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OBamacare: Challenges and Solutions for Medical Practices

January 23, 2014

ACA SolutionsIf your medical practice is like many, you’re probably rating the practice’s operating expenses as your top concern, according to information from the American Academy of Family Physicians (AAFP). At the same time, you are trying to beat the clock to ensure that your office staff receives sufficient training and experience with the new coding to be able to send out clean claims to insurers and other payers and meet additional ACA implementation deadlines.

CMS changes, such as the ICD-10 and new CPT codes, are also part of the shifting health care billing landscape as the push for ACA-mandated switch to all-electronic health records (EHRs) gains momentum. These and other ACA goals are aimed at making access to health care more affordable for the general population of Americans while promoting better-quality patient care.

In the process, four distinct challenges are emerging, which, while generally beneficial to patients are more burdensome for health care providers including more detailed recordkeeping, emphasis on preventive care, and more attention to follow-up with insurers.

1. Due to the requirement that all tax-paying citizens be covered or face stiff penalties, especially after the start of 2014, the tasks of correctly assessing the patient’s insurance coverage will become more important than ever for practices of all sizes. This will include not only determining eligibility but what will be covered as well as related costs – deductibles, out of pocket, and so on.

Solution: Ensure that your staff or billing partner not only verify coverage as printed on the patient’s insurance card but spend the necessary time directly communicating with insurance carriers and Medicare/ CMS, asking questions to verify which procedures, if any, are payable, applicable deductibles, out of pocket limits, and so on.

2. Some services may often exceed available coverage, leaving gaps in unpaid bills even after an insurer’s payment. One goal of the ACA is to spread the responsibility for cost-containment across the spectrum, including patients meeting higher deductibles.

Solution: By accurately determining coverage and eligibility upfront, front desk staff or your billing partner should be able to inform the patient which portion they will be responsible for paying. Reducing unpleasant billing surprises increases the likelihood of patients paying their fair share of the bill and allows them to make payment arrangements, if necessary.

3. A medical practice’s non-medical activities can be expected to increase as well. Some of these duties may include negotiating with insurers and others about denied claims, as well as following up after submitting bills and claims. Staff may be required to deal with bundled claims involving a multitude of medical details from others in the group.

Solution: Depending on the size and other duties of your front office staff, you may want to consider outsourcing at least some reimbursement duties to professionals specializing in medical reimbursement and related services.

4. Due to the ACA requirements that more preventive care services be covered, it will fall to your billing and coding staff, in particular, to accurately code these using the latest ICD-10 and CPT code updates to qualify for payment and demonstrate compliance.

Solution: If your practice hasn’t already done so, it’s time to send your billing personnel to a training session to upgrade their skills to meet the new coding and billing challenges. Organizations such as the American Medical Billing Association offer certification, continuing education and related courses for members.

One direct result of these changes is the trend by practices of all sizes and specialties to assign their billing, coding and reimbursement needs to professional billing, coding and reimbursement organizations, such as M-Scribe Technologies, LLC. Contact our experienced consultants today to learn how you can save your busy practice time, money and peace of mind.


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