Friday 7 December 2012

Coping Medicaid Expansion with Shrewd Medical Billing Practices

The U.S. Department of Health and Human Services (HHS) predicts that the proposed Medicaid expansion will bring an estimated 16 million more Americans into the health-care safety net. The prediction comes even as some twenty-six states are against such expansion.

Although the proposed Medicaid expansion would eventually weigh more on the respective states’ budgetary allocation for meeting Medicaid expenditure as soon as the Federal Government’s ceases to support Medicaid related expenditure, it is imperative that, in a Federal Setup, states follow certain measures as dictated by the Federal mandate. Moreover, Medicaid, expansion, being a pro-healthcare measure, is destined to elevate the quality of public healthcare across the country in tandem with Medicare reforms.
Coming to the composition of the Medicaid expansion, the proposed scheme opens up health insurance eligibility to all people with household incomes up to 133 percent of the Federal poverty level. Irrespective of whether you are unemployed or the so-called working poor – there can be no denial of Medicaid coverage from January 2014. This is going to be a significant shift from the current coverage which covers only low-income parents and children, and the frail elderly and the disabled. Therefore, when it comes to pro-societal issue, quality healthcare should take precedence over the rest. Quite encouragingly, some states – California, Connecticut, Minnesota, New Jersey and Washington have already started with the expansion of Medicaid programs.

While Medicare expansion is going to bring an unprecedented population under the ambit of Medicaid, physicians will have a hard time in coping up with sudden influx of patients. The situation is going to even more serious if the patients happen to be in need of specialty services as there is already a dearth of specialty-specific physicians across the state. And, with the situation requiring sometime to become ideal, the existing physicians will have to bear the additional brunt. Although the additional workload would also bring in additional revenues from Medicaid reimbursements, their medical billing practices would be put to test as Medicaid reimbursement environment has progressively become more stringent over the years. When you consider dealing with such stringent environment along with the mandatory EHR compliance that support ICD-10 and HIPAA 5010 practices, you might get apprehensive of physicians’ ability to devote quality time to patient care.

Therefore, it becomes inevitable that they seek medical billing and Revenue Cycle Management Services (RCM) that would not only ensure maximization of their revenues but also elevate their clinical efficiency. Care should also be taken to analyze your prospective service providers’ credibility and competence for Medicaid-related reimbursement practices.

While you embark on seeking a suitable medical billing and Revenue Cycle Management Services (RCM) provider, Medicalbillersandcoders.com (www.medicalbillersandcoders.com) – by virtue of long-standing reputation as a credible and competent source for Medicaid-related billing and Revenue Cycle Management Services (RCM) comprising Patient Scheduling and Reminders, Patient enrollment, Insurance Enrollment, Insurance verification, Insurance Authorizations, Coding and audits, Billing and Reconciling of Accounts, Account Analysis and Denial Management, AR Management, and Financial Management Reporting – may well prove to be your preferential recourse.

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.