With healthcare reform and system changes underway, accurate medical documentation and coding is critical to the financial health of your practice and to the health of your patients. In 2004 Medicare implemented an HCC (Hierarchical Condition Categories) model to adjust capitation payments to private health care plans for the health expenditure risk of their enrollees.
Representing a departure from the volume based, fee-for-service model, MACRA replaces the SGR (sustainable growth rate) formula to control Medicare costs. Linking Medicare reimbursements to quality metrics with providers being rewarded for quality and value based care; MACRA repeals the set payment rates based on economic growth, which was the hallmark of SGR.
Healthcare practices typically outsource their billing for two reasons – lack of resources and/or lack of time. While outsourcing your billing has many advantages, there are certain factors that need to be checked before hiring a billing company. Remember that most outsourcing contracts generally last for two to three years and it would be detrimental to your practice if you choose a billing company that exhibits most of the following:
- The billing company has no existing clients with the same specialty as yours.
Replacing the much-maligned sustainable growth rate formula and in an effort to increase quality while bringing down costs, the Congress last year passed the Medicare Access and CHIP Reauthorization Act (MACRA). While MACRA rules are still being finalized, it will essentially transform the way Medicare reimburses healthcare providers for services. The main purpose of this overhaul to the payment system is to improve the quality of healthcare that is provided to patients.
Healthcare revenue cycle management has undergone a radical and drastic change in the last decade. From days when most patients had $20 or so as co-payments and insurance companies paid claims in full, to today, when the physician first needs to consider medical necessity before ordering a lab test – things have certainly become more complex and challenging.
Claim submission and denial management are critical components to the revenue cycle of healthcare facilities. As regulations are getting more stringent with the transition to value-based care, healthcare providers are facing an increase in claim denials. It therefore comes as a surprise that nearly one-third of clinicians are still using manual processes to manage their claim denials.
April 28, 2016 witnessed the release of the proposed rule that is intended to guide the implementation of MACRA (Medicare Access and CHIP Reauthorization Act of 2015) which aims to reward clinicians and physicians engaging in activities that support and drive positive patient outcomes. MACRA, once implemented in totality, will change the way physicians taking care of Medicare patients are paid by CMS.
Healthcare facilities across the nation have or will have to face Medicare audits at some point. Even those healthcare facilities that have done everything correctly and have never had to face an audit till date cannot be certain that it may not happen in the future. An audit could be due to a single payment or a multitude of payments – in either case,
One of the recurring problems facing healthcare facilities is incorrect coding of Evaluation and Management (E/M) Services. The recent CERT (Comprehensive Error Testing) claim review analyzed by WPS Medicare reveals that within the fifteen or more services reviewed in that sample, three E/M CPT codes had been coded incorrectly in at least 44% of the total bills raised.
One of the biggest challenges faced by healthcare practices and crucial to their very survival is medical billing and collections. A healthy revenue cycle is important to sustain the process of making patients healthy. Unfortunately, physicians are trained to manage human health rather than revenue health and this is where the challenges arise.