Along with the massive coming changes caused by the switch to ICD-10 diagnosis and treatment codes, the Affordable Care Act (ACA) will further challenge billing personnel with significant—yet, seldom publicized—changes in provider billing and payers’ claims processing rules.
Although millions of words, particularly about constitutionality, have been written about the controversial ACA, billing and reimbursement challenges for medical providers publicly have taken a back seat. However, many physicians are upset and/or confused about the impact ACA operating rules will have on billing procedures.
Provider Billing Unrest
While few argue that health care reform is unnecessary, most medical providers believe the ACA loads undue burdens on them to change their billing and reimbursement responsibilities. This unfair treatment—real or perceived—has most physicians and practice managers up in arms.
Written to be patient-friendly, ACA provisions seem to force providers to use trial and error billing procedures to get the reimbursements they deserve. With a focus on higher quality care, the ACA requires practices to bill for the quality, not the volume, of care given.
This feature confuses lay people, while often infuriating physicians and practice managers. Many providers believe these guidelines are not well-defined, mandating they use guesstimates of how to bill properly, placing timely reimbursement in jeopardy.
Payer and Claims Issues
The ACA targeted guidelines and operating rules to deliver improved reimbursement timing and revenue cycle management. However, as of January 2014, Electronic Remittance Advice (ERA) and Electronic Funds Transfer (EFT) bring more new rules that may not be defined clearly.
Payers also face new operating rules for claims processing, including eligibility determination, which could further burden billing staff and practice managers. Critics believe the new rules will only increase the expense and confusion that result in billing errors and force claims resubmission.
According to the Healthcare Billing and Management Association publication, HBMA Billing, Congress targeted these revised technical guidelines to improve the claims processing and reimbursement process. The ultimate objective: “…adopt a single set of operating rules for each transaction, with the goal of creating as much uniformity in the implementation of the electronic standards as possible.”
Congress gave instructions that the Secretary of Health and Human Services (HHS) should codify the guidelines. The passage of HIPAA in 1996 signaled the dawn of the electronic age for health care. The passage of the ACA and its massive provisions expands this conversion, hopefully further streamlining the reimbursement process.
Regulatory Billing Burdens
Already causing Human Resource personnel in all industries to scratch their heads about how to bring their companies in compliance with the ACA, many medical providers believe “clarifying” new operating rules and guidelines increased the billing confusion, shifting the burden and risk of implementation to the practice and care providers.
Similar to the complaints from the banking industry, since the 1970s, that most new government regulations intended to police and protect bank transactions, such as backup withholding, shifted the burden—and cost—to implement these safeguards to the banks, not government enforcement agencies. Many physicians and practices, already displeased with the perceived added burden to comply, maintain that adding often ambiguous new operating rules might make accurate billing a nightmare as ACA implementation dates get closer.
The medical billing community needs to communicate closely with payers to minimize negative influences of the ACA and its operating rules, however burdensome they may be. As the transition to ICD-10 diagnosis and treatment codes necessitates effective re-training of billing staff, physicians and practice managers should consider adding ACA requirements, particularly electronic claims processing changes, to their training curriculum.
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