Navigating Healthcare's New Payment Landscape: CMMI's Model Terminations and the Path Forward
2 May 2025
The recent announcement from the Center for Medicare and Medicaid Innovation (CMMI)
to discontinue several key payment models by the end of 2025 represents a pivotal shift in healthcare financing. This strategic realignment—projected to save approximately $750 million—will phase out established programs including Making Care Primary, Primary Care First, and the End-Stage Renal Disease Treatment Choices Model.
Beyond the Bottom Line: Understanding the Broader Impact
While CMMI's decision is framed around fiscal responsibility and operational streamlining, the implications extend far beyond simple cost-cutting measures. The abrupt termination of these payment frameworks creates potential regulatory gaps that could significantly complicate billing processes. Healthcare providers now face the daunting challenge of adapting to new payment structures with limited guidance, increasing the likelihood of billing errors and compliance issues.
Strategic Recommendations for Health Plans
To effectively navigate this evolving landscape, health plans should consider implementing these proactive measures:
Implement rigorous pre-payment claim reviews to identify and address potential errors before payment, ensuring only legitimate claims move forward in your process
Establish continuous monitoring systems to track billing patterns and quickly identify anomalies that may indicate broader compliance issues
Foster collaborative provider education initiatives that strengthen accurate billing practices and promote a culture of compliance across your network
How Nokomis Health Can Assist
Nokomis Health's ClaimWise™ technology is designed to meticulously review every professional and facility medical claim daily, regardless of its value. This comprehensive approach ensures that both high-value and low-value claims are scrutinized with equal intensity, identifying errors that might otherwise be overlooked. By implementing ClaimWise™, health plans can detect and prevent billing inaccuracies, safeguarding against the financial risks associated with regulatory changes.
Key Features of ClaimWise™:
Comprehensive Claim Review: Analyzes 100% of claims on a pre-payment basis, ensuring that errors are identified before payments are made.
Advanced Technology and Expert Analysis: Combines proprietary technology with a team of certified medical coders to detect inaccuracies and prevent improper payments.
Customization: Tailors services to align with each client's specific policies and contracts, ensuring seamless integration with existing systems.
Minimized Provider Abrasion: Achieves a low appeal rate of less than 2% and an overturn rate under 0.5%, maintaining positive relationships with providers.
Moving Forward Together
The healthcare payment ecosystem continues to evolve, with CMMI's recent policy changes representing just one of many shifts we'll navigate together. As your partner in payment integrity, Nokomis Health remains committed to helping health plans adapt to these regulatory changes while maintaining financial stability and focusing on what matters most—quality patient care.
By leveraging specialized expertise and innovative payment integrity solutions, health plans can transform these regulatory challenges into opportunities for greater efficiency and accountability.
Interested in learning how our pre-payment review methodology and provider education programs can strengthen your organization's payment integrity?
Visit nokomishealth.com or connect with me here on LinkedIn.
Author:
Chris Wilson
EVP of Sales, Nokomis Health
