Reimbursement Policy

The Federal government’s primary role in the health care system is as a payer. Through Medicare, Medicaid and the Children’s Health Insurance Program, the government is the largest payer for health care in the country. In addition to setting coverage and payment rules for Medicare, Medicaid and CHIP, the federal government also establishes and oversees and enforces healthcare transaction and privacy policies mandated by HIPAA. It is not uncommon for the federal government to use Medicare, Medicaid or CHIP coverage and payment policy as a means of achieving broader social policy objectives.

In recent years, federal health policy makers have sought to move away from a fee-for-service payment methodology that seemingly rewards providers for simply providing more care and instead, promote payment policies that reward providers for providing better care. In effect, institute a payment system that rewards value and the quality of outcomes. New payment models are being introduced and tested by the Center for Medicare and Medicaid Innovation and could if moved beyond the demonstration phase, dramatically change where, when and how health care services are provided.

Recently, Congress consolidated many of the new, innovative payment models into a single program called the Merit-based Incentive Payment System which financially rewards or penalizes healthcare providers based on their relative performance under four categories: Quality, Cost, Practice Improvement and Utilization of Information technology. Meanwhile, Congress and CMS continue to develop and implement new Alternative Payment Models. Understanding the complexities of these new quality-based reimbursement systems will, we believe, prove to be among the most significant challenges for health policy in the near future. 

Capitol Associates staff have been intimately involved in virtually every major healthcare debate that has occurred over the past four decades. Whether it was moving hospitals to a DRG based Prospective Payment System; Rural Health Clinics to a Medicaid PPS payment model, physicians to the Resource Based Relative Value Scale system or the repeal and replace of SGR, CAI staff have been front and center advising elected officials on how to vote on these policy changes or helping Corporate Executives and Association leaders understand the impact of these policy changes. CAI staff bring decades of experience working with both Congress and the Agencies on reimbursement issues to effectively manage an association’s role in the reimbursement process and to make sure their priorities align with current and future trends.

Ultimately, Capitol Associates is most interested in how value-based healthcare impacts patients. President of Capitol Associates, Bill Finerfrock, recently moderated a conversation between two leading physician experts from the Movement is Life Caucus regarding the perverse incentive bundled payment models could have on physicians and their willingness to treat minority patients, women patients and medically complex patients.

If you are seeking a firm that understands healthcare compliance, administrative simplification, regulatory relief, coverage and payment policy, then we’d love to talk with you. Staff at CAI not only know health care policy but we know who to talk to and how to frame your arguments to substantially increase your chances of success in the legislative and regulatory arena.