The Affordable Care Act (ACA) is bringing unprecedented changes to how health care is paid for in the US, and both primary care physicians and specialists need to understand how these changes will affect their revenues. Reductions in Medicare and Medicaid payments, constraints on payer contracts and negotiations, and a fundamental change that emphasizes a risk-based and shared-savings reimbursement model have many practices scrambling to catch up.
It is unclear which reimbursement model—or which combination of models—will ultimately dominate. Further complicating revenue cycle management is that many health organizations are transitioning into being part of an Accountable Care Organization (ACO), in which caregivers are rewarded for both quality and value, rather than for volume.It Starts in the Front Office
At its core, the ACA has expanded coverage to a formerly uninsured population through state and health information exchanges and Medicaid expansion. What does this mean for a private practice hematologist from a revenue cycle perspective?
“It means an increased focus on insurance verification and an emphasis on point of service collections,” said Dan Clark, director of revenue cycle for McGladrey, a provider of accounting, tax, and consulting services. “The pressure to determine insurance coverage and ensure accurate insurance information currently falls to the front-office staff when the patient calls or presents for the office visit,” Clark said.
Because denial of claims is a significant problem, using business intelligence software could be an option providers might consider. Clark said that he frequently works with physician practices to help them understand the denials process. McGladrey uses business intelligence software (
to augment system reporting and “pull data from the host system for detailed analysis in order to help physicians and practice managers understand where the denials are coming from.” He pointed to the front end of the patient workflow as a primary source of denials.
The Affordable Care Act (ACA) requires that the Centers for Medicare & Medicaid Services (CMS) implement a value-based payment modifier that would apply to Medicare fee-for-service payments starting with select physicians on January 1, 2015, and applying to all physicians and groups by January 1, 2017. The value-based modifier is intended to pay physicians differentially based on the quality and cost of their care.
According to the CMS web site, physicians in groups of 100 or more eligible professionals (EPs) who submit claims to Medicare under a single tax ID number will be subject to the value-based modifier, based on their performance in calendar year 2013. In 2013, these groups needed to self-nominate/register and choose 1 of 3 PQRS group reporting methods available in 2013: the web-interface group reporting option, a registry, or request that CMS calculate the group’s performance on quality measures from administrative claims, in order to avoid an automatic negative 1% value modifier adjustment to 2015 payment under the Medicare Physician Fee Schedule.
Groups of 100 or more EPs who self-nominated/registered for, and then participated in, any of the above-mentioned methods of reporting on clinical performance but did not elect quality tiering will have a neutral value modifier in 2015, which results in no impact on 2015 payments. In 2015, the value-based modifier will apply to both participating and nonparticipating Medicare physicians in groups of 100 or more EPs.
“Denials are often due to inaccurate demographic and coverage information or lack of authorizations for services. We are seeing more and more requirements for authorizations of services put in place, especially around managed Medicaid,” said Clark. This makes the shift to improving front-end resources and front-end education all the more important.
Medical practices should use a check sheet or script guide to be sure all pertinent information is collected at the point when the revenue cycle starts—when the patient schedules an appointment.
At the minimum, knowing the type of insurance the patient carries will help the scheduler know what information to collect. Responsibilities of the front-office staff should include informing the patient if the provider is not in the patient’s insurance network, providing information about what the patient should bring to the appointment, explaining to the patient that payment for copayments is expected at the time of the visit, and noting the arrival time of the patient if paperwork needs to be completed before the appointment.