Now that our federal government is working again, components of the Affordable Care Act (ACA) regulations are moving forward with implementation and becoming more obvious and personal to each of us.  While there are significant differences in opinions or philosophies within our Medical Staff toward specific sections of the ACA, I believe that we all understand that we must partner to meet the aims of the ACA:

1. Improve the quality of care
2. Improve the health to our communities
3. Bend the cost curve downward

Addressing the cost of care is being tied to the value perceived by the purchaser to the reimbursement amount. A not so philosophical question being asked by payors is why they should pay us as hospitals or physicians for care that does not conform to quality standards or demonstrate an effort on our part to improve the health status of the insured patient or population. CMS (Medicare and Medicaid) are now aggressively recouping payments that were made to hospitals in which the hospital did not document the appropriate quality of care provided or justification for services provided. Called RAC audits, this CMS effort to assess the value is resulting in many millions of dollars being reimbursed to the government payer purely for poor documentation regardless of a good outcome.

Read on