Health Insurance Exchange Confusion Hinders Patient Sign Ups

HHS Secretary Kathleen Sebelius testified before the House Ways and Means Committee on March 12 that there will be no more tweaking in the of the individual mandates under the Affordable Care Act (ACA).  This after the White House announced the extension of exemptions on the basis of hardship.

A list of those hardships, reported by the Wall Street Journal, includes more than a dozen ways that Americans could qualify, including homelessness, having utilities shut off, and having a very low income in a state that did not expand its Medicaid program. Sebelius also refused to say whether the White House goal of signing up 7 million people will be met by the March 31 deadline, when open enrollment ends. Thus, the deadline for open enrollment will not be extended, according to Sebelius, despite lack of any clear data on the number of people who have both signed up and actually paid their premium. Individuals without coverage by the deadline will face a penalty at tax time, which will likely be deducted from any anticipated tax refund next year. Any way you look at it, the hope of the White House that individuals will actually buy into the private purchase of health plans seems largely misplaced.  A great deal of the problem lies in the confusing array of plans that can be purchased through the exchanges. First, a purchaser must figure out what is being offered. Often termed “metal” plans: bronze, silver, gold and platinum, one would seemingly need to possess an advanced college degree simply to understand the choices.  The lower-premium plans, are the “bronze" plans, which carry higher initial copayment responsibilities.  This may at first seem attractive to a lower wage earner.  However, such a plan would actually benefit a higher-income individual, who could afford the 40 percent copayment.  The platinum plan, which costs more in premiums but carries a 10 percent initial copayment, would seem to be better suited to a person who lacks resources to pay nearly half of his initial healthcare expense from his own savings.  Recognizing the problem faced by lower wage earners, there are three alternative silver plans for lower income earners, which the website Obamacare 411 explains as follows:  “These three alternative health insurance plan options are only available for people that have the lower incomes.  The three health insurance plans have lower out-of-pocket expenses for people that are enrolled in the health insurance plan.  Basically, what this all means is that even though you are buying a silver tier plan; you are actually being given a better health insurance plan.

• 100 percent to150 percent of the federal poverty level (FPL) = 94 percent AV, better than average platinum plan
• 150 percent to 200 percent of FPL = 87 percent AV, better than average gold plan
• 200 percent to 250 percent of FPL = 73 percent AV, better than average silver plan

If you have difficulty following this, you see my point.  One thing people do universally seem to understand:  “What is this going to cost me?”  The answer should open more than a few eyes: All plans cap out of pocket expenses at about $6,350 for an individual, and $12,700 for a family in 2014. This means for an individual in good health, who must pay for coverage without a subsidy, the annual out of pocket expense could be well over $14,000, even with the least expensive plan.  The next question on a consumer’s mind will likely be: “What happens if I just give up and hope I don’t get sick?”  Naturally, without insurance the same individual would be liable for the entire cost of any unexpected care. But Americans have proven more than willing to accept this risk.  If a person does not choose to comply with the individual mandate before the March 31 deadline, he will face a tax bill of between $95 and $285, if I understand the rules and exemptions correctly. Finally, the largest problem facing the White House is the Republican message: “Vote against Democrats, and this all goes away.” It doesn’t, but explaining that, would be complicated.

Article  By Martin Merritt from Physicians Practice http://www.physicianspractice.com/blog/health-insurance-exchange-confusion-hinders-patient-sign-ups?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=18032014

Participating in New Healthcare Exchange Plans

By Susanne Madden from Physicians Practice

It is early with regard to the healthcare exchange plans and yet practices across the country are already feeling the impact. It's not just consumers who have experienced problems while attempting to sign up for the exchange plans on the healthcare.gov website; providers too are dealing with major headaches as they navigate through the first couple of months of this new system.

Let me explain. The insurance companies created something called "narrow networks" within their full network of providers. What that means is that only a subset of physicians within any given insurance company's network "qualified" for participation in the exchange plans. The result is that while some physicians got rolled into these plans, others were excluded, even though they participate in some of the other products with that particular insurance company. For example, a physician could be participating with an HMO and a PPO-type product, but be excluded from the exchange product. This has created a dilemma for many practices. On the one hand, it means no new business coming in from new exchange members. On the other hand, it also means scrambling to hold onto existing patients that have switched to these new, lower-priced health insurance products.

The physicians that were rolled in (or opted in, in many cases) to the new exchange networks are struggling to determine new patients' eligibility under these plans. Many patients have not yet received insurance cards, and those that have are sometimes finding that their physician was mistakenly listed on the website as a "participating" provider.

In addition, those physicians who are participating with the exchange plans are finding that they are getting paid less for doing more. That is, not only are the rates less in these plans, but many patients who previously did not have health insurance may have gone without care for prolonged periods of time. As a result, they are typically sicker than patients who have been under care over time.

Also, signing up for participation in these plans means accepting a lower payment rate because the insurance companies are offering these as "budget" plans with low premiums. Naturally, the discounts have to come from somewhere and this is in the form of lower payments to physicians who participate with these plans.

So where does that leave things for physicians?

Here are four points to consider:

1. Physicians need to know whether they are participating with an exchange plan.

This can usually be readily discovered by looking yourself up on an insurance company's online directory. But don't just trust the data that you find there; double-check by calling the insurance company and verify that you are in fact participating with an exchange plan (there have been many errors on these sites so far).

2. Physicians need to determine what their fee schedule is going to be.

Ask the insurance plan to send you a sample for your specialty or send them your highest utilized codes for pricing.

3. Physicians need to communicate very clearly with patients if they are not in the exchange plans.

Hang posters on your waiting-room walls and get communications out to patients to explain that the insurance company (if this is the case) has decided to exclude you from the exchange product. Many patients wrongly assume that their physician is automatically in the network, so do your best to educate them as soon as possible.

4. Physicians need to quantify the damage.

Take note of the number of patients that you may lose due to their choice of plan and appeal to the insurance company to see if there is a way that you can retain them. If you purposefully opted out of the exchange network then it is unlikely that you can hold onto these patients. But if you were excluded from the network, you may be able to appeal ― in doing so the plan might make an exception and add you in.

If you are participating with an exchange product and you find that you are receiving an influx of these patients, my best advice to you is to set up some very good patient education materials and tools around the most frequently seen chronic conditions, in order to help manage what may be a sicker population of patients. Don't be afraid to look at what the insurance company is offering in terms of chronic-care support. Many have teams of nurses that help to manage the patient's care and do a relatively good job of feeding that information back to the primary-care physician.

Lastly, remember that it is still early. There are going to be a lot of missteps under this new system, on all sides. So I suggest hanging in there to see how things shake out. Like any new program it will take a while to work out the kinks.

Article by: Susanne Madden, MBA, is founder and CEO of The Verden Group, a consulting and business intelligence firm that specializes in practice management, physician education, and healthcare policy. She is also COO, National Breastfeeding Center, and cofounder, Patient Centered Solutions. She can be reached at madden@theverdengroup.com or by visiting www.theverdengroup.com.

From Physicains Practice http://www.physicianspractice.com/healthcare-reform/participating-new-healthcare-exchange-plans?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=27022014

Obamacare's Big Changes Change Little for Physicians

By James Doulgeris and Nicholas Bonvicino, MD taken from Physicians Practice

"It starts with complete command of the fundamentals," Jesse Owens explained about his dominance in the Olympics. Athletes know that. Engineers know that. Plumbers and tradesmen know that.

Congress and the Obama administration could learn a lot from these working folk. Their single-minded conviction that mandating massive changes to healthcare's banking system will somehow fix a fundamentally broken healthcare-delivery system is like trying to fix government bureaucracy by changing the tax code.

With one-sixth of the U.S. economy in the balance, politics and egos have to move aside in both parties to face reality instead of reelection.

American medicine, with all of its technological, training, and fiscal prowess, has lost its way. This is the place to be if you have a complex trauma or disease. We invent and have an overabundance of the most sophisticated diagnostics, pharmacology, and facilities in the world.

But if you have a chronic condition like diabetes, COPD, or CHF, where 80 percent of our overall healthcare dollars go and 96 percent of Medicare dollars go, you are better off in 45 other countries, many of which are in what we consider the “third world.”

As our costs have gone up, our relative standing in many key metrics of population health have fallen far behind. An argument for socialized medicine and more primitive technology? Hardly.

An argument for more attention to prevention, personalized care, and integration of medical care with social institutions, you bet!

Our system has come to treat symptoms instead of people, and Obamacare reinforces the problem fiscally and philosophically. Case in point: Providing a diabetic with insurance that doesn’t pay to motivate, teach, or provide the support for what needs to be done between doctor visits is worse than wasteful. Further, applying high individual deductibles that discourage frequent and regular office and home care visits that can improve compliance and health status are a drop in the bucket compared to the costs of an amputation or blindness.

Since we are talking policy, what are the fundamentals on a policy basis?

1. Technology reform. Obamacare’s $16 billion program encouraging and funding stand-alone electronic medical records systems back fired. They boost compensation instead of collaboration, increasing costs while doing nothing to increase efficiency or effectiveness. EHR systems were created to maximize reimbursement by exploiting the inherent flaws in fee-for-service reimbursement by boosting up-coding and high-cost service production. Supporting common, interoperable platforms that transform EHR data into actionable information to manage population health and cost, removing regulatory stonewalls, and requiring EHR providers to allow access to their data platforms to make common platforms work fixes the problem.

2. Reimbursement reform. Get serious about paying for results instead of tasks. Encourage physician-owned and -led networks financially and with regulatory and tort relief, and eliminate the Rube Goldberg gain-sharing schemes. Make it simple: premium less actual cost = savings. Then split them. Value versus volume. Reimbursement for results. Pay for performance. They all mean savings, and not the few percent from tweaking the status quo, but hundreds of billions from allowing the free market to perform.

3. Reform reform. Get hospitals out of the accountable care business. Savings come from keeping patients OUT of the hospital, and successful accountable care organizations are a fiscal disaster for them. Instead of enabling regional hospital monopolies that eliminate competition, particularly lower-cost community hospitals, enable primary-care physicians to become "purchasing agents" for their patients. This will foster competition on price, quality, and safety through price transparency in the marketplace. Remove the shackles and allow them to do what is right instead of complying with what is regulated.Managing safety, fair play, and honest competition and preventing and dealing with abuses quickly and firmly are the government's job. Central management is not.


4. Tort reform. Instead of holding physicians liable for not using the best technology, indemnify them when they use best practices.These things are not liberal or conservative, political or progressive — they are practical. And, way overdue.

Courtesy of Physicians Practice

Did lots of your patients purchase plans through health insurance exchanges? Here's a helpful link you might want to add to your practice's website.

Physicians Practice

Did lots of your patients purchase plans through health insurance exchanges? Here's a helpful link you might want to add to your practice's website. It provides tips for patients with new insurance.

http://www.whitehouse.gov/share/have-new-insurance-heres-what-you-need-know

Need to verify coverage for patients with marketplace plans? Follow these steps:

Need to verify coverage for patients with marketplace plans? Follow these steps:

First, call the plan number listed on the back of the patient’s insurance card, if you are fortunate enough to have a patient with a plan card.

If not, here are additional steps:...

If the federal government runs the marketplace in your state, you can search through a list of plans and obtain customer service number through that database at
https://data.healthcare.gov/dataset/QHP-Customer-Service-Phone-Numbers/vryg-tdzf?

Sort the database by state and then you can sort by county if necessary. If you still cannot find the contact number, you can call the federal marketplace at 800-318-2596.

If your state runs its own insurance exchange, go to http://www.healthcare.gov to search for your state and phone number information.

Health Insurance Exchanges: Two Key Issues to Discuss with Patients

The American Academy of Family Physicians (AAFP) is encouraging its members to provide their patients with information regarding health insurance exchanges.

The AAFP website advises: "During patient visits, be prepared to discuss the insurance options available through the marketplaces and encourage patients to make coverage decisions that are appropriate for their health care needs. "But not all doctors are ready to get involved.

The majority of physician respondents to a recent Medscape survey said that they should either have a limited role or no role in providing health insurance and health insurance exchange information to patients.

Yet, spending a few minutes sharing some key information about health insurance exchanges with interested patients may benefit you and your practice in the long run.

Here's why: If your patients that are shopping on the health insurance exchanges don't make well-informed purchasing decisions, you may see them less frequently. In fact, you may not see them at all.

Many of the health plans offered in the exchanges appear to have narrower networks — meaning patients will likely have fewer physicians and health systems to choose from within the plans.

In addition, many of the health plans offered in the exchanges have higher deductibles — meaning patients may end up shouldering more of their healthcare costs.

"They are trying to funnel people into narrow networks overall, and simultaneously shift people into higher cost sharing that is higher deductible, higher copay kind of plans," Kip Piper, a healthcare consultant in Washington, D.C., recently told Physicians Practice.

If patients purchase those higher cost sharing plans, it's likely that they will put off or avoid visiting your practice due to cost concerns, said Piper. In addition, higher patient cost sharing will place more burdens on your collections staff, as they will need to step up patient payment collection efforts. 
For that reason, you might want to consider talking to your patients about the importance of finding a plan that does not require a lot of out of pocket costs. "Make sure that ... they're not enticed by a low premium to pick a plan that has a high cost sharing that then keeps them out of the doctor's office," said Piper.

The narrower networks offered by many of the plans may also pose problems for your practice.

If you are excluded from a plan or if you have decided to opt-out of a plan, you run the risk of losing your patients to providers who are participating in that plan. For that reason, you might want to share which plans you are participating in with patients.

"I'm afraid of a lot of people in January are going to start making an appointment and then they're going to find out they can't go to their doctor," said Piper.

Article By Aubrey Westgate from Physicians Practice http://www.physicianspractice.com/blog/health-insurance-exchanges-two-key-issues-discuss-patients?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03122013

A little known rule in the ACA could pose financial risk to doctors

A little known rule published by CMS to implement the Affordable Care Act (ACA) could pose a significant financial risk for doctors, hospitals and other healthcare providers. The rule requires health plans participating in the exchanges to provide individuals purchasing insurance through the exchanges a grace period before terminating the coverage for non payment of the premiums. Doctors and other healthcare providers will continue to provide care during the grace period, but the insurance plan will not be required to pay the claims incurred during most of the grace period. The result could be that physicians and other healthcare providers would provide a significant amount of uncompensated care.

Details of the rule

The CMS rule provides individuals that purchase subsidized coverage through the exchanges a 90-day grace period before their coverage is cancelled for non payment. The insurance plan is required to pay any claims incurred during the first 30 days of the grace period, but the insurance plan is not required to pay the claims incurred during the last 60 days of the grace period if the individual’s coverage is terminated. The insurance plan is allowed to place all the claims during the last 60 days of the grace period in a pending status. The rule requires the insurance plan to notify the healthcare providers when an insured individual is in the last 60 days of the grace period.

Risk falls on healthcare professionals and providers

The rule imposes a significant risk for uncompensated care on the healthcare providers. The rule does require insurers to tell healthcare providers when patients are behind on their premium payments, but he rule does not specify how the health plan will provide that notice to the providers. The only notice some providers receive will probably be the pending status placed on the unpaid claims by the insurance plan.
Many doctors and hospitals are reluctant to participate in insurance plans offered on the exchanges due to the increased financial risk associated with the CMS rule. The result could be that individuals enrolling in insurance plans through the exchanges may find it difficult to find a healthcare provider willing to accept them as patients. CMS has been asked to modify the rule so that insurers are required to pay claims during the entire 90-day grace period.

How grace period can be manipulated to benefit patients

The CMS rule may also result in individuals manipulating the system. Some individuals may intentionally pay premiums for only part of the year and become serial abusers of the 90 day grace period. Another unintended consequence of the ACA is that individuals that choose not to pay their premiums and have their coverage terminated can reenter the exchange and enroll in a plan regardless of their pre-existing conditions so there is little incentive for some individuals to maintain their coverage.

Were you aware of the 90-day grace period? As a healthcare professional or provider, are you worried you don’t have adequate financial protection?

Michael L. Smith is an attorney and George F. Indest, III is president and managing partner, both at The Health Law Firm.
Courtesy of: http://www.kevinmd.com/blog/2013/11/rule-aca-pose-financial-risk-doctors.html

The Affordable Care Act's Effect on Medical Billers

Article By Marsha Sosebee from Physicians Practice

The staunch proponents of Obamacare are joyously dancing in the streets amid a tickertape parade while those who vehemently oppose its inception are hunkered down in a fury of nail-biting anger. I think the vast majority of the population though are in a fog of miscommunication, false hope, and maybe some unnecessary worry.

What does Obamacare really mean to someone like me, an “in the trenches” medical biller? First of all it means that people will be looking to me to answer questions about their insurance now that Obamacare is here. But I have as many questions as they do. The one thing Obamacare has done is put everyone in the same boat, a boat called limbo. We don’t really know how it’s all going to work.

For example, I want to know how reliable eligibility verifications will be. I have claims on my desk right now for which I am fighting retro-termination denials. The day services were rendered, coverage was verified. When the claim was processed, the insurance denied saying the coverage was retro-terminated because the employer didn’t send in notification that the employee had been laid off. In the past, I’ve had denials because the insurance company said the Cobra premiums were not paid. The patient had cancelled checks showing that they did pay the premiums. That fight took me six months to finally receive payment for those outstanding claims. I feel justified in my level of concern for eligibility verification for these government-regulated exchange insurance plans.

Another area of concern for me is precertification. Considering the difficulty regular insurance companies exhibit on occasion, I can’t help but wonder how the governmental connection will affect the precertification process. Just last week, I spent four hours on the phone getting shuffled back and forth between the pre-certification and claims departments of a certain major insurer. The precertification department had told me prior to surgery that no precert was required. I documented the name, date, and time related to this call. Last week the surgery claim was denied because there was no pre-certification. I gave the claims department my documented information and was told that didn’t matter to them because in their system it said precert was required. They said they couldn’t help that the precert department had given me wrong information. I asked if they could get the precert department on the line with us so we could resolve this issue. The response was, “No, we don’t make outgoing calls to other departments.”

So I called the precert department back. They said they were correct, no precert was required and that I should just tell the claims department to pay the claim. I asked if they would please call the claims department for me to verify. That request was met with a prompt, “Once the service is rendered, we are out of the picture.

”Ultimately the issue was resolved, but only because I finally found someone who actually cared about solving the problem and didn’t just pass the buck. I look at instances like this which occur with more regularity that I am comfortable with and I can’t help but think it will there will be worse headaches than this with plans that are overseen by governmental agencies. Maybe we billers should stock up now on aspirin.

My take on the whole Obamacare plan is that making healthcare affordable is a great thing. And if that’s what the Obamacare plan was really doing, I would be more supportive of it. But I think it will do more harm than good. I can very easily see that small businesses will convert employees to part-time status to avoid the penalty. What will that do to families already finding it nearly impossible to stay afloat financially?

I have strong reservations about the government forcing anyone to get health insurance. So many people think that Obamacare is offering free insurance. This is not true. They are forcing you to pay for insurance and the cost of the insurance plans are not readily available. I was just on the healthcare.gov website and I consider myself semi-tech savy. The only way I could find to be able to compare the cost and benefits of the different plans was to actually do your application first. Applying for something before you know the cost is what my dearly departed father would have called "buying a pig in a poke".

"It has been my experience in life that people who are trying to manipulate a situation for their own benefit will create a diversion to get your attention off the truth of what they are doing. I think Obamacare has created a diversion with false concern for the health and well-being of the Amercian people. What is its real agenda? It could be simply to rake in more money for the government or it could be something much more sinister. Whatever the case may be, the next several months are going to be very interesting to say the least.

Article Courtesy of: http://www.physicianspractice.com/blog/The-Affordable-Care-Acts-Effect-on-Medical-Billers?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=01112013

New Measures in Pay-for-Performance Programs

Pay for performance, or P4P as it is more commonly known, is not a new concept and some plans have been using this type of initiative with providers for a decade or more. Those providers that participate in Medicare's Physician Quality Reporting System (PQRS) — which uses a combination of incentive payments and payment adjustments to promote reporting of quality information — as well as those participating in large Blues plans, will be most familiar with this model.

The shift What is new is the shift away from P4P as a "bonus" structure and a shift toward an "earning" structure. That is, the extent to which payers are incorporating P4P into their payment strategies means that a portion (or percentage) of providers' revenue is "earned" through meeting P4P targets or measures.  These new models are referred to as "value-based," shifting away from straight fee-for-service payments to some combination of performance- and fee-based compensation, which puts some of the financial risk on providers. The hope is this type of compensation model will improve the quality of care, reduce medical costs over time, and improve patient outcomes. So you can think of the newer P4P models as Pay for outcomes, or P4O.  Under Medicare  The Affordable Care Act expands P4P efforts in hospitals through the establishment of a Hospital Value-Based Purchasing Program begun last year, where hospitals are rewarded for how well they perform on a set of quality measures, as well as on how much they improve in performance relative to a baseline.  The healthcare law also extends the Medicare PQRS program through 2014. However, beginning in 2015 the incentive payments go away, and physicians who do not satisfactorily report quality data will see their payments from Medicare reduced. This marks the real beginning of P4O, in my view, due to the setting of a "quality care" baseline against which the ability to earn will then be tied.

By commercial payers For commercial payers, value-based contracts are springing up around Patient-Centered Medical Homes (PCMHs) and accountable care organizations (ACOs). However, new and negotiated contracts for generalized services — that is, practices that are not technically a PCMH or ACO — are now typically being crafted with P4P/P4O components that allow practices to "earn" additional dollars or year-to-year increases in multi-year contracts through meeting specific measures and targets.  Theses measure are typically HEDIS-based (Healthcare Effectiveness Data and Information Set) which is a widely used set of performance measures developed and maintained by the National Committee for Quality Assurance (NCQA). Many of these measures are focused on high-cost conditions such as heart disease, diabetes, high blood pressure, as well as preventive measures like immunizations and medication management. New and changed measures for 2014 include breast- and cervical-cancer screenings.

 Commercial payers utilizing P4P measures typically have a combination of HEDIS-type "quality" measures as well as "self-reported" measures, where practices can report on items such as EHR implementation and use, and status in achieving NCQA programs such as Patient-Centered Medical Home (PCMH), diabetes, heart/stroke, and back pain recognition programs. In addition to NCQA measures, there is substantial investment underway by the Agency for Healthcare Research and Quality (AHRQ) and other public policy organizations to identify further evidence-based medicine practices that could be used for measurement. And the National Quality Forum (NQF) is leading focused efforts to collect and normalize data, and endorse additional performance measures.

Article By Susanne Madden of physicians Practice http://www.physicianspractice.com/physician-compensation/new-measures-pay-performance-programs?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=31102013

AMA Insight, No Matter Which Side You Are On (Humor)

The American Medical Association has weighed in on Obama's new health care package. The Allergists were in favor of scratching it, but the Dermatologists advised not to make any rash moves. The Gastroenterologists had sort of a gut feeling about it, but the Neurologists thought the Administration had a lot of nerve. Meanwhile, Obstetricians felt certain everyone was laboring under a misconception, while the Ophthalmologists considered the idea shortsighted.

Pathologists yelled, "Over my dead body!" while the Pediatricians said, "Oh, grow up!" The Psychiatrists thought the whole idea was madness, while the Radiologists could see right through it. Surgeons decided to wash their hands of the whole thing and the Internists claimed it would indeed be a bitter pill to swallow. The Plastic Surgeons opined that this proposal would "put a  whole new face on the matter". The Podiatrists thought it was a step forward, but the Urologists were pissed off at the whole idea. Anesthesiologists thought the whole idea was a gas, and those lofty Cardiologists didn't have the heart to say no.

In the end, the Proctologists won out, leaving the entire decision up to the a-a-a-a-a  - - - - - - people - - - - in Washington.  (sorry can’t pass on the swear word that was there – best to read between the dashes!)

The Evolution of Government Intrusion on the Medical Profession

By Martin Merritt from Physicians Practice

This week found me sitting alone in our law firm library, preparing to defend a physician before the Texas Medical Board. In an era of electronic research, both legal and medical, it is rare to find anyone, (other than me), in the library. I not only enjoy flipping through real pages; some of which were bound and placed on these shelves 70 years ago, I enjoy getting momentarily sidetracked from my original mission.

I picked up this habit as kid reading the World Book Encyclopedia. Regardless of what I might be looking for, I would always stop and absorb eight to ten articles, just to learn about some historical fact I didn’t know existed.  

This week, flipping through historical reports of medical ethics cases, many dating to the 1950s, I began to see a clear picture of something I wasn’t expecting to find.  Virtually every federal regulatory concern currently plaguing the modern practice of medicine also existed in some form in the 1950s.

Comparable to Medicare RAC and external audits; physicians were losing their practices for improper charting and documentation. However, these losses usually pertained to life-and death matters, such as the prescription of narcotics. “Off-label promotion,” similar to the fen-phen scandal, usually concerned mundane, unapproved uses of common household remedies.

For example, a physician in the 1950s lost his license for charging patients $49 each for a treatment to remove gallstones using olive oil. (The board found that the oil, mixed with stomach acid, actually produced “soap balls,” not gallstones, as the physician improperly claimed.)

“Bundling and unbundling” issues were also present sixty years ago when a physician was disciplined by the board for routinely including fee-for-services charges that were already billed to the patient as part of the hospital’s charges.

Time and again, modern coding, charting and regulatory issues “pop” from the pages of history. Some cases represent quaint precursors to FTC “advertising” regulations. These appear as ethics disputes over the size of the lettering appearing on a physician’s office window, to questions about the exact line between acceptable public service promotion and impermissible advertising.

Half a century ago, one party was notably absent from the dusty pages of medical ethics cases: the federal government. There is a reason for this. Until the post-Civil War period of reconstruction, no federal laws governed a person’s conduct in any way. Slowly, beginning with the regulation of racially motivated murder, and laws pertaining to civil rights violations, Title 42 of the United States Code (containing laws related to civil rights and health and human services), began to grow in size and scope.

Today, in addition to racial offenses (42 U.S.C. §1983); Stark Law (42 U.S.C. 1395nn); the Anti-kickback Statute, (42 USC § 1320a–7b); HIPAA (42 U.S.C. § 300gg); and the Medicare law (42 U.S.C. 1395) are located in the growing Title 42 of the United States Code.

Many fear, and rightly so, that as healthcare insurance exchanges offered at healthcare.gov become fully operational, the federal takeover of the practice of medicine will soon be complete.

In the not-too-distant future, the common law principle, “A physician and patient are free to contract for services in any way they see fit,” will seem just as quaintly anachronistic as limits on the size of lettering on a physician’s office window.

Courtesy of Physicians Practice http://www.physicianspractice.com/blog/evolution-government-intrusion-medical-profession?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=22102013

“Expanded Coverage Under the Affordable Care Act: Information for Health Care Professionals” Fact Sheet — Released

The “Expanded Coverage Under the Affordable Care Act: Information for Health Care Professionals” Fact Sheet (ICN 908826) was released and is now available in downloadable format. This fact sheet is designed to provide education on the Health Insurance Marketplace under the Affordable Care Act. It includes information health care professionals need to know about the Marketplace, an explanation of how the Affordable Care Act expands access to health coverage, and an explanation of the Marketplace, how it affects health care professionals and their patients, and resources.
From Medicare Learning Network eNews update.

The Affordable Care Act and Model 4 Bundled Payments for Care Improvement

MLN Matters® Number: MM8070 Revised
Related Change Request (CR) #: 8070
Related CR Release Date: June 27, 2013
Effective Date: July 1, 2013
Related CR Transmittal #: R1251OTN
Implementation Date: July 1, 2013
This article was revised on September 23, 2013, to add clarifying language on page 3 (bold). This article was previously revised on July 26, 2013, to reflect a revised Change Request (CR). The CR added Part B MAC responsibility to the CR's business requirement 18.3. The release date, transmittal number and link to the CR were also changed. All other information remains the same.

Provider Types Affected
This MLN Matters® Article is intended for hospitals, physicians, and non-physician providers participating in the Model 4 Bundled Payments for Care Improvement (BPCI) initiative and submitting claims to Medicare contractors (Fiscal Intermediaries (FIs) and A/B Medicare Administrative Contractors (MACs)) for services to Medicare beneficiaries.

What You Need to Know
This article provides an overview of Medicare's implementation of the Model 4 Bundled Payments for Care Improvement initiative. General program information is provided along with separate sections containing information of special interest to hospitals and physicians and non-physician providers. It addresses issues related to readmissions, claims crossover, remittance advice, and claims submission, among others. This pilot program is being conducted under the Centers for Medicare & Medicaid Services (CMS) Innovation Center's model testing authority. The program is slated to be implemented in October 2013.

Background
The Affordable Care Act provides a number of new tools and resources to help improve health care and lower costs for all Americans. Bundling payment for services that patients receive during a single episode of care, such as heart bypass surgery or a hip replacement, is one way to encourage doctors, hospitals, and other health care providers to work together to better coordinate care for patients, both when they are in the hospital and after they are discharged. Such initiatives can help improve health, improve quality of care, and lower costs.
CMS is working in partnership with providers to develop models of bundling payments through the BPCI initiative. On August 23, 2011, CMS invited providers to apply to help test and develop four different models for bundling payments. Model 4, one of these four models, is discussed in this article. In Model 4, the episode of care is defined as the acute care hospital stay and includes inpatient hospital services, Part B services furnished during the hospitalization, and hospital and Part B services for related readmissions.

Information in this article is based on the change requests implemented for Bundled Payments for Care Improvement Model 4, including CRs 7887, 8070, and 8196.

General BPCI Model 4 Information

Beneficiary Eligibility
In order to be eligible for Model 4, the beneficiary must meet the following requirements:

• Beneficiary is eligible for Part A and enrolled in Part B;
• At the time of admission, beneficiary either (a) has at least 1 day of utilization left and that day is
• also a day of entitlement or (b) has at least one lifetime reserve day remaining;
• Beneficiary does not have End-Stage Renal Disease;
• Beneficiary is not enrolled in any managed care plans; 
• Beneficiary must not be covered under the United Mine Workers; and
• Medicare must be the primary payer.

If the beneficiary does not meet all of these requirements, the following codes will be assigned to rejected or cancelled NOAs:

• Claims Adjustment Reason Code (CARC) B5: Coverage/program guidelines were not met or were exceeded.
• Remittance Advice Remarks Code (RARC) N564: This patient did not meet the inclusion criteria for the demonstration project or pilot program.

Model 4 Bundled Payment Provision

• Hospitals that participate in the BPCI Model 4 initiative will receive a prospectively established bundled payment for agreed upon Medicare Severity Diagnosis Related Groups (MS-DRGs).  
• This will not apply to claims that are paid on a transfer per-diem basis.
• This payment will include both the DRG payment for the hospital and a fixed amount for the Part B services anticipated to be rendered during the admission. Separate payment for providers' professional services rendered during the inpatient hospital stay will not be made.
• Participating Model 4 hospitals will receive a Model 4 payment and will be responsible for payment to providers who would otherwise be paid for professional services under the Physician Fee Schedule (PFS). As such, physicians and non-physician practitioners should seek payment for professional provider services from the Model 4 hospital. 
• Per the conditions of the Agreement between CMS and the Model 4 hospital, payment to physicians and non-physician practitioners must be made at a rate that is equivalent to the amount that would otherwise apply under the PFS, unless a different amount has been agreed to in writing by the Model 4 hospital and the physician.
• Claims from physicians will be processed as no-pay claims if they occur between the inpatient hospital admission and discharge date in order to prevent duplicate payment of physicians under the bundled payment.

Co-payments, Co-insurance, and Deductibles

• The regular Part A deductible, including the Part A blood deductible, and daily coinsurance amounts (when applicable) will continue to be applied to the claim. 
• The fixed Part B portion of the negotiated bundled payment will first be applied to the Part B deductible, if applicable. 
• A fixed Part B copayment will be applied to the claim. This will be the responsibility of the beneficiary and will be calculated as an approximation of what the Part B coinsurance would have been in the absence of Model 4.
• Both the copayment and the deductible to be paid by the beneficiary for the Part B services will appear on the MSN along with the Part A deductible and any applicable coinsurance.

Appeals
Payments made under Model 4 have no rights of appeal, except in the case of calculation errors.

• RARC N83: No appeal rights. Adjudicative decision based on the provisions of a demonstration project.

Information for Hospitals
Notification of Admission (NOA)
Hospitals participating in this initiative should submit a Notice of Admission (NOA) when a beneficiary expected to be included in the model is admitted. Timely filing of the NOA allows subsequent Part B claims submitted before the hospital claim to be properly processed as "no-pay" claims, which indicates that payment for these claims are to be included in hospital payments under Model 4. By extension, these Part B claims will then be included timely on weekly Part B reports provided to the hospital to be used in calculating payments for Part B providers.

• Hospitals will be paid a $500 payment upon submission of the NOA and will receive the balance of the prospectively established bundled payment when the hospital claim is processed.
  • RARC N568: Initial payment based on the Notice of Admission (NOA) under the Bundled Payment Model IV initiative.
  • If the patient ultimately does not qualify for a Model 4 prospective payment based on the MSDRG ultimately assigned to their inpatient stay, or if the NOA is cancelled, the $500 NOA payment will be recouped.
  • Medicare systems will initiate a "look back" into the claims history records upon receipt of a canceled NOA to identify Model 4 BPCI claims- i.e., Part B physician or other professional claims - which were processed as "no pay" as a result of the NOA being opened. If such claims were processed, the Medicare contractor will adjust the claims automatically and remit payment for services rendered based on regular Medicare Fee-for-Service claims processing rules.
  • Hospitals must submit the final claim within 60 days of the beneficiary's hospital admission or submit an interim claim during that time period to demonstrate that the beneficiary is still an inpatient. Otherwise, the beneficiary will be considered not subject to episode payment and the $500 will be recouped.
    • The following codes will be assigned when a Model 4 claim matches an NOA for admission date and beneficiary, but not provider.
      • CARC 208: National Provider Identifier - Not matched
      • RARC N562: The provider number of your incoming claim does not match the processed Notice of Admission (NOA) for this bundled payment
    • The following codes shall be assigned when an NOA is cancelled because a matching claim is not received within 60 days. A match consists of beneficiary, admit date, and provider.
      • CARC 226: Information requested from the Billing/Rendering Provider was not provided or not provided timely or was insufficient/incomplete
      • RARC N560: This pilot program requires an interim or final claim within 60 days of the Notice of Admission. A claim was not received.

Readmissions
Model 4 hospitals will not be paid for readmissions that occur to the same hospital (i.e., another admission with a date of admission within 30 days of discharge of the Model 4 stay) under this model unless the MS-DRG assigned to that readmission is expressly excluded as unrelated to the MS-DRG assigned to the original admission.

• Unrelated readmissions have been defined by CMS, and a list of DRGs defining unrelated readmissions has been provided for each included MS-DRG to every Model 4 participating hospital. This list can also be found on the Bundled Payments collaboration site, accessible to Model 4 Awardees.
• Related readmissions to a hospital other than the original treating hospital, as well as payments for physicians' services during related readmissions to hospitals other than the original treating hospital, will be reconciled retrospectively by a BPCI payment reconciliation contractor and payment will be recouped, as applicable, by the Model 4 awardee.
  • If claims for a Model 4 anchor admission and a readmission are submitted out of order, the readmission claim will be canceled and must be resubmitted to receive payment. The following codes will be used in this situation:
    • CARC 249: This claim has been identified as a readmission.
    • RARC N561: The bundled payment for the episode of care includes payment for related readmissions. You may resubmit your claim to receive a corrected payment.

Payment Rate Updates and Adjustors
Payment rates may be updated as often as quarterly to allow for ongoing updates to Medicare payment rates, including regular recurring changes made to the Physicians Fee Schedule (PFS) and Inpatient Prospective Payment System (IPPS). Indirect Medical Education (IME) and Disproportionate Share Hospital (DSH) payments, as well as outlier payments and hospital capital payments to Model 4 hospitals will be calculated based on the non-discounted base DRG payment that would have been made in the absence of the model. This is true for both anchor admissions and related readmissions to the Model 4 hospital. In the case of readmissions, these payments will be denoted by the following:

• CARC 249: This claim has been identified as a readmission.
• RARC N524: Based on policy this payment constitutes payment in full.

Other applicable payment adjustors will also be calculated based on the base DRG that would otherwise have applied to the case, as opposed to the prospectively established amount paid through this initiative, which will be higher as it includes payment for Part B services in addition to the base DRG payment.
Information for Physicians and Non-Physician Providers
Claims Submission and Processing
Physicians and non-physician practitioners shall submit claims for dates of service during an episode of care included in Model 4 BPCI as usual.
Physicians and non-physician practitioners shall be required to accept assignment for all claims covered under the Model 4 BPCI payment.
For those Part B services rendered during a Model 4 admission or a related readmission to that Model 4 hospital, Medicare will process claims as no-pay. In processing no-pay professional claims, Medicare will assign the following:

• CARC 234: This procedure is not paid separately.
• RARC N67: Professional provider services not paid separately. Included in facility payment under a demonstration project. Apply to that facility for payment, or resubmit your claim if: the facility notifies you the patient was excluded from this demonstration; or, if you furnished these services in another location on the date of admission or discharge from a demonstration hospital. If services furnished in a facility not involved in the demonstration on the same date the patient was discharged from or admitted to a demonstration facility, you must report the provider ID number for the non-demonstration facility on the new claim.

Physicians submitting claims should take care not to include on the same claim services that are both within the dates (admission and discharge) of a Model 4 BPCI episode and outside the dates of the episode. If such claims with both Model 4 and non-Model 4 services are received, Medicare contractors will reject the claims and advise the physician to separate the services and rebill. The following remittance messages will be used in this situation:

• CARC 239: Claim spans eligible and ineligible periods of coverage. Rebill separate claims. 
• RARC N61: Rebill services on separate claims.

Incentive Payments
Bonus or incentive payments calculated by CMS, such as HPSA bonus payments, will not be affected by physician or non-physician practitioner participation in the Bundled Payments initiative.
Participation Declination
Physicians have the right to decline participation in this program. Declination will be indicated by including a HCPCS modifier on each claim. Further details will be provided at a future date.
Readmissions
Part B services provided during a related readmission to the original treating hospital will not be paid separately. If Part B claims were processed prior to receipt of the hospital's readmission claim, Medicare will take steps to recover payments to the physician.

• CARC A1: Claim/Service Denied; and
• RARC N68: Prior payment being cancelled as we were subsequently notified this patient was covered by a demonstration project in this site of service. Professional services were included in the payment to the facility. You must contact the facility for payment. Prior payment made to you by the patient or another insurer for this claim must be returned within 30 days. 

Claims Crossover
In association with this initiative, CMS will make changes to allow for the reporting of two new Claim Adjustment Reason Codes (CARCs) within the 2320 Claim Adjustment Segment (CAS), so that supplemental payers can more easily determine these amounts when adjudicating Medicare Health Insurance Portability and Accountability Act (HIPAA) 837 institutional Coordination of Benefits (COB)/crossover claims.

• CARC 247 will be defined as "Part B deductible on a Part A claim." 
• CARC 248 will be defined as "Part B coinsurance on a Part A claim."
• An adjusted RARC M137 will be defined as "Part B coinsurance under a demonstration project or pilot program.

This initiative will also result in the reporting of a new value code within the 2300 Health Care Information Codes (HI) Value Information (qualifier BE) portion of outbound HIPAA 837 institutional COB/crossover claims.
Additional Information
The official instruction, CR8070, issued to your Medicare contractor regarding this change may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1251OTN.pdf on the CMS website. In addition, CR8196 is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1189OTN.pdf  and CR7887 is available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R1240OTN.pdf on the CMS website.

Last Updated Sep 26, 2013

The Unknown Impact of Health Reform on My Private Practice: An Honest Opinion From a Real Physician... "I honestly don't know."

By Melissa Young, MD, Courtesy of Physicians Practice

Patients have been asking me for the last few months, "So what do you think is going to happen to your practice with Obamacare?"  I told them what I assume most physicians are thinking, "I really don’t know. I’m apprehensive. But I guess I’ll find out."

There’s been talk about physicians being inundated with new patients because there will be an increase in demand for physicians without increasing the supply. In our case, we already have such a backlog, I don’t know what we’ll do if more patients call to make new patient appointments. I am concerned that we are going to have to close to new patients for a while if the wait for a new patient appointment gets any longer. As it is, patients are very dissatisfied with the wait. I can’t begin to imagine how primary-care physicians will handle this.

There is also the concern about increasing patient financial responsibility. That will put a greater strain on the patients, as well as on our staff who will have to collect more from patients. As many patients don’t understand when they have deductibles or how much their copays are, if their portion of the bill increases, it may become increasing difficult to get paid for services.

As a business owner and employer, there is also the question of providing health insurance to employees. We are a small enough practice that, as I understand it, I am not legally obligated to provide insurance coverage for the employees, but I have always done that anyway. I think it helps keep employees happy and instills some loyalty to the practice. Having said that, I was still obligated to print out and complete a form that I had to distribute to each employee, stating who is eligible for insurance, that we offer it, and that it is deemed affordable. They actually found it somewhat amusing that I had to inform them of something they already knew. Sigh. To think trees had to die for this paperwork.

So, what do I think will happen? Will Obamacare have a significant impact on the way our practice is run now? I honestly don’t know. But I guess I’ll find out.

Article Courtesy of: http://www.physicianspractice.com/blog/unknown-impact-health-reform-my-private-practice?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=24092013

Jimmy Kimmel: Do you prefer Obamacare or the Affordable Care Act? This made me laugh and shake my head...

Jimmy Kimmel: Do you prefer Obamacare or the Affordable Care Act?

This made me laugh and shake my head...

 

 

Patient Out-of-Pocket Expenses Rise, Squeezing Physician Cash Flow

Maintaining cash flow is a growing challenge for physician practices now that their "bread and butter" privately insured patients are paying more and more of their healthcare expenses out of pocket, and it will get worse.

Out-of-pocket expenses not including premiums have increased to an average $768 for each privately insured consumer in 2012 according to the nonprofit, non-partisan Health Care Cost Institute, and are projected to skyrocket as much as 50 percent in 2015 under Obamacare’s numerous mandates.

Maintaining your practice’s cash flow requires much more than initiating more aggressive patient obligation collections policies. Payer contracting, practice marketing, and patient-service strategies must change to keep pace.

Payer Contracting

The market will soon be flooded with newly insured and reinsured through exchanges, mostly women because newly mandated coverage favors women and relies on men to share the cost. Employers will be re-evaluating policies and, if they keep insurance at all, will be gravitating to higher-deductible policies to keep pace with subsidized premiums.

Identifying major area employers with whom they insure, and whether or not they have high-deductible policies, is a new must. It isn’t just how much the insurer pays you anymore, it is how much the employee must pay you as well. Upscale employers typically have upscale insurance with higher reimbursements, lower co-pays and deductibles, and employees who can afford to pay them. As obvious as focusing on them as this may seem, going in-network with these payers and competing for their members has not dawned on most, if any, practices as a strategy.

Practice Marketing

Identifying and stratifying the best-insured employees and their families is a key competitive and marketing strategy. Getting those patients established with your practice is goal number one. Strategically, getting in network and understanding their needs is a must. Tactically, your marketing should be keyed to them. Your message should resonate with them. Your practice services should cater to their needs. And, you should be using experienced professionals for research, branding, messaging, and marketing.

Patient Services

Doing things right to gain a competitive advantage requires an investment in time and money. Keeping patients does not. It requires something else except in rare cases: a change in practice culture.

With all of the focus on patient-centered care, there is almost none on patient-centered services despite reams of literature showing that satisfied patients feel better, do better, and bring their friends and family along with them.

Change begins at the front desk with two very simple things: welcoming people and having an experienced staffer answer phones. How patients are treated sets the tone for the rest of the visit and determines the “patient experience,” and it all rests on office culture: Does your practice accept patients, or welcome them?

It all circles back to the beginning with two straightforward quirks of human nature: Happy patients are most likely to pay their bills while unhappy patients are most likely to sue.

For good advice on how to provide excellent customer service, click here.

Update – ACA Increased Medi-Cal Payments for Primary Care Physicians (California MediCaid)

The Department of Health Care Services (DHCS) plans to implement increased fee-for-service Medi-Cal payments for primary care physicians in late October 2013.

 

The Patient Protection and Affordable Care Act (ACA), as amended by House Resolution 4872-24 Health Care and Education Reconciliation Act of 2010, Section 1202, requires that payments to primary care physicians be increased to the Medicare equivalent for certain Evaluation and Management and Vaccine Administration services.

 

These increased payments are contingent upon pending Centers for Medicare & Medicaid Services (CMS) approval of a DHCS State Plan Amendment (SPA). The increased payments are retroactive for dates of service on or after January 1, 2013.

 

The first interim payment will be issued in October. A final settlement of payment owed but not reimbursed by the interim payment will be issued as early as February 2014.

 

The increased payments are not automatic. Providers must attest to their eligibility, but DHCS estimates that less than half of eligible providers have self-attested. Completing your attestation prior to CMS approval of the SPA and system updates will ensure you receive increased payments as soon as possible. Visit the Medi-Cal ACA Program Page on the Medi-Cal website for more information or to submit a self-attestation form.

 

You should complete your attestation form as soon as possible.

Attestation form link: https://www.medi-cal.ca.gov/acaattest/acaattestmenu.aspx

 

 

Health Insurance Exchange Information for Physicians and Patients

A primary mission of the Affordable Care Act is to provide universal health coverage through the creation of health insurance exchanges or marketplaces. The triad of employer-sponsored coverage, marketplace insurance exchanges, and expanded Medicaid coverage should cover most Americans under 65 years old, with some exceptions.

Unfortunately, there will be coverage gaps for low-income people who fall between certain income levels and live in states where the Medicaid expansion was rejected, according to Jennifer Tolbert, director of state health reform for the Kaiser Family Foundation.

Tolbert is charged with monitoring state implementation of the Affordable Care Act and the establishment of state insurance exchanges for Kaiser. She recently discussed in a webinar some consumer-based elements of the law that are also helpful for medical practices to understand and communicate with current or potential new patients.

Consumers will be able to shop and enroll in new insurance plans through the federal government's website (www.healthcare.gov), or their own state's website if available, beginning Oct. 1, 2013. Open enrollment will continue through Mar. 31, 2014, with the option of enrolling after that date if a qualifying event occurs.

Coverage through the marketplaces and the expanded Medicaid program (where approved by individual states) will begin Jan. 1, 2014, when insurance market rules also go into effect. That is also when the individual mandate to have insurance coverage begins.

The exchanges will offer a choice between four plans (figures are for single coverage; family coverage would be double):

• Bronze – typical deductible $5,000 / typical coinsurance 30 percent
• Silver – typical deductible $2,000 / typical coinsurance 20 percent
• Gold – typical deductible $0 / typical coinsurance 20 percent
• Platinum – typical deductible $0 / typical coinsurance 10 percent

They will also offer a catastrophic plan for people up to age 30, with a typical deductible of $6,350 and no coinsurance. While these levels of cost sharing may seem prohibitive, most consumers will be eligible for federal subsidies and tax credits.

The cost of premiums will vary by state and locality; and also by age. Consumers who wish to get a ballpark estimate of the costs of different plans can use the Health Insurance Subsidy Calculator provided by Kaiser.

For example: A 40-year-old pre-school teacher making $30,750 — or 250 percent to 300 percent of the federal poverty level —  would be required to pay 8 percent to 9.5 percent of her income for healthcare premiums on the exchange. Her subsidized cost for the Silver Plan would be $2,633 annually. (The unsubsidized annual cost would be $3,857.)

All of the plans offered on the health insurance exchanges are mandated to offer "essential health benefits," said Karen Pollitz, a senior fellow on health reform and private insurance for Kaiser:

1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drugs
7. Rehabilitative and wellness services, and chronic disease management
8. Pediatric services, including oral and vision care

There are multiple health-reform resources available online through Kaiser and Healthcare.gov that would be helpful additions to your own medical practice website; even if your own patients don't need this information, most everyone has a family member who may benefit from knowing the facts, e.g. a young adult child who does not receive health insurance from her workplace, or perhaps a single professional who does freelance work or is self-employed.

As leaders in the health community, it is important for physicians to be knowledgeable about the coming changes in health insurance coverage. It also allows physicians to make informed choices about the types of new insurance they will participate in, and the numbers of new patients they take into their practices.

Article By Erica Sprey, Courtesy of Physicians Practice http://www.physicianspractice.com/blog/health-insurance-exchange-information-physicians-patients?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=17092013

Health Reform Doesn't Mean the End of Independent Medical Practices

By Wayne Lipton, Physicians Practice                                                   

There seems to be much public and private hysteria these days over the Affordable Care Act (ACA), or what many call "Obamacare." The rush for implementation of the health insurance exchanges has made real the intended changes to the healthcare system both locally and nationally. In the midst of all this uncertainty, I'm reminded of the British philosophy of, "Keep calm and carry on."

While a good message, I do understand why physicians are concerned. Physicians' earnings have been stagnant over the past several years, despite so-called bonuses for primary care and EHR implementation. Worse has been the uncertainty over Medicare —Will it or won't it get slashed? Because the work keeps getting harder, patients' needs are increasing, and the risks of operating an independent business grow more intense, many physicians feel driven to seek out "protection" by accepting employment with their local hospitals. After all, aren't the hospitals with their layers of administration better prepared for the changes this national "mandate" has created?

Not so fast say some practice management experts. One of the odd consequences of the political shift which accompanied the reform law is a focus on the way hospital systems are reimbursed. Many hospitals are not only seeing reductions in Medicare revenue but are also seeing state-based initiatives in the form of direct taxes on services with the thought that greater reimbursement of uncompensated care will shore up their bottom lines.

If anything, hospital administrators are looking more and more critically at physician employee compensation with an eye toward reducing their outpatient costs and increasing physician productivity. The message is that the fat package offered at the outset to physicians who "sell" to the institution is likely to be reduced significantly when renewal time arrives.

So it's time to take a closer look at decisions to sell or merge a medical practice. And this is where we get back to the infamous British philosophy.

Physicians who want to remain independent or who don't want to feel forced to sell their practices need to stop and really consider what is really happening in the market and what it means for their practice and patients.

Here are some important points to consider:

1. The ACA makes a point of assuring adequate primary-care reimbursement in two different ways. First is the broader definition of preventative services and the means by which providers are paid. Many of the newly insured patients registered with the exchanges will be facing large deductibles. However, the preventative services (those without copays) are paid first by these insurers so physicians will have fewer burdens chasing those patients for money initially.

2. A further mandate for those primary care physicians who provide Medicaid services is that their evaluation and management (E&M) services will now be paid at the federal Medicare level rather than the state, meaning more stability in revenue.

3. Those completing EHR conversion are beginning to see their checks. If you are with a large medical system or hospital, as a physician employee, you may not see those monies. If you have your own practice, you will.

4. Many physicians are beginning to recognize the value of alternative practice models such as full model or hybrid concierge programs. These programs give physicians who want to remain independent that option — plus, and this is important — they provide real choices and options for patients.

Most advisors I speak with have recognized for a long time that solvency in independent medical practice is dependent upon growth. Many primary-care practices have focused on reducing overhead and securing better fees. This "hunker down" mentality has resulted in stunted growth and reduced compensation. It's understandable why those practices would feel the need to consider selling. However, those practices that have embraced growth by looking at alternative practice models, or growing their practice by adding more physicians, extenders, and other specialized services, continue to see growth. This often involves financial investment in a practice by way of loans, but the added revenue often more than offsets the related expenses and improved income can be expected.

The message is — don't panic — and don't sell because you think there are no options. Independent primary-care practice should be able to flourish in this new environment giving physicians who want it the ability to own and maintain their destinies. In fact, the current environments make them more valuable as there are fewer independents physicians, making those services greater in demand.

The key is an eye toward growth and diversification of the medical delivery model. Implementing and/or expanding the physician extender model and incorporating an element of concierge care to facilitate compensation growth while ensuring the practice continues to meet the needs and preferences of all patients.

Article By Wayne Lipton, Physicians Practice            
http://www.physicianspractice.com/blog/health-reform-doesnt-mean-end-independent-medical-practices?GUID=2E8F906E-CDE7-43B7-AC93-7066F83372C7&rememberme=1&ts=03092013

Health Insurance Exchanges: Good News, Bad News for Physicians

USA Today recently reported that people have been signing up for health insurance exchanges for in excess of expected levels.

Staff writer Kelly Kennedy reports that a survey of each of the 50 states yielded 19 states reporting estimates for how many of their uninsured residents they expect will buy through the exchanges. The reported 8.5 million would far outstrip the federal government's estimate of 7 million new customers for all 50 states under the Affordable Care Act (ACA).

In the short term, this is great news for physicians' practices. This statistic means there will be 8.5 million new paying customers. This is even better news for physicians in states which have refused to expand Medicaid to the level mandated by the reform law, commonly termed "Obamacare."

Prior to the law, many states were permitted to set their own limits for Medicaid eligibility. Alabama, for example, reportedly disqualified a family from Medicaid eligibility if the family earned 25 percent of the federal poverty level (about $6,000 per year for a family of four). Under the reform law, states would have been required to expand Medicaid roles to conform to a new national standard of 133 percent of the federal poverty level (about $31,300 per year for a family of four). On June 28, 2012, the U.S. Supreme Court upheld the constitutionality of most of the ACA in the case National Federation of Independent Business v. Sebelius. However, the Court held that states cannot be forced to participate in the law's Medicaid expansion under penalty of losing their current Medicaid funding. Therefore, patients in states which did not expand Medicaid roles to include these "newly eligible" patients are able to purchase federally subsidized private plans through health insurance exchanges, which is the subject of the USA Today article.

This is good news for physicians’ practices, because Medicaid simply doesn’t pay very well (so low in fact, about one-half of all physicians would refuse to accept a new Medicaid patient).) Private plans which are subsidized by the government would almost certainly provide reimbursement rates which are above the rock-bottom rates for Medicaid patients. Open enrollment begins October 1, 2013, and coverage is set to begin January 1, 2014.

Before we all get too drunk on all this free government Kool-Aid, recall that the Kool-Aid isn’t "free." The reform law was enacted because the Medicare trust fund could not afford to pay for all the aging baby boomers set to turn 65 in the next few years.

The idea behind the law was to save Medicare by forcing more healthy Americans into the system through individual mandates, employer mandates, expansion of Medicaid for the poorest Americans, and providing health insurance exchanges for those who are just above the level needed to qualify for Medicaid. But how is this supposed to help save the Medicare trust fund? Obviously, by cutting future Medicare reimbursement rates.  But on what part of "planet crazy" does it make sense for the government to pick up the tab of the cost for all the newly insured, (which was supposed to save the system from failing, because the government is broke)?

In her book, "Your Doctor is Not In," Jane Orient draws the analogy between our nation’s healthcare model and the one created by Ptolemy, which contained multi-layered epicycles to explain the universe. "Wheeling and whirring, the Ptolemaic universe could be turned to predict almost any observed planetary motion — and when it failed, Ptolemy fudged the data to make it fit," Orient writes.

Here, the Obama Administration is so desperate to make the healthcare reform law work, any solution that will keep the wheels whirring, is perfectly acceptable. By the time anyone figures out it is a bad model, the president will be working on a location for his presidential library, and paying for healthcare will be the next administration’s problem.

Article By Martin Merritt http://www.physicianspractice.com/blog/health-insurance-exchanges-good-news-bad-news-physicians