By: Lisa Milliken, MA, CCC-SLP, FNAP, CDP, RAC-CT, TSHA President
When we hear about federal regulatory changes, such as those from the Centers for Medicare and Medicaid Services (CMS), we might think such issues only apply to clinicians who work in settings that bill Medicare, but in fact, updates from CMS will often directly influence how all other payers operate and the resulting changes may affect many other payers’ policies, protocols, and rate structures.
One of the most significant results from the CMS updates is the adjustment of reimbursement rates for other payers, including Medicare Advantage plans, Medicaid Advantage plans, private insurances, managed care plans, and even private pay plans.
When CMS sets the rates for services covered under Medicare and Medicaid, these rates also serve as benchmarks for many private payers. Therefore, any updates by CMS on rates for therapy services will then affect the amount of revenue healthcare payers receive from government-sponsored plans. This will then subsequently influence the rates they negotiate with providers. Consequently, payers may need to adapt their cost structures, premium pricing, or network strategies to maintain financial sustainability.
In addition, these federal CMS updates often change the rules for documentation, coding, and billing requirements. The different organizations and payer plans must then invest in compliance efforts to ensure they are meeting the constantly changing regulatory standards. This also can result in increased administrative costs and require ongoing training and education for staff.
Finally, CMS policies can affect how healthcare payer contracts are negotiated, due to changes in reimbursement rates and performance-based incentives. Changes in coverage policies, eligibility criteria, or access to certain treatments can influence the patient’s satisfaction and retention with that plan, so each payer/organization must communicate these changes effectively to members and provide support to navigate the constantly changing plan options.