Negotiating Your Reimbursement Rates during this Phase of Payer Consolidation & Health Insurer Monopoly Power

Physicians’ choice of health plans and contracts seem to be getting fewer and fewer with each passing moment as U.S. health insurance sector, particularly the private sector, witnesses unprecedented payer consolidation, acquisitions, and mergers amongst private health insurance carriers. Besides contradicting the hope that such consolidation, acquisitions, and mergers would bring down the cost premiums for patients, it has virtually helped a few players to wield monopoly over the entire commercial health insurance landscape. The situation has grown so unchecked 70 percent of 385 metropolitan areas in the U.S. do not have competitive conditions, and as much as 40 percent of these areas have a single health insurer controlling the majority share of the commercial health insurance market. As a result, physicians have virtually lost the bargaining leverage that they would have enforced had there been a perfect competitive market for commercial plans.

Physicians only source of revenue is from reimbursements from services they offer to patients, who may be supported commercial health insurance plans or public programs, such as Medicaid and Medicare. With most of the commercial health insurance market moving toward monopoly, physicians, mostly those practicing in small groups, are finding it difficult to negotiate adequate reimbursements. As a result, those insurers with monopoly powers are dictating the payment rates, which are often below the acceptable scale. Such unilateral administration of payments could leave physicians struggling to meet their financial obligations, obligations, including payroll, and to invest in and sustain desirable quality of medical care to their patients.

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Even the thought of accepting public insurance plans may not prove to be all that profitable – most of the patients may not have the resources to pay for out-of-pocket expenses well above the rates borne public programs, such as Medicare and Medicaid, whose rates are deemed insufficient to cover for a decent quality of medical cost. Thus, small physicians are often left with no choice but to accept rates dictated by dominant commercial insurers.

While the physicians associations have voiced strong protest against health insurer consolidations, in particular, mergers between two health insurers which threaten to create a single insurer with absolute power, it may take a while to disintegrate the trend towards a competitive market that can bring back bargaining power to physicians and patients alike. Till such time, physicians may well have to be content with rates as fixed their commercial payer. Alternatively, they can entrust their Medical Billing processes to an external entity that can use its competence and experience to arrive at as profitable a rate as possible. 

Medicalbillersandcoders.com – which has been a preferred platform for comprehensive medical billing resources – can help physicians impacted with the trend of commercial insurance consolidation. Our nation-wide affiliation with chosen pool of medical billing experts helps us to deploy resources that enhance medical billing efficiency, reduce the possibility of delay, denials, and improve practice revenues. Their expertise and experience could easily be extended for negotiating as best a reimbursement rate as possible even at this juncture of commercial payer monopoly.

How best are medical practices prepared to address HIPAA breaches?

Contrary to the notion that government’s move to digitize healthcare information would enable healthcare providers, doctors, and insurance companies comply more aptly with HIPAA’s guidelines for patients’ privacy and security, there has been an upsurge in HIPAA breaches with providers being reported for breaches of some kind or the other. Electronic Health Record (EHR) systems, which are made mandatory for providers seeking to attain ‘Meaningful Use’ status, have shown propensity to be manipulated either internally or by unscrupulous external elements. Either way, providers have been held accountable and penalized for breach of HIPAA’s mandate for ensuring patients’ information safety and security. With the cost data breaches being unbearable and providers or doctors’ credibility at stake, it is inevitable that HIPAA breaches are responded instantly with remedial measures, such as:

• Replacing or removing the staff that may have committed the violation at a particular EHR access point. If the HIPAA breach is traced to an external attack, EHR access may need to be secured against all possible external threats such as hacks or thefts by manipulating EHR system passwords.
  
  
• Parallel recommendation to improve the HIPAA program; an intrinsic part of such improvement program would necessarily mean reframing EHR policy and staff training or reorientation in accordance with changing EHR environment.
  
  
• Apprising your EHR vendors of the need for better customizing the EHR systems so that you may possibly withstand any kind of threats to patients’ health data.
  
  
• Establishing protocols for tasks, timelines and communication among the team to ensure everything on your EHR system runs as smoothly as possible.
  
  
• Accurate and thorough assessment of the potential risks and vulnerabilities to the confidentiality, integrity and availability of electronic protected health information (EPHI).Irrespective of the compliance requirements, it is important that scope of the assessment is clearly defined, and communicated across the staff entrusted with the responsibility of conducting healthcare data in accordance with ‘Meaningful Use’ criterion under HIPAA.
  
  
• Determining how personal health information (PHI) and electronic personal health information (EPHI) are received, stored, transmitted, accessed or disclosed.
  
  
• Documenting HHS, which will require the analysis in writing, including material gathered and the corrective actions took to remediate problems uncovered by the assessment. The significance of such reports is that they act reference as well as proof during audits or verification by authorities.
  
  
• Conducting periodic risk assessments to mitigate the possibility of a potential data breach.

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While providers or doctors may have some form mechanism to respond any case of healthcare data breach or violation, it may not always possible for everyone to have comprehensive set of measures, working to put their EHR systems compliant with HIPAA audits. Therefore, they may have to seek external help to keep eternal vigil on their data systems.

And, when it is the question of sourcing resources for such an array of data-related tasks, Medicalbillersandcoders.com offers to mediate for the deployment of best resources that have demonstrated expertise and experience in implementing secure and HIPAA compliant healthcare data management systems and processes.

What Do Stage 2 Meaningful Use Guidelines Have in Store for Radiologists?

Stage 2 meaningful use guidelines are finally out, and radiologists may heave a sigh of relief since most of the ambiguity that existed in Stage 1 about their eligibility and the ways to approach the qualification criterion seem to have been made amply clear by CMS and the Office of the National Coordinator (ONC). The American College of Radiology (ACR) needs word praise for its relentless effort in getting most of the necessary changes made to radiology guidelines before the Stage 2 meaningful compliance regime comes into force.  While it is not before 2014 that radiologists should complying with newly laid out guidelines, it may still require some crucial adjustments in processes and technology to be fully ready for compliance and qualification under State 2 of meaningful use criterion.

Even as the Stage 2 requirements offer clarity for how computerized physician order entry (CPOE) will impact radiology, providers would still be required to use CPOE to order more than 30 percent — instead of the 60 percent CMS originally proposed — of radiology procedures during an EHR reporting period in order to qualify for MU incentive payments. Therefore, the necessity of having an efficient and effective computerized physician order entry (CPOE) would still be there.

As regards the problem of complying with the MU requirements on account of rarity of face-to-face contact with patients, radiologists and other providers may get reprieve from noncompliance penalties, but still they would be required to be versatile with specialty codes use in the Provider Enrollment Chain and Ownership System (PECOS). And this proficiency in using the Provider Enrollment Chain and Ownership System (PECOS) would definitely require specialized training or they might have to appoint external coding specialists for the purpose.

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While Stage 2 rules do not require an EHR to store images, providers or radiologist would still be required to ensure that they an active link to the images. Despite the initially proposed linkage of 40% being brought down to 10% finally, it would still be quite a task to keep those 10% active as and when required for clinical study, interpretation, or sought by patients for various documentation needs.

Along with these inherent challenges, providers or radiologists may still have to sort out the issue with employing clinical decision support (CDS) as The Stage 2 rules to do not expand the definition of CPOE to include computerized decision support (CDS). Also, there may be issues with transporting images in the absence of clear cut rules even in Stage 2. While DICOM mode can be relied upon for secure encoding images,   IHE profiles, such as XDS-I and XDR-I would still have to be sent via secure email, which may sometimes be vulnerable to security and privacy threats. Therefore, it could require a dedicated monitoring to see that such files are not exposed to threats.

Amidst managing as critical a practice as radiology, complying with these set of Stage 2 guidelines for meaningful use might either be too demanding or detrimental to the very purpose of diagnostic or imaging excellence.  Medicalbillersandcoders.com – with an objective to ensure diagnostic or imaging excellence unaffected by Stage 2 demands – has offered to mediate the deployment of Radiology Billing specialists that have the requisite competence and experience to implement processes and technology on behalf of radiologists, seeking to comply with the Stage 2 guidelines, and qualify for incentives.

Medicare Fraud Claims, A New Challenge Even For Honest US Physicians – is Competent Billing and Coding A Way Out?

In 2010, Medicare improper payment amounted to $47.9 billion. Human and Health Services, in 2011, recovered $4.1 billion paid through reimbursements as a result of ‘fraudulent’ or ‘improper’ claims. You may be right if you think you won’t ever be among the fraudulent care practitioners who contributed to these figures because you are scrupulous.

But being scrupulous can’t prevent you from being suspected by federal authorities, thanks to the profusion of fraudulent cases – because bizarrely all some care providers have had to do to attract the scrutiny of federal authorities is over use a billing code, regardless of whether they did it for right or wrong reasons.

Why guard against Medicare fraud claims?

What federal authorities track is which codes are being used the most in terms of charges and unit volume at a national level. And then monitors the use of these codes by care practitioners. Currently E&M codes, for instance, have been found to be high in terms of charges and unit volume at a national level and are expected to be a potential target. It means merely using E&M codes can actually expose physician centers to scrutiny by Medicare authorities.

However, to negotiate this situation, you have to understand why it’s happening. And to understand this phenomenon, let us use E&M codes as an example to see how they actually can become subjects of potential abuse. (Remember, it could be any codes; E&M has just been used as an example here.) E&M services are ones provided by physicians and non-physician practitioners to assess patients and manage their care – and the code to get reimbursement is chosen based on the location where the service is performed, medical history, examination and medical decision making.

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As is evident, while some of the bases of choosing E&M codes are objective and straightforward, others are subjective in nature and dependent on availability of information (medical decision making, medical history etc) to the coder who is making the choice. This leaves a scope for human error (both deliberate and otherwise) and misjudgment.

The problems physician practices face today are in the subjective areas. Their in-house billers and coders mostly contend with ineffective in-house coordination between billing and coding and medical processes leading to inadequate medical information based on which coding judgments are made. Even if medical information is available, billers and coders are sometimes beset by lack of sound-enough familiarity with complex medical procedures where diagnoses may often overlap making it difficult to decipher where one ends and another starts leading to wrong assignment of codes and overbilling through coding of diagnoses not covered by Medicare.

With most physician centers the concern is not intended fraud but misinformation and inaccuracy in coding construed as fraud by Medicare or over coding a code under surveillance without documents and details to support it.

Guarding your practice...

You can guard yourself against eventualities stemming from this by tightening up your revenue management system so that there is adequate coordination between various processes ensuring a seamless flow of information and then conducting periodic internal audits by certified coders who will randomly pull up billing and coding documentation of recent patients to check their accuracy.

A clean in-house process or billing and coding handled by experienced billers and coders is the best way to avoid fraudulence and wrong data leading to financial penalties and resulting and attendant consequences.

MBC has helped several big and small care providers to spruce up their revenue management system through its Revenue Management Consulting services. We perform a thorough analysis of your revenue management cycle and lubricate various points of interaction it has with other areas of operation ensuring smooth flow of data. This involves identifying gaps in your process and addressing them by replacing, if necessary, old software applications with new ones, blocking areas of revenue leakage and identifying areas of staff training.  

Medicalbillerandcoders.com, the largest consortium of billers and coders in the US, who are experienced, certified and updated regularly, has helped medical practices improve their finances due to accurate electronic billing, intricate procedure coding, electronic filing of claims and a multi-layered application process - collectively resulting in reduced claim denials and enhanced core-business focus.

Protect Your Medical Practice in Uncertain Times with a Medical Billing Specialist

The healthcare reforms brought by the Obama administration have in many ways been an industry-churning affair. They have changed the number of patients the healthcare centers receive today, affected the administrative activities that revolve around a typical treatment episode, shifted the professional location of several medical practitioners (independent physicians aligning with hospitals) etc.

These changes have caused severe hurt to small healthcare centers and left the big ones financially ruffled, leaving organizations ill-equipped to meet their future goals leaving them far behind organizational aspirations.  

If we look at the changes triggered by reforms as separate facts without any connecting link between them, the situation will look irretrievable. But if we look a little closer to find out that link which unites them, what will spring to our attention is the fact that all of them have a revenue impact on a healthcare organization.

For example, a healthcare organization receiving more patients stems from the fact that the reforms have widened the healthcare security net to include more people than before. It is commendable but more patients may lead to more rejection of reimbursement claims if their insurance eligibility and extent of insurance coverage are not properly checked and proper codes not assigned while preparing their claims, not to mention the fact that more volume causes oversight of minor details.

The second example pertains to administrative responsibilities. While administrative responsibilities were always part of a treatment episode, they have become a concern today as the new changes brought by reforms need a greater collaboration among medical and nonmedical (billing and coding) sections of a healthcare organization to ensure a steady flow of medical information between them based on which decisions will be made. A point in case is the Medicare frauds coming to light in case of E&M coding where the choice of appropriate codes is done by the coder based on medical inputs he/she receives. 

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There is also a need to understand the medical information (about procedures and diagnoses) passed on to billers and coders accurately so that proper coding choices can be made preventing making under-claims and over-claims, especially the latter as it can lead to security by Medicare authorities, now overly sensitized by rising insurance frauds. Similarly, there are other operational challenges brought in by reforms.

Independent physicians aligning with hospital is not a very old phenomenon and one that had been sparked by healthcare reforms – because, to transfer cost benefit to the patient, reimbursement requires services to be bundled up, which has forced hospitals to align with independent physicians to offer varied medical services under one roof, begetting a new set of problems for in-house billing and coding and administrative teams to contend with.

And the impacts of these challenges accumulated over a period of time starts showing on the financial performance of a healthcare organization leading to a situation where yearly financial targets missed by small margins each year adds up to form a big lag after the lapse of a passage of time, sapping vigor and life out of the organization. 

Medicalbillersandcoders.com the largest billing and coding consortium in the US has helped both small and big healthcare centers to avoid this scenario by offering billing and coding service modules that are flexible and can be adjusted to fit the billing and coding needs of any healthcare organization regardless of size.

If you are a large medical outfit with an in-house team of billers and coders to handle claims, as part of our Revenue Management Consulting services, we can prune up your revenue management system by advising you about software applications suiting your purpose and environment, sprucing up your lengthy processes or replacing them with new ones if required and training people in new billing and coding techniques and methodologies.

However, if you neither have an in-house team of billers and coders nor any reason to have one, you can outsource your entire billing and coding process to us and nullify your claim rejection rates and boost your revenues.