Threshold of Commercial Reasonableness: Quantitative Analysis
Due to heightened legal and regulatory scrutiny related to healthcare transactions, the issuance of commercial reasonableness opinions is a growing area of focus for professional advisors and consultants in the healthcare industry. The first and second installments of this series discussed: (1) the definition of commercial reasonableness; and, (2) the qualitative factors of a commercial reasonableness analysis. This is the third and final article in the three-part Health Capital Topics series on commercial reasonableness, and addresses the quantitative components of a defensible commercial reasonableness analysis in today's increasingly scrutinized healthcare marketplace. (Read more...)

Interventional Cardiology Recognized as Distinct Specialty by CMS
Traditionally, the Centers for Medicare and Medicaid Services (CMS) has not made a distinction between interventional cardiologists and general cardiologists in regards to reimbursement, which has led to many consultations and referral claims being denied, because both general cardiology and interventional cardiology are considered to be the same specialty. Quality metric comparisons also present confounding results because of the different patient populations and complexities that interventional cardiologists treat, in contrast to general cardiologists. To assist in remedying these issues, the Society for Cardiovascular Angiography and Interventions filed for a dedicated physician specialty code in 2013. CMS granted this request in 2014, and the specialty code was implemented on January 5, 2015. (Read more...)

Private Exchange ACOs Emerge as Next Generation ACO Model
Public health insurance exchanges, created by a provision of the Patient Protection and Affordable Care Act (ACA), have received considerable attention as health insurance coverage has been expanded to cover previously uninsured individuals. These public health insurance exchanges alone are expected to provide coverage to approximately 13 million individuals in 2015, a significant increase over the average coverage of individuals by exchanges in 2014, of approximately 7 million individuals. Private exchanges are also grabbing the attention of consumers, with enrollment in private exchanges expected to equal the enrollment in public exchanges as early as 2017. Consequently, both public and private payors are devising innovative strategies, such as partnering with Accountable Care Organizations (ACOs), to capitalize on the increasing demand for affordable health insurance plans, which offer the consumer a range of health insurance plan options. This article will discuss these new private exchange ACO models, as well as the driving factors behind the increased interest from consumers in choosing private exchanges over public exchanges. (Read more...)

The State of Mental Health Services, Treatment, and Stigma
In its simplest form, mental health is defined as: "one's emotional, psychological and social well-being. It affects how we think, feel and act as we cope with life. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood." Mental health is becoming increasingly integrated into the realm of public health; as there is a growing recognition that: (1) more people are succumbing to behavioral health issues; and, (2) greater attention is needed for these individuals. This article will explore the myriad factors that can cause mental illness; how the Affordable Care Act addresses the availability and accessibility of mental health services and treatment; and, the social stigma associated with mental illness. (Read more...)