ARTICLE WRITTEN BY:
Laurie DeSantis, CPC
Vice President of Operations: Healthcare Revenue Logic, LLC
Suzanne Lavin, CPA
President: Healthcare Revenue Logic, LLC
Each year seems to bring with it more complexities in how healthcare is administered in the United States. Controlling costs by limiting the supply of care has led to a chaos of bureaucratic rules, medical protocols, primary care “gatekeepers”, three-four-five tier prescription drug formularies, added outpatient utilization reviews, carved in (or out) mental health and substance abuse coverage, arbitrary medical necessity mandates, and increased patient deductibles. The list goes on and on! It is no wonder that both patients and their physicians are left confused and angry. Employers are forced to choose between increasing deductibles, copays and additional out-of-pocket costs or effectively lowering wages by increasing the employee’s premium contributions.
One alternative approach to controlling costs was to promote a consumer-driven health care system with the use of high-deductible plans. The purpose was to reduce health care expenses and improve quality of care by creating pricing transparency and awareness thereby incentivizing consumers to take control of their health care decisions.
With the implementation of the Affordable Care Act (ACA) of 2010, American people were promised the stability and flexibility they need to make informed choices about their health. For consumers, the key benefits are the elimination of pre-existing conditions, young adult’s coverage under their parent’s health plan until the age of 26, access to affordable care and an end to lifetime limits on coverage. The Obama administration has focused on the low premiums for plans on the insurance exchanges created by the new health law. But as consumers dig deeper into the details, they are finding that the out-of-pocket costs, including deductibles in the thousands of dollars, are often much higher than what is typical in employer-sponsored health plans. This presents a problem for both the consumer and the provider. Patients are asked to pay large amounts at the time of service, which many cannot afford. Providers over-head expenses increase with the added expense of collecting from the patients after services are provided. Employers offering high-deductible health plans, in general, have grown 31% since 2012.
Payers are consolidating networks and repositioning in the markets as a result of the ACA. Narrow networks are believed to offer payers more bargaining power in negotiating lower rates to providers. Narrow networks also limit the choice for consumers with a smaller pool of providers and hospitals.
With the escalating costs of doing business physicians will need to redesign their operations to create efficiencies, adopt new technologies to improve patient care and re-engineer workflows to adapt to the dynamics of a changing market. Add to that the comprehensive rules for guarding patients’ protected health information (PHI) under the Health Insurance Portability and Accountability Act (HIPAA) which have become more stringent with penalties to providers failing to do so.
Physician practices that want to remain independent must make financial decisions that will keep their practice afloat in today’s health care environment. The business of medicine is growing increasingly complex as insurance reimbursement rates decline, operating costs increase and administrative challenges surge. It is becoming difficult for physicians to manage the business without losing focus on the quality of care for their patients. The consequences of neglecting the business operations are serious. Healthcare providers know that medical billing is one of the most complex yet crucial components of their business. They must decide what operational processes will save expenses as well as enhance both the patient experience and the practice revenue.
Is it better for practices to “outsource” practice management tasks? It is crucial that a practices financial service be expert with billing, coding and denials management. Knowledge in quality improvement methods that increase practice efficiencies and patient satisfaction will reap benefits with both increased patient throughput and new value-based purchasing arrangements. Potential additional benefits of outsourcing include a reduction in expenses related to personnel salaries and benefits, as well as the associated costs of hiring and training staff with inevitable turnover. Providers can reallocate space that could be used to generate additional revenue streams. Additional significant savings would include the avoidance of purchasing and maintaining an expensive billing system and electronic medical record.
Reputable billing companies have well-trained teams of certified professional coders and seasoned staff who can focus on the complete revenue cycle to maximize reimbursement. Performance of the billing service can be best gauged by an increase in practice revenue and the speed in which it is received. It is often more cost effective to outsource billing functions. Practices that prefer to focus solely on patient care must be sure that their billing service offers access to the information needed to make the quality decisions that affect their profitability.
ABOUT THE AUTHORS:
Ms. DeSantis has spent the last 26-years as Director for Patient Financial Services in both academic and private practice settings for large multi-specialty groups in both pediatric sub-specialty and adult medicine. In addition she has extensive experience consulting with large group practices and hospitals across the country in the streamlining of revenue cycle work flow processes.
Ms. Lavin has over 25-years of accounting, finance and healthcare management experience. She has served as a Chief Financial Officer and Chief Executive Officer of large multi-specialty group practices. She’s worked in not-for profit and for-profit systems. Her expertise lies in contract negotiations with insurance companies and business partners, practice and program development, profitability evaluations, human resource management, employee benefit plan development and administration, business insurance needs, and accounting controls and procedures.
811 Redgate Avenue
Norfolk, Virginia 23507