Accountable Care Organizations (ACO’S)
Thursday, August 19th, 2010The concept of Accountable Care Organizations (ACO’s) was given a prominent place in this year’s reform legislation. In essence, an ACO is a network of healthcare providers that manage the full continuum of care for all patients within the provider network.
The goal of an ACO is to reduce costs and improve quality of care through cooperation and coordination among providers.
It is critical to avoid the temptation to act before you have determined what precisely the ACO will do differently.
Physicians used to having control over their own fee-for-service models may well hesitate to sign up for a “shared savings” that is based on reduced billings by ACO providers, especially considering the administrative costs necessary to support the ACO.
Other obstacles to ACO’s include possible FTC and DOJ desires to quash ACO’s on anti-trust grounds.
Further, state governments may need to change laws related to insurance regulation as well as organizational and professional liability.
Stay Tuned!
Increasing Revenue
Friday, May 21st, 2010Have you considered your managed care contracts as a source of increased revenue?
Too often, physician practices overlook the opportunities inherent in managed care contracting for improving revenue performance and building their bottom line.
Effective managed care contracting depends on performing three types of analysis:
1. Internal – comparing performance among your current managed care contracts
2. External – comparing your contracts with those of other payers in your market
3. Payment performance – assessing how contractual provisions affect performance
The managed care contracting process entails a series of distinct phases:
• Negotiation
• Implementation
• Contract monitoring, and
• Renegotiation
Successful managed care contracting requires an organization to view these phases as fluid and overlapping, rather than distinct.
The goal in managed care contracting is to create a framework for payment decisions that is as beneficial as possible for both payers and providers.
Negotiating Managed Care Contracts
Monday, April 19th, 2010Today, most health plans operate with fixed fee schedules. While most are based on a percentage of what Medicare pays, they may be tied to payment levels that are three or more years old. Physicians who question this methodology for paying for professional services are told to take it or leave it.
We are finding, however, that negotiating with Payers for fairer payments is possible. This does not mean Payers are willing to grant large increases just because you ask. But with the right data and a reasonable approach, you will be able to overcome inequities in existing fee schedules.
KEY POINTS
A simple analysis of your fees and your health plans’ reimbursement rates can help you reveal and overcome payment inequities.
Make sure you review your fees annually and set them reasonably.
Negotiating even small increases for a few codes can generate valuable income for your practice.
Solid data and a well-reasoned approach are vital to negotiating better reimbursement rates.
21.2% Medicare Pay Cut Will Take Effect Monday
Saturday, February 27th, 2010February 26, 2010 — Unless a minor bipartisan miracle happens in Congress over the next few days, physicians will go over the cliff on Monday. That’s when a scheduled 21.2% reduction in Medicare reimbursement takes effect.
A recent poll conducted by several medical societies representing neurosurgeons, for example, revealed that almost 40% would cut back on seeing new Medicare patients if reimbursement continues to decline, while 18% would stop accepting new Medicare patients altogether. Another 27% said they would treat fewer established Medicare patients.
Medicare Eliminates Consultation Codes
Monday, January 11th, 2010CMS (Centers for Medicare and Medicaid Services) announced the elimination of consult codes. Officially released and documented in Change Request “CR 6740″as of January 1, 2010 consult codes will be eliminated from the Medicare fee schedule. Medicare will no longer recognize or pay for services billed with consult codes 99241-99245 or 99251-99255.
CR6470 impacts only Medicare claims as of January 10th 2010, Medicare Advantage plans are likely to follow the Medicare rules. Medicare claims will not use consult codes, while private payers will (for now.) Verification of patient insurance prior to the physician visit is more critical than ever.
Declining Doctor Reimbursements Continue Closing Offices
Wednesday, September 10th, 2008 For 26 years, Dr. Joseph Lalka has been a family doctor, treating 3,000 patients in his cramped office in Chatham, N.Y., a small town nestled in the rural northern part of the state. But Lalka recently told his patients he is taking down his shingle and closing his practice. He says he no longer can afford to maintain a family practice.
Now his patients fear a future without the man who has cared for some of them for a quarter of a century. And they say they are angry at a system that has forced their doctor to leave because of escalating operating costs and declining reimbursements. Lalka, 54, says that with an income of only $60,000 last year, and little opportunity to expand his practice, he no longer is able to make ends meet.
The physicians contract is at the center of the reimbursement issue; specifically “payment terms.” This has been un-manageable for many physicians; it’s not that they don’t care; it’s that their practices have turned into revolving doors to try and keep up with declining reimbursements and the demand for healthcare.
Consider this, a family practitioner can spend up to an hour with one patient and be reimbursed in the area of $25.00; factor in expenses and you see the problem. At the end of the day physicians must identify and manage these contracts. It is no longer sufficient to trust their income to others.
If Dr. Lalka, and others like him, had the necessary data; the outcome could have been far different.
Yet Another Fine
Thursday, August 14th, 2008 Yet another payer has been ordered by state regulators to pay restitution of $3.9 million to thousands of members and a $250,000 fine for underpayment of claims related to care in out-of-network hospitals and other medical facilities.
State Insurance Commissioner Mike Geeslin ordered the health insurer to make the payments over the next several months and specified that if they don’t total at least $3.9 million, the balance must be paid to the state as an additional fine, reported the Dallas Morning News.
Doug Danzeiser of the Texas Department of Insurance said the underpayments date to Jan. 1, 2004, and involves thousands of members in Texas enrolled in Preferred Provider Organization plans.
Dallas Morning News, August 9, 2008
Healthcare Payment Reform
Thursday, July 24th, 2008 In many ways, the nation’s current healthcare payment system creates inefficiencies by adding cost and complexity to healthcare administration. Achieving payment system reforms will require a level of cooperation among all stakeholders.
In the current volume-based payment system physicians and others who provide high-quality, efficient care and thereby reduce the volume of patient services, receive reduced payment. The payment system encourages competition among healthcare providers for high-margin services, leading to increased fragmentation and, in some cases, an overuse of those services.
Principles of a New Payment System
1. Payments should encourage and reward high-quality and efficient care.
2. Payments should align incentives among all stakeholders to maximize the efficiency.
3. Payment systems should balance the needs and concerns of all stakeholders.
4. Payment processes should be simplified, standard, and transparent.
Only by operating within a shared framework of principles and goals will meaningful change be possible.
Virtual Office Visits
Friday, July 4th, 2008 The doctor doesn’t have to see you now. Thanks to new technology, patients may not always need a face-to-face visit with their doctor to get the care they need.
And thanks to a growing awareness of this fact on the part of health plans, structured, Internet-facilitated and reimbursable “virtual visits” are on the verge of entering mainstream medicine. Virtual visits also are seen as a tool that will save money, provide convenient care and maybe do something to solve the problem of patients not having access to their doctors.
This is especially true in Minnesota, where five of the six largest private health plans reimburse physicians about $35 per virtual office visit, and the last holdout announced that it will soon join the club. Unresolved, however, are issues over standards for billing and legal jurisdiction matters concerning doctors conducting e-visits during travel to states they are not licensed to practice in.
Health information technology vendors are helping to bring the parties together, and a message is being spread that virtual visits benefit patients by offering affordable and convenient access to their doctors; help providers more efficiently process routine cases; aid employers by reducing absenteeism created when workers take time off to see their physician; and—perhaps most significant—assist insurance companies in saving money.
“I would hope that 100% of the companies will be doing this in the next few years,” said independent family physician and e-visit advocate Michelle Eads of Woodland Park, Colo. “Once the insurance companies get it through their thick skulls that it saves money, they’ll be more than willing to do it.”
Eads is also the sole practitioner in a pilot study Kaiser Permanente of Colorado Springs is conducting exploring the use of virtual visits by in-network independent physicians. She receives $50 for an online consultation and said preliminary figures from 2006 show that Kaiser is saving between $70 and $120 on each virtual visit.
Internist Paul Tang, the vice president and chief medical information officer of the Palo Alto (Calif.) Medical Foundation, believes employers should pay more attention. He said, in a study, his organization found that for every $1 employers invested in virtual-visit programs, they received a $4.50 return—mostly in the form of savings generated from having less lost productivity.
Eads, speaking at the AAFP’s annual scientific assembly in Chicago earlier this month, said it takes about 16 minutes to complete the typical virtual visit, and that they have been particularly useful in monitoring patients with hypertension and depression. Besides chronic conditions, Eads said these visits are also helpful for patients who work nights or who are just under the weather.
“I live in the mountains,” she explained. “Some people don’t want to drive into the mountains just for me to say ‘Yes, you’re sick.’ ”
E-visits also work out for patients without insurance who find the $50 online-consult fee easier to swallow than the price of an office visit, Eads said.
Miami-based family physician Bernd Wollschlaeger has nothing but self-pay patients in his cash-only, paper-free practice, and he said his patients don’t mind paying for electronic communication. Fees start at $15 to $20 for a prescription refill, $25 for chronic condition management, and then go higher the more complex the task. “Most people in my practice understand that my time is money,” Wollschlaeger said. “I’ve never heard a complaint.”
How Are Employer Medical Premium Dollars Being Spent?
Friday, July 4th, 2008 The Texas Medical Association and the National Federation of Independent Businesses have teamed up to help their members, most of which are small business owners, find out how much of their medical premium dollars are actually being spent by insurers on health care.
Thanks to a little-known piece of legislation passed by the Texas Legislature in 2007, insurance companies must disclose this information, reported the Houston Business Journal. TMA and NFIB hope that if enough small business owners demand this information and then use it to contest premium-rate increases or to shop for better pricing, it might be a small step toward more transparency and competition in the health insurance market, the Business Journal added.
Houston Business Journal, June 13, 2008
