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A recent letter addressed to the acting Centers for Medicare and Medicaid Services (CMS) administrator, Elizabeth Richter, by Representative Scott Peters of California and Representative Bobby Rush of Illinois, expressed concern over reimbursement methodology as it concerns radiopharmaceuticals (a group of pharmaceutical drugs with radioactive isotopes used in diagnostic and therapeutic agents).

Previously, CMS trusted reports sent via its Risk Adjustment Processing System (RAPS) mechanism to supplement encounter details in the estimation of payment but claimed that the approach would be discontinued by 2022.

Many value systems continue to be built on a fee-for-service foundation, where doctors are being limited in what they are able to do with the traditional billing and coding methods. These systems too frequently calculate procedures versus outcomes (for example, blood pressure tests versus actual progress and reducing hospitalization). It is not clear whether determined actions will result in the genuinely desired outcome of less costly, more sustainable healthcare, and those actions say nothing about real patient experiences.

As of January 1, 2021, providers who serve Medicare patients will be required to consult a Clinical Decision Support Mechanism (CDSM) and obtain a determination as to whether the test conforms to the Appropriate Use Criteria (AUC) before the test can be administered. Advanced diagnostic imaging services are crucial tools for ensuring accurate diagnoses and planning suitable treatment.

The Centers for Medicare & Medicaid Services (CMS) recently called for a greater national commitment to value-based care, based on Medicare claims data showing the effects of COVID-19 on Medicare beneficiaries. Value-based reimbursement links payments to patients’ health outcomes and quality of care. It’s been the direction healthcare is heading, and the pandemic has only accelerated the movement and highlighted the benefits to patients and practices with a comprehensive, well-implemented value-based program.

The COVID-19 pandemic has fundamentally changed the way healthcare providers provide their services, requiring them to respond to previously unforeseen challenges. CareOptimize continues to track the pandemic closely and its far-reaching consequences. As changes arise, the CareOptimize COVID-19 Insights webinars continue to highlight them.

The COVID-19 pandemic has radically changed the way healthcare providers offer their services, forcing them to adapt to unprecedented challenges. In response to these changes, CareOptimize recently launched its weekly COVID-19 Insights webinar series.