Getting value from health spending: going beyond payment reform.

It is widely held that fee-for-service (FFS) payment systems reward volume and intensity of services, contributing to overall cost inflation, while doing little to reward quality, efficiency, or care coordination. Recently, The National Commission on Physician Payment Reform (sponsored by SGIM) has recommended that payers "should largely eliminate stand-alone fee-for-service payment to medical practices because of its inherent inefficiencies and problematic financial incentives." As the current and former Chief Medical Officers of a large national insurer, we agree that payment reform is a critical component of health care modernization. But calls to transform payment simultaneously go too far, and don't go far enough. Based on our experience, we believe there are several critical ingredients that are either missing or under-emphasized in most payment reform proposals, including: health care is local so no one size fits all; upgrading performance measures; monitoring/overcoming unintended consequences; using a full toolbox to achieve transformation; and ensuring that the necessary components for successful delivery reform are in place. Thinking holistically and remembering that healthcare is a complex adaptive system are crucial to achieving better results for patients and the health system.

The Medicare audit and appeals process: a guide for interventional pain practitioners.

BACKGROUND: Health care is a highly regulated industry and interventional pain physicians (IPPs) are right in the government's bull's eye. Over the next few years, IPPs will find themselves responding to audit requests from Medicare. An IPP's response to a Medicare record request should be tailored specifically to the type of request and the specific circumstances of the IPP. With so much at stake, IPPs should not underestimate the importance of an immediate and thoughtful response. OBJECTIVES: This article discusses 1) the various types of record requests used by Medicare, 2) the practical steps an IPP should take in response to a record request, 3) the Medicare appeals process, and, 4) the practical steps an IPP should take in connection with the appeals process. DISCUSSION: IPPs should maintain an effective compliance program and ensure that medical records are appropriately documented before any audit takes place. If a Medicare audit decision is unfavorable, IPPs should understand the available appeals process and the steps that need to be taken to win the appeal. CONCLUSION: With advance preparation and a considered response, IPPs can positively influence the outcome of a Medicare audit.