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HealthCare Reform Upheld by SCOTUS… What’s a CHC to do?

October 21, 2013

After much debate, universal healthcare is here… or is it? Only time will tell what reality this will take. As a CHC, what does this really mean for you?  Let’s assume for a moment that the health care “exchanges” come to full fruition and by 2014 the majority of the uninsured patients suddenly have some form of coverage. Following are some thoughts to ponder or perhaps things to do…

  1. Become Expert Billers.  If you cannot manage your current billing process at desirable levels (e.g., AR < 45 days, less than 20% of AR over 90 days, Net AR (Growth of AR over fixed period) not exceeding 10% of total Charges)…what happens when the 20-30% or more of your patients suddenly have claims which must be submitted and managed? Get your CHC billing house in order now or prepare for exponential madness when 2014 hits.
  2. Improve Eligibility Verification & Enrollment  Processes. More than ever, a CHC must have an expert process of determining which insurance (commercial or governmental) is paying for a beneficiary’s care and when/who is eligible for new enrollment. Front desk and/or scheduling teams must improve these processes today so they can manage the expanding volume of patients in 2014. The historic mantra of “we’re too busy” won’t hold as it will only result in a growing volume of AR stemming from eligibility and enrollment mismanagement.
  3. Be fully Functional with Your EMRA CHC cannot be toying with dysfunctional systems and non-compliant core provider staff unable to close and bill visits on the date of service. With more patients than ever requiring claim submission, EMR utilization needs to be as commonplace and transparent as breathing. Keeping up with expanded volume resulting from new patients with benefits to spend freely is one thing…managing the patient flow with the ability to extract qualitative information necessary for compensation is another thing entirely.
  4. Prepare for lost FundingNational and some state CHC leaders have criticized me for publicly speaking this thought….is special CHC funding viable or even necessary if the vast majority of CHC patients have some form of coverage? PPS and cost-based Encounter Rate payments, 330 Grant funding, Title X, Ryan White, etc. were created to afford healthcare access to special populations in need. Are the populations still in need if everyone has access to coverage?? AND healthcare reform funding has to come from somewhere…these special interest programs may be ripe low hanging fruit ready for harvesting.
  5. Embrace ICD-10With all the hoopla about healthcare reform and the intentional delay of ICD-10 until October 1, 2014…the transition to ICD-10 seems to reside in the proverbial back seat. Has your CHC created a plan AND do you realize it is being rolled out in the same year that healthcare reform is expected to hit the US marketplace? Don’t be naive and believe ICD-10 will be perpetually delayed or is avoidabel…it is an absolute must as ICD-11 is less than two years from beta.
  6. Manage (the remaining) “uninsured” PatientsNot a readily discussed topic at this moment BUT there will always be a percentage of patients who fall through the cracks and CHCs will be the safety net as always. So…if funding is more limited after 2014, how can a CHC still manage uninsured patients unless all other cash flow is operating at peak levels? The same PMG adage that existed pre-healthcare reform applies post healthcare reform implementation…a CHC must get paid as much as it legally and ethically is able for as many visits as possible so that the CHC can afford to give services away when it is necessary. Getting paid when you can, so you can afford to give it away when you want or need to, is still the law of the CHC land.
  7. Compete with Private Practice OK…so the private practice never wanted to see the uninsured but now that they have insurance is your CHC at risk of losing patients to a “real” doctor? Certainly we all know that CHC core providers ARE real doctors (and NPs, PAs, CNMs, LCSWs, PhDs, etc.) but is your CHC prepared to compete in the open market? All CHCs must improve customer service, primary and urgent care access, and other special offerings to assure long term viability.
  8. Manage “Quality” over QuantityThis may be the most maddening and prejudicial aspect of health care reform as it relates to CHCs. If, as anticipated, future compensation is based on the improved and stabilized health status of patients…how do CHCs compete when their patients are intrinsically less well due (most often) to recent immigrant status, indigence, (and as a result) under-education, and the host of other social/ethnic barriers limiting their upward healthcare mobility? CHCs must find a way to demonstrably improve their patients’ healthcare outcomes as they will be the systems’ repository for those patients who will make other private practices’ data trend in an undesirable fashion. Providers still need to hit production thresholds but overall compensation will not be exclusively driven by “units” sold.

Certainly, there will be more to discuss on this topic. As a CHC, being nimble and prepared to manage an expanding base of “insured” patients will afford you the most optimal chance for thriving success as we plunge head long into this new landscape.

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