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.

‘Pay-as-you-go’ as a value-based medical billing service model

While we are not alien to the term ‘pay-as-you-go’, it is something that is catching the imagination of physicians opting for outsourced medical billing services. Unlike in the past, when ‘pay-as-you-go’ was sporadically availed by a few physicians, it is now emerging as a viable alternative to long-term contractual medical billing services. Well… what is this ‘pay-as-you-go’ service model after all and what makes it so affable to physicians opting for outsourced medical billing services? Much true to its name, ‘pay-as-you-go’ service model’ is a niche medical billing service wherein physicians are obliged to pay their service provider (usually a percentage of the eventual reimbursement) only when they approach for getting their bills reimbursed. Usually, a percentage is worked out prior to soliciting ‘pay-as-you-go’ medical billing services from prospective medical billing companies. The reason why the present-day generation physicians deem ‘pay-as-you-go’ service model’ appropriate is primarily because of their restrictive financial ability as well as being able to transact on value-based system.

The surge in the demand for ‘pay-as-you-go’ service model’ has its roots in a combination of factors – spiraling cost of contractual billing services, continuous fall in reimbursement rates, rapid increase in stand-alone or small physician practices, and less incidence of insurance-backed medical services, popularly known as cash-based services. The thought of countering this adverse impact on physicians’ revenues through in-house medical billing seems to have lost its significance amidst the monumental cost associated with switch over to mandatory EHR, and the ensuing ICD-10 & HIPAA 5010 compliant clinical and operational mandate. While physicians are convinced of the efficacy of ‘pay-as-you-go’ service model’ in countering their sagging revenue fortunes, service providers need to be equally responsive to such demand from physicians. Notwithstanding it being an additional service portfolio in the medical billing companies’ service offering, many medical billing companies are apprehensive of the future of the contractual model. But, their reasoning may not be true.

The main reason why they may not be true in assuming ‘pay-as-you-go’ service model to be detrimental to the future of the contractual model is the fact that large hospitals, clinics, multispecialty groups, and more importantly the ACOs will continue to drive the demand for contractual model of medical billing services.  Therefore, ‘pay-as-you-go’ service model will not come in the way of their main service portfolio, but will only evolve to be an additional revenue source. In view of such scope for additional portfolio of service, medical billing services would do well to strategically expand their ‘pay-as-you-go’ service model to the areas where challenges faced in medical billing are rampant. On the whole, it puts both physicians as well as service provides in a win-win position.

While most of the medical billing companies are still analyzing the pros and cons of ‘pay-as-you-go’ service model, Medicalbillersandcoders.com (www.medicalbillersandcoders.com) – by virtue of being the largest consortium of medical billers and coders across the U.S – has already begun to reach to the physician practices in need of ‘pay-as-you-go’ service model. The strategic spread of its diverse medical billers and coders across the regions dominated by stand-alone practitioners makes it easily accessible and affordable.

How are States retaining physicians in times of shortage?

Physician shortages is a growing concern and is pushing various states to keep doctors trained in medical schools and residency programs from crossing state lines to practice medicine. According to new statistics from the Assn. of American Medical Colleges- nationwide, there were 258.7 active physicians per 100,000 people and in individual states, ratios range from a high of 415.5 physicians per 100,000 people in Massachusetts to a low of 176.4 per 100,000 in Mississippi.

In this scenario medical school, hospitals, medical societies and state legislatures are increasingly taking a practical approach to retain the physicians and doctors-in-training in their state. According to a report by AAMC Center for Workforce Studies on average:

39% of U.S. physicians practice	State where they went to medical school
48% of U.S. physicians practice	State where they completed graduate medical education

Methods adopted by states to retain physicians

AAMC projections depict that physician shortages nationwide are projected to reach 62,900 doctors by 2015 and 91,500 by 2020 and several states to retain physicians have:

• Opened new medical schools or expanded existing ones
• Are offering incentives such as bonuses, scholarships or loan repayment programs to physicians
• Communities are developing new residency programs with the aim that physicians will develop long-term professional and personal relationships during GME training and keep them from moving out
• Certain schools’ mission is to train physicians from their states to practice in their states. However states need enough GME training positions else this efforts are wasted as then physicians will shift to another state

Iowa is below national average retaining 22% of its medical school graduates and 37% of physicians who complete GME training in the state and several efforts in Iowa have been designed to attract physicians to stay in the state. Several other states including Kansas, Mississippi and Alabama offer loan repayment programs for doctors to practice locally.

In Oklahoma, the state offers scholarships and loans to medical students and residents who agree to practice in rural Oklahoma for a set amount of time. Hence Oklahoma is above national averages, retaining 48% of its medical school graduates and 52% of physicians who complete residency training.

Physician adapting to this shortage

Higher revenues and incentives would attract more physicians to the profession and also keep doctors from moving out from states. Healthcare reforms are striving to improve quality of care and physician incentives, to entice more doctors to stay in the profession; but this leaves doctors with little time to balance both patient care and Revenue Cycle Management. As physicians move towards a value based system of healthcare delivery, they would be well-off by partnering with experienced Medical Billing Companies which can offer a balanced approach for both operational as well as revenue maximization.

Medicalbillersandcoders.com experienced in offering cost-optimizing and revenue-maximizing Medical Billing Revenue Cycle Management in tandem with their goal to assist healthcare should be able to play an essential role in making physicians’ transition towards a value based model easier and profitable, hence also helping towards eliminating physician shortage in the long term.

Medicalbillersandcoders.com offers 35 weeks of ICD-10 training updates for Billers & Coders across 50 US States

Wilmington, 1st March, 2012

Medical Billers and Coders consistently updating themselves on industry requirements, is gearing up for ICD-10 and is launching an 87 week journey towards ICD-10 orientation today. Being more than two years since the final rule was released and at the mid-point for ICD-10-CM/PCS implementation, Medicalbillersandcoders.com cautions all Medical Billing and Coding Professionals especially those who haven’t, to start planning for the transition right away!

The 1st step in a long journey being the most important, Medicalbillersandcoders.com invites all Medical Billers and Coders to take the first step in the initial 35 week journey - when updates and training material will be shared to help them evolve with the US healthcare industry.

For Medicalbillersandcoders.com ICD 10 orientation, countdown begins 1st of March 2012 and ends 13thof October 2013- in this 87 week program Medicalbillersandcoders.com in the first 35 weeks will share updates and build base for the latest coding updates, while in the remaining 52 weeks will comprise of actual training. In the scenario where The Centers for Medicare and Medicaid Services stands firm on the ICD-10 compliance date of 1st October 2013, stating there will be no delays or grace period, and post this date providers claims only in ICD-10 format will be paid, Medicalbillersandcoders.com urges all related healthcare professionals to get ready to ensure smooth flow of revenue and avoid reimbursement issues.

Medicalbillersandcoders.com boosts billers and coders to face the humungous ICD-10 challenge

Preparation for ICD-10 brings huge and exciting challenges to the healthcare industry along with benefits in the form of improvement of the capture of healthcare information. However Medicalbillersandcoders.com in anticipation of the changes it can bring about in medical billing practices, likely to cause considerable slowdowns in billing and payment and the upheaval it can create if not implemented the right way, encourages all medical billers and coders to be ready for this challenge.

ICD-10 & challenges:

• ICD-10 has 10 times the number of codes compared to ICD 9CM - Coders knowledge of anatomy and physiology, as well as medical terminology will require to be more detailed
• Coders will need to work more closely with doctors to update them on proper coding methods
• More codes to choose from may eliminate use of super bills – a means of quick coding diagnoses
• Providers may need to invest in new software designed to accept the longer digit codes
• Physicians will need to be more specific in their documentation and code observations as ICD-10 codes include more payment limitations for services
• Case managers will need to increase patient education on coverage charges

Medicalbillersandcoders.com is gearing up for this change already and wants to contribute in propelling the concerned professionals to meet these challenges keeping in mind industry standards and ICD-10 deadline of 13th October 2013. The expert panel of advisors at Medicalbillersandcoders.com is striving through the ICD training program to help all billing and coding professionals on any training or information they may need to gear up for this change.

Brief insight into what MBC’s ICD-10 training program is offering to counteract ICD-10 challenges:

• Tips for a smooth transition from ICD 9 to ICD 10
• Problem solving webinars
• Weekly updates of ICD implementation
• FAQ documents of ICD 10
• Coding Practices forum with other experts and participants

This training program also offers subscribers to share their views participate in polls and associate with industry experts and contribute to ICD-10 in their own way at no cost.

As physicians are undergoing healthcare revolution, we as Billing & Coding professionals will need to go through a learning evolution to streamline practices. Medicalbillersandcoders.com billing and coding professionals are charged up for the change and to further this trend Medicalbillersandcoders.com is offering a platform to a career revamp ensuring transition to ICD-10 with confidence. All Medical billers and coders are invited to be a part of this endeavor along with Medicalbillersandcoders.com at no cost from the 1st of March.

About Medicalbillersandcoders.com

Medicalbillersandcoders.com is the largest 'Consortium of Medical Billers and Coders,' across the US. The portal brings together hundreds of billers, with experience in different specialties, on the same platform to service physicians in their local areas. This network of coders and billers is growing rapidly and is currently servicing over 50 specialty physicians, across the US ( California Medical Billing, Pennsylvania Medical Billing, Idaho Medical Billing, Mississippi Medical Billing, New Jersey Medical Billing, Virginia Medical Billing, Arizona Medical Billing ) with the most prominent being Dental Medical Billing, Chiropractic Medical Billing, Pain Management Medical Billing, Physical Therapy Medical Billing and General Practice.

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States mimicking Medicare – experimenting with Accountable Care Models for Medicaid

Accountable Care Organizations (ACO) model’s popularity is growing and mirroring Medicare almost 11 states are trying ACO models for their Medicaid programs by adding initiatives resembling ACO’s to their programs, moreover various providers who initially were vary of Medicare ACO models are showing interest in the state versions as well.

With the exact number of states experimenting with ACO model programs unknown, 13 states have already submitted Medicaid amendments to the CMS to implement the new medical home model including aspects of ACOs, with four amendments already approved as reported by Federal officials. According to health policy experts, state interest has evolved in the past two years, to control spending due to their increasingly costly Medicaid programs; moreover part of the increased interest could be an outcome of the national attention the federal Medicare ACO programs received.

In North Carolina one Medicaid program is building an ACO-like structure off a longstanding medical home model. Other states are modifying their Medicaid managed-care programs into ACO-type pilots- in January, Minnesota, launched a two-year expansion of its managed-care program that will provide extra provider payments for up to 10,000 Medicaid beneficiaries. In another initiative viewed as an ACO-like model, a Colorado Medicaid program launched in mid-2011 gives providers regular bonus payments for offering extra care to patients, with plans to add bonus payments to practitioners whose patient’s outcomes improve.

Various states are still implementing their ACO-like Medicaid changes but are expected to complete their plans soon. The Cambridge Health Alliance, Massachusetts, already considers itself an ACO and has begun moving some of its Medicaid patients into a global payment model through the managed-care plan under which it operates.

High potential to improve health while saving money, practitioners eventually expect the state and federal efforts to result in widespread ACO adoption within Medicaid programs. As the ACO model transforms the system from the current fee for service system to pay for value system – physicians would benefit from seeking help from medical billing companies, who can provide consultancy for integrating this system of healthcare delivery. Medicalbillersandcoders.com having capability of providing operational and revenue management to various specialties and being equipped with an insider-knowledge of the Healthcare Industry can help make the choice of transitioning to the ACO model easier.

Seeking Possible Solution to Intensifying Medical Billing Documentation

“Beset with spiraling Medicare expenditure amidst a rather volatile economy, the Federal Government policy of linking physician reimbursement to quality outcomes will not only test physicians’ level of quality medical care, but also how they are going to document patient encounters. Therefore, physicians, required to furnish evidence-based healthcare documenting & reporting, will find hard to manage within the limited time and resources”.

Amidst healthcare reforms (both federal as well as provincial healthcare quality initiatives) –  linking physician reimbursements to quality outcomes, making Electronic Health Recording mandatory for availing incentives under ARRA, the possible compliance to Medicare Medical Billing norms, the documentation demand under Medicare’s Accountable Care Organization (ACO) model, and the last but not the least, the imminent ICD-10 and HIPAA 5010 transition – healthcare documenting is never going to be the same. While these healthcare reforms are objectively promulgated for ushering in clinical and operational efficiency, the level of transformation those physician offices need to cope up with can severely come in the way of the core-focus of medical services.

Beset with spiraling Medicare expenditure amidst a rather volatile economy, the Federal Government policy of linking physician reimbursement to quality outcomes will not only test physicians’ level of quality medical care, but also how they are going to document patient encounters. Therefore, physicians, required to furnish evidence-based reporting, will find hard to manage within the limited time and resources.

As Electronic Health Recording becomes mandatory, physicians may not be able to afford heavy capital investments associated with installing the requisite technology. But, as the EHR carries clinical and operational consequences – incentives for meeting and surpassing the benchmark as well as penalty for compliance – physicians will invariably have to outsource their EHR capability. Even then, amidst numerous service providers, their decision to decide upon competent provider will become crucial.

Further, Medicare, being revamped radically, physicians’ documentation for medical billing reimbursement is likely to be more detailed and exhaustive, resulting in complex medical billing procedures that can only be managed by competent medical billing houses. Invariably, physicians will have to allocate overheads for advisory from such medical billing houses. Although, the initial expenditure might seem high, yet, the associated returns will eventually outweigh the expenditure.

Above all, the imminent ICD-10 transition looming large, physicians’ medical coding is in for a major overhaul, prompting allocation of resources and time on an unprecedented scale. But, with internal competencies likely to fall short of the requisite ICD-10 benchmark, yet again, outsourcing could become a possible recourse, prompting judicious selection of competent service provider.

As physicians seek to safeguard clinical, operational, and revenue-generation interests, Medicalbillersandcoders.com tried, tested and proven credentials in medical billing management may well become indispensable. Its proven credentials in Revenue Cycle Management for clinical and operational excellence – complete with   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 – could proactively address the documentation challenges in the changing landscape.

Unbalanced equilibrium: US States facing shortage of Medical Coders in spite of high supply

As if hospital shortages of nurses and pharmacists were not enough, the shortage of medical coders has risen to high levels in some areas in the US and physicians need to act fast least they lose millions of dollars in unbilled charges. American Health Information Management Association (AHIMA) has reported a nationwide shortage of certified medical coders in hospitals, physician practices, and other healthcare facilities, with the most critical shortage in the northeastern and western parts of the country.

President of Provider HealthNet Services Health Information Management Inc. estimates a nationwide shortage of almost 30%. According to The Bureau of Labor Statistics, U.S. hospitals will need a large number of new medical record and medical health technicians to replace those who are leaving the field now.

Imbalanced scales 

On the upside with the increasing demand for coders, their role in health management is expanding, however there is a nationwide shortage of credentialed coding professionals, Coders already present in the profession are facing a difficult time keeping up with the various changes demanded by the industry. There are a multitude of circumstances contributing to this shortage-most graduates are unaware about medical record coding professions, while ongoing changes in the coding profession make it difficult for even skilled coders to keep up. A recent American Hospital Association survey showed that about 18% of billing and coding positions remain unfilled due to a lack of qualified candidates.

Many hospitals are also beginning to implement internal measures to ease the shortage: upgraded pay scales; sign-on bonuses; flex-time and overtime opportunities; scholarship programs for coding education; online training programs; in-house training for internal employees; and increased use of freelance coders.

Increased demand for coders

Coding is highly critical to a physicians practice as any discrepancy in this area can result in high penalties. The scope of health information management (HIM) has grown significantly over the past five years. The health care system has employed a number of techniques to combat the shortage, including contract services. According to the U.S. Bureau of Labor Statistics, medical billing and coding demand is projected to increase by nearly 20% by 2018.

Coders are an integral part of a health care system playing a key role in reimbursement and processing claims. Medicialbillersandcoders.com is the largest consortium of medical billers and coders in the US providing updated knowledge, placement opportunities and analyzing current salary trends.