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Medical Claims Issues Under the Obamacare

February 7, 2014

ACA ICD 10 MarchUnder the ACA or Affordable Care Act, Americans have until March 31, 2015 to purchase health insurance during the open enrollment period. This represents a significant extension over the typical open enrollment period, due to the confusion in the new law and the health care website portal. As individuals browse plans and purchase care, those in the medical industry continue to brace for changes. Medical billers who depend on the healthcare industry for their living received a glimpse into how the ACA may affect their positions with the troubled healthcare website rollout in late 2013. While the full impact of the ACA on medical claims is unknown at present, some issues may arise.

More Claims Purported to Hike Premiums

Much has been said about the impact of the Affordable Care Act on medical claims. Critics of the ACA claim that it will raise the cost of medical claims by as much as one-third, because more sick people will now have health insurance. As spending on aged and sick people increases, so will medical claims. To offset this, healthcare premium will increases, critics say.

The truth about whether higher claims levels impact insurance premiums may not be fully known until summer 2015, however, as insurers must first submit their bids. If projections about the numbers of unhealthy people enrolling in healthcare after insurance eligibility verification prove false, there may be little impact on the cost of medical claims.

Delays in Claims Processing as Patients, Insurers Adjust

Whatever the ultimate outcome for medical claims, at present everyone is in a bit of a holding pattern. Medical billers, including those from top third party firms like M-Scribe Technologies, have expressed concern insurance eligibility and precertification problems will arise as more individuals flood the marketplace. In a worst case scenario, this leaves medical billers in flux with a growing backlog of unprocessed claims as insurers wade through paperwork. Billers may be reluctant to process claims without receiving eligibility verification, for fear of retro-termination denials from insurers.

In a best case scenario, billers remain unaffected and can continue to process medical billing. The market for qualified medical billers is projected to grow as more and more individuals who were not insured purchase insurance and receive needed health care.

ICD-10 to Bring New Coding Issues

Meanwhile, medical billing professionals must switch to a new coding system by October of 2015. The new system is much more comprehensive than the present system, but represents a big shift for medical billers. Presently, billers can use the same code when charging for an injury to the left side of the body and one on the right side. Under ICD-10, billers must use one code to refer to the left side injury and a different code to refer to the right side injury. As billers adjust, there are bound to be some mistakes that complicate the medical claims and medical documentation process.

As these issues show, many medical billers are in as much of a state of limbo as insurers and consumers. Everyone has questions about the rollout of the Affordable Care Act and its impact on their jobs. The ACA is supposed to make health care more affordable for everyone, regardless of income. In the short term, however, it seems to be creating more headaches for all involved and presenting medical billers with new challenges. The best in the field will ride these challenges out and continue to thrive under the new healthcare law.


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