Are Medical Practices Moving Forward at the Same Pace as Healthcare Reforms?

Healthcare Reforms or Obamacare that had been facing a few political hurdles may have finally broken through all shackles and assumed greater acceleration. While healthcare reforms or Obamacare are largely perceived to pro-patient, physicians or medical practices have no option but to move with the requisite adaption. Amongst a host of reforms, the recommendation of the Affordable Care Act, which seeks to make medical care affordable to every US citizen, may possible be the most demanding adaption ever to have been undertaken by medical practices. This ominous burden plus the pulls of other reforms may have actually impeded their progress, which is currently way short of the expected. In fact, the industry sources believe that medical practices across the US are still struggling with implementation stage of adaptation to healthcare reforms mandates.

What makes these healthcare reforms so daunting is that:

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• Medical practices would find themselves treating more number of Medicare patients than ever before. The extension of Medicare to pre-existing cases as well as dependents under the age of 26 could prove to be exhausting of physicians, who are likely to be disproportionate or short against the patient population. According to a reliable estimate the extension of Obamacare could leave the primary care sector short by 90,000 physicians by 2020!
  
  
• The likelihood of reimbursements being progressively reduced for specialties – contrary to the general feeling of reimbursements improving with patient volume, the proposed Medicare cuts would reduce physicians’ reimbursements by as much as $700 billion. Because the Medicare and states-specific Medicaid account for nearly half of the nation’s health insurance, qualitative appreciation under ACO model of care can only help off-set the Medicare cuts with incentive-based collaborative healthcare delivery.
  
  
• The compulsory implementation of EHR under the HIPAA-5010 mandate, which is likely to disrupt operational flow, consume considerable capital expenditure, as well as train or source staff to conduct EHR systems in the way that best supports patients’ privacy and security norms.
  
  
• There could be considerable change in billing and coding under ICD-10. While ICD-10 may help in streamlining the entire process of reimbursements, physicians will still have to deal with coding-specificity.
  
  
• Fee schedules will get more and more constricted under the new healthcare reforms. While Medicare and Medicaid fees schedules will set the trend of rationalized fee-schedules, it may eventually be followed by the commercial payors as well. Physicians, amidst such dual-impact, may well be forced to optimize their billing efforts to avail maximum reimbursements. And, the process of migrating to a higher system of medical billing may be costly as well as gradual.
  
  
• Under ACO care model, physicians’ reimbursements will happen through bundled fee for services. Therefore, because ACO involves coordinated services among several doctors, there needs to be systematic appropriation of reimbursements based on the involvement of each of the doctors.

While it is true that the face of adapting to the healthcare reforms may have been and likely to be impeded by the reasons highlighted above, they can still be overcome with competent services. Medicalbillersandcoders.com – which offers inclusive Medical Billing Services to a range of medical practitioners across the 50 in the US –promises to help medical practices maneuver through, and adapt effectively and efficiently to the pace of healthcare reforms.

Billing Specialists to Look After Major Billing Issues Likely to Be Faced By Radiologists in 2013

Radiologists, who have been striving to maintain a balance between diagnostic priorities and operational compliance, may well find pulled further into a host of billing and compliance issues throughout 2013:

To begin with, they will have to discern the vital connect between diagnosis coding and procedural coding systems and the systems that have evolved to provide a common method of describing diseases, diagnoses, and procedures.

Second, like in other disciplines, they may be bound by the medical necessity clause while diagnosing high-cost tests. In fact, Medicare requires that the medical necessity of high-cost diagnostic radiology tests be proved and the extent to which they may be prescribed for beneficiaries by either primary care physicians or physician specialists. Therefore, radiologists need to be aware of both the medical necessity as well as the extent to which beneficiaries are entitled for radiology reimbursement under Medicare, Medicaid, or commercial health insurance plans.

Third, admissible radiologic expenses for Part B imaging services may be rationalized on par with industry standards. As a result, radiologists may see their reimbursements dropping or appreciation depending on where they stand vis-à-vis industry standards.

More importantly, radiologists may be under increased monitoring for billing errors, and irregularities. It could even lead to being black-listed for repeated history of billing malfunction. Therefore, it may require a concerted effort to stay clear of being guilty under Medicare, Medicaid, and other HHS programs or commercial health insurance plans.

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These ensuing operational issues may prompt radiologists to:

Screen medical necessity and ask for advanced beneficiary notices (ABNs) on Medicare patients. This could require radiologists to function in tandem with the facility staff at the patient’s hospital to ensure the ABNs are accompanied by component fee as well.

Be prepared for Recovery Audit Contractors (RACs) and Comprehensive Error Rate Testing (CERTs), which are integral to standard scrutinizing. This would call for tactical and shrewd documentation and explanation of the radiologic services billed for claiming.

Evaluate templates and exam titles in accordance with the prevailing standard of equipment, technique or procedure, and the admissible CPT codes as amended from time to time.

Establish smooth communication with billing processes during revision to equipment, techniques or procedures. This would ensure that the modifications are adequately reflected in coding and billing, and claims are devoid of either under-coding or up-coding.

Make provision for reporting discrepancies, such as number of views or extent of technical complexity. This could help radiologists recover maximum claims as well as minimize the chance of denials and auditing issues

Even as radiologists seek to implement tactical moves to counter the impact of billing issues, they may find themselves swayed more towards clinical focus. That is why it makes sense to hire Radiology Billing specialists for the purpose. Medicalbillersandcoders.com – having nation-wide affiliation with a chosen pool of radiology billing specialists – offers to deploy billing resources that are competent and experienced to address and maneuver radiologists through the billing issues likely to surface in 2013.

How Radiologists Can Refine Their Revenue Cycle Management (RCM) With Radiology Billing Specialists

The emphasis on Revenue Cycle Management could never have been so high as it is now – as radiologists begin to comply with of the Affordable Care Act’s (ACA) requirements, they would realize the importance of reinvent their billing and revenue cycle management process to suit the bundled care, shared risk, and quality-driven reimbursement models. With fee-for-service likely to be phased out in favor of value-based service model, radiologists’ revenues may be vulnerable to reductions or long hold-up at the hands of either public plans such as Medicare, Medicaid, or commercial payors. In fact, the population health management requires diagnostic radiologists to adopt shared-risk model with in a period of five years or so. Therefore, radiologists will be under the obligation to coordinate and conform to performance standards for diagnostic services, rendered to both Medicare-supported beneficiaries as well as commercial insurance beneficiaries.

While displaying the requisite level of diagnostic competence may qualify them for value-based reimbursements and incentives, it is no guarantee that they automatically get converted to monetary returns unless they have substantially modified their medical billing and RCM process to the demands of value-based reimbursement model. Notwithstanding radiologists’ internal billing resources, it may not be possible to maneuver through a more regulatory payment environment without an exclusive third party diagnostic radiology Revenue Cycle Management specialist or specialists. The advantage of having such specialists onboard your Radiology Billing and RCM is that they prove catalytic in the entire process of RCM cycle, comprising:

Credentialing with inclusion of turnkey services, payer enrollment and contracting, credentialing and verification services, state medical licensing services, and personalized attention for individuals or group radiologists

Patient Access with key demographic patient information – including name, social security number, and insurance coverage – to serves as the foundation for payment of services. It is critical that this information be accurate, and linked to other billing functions from centralized registration or pre-registration systems.

Accurate and timely charge capture to make sure that all radiology services produce payable claims; it may be remembered that reconciliation of procedures-to-charges will help confirm that an accurate number of claims have been generated.

Coding powered by automatic and electronic coding of ICD-9 and ICD-10 codes, supervised by trained coders that specialize in CPT, ER and E&M coding

Billing, complete with electronic claim submission, posting denials and aggressive follow up of delays and denials

Collection with emphasis on conversion of older account receivables first and within the permissible time limit.

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As radiologists seek to uplift their revenue fortunes with Radiology Billing Specialists, Medicablbillersandcoders.com offers to mediate the employment of radiology billing specialists, who are capable of:

• Keeping reimbursements as per negotiated fee schedules with Medicare, Medicaid, or commercial health insurance carriers
• Guaranteeing payment contracts as per prevailing market
• Minimizing A/R days through complete and timely charge capture
• Enhancing payment accuracy with line-item posting of charges and payments
• Averting risk through the industry’s most comprehensive compliance program

Efficient Billing Practice to Aid Physicians amidst Continual Coding Revisions, and Avert the Possibility of Denials

Amongst the possible reasons for denials, coding inadequacies seem to have a major impact. Because codes quantify and qualify physicians’ medical services for medical reimbursements from payers, any inherent coding error, miscoding, over or under-coding can lead to denials upon found to be incongruent with acceptable coding practices. While a few coding manipulations may happen intentionally, most of the time it is the complexities of coding that often expose physicians or their staff to coding errors. With revisions made to CPT and HCPCS Level II codes every year, coding-related complexities are destined to multiply further. Failure to discern and apply revised coding systems may eventually result in disqualification or outright Denial of Physicians’ claims. As a result, physicians may have to forgo a considerable chunk of their revenues in the absence of remedial measures.

Even as most of the physicians have some form of in-house medical billing that addresses coding demands, the growing coding revisions and complexities require much more than simple form of in-house medical coding. It really takes an efficient medical billing management to monitor and resolve coding errors and denials. The value of such efficient medical billing management is that it can:

Renew your encounter forms or super bills and systems (where codes are stored and used for claim submission) as and when coding changes are announced.

Update physicians’ internal clinical documentation in a way that best suffices the demands of evolving coding revisions or changes.

Apply revised CPT coding guidelines to validate and minimize the risk of denials. It is noteworthy that such instant adherence to coding guidelines will naturally be appreciated by payers, which may be reflected in fewer audits and denials.

Bargain for better fee schedules based on revised reimbursement rates for the new and revised codes.

Help understand and respond to payers’ payment policies towards revised codes, establishing medical necessity of a medical service, and clinical reporting.

Employ National Correct Coding Initiative (NCCI) edits while resolve the bundling of codes.

Parallel to these comprehensive medical billing management initiatives, it could also monitor and resolve denials through:

• Payer-specific report generation of denials using Review practice management system (PMS).
  
• Discover the main reason behind denials, and resubmit claims with requisite modification and correction to codes.
  
• Supporting the applied codes with solid proof of medical necessity of medical services
  

As physicians across the U.S. seek to adapt to evolving coding revisions – of which ICD-10 alone will have 70,000 odd PCS codes, it may seem difficult without experts’ intervention.

Medicalbillersandcoders.com has effectively positioned to play the role of a facilitator during this phase of coding transformation. Our affiliation with medical billing specialists – competent and experienced to bring about systematic elevation in physicians’ coding practices – should help physicians respond to the challenges of continual coding revisions, and mitigate the possibility of denials as far as possible.

Responding To Growth-Induced Orthopedic Medical Billing Needs with Specialist Intervention

Orthopedics have been on upward growth trajectory thanks to a host of conducive factors – continued pro-orthopedic Medicare reimbursement reforms, innovative care procedures, breakthroughs in orthopedic technology and anesthesia administration have largely been responsible for upsurge in practice volumes. The combination of these factors has enabled shifting orthopedic from hospital-based inpatient form to a more popular and affordable form – outpatient or ambulatory settings. It is noteworthy that this form of orthopedic care is currently growing at over 20%, which is comparable with other fastest growing specialties.

While orthopedic practitioners have reasons to be upbeat about their practice prospects, they should equally be cautious and prepared for billing complexities that may be accompanying the swelling practice volumes.

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One of the primary reasons why Orthopedic Billing may be susceptible to billing complexities is that orthopedic comprises a broad spectrum of procedures to treat a variety of orthopedic conditions, which are perceived and valued differently by payers. Therefore, it would require orthopedic practitioners to be versatile to respond with orthopedic billing and coding in conformity with individual perception of the payer who they are submitting their claim to. More than mere submission of claims, they should necessarily have a systematic Revenue Cycle Management with comprehensive processes such as coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

Significantly, insurance underpayments, which are more rampant in orthopedic and as high as 10 to 15% of the actual claims, may push orthopedic practices into a state of revenue erosion that could jeopardize their clinical and operational efficiency. As a result, they might have to emphasize on monitoring and minimizing underpayments with an effective process of credentialing, verification, patient eligibility, and proper coding & billing.

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Coding revisions too would substantially add up to Orthopedic Billing woes – with the on-set ICD-10, orthopedic codes will be more complex, detailed, and numerically too many to code a wide array of orthopedic procedures such as bone graft, open surgical partial removal of collar bone, partial repair or removal of shoulder bone, open repair of rotator cuff, open repair of rotator cuff, reconstruction rotator cuff, open repair elbow fracture involving ulnar bone, wrist fracture pinning through skin, open surgical treatment wrist fracture, shoulder scope, repair cartilage tear, shoulder scope, partial removal collar bone, shoulder scope, bone shaving, shoulder scope, rotator cuff repair, injection of lower back joint, and many more. This monumental coding revision might warrant appointment of specialist coding professionals.

The changing orthopedic coding and billing landscape would require, among various other things,

To evaluate where you stand currently as against the projected requirements for a comprehensive orthopedic RCM comprising coding, charge posting, claims filing, payment posting, A/R follow-up including denial management, and reporting.

To earmark resources to monitor finances, and assigning them the responsibility of meeting with patients before admission to pre-collect copays, deductibles and co-insurance amounts, and work out payment plans as needed.

To improve front-end revenue cycle management, comprising checking coverage and verifying patient information before hand.

To facilitate training coders on coding revisions as and when they happen.

As in the case of most busy and critical medical disciplines, orthopedics may also be bound by an overriding clinical focus that may be limiting their exposure to full-pledged orthopedic medical billing reforms. Medicalbillersandcoders.com – having successfully mediated resource-deployment for growth-induced medical billing requirements across the broad spectrum of medical disciplines – offers to replicate it in orthopedics too. With an affiliation with chosen pool of orthopedic medical billing specialists across the 50 states in the U.S., orthopedics can expect to have instant access to specialist medical billing services.