Navigating Through a Multiple Payer Environment – Providers’ Perspective

Healthcare delivery in the United States of America has come a long way from cash-based to insurance-backed. Currently, over 85% of the nation’s residents have health care plans either through employers’ private pools, private companies, the veterans’ health administration, the children’s health insurance program and Medicare/Medicaid/TRICARE. While insurance payers (whether Federal or private) essentially cover health risks of the insured, they differentiate themselves with their respective restrictive operational requirements. The impact of this restrictive payment environment is such that health care providers are increasingly finding it difficult to procure their payments on time. And, with the Federal Government inclined to make health insurance mandatory, care providers’ only hope is to find a way to deal with multiple regulatory insurance payers.

Unlike United Kingdom and Canada, which have single-payer system, US is characterized by Federal and Private Payer systems. And Federal system is again sub-divided into Medicare/Medicaid/TRICARE.

The majority of insured Americans receive their health care (insurance) coverage via a private insurance company. Currently in the country, 59.3% of all insured Americans have coverage through private insurers. These private insurance holders can once again be classified under:

• Group insurance, which is availed through an employer with provision to cover spouses and children, based on the particular package
• Individual Insurance, which is purchased by the insured himself to cover his or his family health risks
• Managed-care plans: The two most popular types of managed-care plan providers in America are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). An HMO plan will have a predetermined facility and doctor for you and/or family. When you need treatment, you will have to visit the contracted facilities and see the contracted physicians in order for the insurance to pay the bill

With so many variants of private healthcare policies, healthcare providers usually have a hard time understanding and billing with private payers. The stress is so much that it is actually started to impede their clinical efficiency, which is their main concern. There is a whole lot of stressful restrictions that providers will come across, such as:

• dealing with deductibles and copayments,
• establishing medical necessity of a procedure
• dealing with preexisting conditions

Though dealing with Federal Payer system is relatively less difficult, providers have to deal with state-specific rules that govern Medicaid/Medicare:

• With the Federal Government hinting at extending Medicare base from the current 28%, providers will have more Medicaid/Medicare supported visitors
• Federal Government entertains Medicaid/Medicare beneficiaries’ bills from only a few designated providers. Therefore, care providers have an overriding duty to check insurance authorization prior to administering medical services
• Further, Medicare/Medicaid is also bound by restrictions on repetitive, pre-existing, and quantum of admissible medical expenditure to its beneficiaries

If understanding multiple payer system and their respective restriction constitutes half of the battle, billing and coding in ICD-10 and HIPAA 5010 Version will constitute the other half. But, providers, with their clinical efficiency at stake, would do well to assign these operational issues to external billing consultants.

Medicalbillersandcoders.com with credible history of helping physicians realize maximum claim realization amidst multiple payer environment – will help make the task a lot easier. Our medical billing professionals are highly trained and certified with experience in handling multiple payer environment and the latest coding practices. Their expertise combined with our technology edge is a sure way to turnaround your practices’ revenues.

The Financial Importance of Timely Medical Claim Submission

The importance of timely claims submission is not lost on physicians or their staff and is an integral part of the revenue cycle management (RCM). The dynamic nature of the health industry and the reforms has further exacerbated the already volatile situation when it comes to claim submission, denials, and re-submissions. There are numerous factors that affect the efficiency of the claim submission process and these may range from type-o errors to other issues regarding medical billing and coding or policy matters. Moreover, the tendency to deny or reject claims based on simple errors seems to be the unwritten principle of most of the insurance companies in the market which further hampers the whole RCM process, thus affecting physician revenue and patient satisfaction.

The most important aspect in RCM is the timely filing of claims that has an undeniable impact on how much and when the providers get paid. There are, however, numerous hurdles in timely filing of claims that can be encountered in a clinic and by their staff or even medical billers and coders:

• One of the most common hurdles in timely filing of claims is the fact that simple errors can and do occur while submission and this rate is even higher for an in-house staff that juggles with numerous issues and interacts with numerous payers
• The biggest hurdle in timely filing is resubmission which is when the claim is denied and filed again due to some error or incompetence on the part of insurance companies
• However, there are other more practical hurdles such as unavailability of time, work pressure on staff, increased demand, and other pecuniary factors that influence the timely filing of the claim

The most important factor that affects the timely filing or submission of claim is whether the in-house staff is handling claim submission or interaction with payers or if the complete RCM process has been outsourced to a professional billing company that not only has competency and professionalism but is also professional and scientific in its approach. The dynamic insurance market also plays a role in the timely submission of medical claims and the rules and regulations governing various providers are also responsible for influencing the way in which claims are filed. Usually claims should be filed within 30 days of the day when the service(s) was provided; however, this may differ according to the provider policies and government guidelines.

There are many ways of dealing with the issue of untimely claims submission and its inevitable negative repercussions. However, the most important method of ensuring that claims are filed on a timely basis is to analyze the whole process of RCM so that the lacunae and repeated errors can be isolated and corrected. For instance, if a provider is denying more claims or is denying claims even when filed in a timely manner, then such situations need to be analyzed and resolved immediately. This process of finding habitual and regular errors in the process of timely submission can be easily handled by a medical billing specialist in a better manner compared to a novice or an in-house staff member.

The inevitable impact of the health reforms on claim submission and RCM is palpable in the form of adoption of 5010 platforms, Electronic Health Records (EHRs) and numerous other factors and requires specialized training and skill that can only be achieved by dedicated professionals who are capable of submitting claims in a timely manner. Moreover, recent issues such as the rapid changes in legislation, intervention of the Supreme court, legal, financial, and administrative issues surrounding ‘Obamacare’ have made it necessary to have specialized professionals who can keep up with the changes and assist in timely submission of medical claims.

Medical billers and coders at www.medicalbillersandcoders.com are not just HIPAA compliant and legally updated but also perform research and analysis of claims and strive to achieve the maximum efficiency through a scientific approach, be it claims submission or accounts receivables. To find more information and for consultancy as well as other medical billing and coding services.

Predicting the scope of medical billing consultants after 2014 and beyond

Although it has been quite a while since the Federal Government announced a series of far-reaching healthcare reforms, we are yet to experience their full impact across the healthcare continuum. And, with the Senate bill deferring a major chunk of the reforms further, it is expected that we may have to wait as late as 2014 to witness their full impact.

Amongst a string of reforms that will take effect from 2014 are the ones emanating from the Patient Protection and Affordable Care Act, which will bring immediate benefits to millions of Americans, including those who currently have coverage. The following benefits will be available in the first year after enactment of the Patient Protection and Affordable Care Act:

• Access to affordable coverage for the uninsured with pre-existing conditions, which means the act will provide $5 billion in immediate federal support for a new program to provide affordable coverage to uninsured Americans with pre-existing conditions
• Re-insurance for Retiree Health Benefit Plans, wherein the act will create immediate access to re-insurance for employer health plans providing coverage for early retirees. This re-insurance will help protect coverage while reducing premiums for employers and retirees
• Closing the Coverage Gap in the Medicare (Part D) Drug Benefit, under which the act will reduce the size of the “donut hole” by raising the ceiling on the initial coverage period by $500. There would also be guarantee of 50 percent price discounts on brand-name drugs and biologics purchased by low and middle-income beneficiaries in the coverage gap
• Extension of dependent coverage for young adults, wherein act requires insurers to permit children to stay on family policies until age 26

Coupled with this set of reforms, which are believed to improve physicians’ revenues, there are also reforms that are likely to test their ability to practice delay-and-denial-free reimbursement practices:

• The Accountable Care Organization Model, which requires physicians to realign their practices in congruence with Medicare incentive framework
• The ghost of Sustainable Growth Rate (SGR) fix, which threatens to substantially erode physicians’ share of Medicare reimbursements
• Last but not the least, the radical ICD-10 and HIPAA 5010 compliant clinical and coding practices, which, though indispensable to reduce healthcare fraud and abuse, are going to force medical practices into a more stringent reimbursement environment than ever

While the impact of the ensuing healthcare reforms are going to be felt across the whole healthcare continuum, it is the medical billing practices that would be most affected. Therefore, it is going to be crucial that medical billers and coders respond with highest degree of professional dynamism to mitigate the chances of physicians’ medical claims running the risk of denial or delay. When one thinks of the possible areas that medical billers and coders would be addressing post 2014, the following come up to the fore:

1. Ensuring compliant EMR Systems for physicians: As a seamless EMR System is the foundation for apt medical coding, medical billers will be called upon to advice their clients’ on the efficacy of implementing EMR System as part of their effective and efficient medical billing management.
2. Upgrading their competence to ICD-10 and HIPAA 5010: As the new coding and reporting regimen takes over shortly, medical billers – to avoid being outdated and obsolete – need to make a successful transition to the ensuing ICD-10 and HIPAA 5010 requirement.
3. Helping physicians on public and private insurance composition: With the healthcare reforms deciding to minimize reimbursement on Medicaid and Medicare policies, physicians/hospitals are rethinking on what should be the composition of public and private insurance holders in their patient population. Consequently, medical billers’ role assumes greater significance in recommending a judicious mix of public and private health insurance holders in their clients’ patient population.
4. Establishing a mutually respectable relationship with insurance carriers: Forging a cordial relationship can go a long way in ensuring fast, and delay free reimbursement of physicians’ medical bills; medical billers would do well to build a rapport with heterogeneous insurance carriers.
5. Educating physicians about internal preparation for medical billing: Apart from ensuring a compliant system of billing, submission, and realization, medical billers will also be called upon to educate physicians about the efficacy of upgrading internal system of data recording and filing for complimenting comprehensive needs of medical billing management.
6. Approaching Medical Billing as a wholesome exercise: Above all, medical billers will be asked to view physician’s medical billing from a complete revenue cycle management perspective rather than one-off billing exercises. Such a comprehensive approach improves the probability of positive outcomes immensely.

As physicians, in the wake of these sweeping healthcare reforms, look to elevate their billing and coding practices through outsourced medical billing services, Medicalbillersandcoders.com – known for its proven medical billing solutions to a majority of physicians, hospitals, clinics, and multispecialty groups across the whole of U.S – should be a preferential choice for streamlined medical billing practices.