Payment reform is here to stay. Although reimbursement will continue to evolve over the next several years, it’s unlikely that payers, commercial or government, are going to abandon risk-based models and value-based purchasing and turn the clock back to fee-for-service and volume over value.
As OPPS packaging has increased, providers may be less likely to appeal claims for certain denied charges based on medically unlikely edits, since it would not increase payments. However, providers should consider appeals when services are medically necessary and appropriate, as CMS bases future payment rates on accepted claims.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.