The Affordable Care Act (ACA) or Obamacare is here, with all its advantages and drawbacks for Americans. While dissenters still abound, a sense of resignation is descending upon the nation.

Those hoping for a repeal of the ACA continue to be steadfast, although most seem to realize this may be more dream than a real possibility. Critics continue to maintain that the goal of healthcare reform is worthy, but the ACA attacks the wrong problem component. All that may be “accomplished” is transferring the cost of a broken system to Americans, without addressing the core problem.

Preventative Versus Diagnostic Services

One of the patient positives with the ACA is the renewed emphasis on preventative servers, eliminating patient cost sharing. Even the AARP has weighed in on this issue, noting in a recent issue of their magazine some 10 diagnostic tests to avoid, as their cost pales in comparison to their effective results.

Yet, patients and physicians still face a quandary. For example, a preventative service, such as an annual mammography seems to fall within the purview of a test dedicated to prevention. However, should the test result in an abnormal result, physicians often prescribe another such test. This then becomes a diagnostic service, subject to deductibles and patient cost sharing in most ACA insurance plans.

Both patients and physicians would welcome a better defined distinction to eliminate confusion. For example, a physician filing a claim should be confident that the claim is either preventative or diagnostic—it can affect reimbursement levels and/or cause delays.

Diagnostic and Treatment Options

Preventative versus diagnostic services is but one of several ACA-qualified insurance plans inconsistencies. Some are concerned that this and other ACA provisions may change the diagnostic and treatment regimens providers have used in the past.

For example, the ACA seems to include pay-for-performance provisions similar to CMS’ PQRS standards. Physician dissatisfaction with this issue is widespread.

However, the issue of preventative versus diagnostic services may become an equal source of concern. There are numerous real-world potential problems that could affect physicians’ diagnostic or treatment options because of this one distinction. Here are a few examples noted by Physicians Practice.

• Your billing staff or third-party firm bills for preventative and diagnostic services accurately. But, then your patient complains that, thinking these were preventative services, the patient is very unhappy that some were diagnostic and subject to large deductibles and cost sharing.
• You spend extra time addressing patient concerns during a preventative visit, but only bill for the preventative services, costing you time and money, as you’ll not be reimbursed for your extra evaluation, analysis and professional advice.
• You bill for both the preventative and diagnostic portions of patients’ visits, but waive deductibles. You may open your practice to more billing audits for perceived irregularities.
• Even the time spent deciding which were preventative and which were diagnostic services will challenge the goal of reducing or controlling costs.

Physicians may modify their diagnostic and/or treatment procedures to accelerate or smooth the process for the benefit of the practice. Should this affect patient well-being, when combined with pay-for-performance initiatives, this could negatively affect your revenue stream over time.

Regardless of ACA provisions or restrictions, physicians are cautioned to continue to use good patient welfare judgment with diagnostic and treatment regimens. Delivering quality patient care, while keeping your practice viable, is a required goal, however you get to the end result.

Congressional action, like the ACA, should not dictate diagnosis and treatment selections that “fit” a bureaucratic “box” that must be “checked” to fulfill government or payer regulations. Focus on delivering quality care at the expense of governmental considerations. Your patients’ welfare should always take center stage. You can fine tune your claims reimbursement procedures to better conform to ACA mandates with some practice and repetition.

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