cannot afford coverage provided by their employer will be able to purchase a more affordable plan. As a whole, the ACA's emphasis on quality care and healthcare management will create opportunities for healthier communities. In this evolving climate of healthcare reform, CMCS is strategically positioned to provide the crucial services necessary for the success of our providers. CMCS strives to be an innovative and supportive partner for all of our clients, by proactively working side by side with the healthcare plans and providers, arming them with data and effective strategies to be successful, no matter what the challenges in healthcare management the future may hold. 4th quarter 2012

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