No matter how healthy your lifestyle, how wisely you plan your diet or how much you exercise in an effort to take care of your body, unexpected situations may arise. You may land in the hospital with bills that could potentially wipe out everything you own. Thus it is extremely important to acquire an adequate insurance medical policy that will take care of your expenses in case of just such an emergency.
Everyone needs at least some form of health insurance. Some people are concerned about qualifying for an insurance plan especially if they have health issues. There are so many options available and although some are not easy to find, they can be quite simple to qualify for.
Before signing up for a plan, consider your family's medical needs and budget requirements. There are basically two types of plans to consider, a private plan and a government plan.
Types of Coverage
The private plan is commonly obtained through employment. Most employers will offer some form of insurance for their full time employees. In some states employers are required to provide insurance if the employee exceeds a certain level of hours worked during the course of a week. Often times the employer will offer some sort of group health plan for their employees which decreases the monthly premium costs. Normally this type of plan will cover your spouse and family. Many people may not be able to participate in group plans. There are many individual plans are offered although they may be a bit more expensive in relation to group plans.
If you are going to sign on with a private plan learn all you can about the coverage in the contract. Read all the inclusions and exclusions and avoid signing up with a plan that has a long list of exclusions. Also make sure you obtain a copy of all the paperwork you sign.
Health insurance offered by the government is generally on a state or national level. One example would be Medicare which is a national plan. Medicare is available for those people over 65 years of age and also is available to disabled people. Some other types of government assisted health care plans include Medicaid which is based on income level, health and care for veterans and children's health programs.
Article Source: http://EzineArticles.com/?expert=Peter_Kingston
Sunday, October 12, 2008
Medical Billing Audit, Clean Claims Metrics, And the Payer-Provider Conflict
Dr. Noah Payne shook his head in disbelief: the practice reimbursements shrank instead of climbing in response to the recent hiring of Dr. Inna Ternist. The new doctor clearly added to the total number of patients seen yet overall payments did not reflect the added charges. Perhaps the new claims were not created, submitted, or paid? Dr. Noah remembered noticing the growing pile of rejected and denied claims accumulating dust on his desk - he never had the time to review them...How many of these claims are clean? How many of them require manual review and correction?
Dr. Noah looked at his Vericle screen and began analyzing the numbers. The system showed 58 percent clean claims (PCC). In other words, almost every second claim required manual correction. Who could be causing such a high level of problems: the practice, the billing service, or the payer? Dr. Noah's instinctively felt that perhaps the billing service was negligent about data entry process and kept introducing massive data errors. But the service manager was quick to explain a rigorous quality assurance process for data entry. What else could be causing such a high level of manual work in a seemingly streamlined process?
A quick review shows that PCC varies along several dimensions:
1. 19 and 70 percent for financial class
2. 37 and 66 percent for month of service
3. 55 and 59 percent for physician
4. 29 and 70 percent for various CPT codes
Trying to discover a pattern, Dr. Noah looked for a root cause dimension. He drilled into 99213 - the single largest frequency CPT code for his practice. Vericle showed 3,135 claims and the above average 62 PCC carrying charges and payments for 99213 code.
Having isolated the single most frequent CPT code, Dr. Noah was thinking about other dimensions that influence PCC. He hypothesized that if all doctors in his practice had the same coding skills, and assuming uniform distribution of errors, he should observe no PCC variance across the doctors. Yet, a quick click on a Vericle screen yielded a spread, confirming his suspicion that different doctors maintained slightly different coding skills:
1. Dr. Ted 1,554 claims and PCC = 63%
2. Dr. Lori 865 claims and PCC = 62%
3. Dr. Inna 194 claims and PCC = 61%
4. Dr. Noah 516 claims and PCC = 60%
Next, Dr. Noah switched his attention to distribution of PCC across the financial classes. Again, he hypothesized that if all payers used the same rules to deny claims then there should be no difference in the average PCC for different payers, subject to a uniform distribution of errors over a large sample of submitted and paid claims. Yet the numbers showed a significant (30 percent) variation of PCC for the same CPT code: UHC - 82, Blue Cross Blue Shield - 73, Oxford - 64, Aetna - 59, Medicare - 59, and Cigna - 51, confirming his conclusion that various payers used various rules to deny and underpay claims.
Dr. Noah recalled reading an article about PacifiCare, a Californian insurance company being fined upon an audit. The joint Department of Managed Health Care and Insurance Department recently analyzed 1.1 million paid claims from June 2005 to May 2007 that covered about 190,000 members in PacifiCare's HMO plans and PPO coverage [Gilbert Chan , "PacifiCare fined record $3.5 million," www.sacbee.com , January 30, 2008]. They discovered 30 percent of the HMO claims wrongly denied and 29 percent of the disputes with doctors were handled incorrectly. PacifiCare paid out over $1 million and was fined additional $3.5 million. Dr. Noah's findings roughly matched PacifiCare audit - the insurance companies were failing anywhere between twenty to fifty percent of his claims and each insurance company showed a different failure rate, depending on a system used to fail submitted claims.
Finally, Dr. Noah thought of the billing service operation. Is his billing service systematically working to discover failed claims and improve its response to such discoveries? Is there a pattern of an occasional drop of PCC reflecting its deterioration in response to various payer's initiatives? Conversely, is there any evidence for a systematic improvement effort? A chart of the distribution of a single CPT-code clean claim percentage over the entire year must answer his question. In his mind, PCC should iterate between drops and climbs, hopefully each time at a higher level. Vericle confirmed his expectations, showing an overall improvement of PCC over the year (46% 1-07, 39% 2-07, 52% 3-07, 55% 4-07, 63% 5-07, 67% 6-07, 72% 7-07, 69% 8-07, 72% 9-07, 68% 10-07, 74% 11-07, 73% 12-07)
Article Source: http://EzineArticles.com/?expert=Yuval_Lirov
Dr. Noah looked at his Vericle screen and began analyzing the numbers. The system showed 58 percent clean claims (PCC). In other words, almost every second claim required manual correction. Who could be causing such a high level of problems: the practice, the billing service, or the payer? Dr. Noah's instinctively felt that perhaps the billing service was negligent about data entry process and kept introducing massive data errors. But the service manager was quick to explain a rigorous quality assurance process for data entry. What else could be causing such a high level of manual work in a seemingly streamlined process?
A quick review shows that PCC varies along several dimensions:
1. 19 and 70 percent for financial class
2. 37 and 66 percent for month of service
3. 55 and 59 percent for physician
4. 29 and 70 percent for various CPT codes
Trying to discover a pattern, Dr. Noah looked for a root cause dimension. He drilled into 99213 - the single largest frequency CPT code for his practice. Vericle showed 3,135 claims and the above average 62 PCC carrying charges and payments for 99213 code.
Having isolated the single most frequent CPT code, Dr. Noah was thinking about other dimensions that influence PCC. He hypothesized that if all doctors in his practice had the same coding skills, and assuming uniform distribution of errors, he should observe no PCC variance across the doctors. Yet, a quick click on a Vericle screen yielded a spread, confirming his suspicion that different doctors maintained slightly different coding skills:
1. Dr. Ted 1,554 claims and PCC = 63%
2. Dr. Lori 865 claims and PCC = 62%
3. Dr. Inna 194 claims and PCC = 61%
4. Dr. Noah 516 claims and PCC = 60%
Next, Dr. Noah switched his attention to distribution of PCC across the financial classes. Again, he hypothesized that if all payers used the same rules to deny claims then there should be no difference in the average PCC for different payers, subject to a uniform distribution of errors over a large sample of submitted and paid claims. Yet the numbers showed a significant (30 percent) variation of PCC for the same CPT code: UHC - 82, Blue Cross Blue Shield - 73, Oxford - 64, Aetna - 59, Medicare - 59, and Cigna - 51, confirming his conclusion that various payers used various rules to deny and underpay claims.
Dr. Noah recalled reading an article about PacifiCare, a Californian insurance company being fined upon an audit. The joint Department of Managed Health Care and Insurance Department recently analyzed 1.1 million paid claims from June 2005 to May 2007 that covered about 190,000 members in PacifiCare's HMO plans and PPO coverage [Gilbert Chan , "PacifiCare fined record $3.5 million," www.sacbee.com , January 30, 2008]. They discovered 30 percent of the HMO claims wrongly denied and 29 percent of the disputes with doctors were handled incorrectly. PacifiCare paid out over $1 million and was fined additional $3.5 million. Dr. Noah's findings roughly matched PacifiCare audit - the insurance companies were failing anywhere between twenty to fifty percent of his claims and each insurance company showed a different failure rate, depending on a system used to fail submitted claims.
Finally, Dr. Noah thought of the billing service operation. Is his billing service systematically working to discover failed claims and improve its response to such discoveries? Is there a pattern of an occasional drop of PCC reflecting its deterioration in response to various payer's initiatives? Conversely, is there any evidence for a systematic improvement effort? A chart of the distribution of a single CPT-code clean claim percentage over the entire year must answer his question. In his mind, PCC should iterate between drops and climbs, hopefully each time at a higher level. Vericle confirmed his expectations, showing an overall improvement of PCC over the year (46% 1-07, 39% 2-07, 52% 3-07, 55% 4-07, 63% 5-07, 67% 6-07, 72% 7-07, 69% 8-07, 72% 9-07, 68% 10-07, 74% 11-07, 73% 12-07)
Article Source: http://EzineArticles.com/?expert=Yuval_Lirov
Tuesday, October 7, 2008
Medical Billing and the Discrepancy Paradox of the Rising Healthcare Costs
Health care spending continues to rise at the fastest rate in our history. In 2005, total national health costs rose 6.9 percent -- twice the rate of inflation - reaching $2 trillion, or $6,700 per person [Catlin, Cowan, Heffler, et al, 2006]. Currently, total health care spending represents 16 percent of the gross domestic product (GDP). In the next decade, U.S. health care spending is expected to increase at similar levels, reaching $4 trillion in 2015 [Borger et al, 2006].
While some experts maintain that our health care system is costly because it is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, waste, inappropriate care, and fraud [Health Insurance Cost, National Coalition on Health Care, 2008], at least three remaining key factors, namely, aging population, expensive medical innovation, and defensive care, contribute substantially, to the overall cost picture.
1. Aging population
In the United States, the proportion of the population aged >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons aged >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons aged >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030 [Public Health and Aging: Trends in Aging --- United States and Worldwide, 2008; Kaiser Family Foundation, 2006].
"The growing number of older adults increases demands on the public health system and on medical and social services. Chronic diseases, which affect older adults disproportionately, contribute to disability, diminish quality of life, and increased health- and long-term--care costs." [UN, 2002] 125 million Americans have one or more chronic conditions (e.g. congestive heart failure, diabetes.) Chronic diseases account for 75% of all health care expenditures. Source: Burrill & Company, 2006
2. Expensive innovation
* The American biotechnology industry has surpassed pharmaceutical companies for the third straight year as the primary source of new medicines, and biotech revenue jumped nearly 16 percent to a record $50.7 billion in 2005. Source: Ernst & Young LLP, 2006
* The USA is the world's largest and wealthiest pharmaceutical market, accounting for around 48% of the world total. Per capita expenditure on drugs is US $1,069 in 2006, nearly double the level found in the rest of the world. Source: Espicom Business Intelligence, 2006
* ...an estimated 30% of new products under development are "combo products" - involving medical devices embedded with pharmaceutical or biologics components. [Combination Products- Navigating Two FDA Quality Systems, Microtest White Paper, 2007]. The combination products market is estimated at $5.9B in 2004, and will continue to grow at a compound annual rate of 10% through 2009. By 2009, the market is expected to reach approximately $9.5B worldwide with a majority of these revenues from drug-eluting stents and steroid-eluting electrodes. Source: Navigant Consulting, Inc. In 2004, the US held approximately 65% of the drug-device combination product market. By 2010, the US is projected to hold 57%. Source: Business Communications Inc.
3. "Defensive" Medicine
"One of the major cost drivers in the delivery of health care are these junk and frivolous lawsuits. The risk of frivolous litigation drives doctors -- and hear me out on this -- they drive doctors to prescribe drugs and procedures that may not be necessary, just to avoid lawsuits. That's called the defensive practice of medicine.. . . . See, lawsuits not only drive up premiums, which drives up the cost to the patient or the employer of the patient, but lawsuits cause docs to practice medicine in an expensive way in order to protect themselves in the courthouse. The defensive practice of medicine affects the federal budget. The direct cost of liability insurance and the indirect cost from unnecessary medical procedures raise the federal government's health care costs by at least $28 billion a year." [US President George Bush, Arkansas, January 26, 2004]
Now let us observe the paradox:
1. On one hand, the participants of every ancillary industry to health care, including insurance companies, hi-tech and pharmaceutical engineers and scientists, as well as lawyers, have increased their profits in step with the rising costs of health care at ever accelerating pace.
2. On the other hand, the medical and chiropractic office owners - the actual health care providers - have not only failed to keep up with raising costs but have lost a significant part of their income. In fact, between 1995 and 1999, at a time when most wages and salaries in the United States rose 3.5 percent after adjusting for inflation, average physician net income from the practice of medicine, adjusted for inflation, dropped 5 percent [Reed and Ginsburg, 2003]. In 2006, the median compensation for specialty and primary physicians grew only 1.7 ($322,259) and 2 ($171,519) percent respectively, slower than consumer price index of 3.2 percent [MGMA Physician Compensation and Production Survey: 2007 Report]. In comparison, health care costs beat the inflation by 3.5% reaching the annual growth rate of 6.7 [Health Care Spending, 2008]
Diverting our focus away from trying to find solutions to the problem of rising health care costs, we ask a different question: How such a paradoxical situation is possible without a deliberate and systematic strategy against health care providers?
References:
1. Catlin, A, C. Cowan, S. Heffler, et al, "National Health Spending in 2005." Health Affairs 26:1 (2006): 142-153.
2. Borger, C., et al., "Health Spending Projections Through 2015: Changes on the Horizon," Health Affairs Web Exclusive W61: 22 February 2006.
3. Health Insurance Cost, National Coalition on Health Care as of January 4, 2008
4. Public Health and Aging: Trends in Aging --- United States and Worldwide, as of January 4, 2008
5. United Nations. Report of the Second World Assembly on Aging. Madrid, Spain: United Nations, April 8--12, 2002.
6. Kinsella K, Velkoff V. U.S. Census Bureau. An Aging World: 2001. Washington, DC: U.S. Government Printing Office, 2001; series P95/01-1.
7. U.S. Census Bureau. International database. Table 094. Midyear population, by age and sex. 2008
8. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2006 Annual Survey. 26 September 2006.
9. President Bush Calls for Medical Liability Reform, Baptist Health Medical Center, Little Rock, Arkansas, January 26, 2004 http://www.whitehouse.gov/news/releases/2004/01/20040126-3.html as of January 4, 2008
10. Marie C. Reed, Paul B. Ginsburg, Behind the Times: Physician Income, 1995-99, Data Bulletin No. 24, March 2003
11. Medical Group Management Association (MGMA) Physician Compensation and Production Survey: 2007 Report
12. MEDICARE SPENDING - United States Government Accountability Office (GAO), Testimony Before the Subcommittee on Health, Committee on Energy and Commerce, House of Representatives, March 6, 2007, Healthcare Costs 101
13. Health Care Spending http://www.cms.hhs.gov/NationalHealthExpendData/01_Overview.asp as downloaded on January 15, 2008
Article Source: http://EzineArticles.com/?expert=Yuval_Lirov
While some experts maintain that our health care system is costly because it is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, waste, inappropriate care, and fraud [Health Insurance Cost, National Coalition on Health Care, 2008], at least three remaining key factors, namely, aging population, expensive medical innovation, and defensive care, contribute substantially, to the overall cost picture.
1. Aging population
In the United States, the proportion of the population aged >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons aged >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons aged >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030 [Public Health and Aging: Trends in Aging --- United States and Worldwide, 2008; Kaiser Family Foundation, 2006].
"The growing number of older adults increases demands on the public health system and on medical and social services. Chronic diseases, which affect older adults disproportionately, contribute to disability, diminish quality of life, and increased health- and long-term--care costs." [UN, 2002] 125 million Americans have one or more chronic conditions (e.g. congestive heart failure, diabetes.) Chronic diseases account for 75% of all health care expenditures. Source: Burrill & Company, 2006
2. Expensive innovation
* The American biotechnology industry has surpassed pharmaceutical companies for the third straight year as the primary source of new medicines, and biotech revenue jumped nearly 16 percent to a record $50.7 billion in 2005. Source: Ernst & Young LLP, 2006
* The USA is the world's largest and wealthiest pharmaceutical market, accounting for around 48% of the world total. Per capita expenditure on drugs is US $1,069 in 2006, nearly double the level found in the rest of the world. Source: Espicom Business Intelligence, 2006
* ...an estimated 30% of new products under development are "combo products" - involving medical devices embedded with pharmaceutical or biologics components. [Combination Products- Navigating Two FDA Quality Systems, Microtest White Paper, 2007]. The combination products market is estimated at $5.9B in 2004, and will continue to grow at a compound annual rate of 10% through 2009. By 2009, the market is expected to reach approximately $9.5B worldwide with a majority of these revenues from drug-eluting stents and steroid-eluting electrodes. Source: Navigant Consulting, Inc. In 2004, the US held approximately 65% of the drug-device combination product market. By 2010, the US is projected to hold 57%. Source: Business Communications Inc.
3. "Defensive" Medicine
"One of the major cost drivers in the delivery of health care are these junk and frivolous lawsuits. The risk of frivolous litigation drives doctors -- and hear me out on this -- they drive doctors to prescribe drugs and procedures that may not be necessary, just to avoid lawsuits. That's called the defensive practice of medicine.. . . . See, lawsuits not only drive up premiums, which drives up the cost to the patient or the employer of the patient, but lawsuits cause docs to practice medicine in an expensive way in order to protect themselves in the courthouse. The defensive practice of medicine affects the federal budget. The direct cost of liability insurance and the indirect cost from unnecessary medical procedures raise the federal government's health care costs by at least $28 billion a year." [US President George Bush, Arkansas, January 26, 2004]
Now let us observe the paradox:
1. On one hand, the participants of every ancillary industry to health care, including insurance companies, hi-tech and pharmaceutical engineers and scientists, as well as lawyers, have increased their profits in step with the rising costs of health care at ever accelerating pace.
2. On the other hand, the medical and chiropractic office owners - the actual health care providers - have not only failed to keep up with raising costs but have lost a significant part of their income. In fact, between 1995 and 1999, at a time when most wages and salaries in the United States rose 3.5 percent after adjusting for inflation, average physician net income from the practice of medicine, adjusted for inflation, dropped 5 percent [Reed and Ginsburg, 2003]. In 2006, the median compensation for specialty and primary physicians grew only 1.7 ($322,259) and 2 ($171,519) percent respectively, slower than consumer price index of 3.2 percent [MGMA Physician Compensation and Production Survey: 2007 Report]. In comparison, health care costs beat the inflation by 3.5% reaching the annual growth rate of 6.7 [Health Care Spending, 2008]
Diverting our focus away from trying to find solutions to the problem of rising health care costs, we ask a different question: How such a paradoxical situation is possible without a deliberate and systematic strategy against health care providers?
References:
1. Catlin, A, C. Cowan, S. Heffler, et al, "National Health Spending in 2005." Health Affairs 26:1 (2006): 142-153.
2. Borger, C., et al., "Health Spending Projections Through 2015: Changes on the Horizon," Health Affairs Web Exclusive W61: 22 February 2006.
3. Health Insurance Cost, National Coalition on Health Care as of January 4, 2008
4. Public Health and Aging: Trends in Aging --- United States and Worldwide, as of January 4, 2008
5. United Nations. Report of the Second World Assembly on Aging. Madrid, Spain: United Nations, April 8--12, 2002.
6. Kinsella K, Velkoff V. U.S. Census Bureau. An Aging World: 2001. Washington, DC: U.S. Government Printing Office, 2001; series P95/01-1.
7. U.S. Census Bureau. International database. Table 094. Midyear population, by age and sex. 2008
8. The Henry J. Kaiser Family Foundation. Employee Health Benefits: 2006 Annual Survey. 26 September 2006.
9. President Bush Calls for Medical Liability Reform, Baptist Health Medical Center, Little Rock, Arkansas, January 26, 2004 http://www.whitehouse.gov/news/releases/2004/01/20040126-3.html as of January 4, 2008
10. Marie C. Reed, Paul B. Ginsburg, Behind the Times: Physician Income, 1995-99, Data Bulletin No. 24, March 2003
11. Medical Group Management Association (MGMA) Physician Compensation and Production Survey: 2007 Report
12. MEDICARE SPENDING - United States Government Accountability Office (GAO), Testimony Before the Subcommittee on Health, Committee on Energy and Commerce, House of Representatives, March 6, 2007, Healthcare Costs 101
13. Health Care Spending http://www.cms.hhs.gov/NationalHealthExpendData/01_Overview.asp as downloaded on January 15, 2008
Article Source: http://EzineArticles.com/?expert=Yuval_Lirov
Medical Billing Audit - Why Should Providers Audit Payers?
A Sacramento-area surgeon couldn't schedule surgeries for more than six months because his contract was not loaded in the insurer's computer system. More than 200 of Dr. Watson's patients received letters indicating incorrectly that he was no longer participating in the network. Watson lost about 25 percent of these patients and was not paid for about eight months. Another insured spent eleven months trying to get claims paid for his family, including an autistic child. The insurer never specified what information was needed to make the denied claims eligible for payment.
Are these three isolated incidents or are they three symptoms of a growing problem with the entire provider's reimbursement system? The owners of health care practices easily recognize these painfully familiar symptoms. The better questions are: how are they related to the rising healthcare costs and what can a provider do to help?
In 2005, national healthcare costs rose 6.9 percent - twice the rate of inflation, reaching $2 trillion. National healthcare costs are predicted to double to $4 trillion by 2015. While key health care cost factors include aging US population, the arrival of new and expensive drugs and bio-tech devices, and the defensive medicine, the insurance costs alone stand out as a key contributor to rising healthcare costs. Exorbitant executive compensation became a hallmark of healthcare insurance industry, where William McGuire, CEO of UnitedHealth Group, has reportedly received over $500 million since 1992, more than $1 billion worth of options, a lump sum payout of $6.4 million upon leaving the company, and an annual pension of $5.1 million. But such compensation can be easily justified on Wall Street, when comparing it to outstanding insurance industry profits, such as 38 percent growth in earnings in the 3rd quarter of 2006.
The problem for any successful insurance company is how to make such growth sustainable? This question is difficult because the premium growth (68.4 percent) has disproportionally outpaced both inflation (16.4 percent) and workers earnings (18.2 percent) during the same period (2001-2006), making it impossible to continue to rise the premiums without losing major segments of insured population.
Without the ability to attract new clients or to further raise insurance premiums, cost reduction becomes the next most important approach to enhance profitability. Such cost reduction can be done in a variety of ways, which we conveniently divide into strategic and tactical or opportunistic approaches.
Strategic insurer's arsenal
The creation of an oligopsony through consolidation is the main weapon in the strategic arsenal of insurance companies. Oligopsony exists when providers significantly outnumber buyers, enabling them to dictate prices. Take for example, the PacifiCare's $9.2 billion merger with United Health Group Inc. in late 2005, which created a vast network of HMO and PPO plans covering more than 3 million Californians. Today, three plans alone (UnitedHealthcare, WellPoint and Aetna) cover 77.7 million insured lives. Oligopsony allows the systematic and continuous cost reduction without extra investment, e.g., annual cut of allowed rates (such as the average reimbursement for E&M allowable dropped 10 percent in 2006 and another 6.5 percent in 2007), payment suspension for specific procedures (such as EKG tests for routine physicals), offering "all or none" participation alternatives, or the creation of "tiered networks" that profile providers and incentivize patients to see lower cost providers.
Tactical insurer's weapons
Increasing billing process complexity and inventing new denial reasons through arcane terminology, disparate data formats, and modifications of CPT/ICD codes and medical necessity rules - these are all examples of tactical methods designed to increase providers costs for both billing and follow up and reduce the payments at the expense of practice owners. These methods need continuous investment in personnel training, better process management, and improved technology to keep them effective as the providers begin building more sophisticated systems to scrub and analyze claims and discover payment discrepancies and irregularities.
Provider's Response
Returning to the three incidents mentioned at the outset of this article, the joint Department of Managed Health Care and Insurance Department determined that these are not isolated cases. It analyzed 1.1 million paid claims from June 2005 to May 2007 that covered about 190,000 members in PacifiCare's HMO plans and PPO coverage [Gilbert Chan , "PacifiCare fined record $3.5 million," www.sacbee.com , January 30, 2008] and discovered 30 percent of the HMO claims wrongly denied and 29 percent of the disputes with doctors were handled incorrectly. PacifiCare paid out over $1 million and was fined additional $3.5 million.
In summary, providers need new and effective approaches to mobilize both legal and organizational talent to reverse their revenue decline. Legal methods battle market conditions like oligopsony while large-scale medical billing networks aggregate claim volumes and create resulting economies of scale to enable analytical discovery of under-payments.
Article Source: http://EzineArticles.com/?expert=Yuval_Lirov
Are these three isolated incidents or are they three symptoms of a growing problem with the entire provider's reimbursement system? The owners of health care practices easily recognize these painfully familiar symptoms. The better questions are: how are they related to the rising healthcare costs and what can a provider do to help?
In 2005, national healthcare costs rose 6.9 percent - twice the rate of inflation, reaching $2 trillion. National healthcare costs are predicted to double to $4 trillion by 2015. While key health care cost factors include aging US population, the arrival of new and expensive drugs and bio-tech devices, and the defensive medicine, the insurance costs alone stand out as a key contributor to rising healthcare costs. Exorbitant executive compensation became a hallmark of healthcare insurance industry, where William McGuire, CEO of UnitedHealth Group, has reportedly received over $500 million since 1992, more than $1 billion worth of options, a lump sum payout of $6.4 million upon leaving the company, and an annual pension of $5.1 million. But such compensation can be easily justified on Wall Street, when comparing it to outstanding insurance industry profits, such as 38 percent growth in earnings in the 3rd quarter of 2006.
The problem for any successful insurance company is how to make such growth sustainable? This question is difficult because the premium growth (68.4 percent) has disproportionally outpaced both inflation (16.4 percent) and workers earnings (18.2 percent) during the same period (2001-2006), making it impossible to continue to rise the premiums without losing major segments of insured population.
Without the ability to attract new clients or to further raise insurance premiums, cost reduction becomes the next most important approach to enhance profitability. Such cost reduction can be done in a variety of ways, which we conveniently divide into strategic and tactical or opportunistic approaches.
Strategic insurer's arsenal
The creation of an oligopsony through consolidation is the main weapon in the strategic arsenal of insurance companies. Oligopsony exists when providers significantly outnumber buyers, enabling them to dictate prices. Take for example, the PacifiCare's $9.2 billion merger with United Health Group Inc. in late 2005, which created a vast network of HMO and PPO plans covering more than 3 million Californians. Today, three plans alone (UnitedHealthcare, WellPoint and Aetna) cover 77.7 million insured lives. Oligopsony allows the systematic and continuous cost reduction without extra investment, e.g., annual cut of allowed rates (such as the average reimbursement for E&M allowable dropped 10 percent in 2006 and another 6.5 percent in 2007), payment suspension for specific procedures (such as EKG tests for routine physicals), offering "all or none" participation alternatives, or the creation of "tiered networks" that profile providers and incentivize patients to see lower cost providers.
Tactical insurer's weapons
Increasing billing process complexity and inventing new denial reasons through arcane terminology, disparate data formats, and modifications of CPT/ICD codes and medical necessity rules - these are all examples of tactical methods designed to increase providers costs for both billing and follow up and reduce the payments at the expense of practice owners. These methods need continuous investment in personnel training, better process management, and improved technology to keep them effective as the providers begin building more sophisticated systems to scrub and analyze claims and discover payment discrepancies and irregularities.
Provider's Response
Returning to the three incidents mentioned at the outset of this article, the joint Department of Managed Health Care and Insurance Department determined that these are not isolated cases. It analyzed 1.1 million paid claims from June 2005 to May 2007 that covered about 190,000 members in PacifiCare's HMO plans and PPO coverage [Gilbert Chan , "PacifiCare fined record $3.5 million," www.sacbee.com , January 30, 2008] and discovered 30 percent of the HMO claims wrongly denied and 29 percent of the disputes with doctors were handled incorrectly. PacifiCare paid out over $1 million and was fined additional $3.5 million.
In summary, providers need new and effective approaches to mobilize both legal and organizational talent to reverse their revenue decline. Legal methods battle market conditions like oligopsony while large-scale medical billing networks aggregate claim volumes and create resulting economies of scale to enable analytical discovery of under-payments.
Article Source: http://EzineArticles.com/?expert=Yuval_Lirov
Saturday, October 4, 2008
Selecting Medical Billing Services Using Smart Reference Checks
The path from deciding to outsource medical billing to selecting your medical billing company requires a well planned selection strategy. A cornerstone of this strategy is well thought out and executed reference checks.
Reference checking is certainly not the only element that must be properly executed in your medical billing company selection. It is, however, one of the more critical and it has several sub-steps that must be properly considered.
Although today's write-up is geared towards creating an effective interview guide, this is far from the only ingredient of a successful medical billing services company selection. Other critical ingredients include outlining the minimum requirements of an acceptable reference (e.g., does it need to be in your state, what specialties are acceptable, etc), deciding if you want to speak with a former client, outlining the roles of the people with whom your wish to speak (e.g., lead partner, practice administrator, day-to-day billing contact, etc), creating the interview guide, call the references, and making the final go/no-go decision.
Your interview guide will allow you and not the references to determine what topics are addressed in the reference calls. If you do not drive the calls, you may well end the process still unsure about your final decision. To kick-off the interview guide creation think about the worst things and the best things that could happen as a result of medical billing outsourcing. Keeping your mind on these best and worst cases develop questions that will help you determine where between these two extremes your potential medical billing company operates.
It is critical to ensure that your questions are specific enough that you can come away with real facts from the reference calls. You do not want to ask broad questions like "Are you happy with this company's performance?" Such questions are open to much interpretation and are driven by the individual's previous experiences.
Given this issue, your next task is to make the question more geared towards gathering objective facts. For instance, you might change the question above to say, ?How many hours per week did you spend before outsourcing on reviewing billing performance reports, reviewing EOBs, and reconciling your bank deposits with your billing system reports? How many hours per week do you spend on this now??
Once you complete the list of questions and make them specific enough to gather objective data type them out in a logical manner and leave the space required to jot down the answer right on the interview guide. Before the first call sit down and look at the questions one final time. Make sure that the answers to these questions will give you the comfort you need to make a final decision. Start making the reference calls once you are confident your interview guide is ready.
It is your job to make sure you get specific answers to all of all your questions. Think of yourself as a reporter and do not let the call end until you have all of your questions specifically answered. You will need to practice good time management to make sure this happens in the period the person is allowing for the reference call. If you do not get all of your questions answered, then ask to schedule a second call.
You may find that one of your references brings up a point you had not considered. If they do, add the relevant question to the end of your interview guide and call back any individuals with whom you have already spoken to get this additional information.
With your well planned and structured reference checks complete you will be in a position to make an informed medical billing service decision.
Article Directory: http://www.articledashboard.com
Reference checking is certainly not the only element that must be properly executed in your medical billing company selection. It is, however, one of the more critical and it has several sub-steps that must be properly considered.
Although today's write-up is geared towards creating an effective interview guide, this is far from the only ingredient of a successful medical billing services company selection. Other critical ingredients include outlining the minimum requirements of an acceptable reference (e.g., does it need to be in your state, what specialties are acceptable, etc), deciding if you want to speak with a former client, outlining the roles of the people with whom your wish to speak (e.g., lead partner, practice administrator, day-to-day billing contact, etc), creating the interview guide, call the references, and making the final go/no-go decision.
Your interview guide will allow you and not the references to determine what topics are addressed in the reference calls. If you do not drive the calls, you may well end the process still unsure about your final decision. To kick-off the interview guide creation think about the worst things and the best things that could happen as a result of medical billing outsourcing. Keeping your mind on these best and worst cases develop questions that will help you determine where between these two extremes your potential medical billing company operates.
It is critical to ensure that your questions are specific enough that you can come away with real facts from the reference calls. You do not want to ask broad questions like "Are you happy with this company's performance?" Such questions are open to much interpretation and are driven by the individual's previous experiences.
Given this issue, your next task is to make the question more geared towards gathering objective facts. For instance, you might change the question above to say, ?How many hours per week did you spend before outsourcing on reviewing billing performance reports, reviewing EOBs, and reconciling your bank deposits with your billing system reports? How many hours per week do you spend on this now??
Once you complete the list of questions and make them specific enough to gather objective data type them out in a logical manner and leave the space required to jot down the answer right on the interview guide. Before the first call sit down and look at the questions one final time. Make sure that the answers to these questions will give you the comfort you need to make a final decision. Start making the reference calls once you are confident your interview guide is ready.
It is your job to make sure you get specific answers to all of all your questions. Think of yourself as a reporter and do not let the call end until you have all of your questions specifically answered. You will need to practice good time management to make sure this happens in the period the person is allowing for the reference call. If you do not get all of your questions answered, then ask to schedule a second call.
You may find that one of your references brings up a point you had not considered. If they do, add the relevant question to the end of your interview guide and call back any individuals with whom you have already spoken to get this additional information.
With your well planned and structured reference checks complete you will be in a position to make an informed medical billing service decision.
Article Directory: http://www.articledashboard.com
Texas Medical Billing Services
Medical billing is a rapidly expanding field in the healthcare sector, and the demand for skilled medical billing specialists is on the rise. There are many companies now offering medical billing services in Texas in an effective and prompt manner. These companies assist with the tedious tasks of billing and follow-up functions, thus allowing you to concentrate more on your core business.
The process of medical billing involves preparing, submitting as well as following up on insurance claims. The procedures involved in medical billing applications and insurance claims are highly complex. Since most medical office personnel do not have much time to process claims with the insurance companies, they outsource their medical billing assignments to other locations.
Most of the medical billing companies in Texas provide medical billing services to all types of practices and organizations, including physicians’ groups, clinics, hospitals, large healthcare facilities and insurance companies. The companies appoint well trained and highly qualified billing specialists to carry out all the medical billing procedures in an efficient way. They also take care of your insurance details and medical coding processes as part of their services.
Mentioned below are some of the medical billing services provided by medical billing companies:
o Demographic and insurance information
o Insurance verification procedures
o Authorization
o Cash posting
o Charge entry
o Accounts receivable follow up and collections
o Insurance collection
You can enjoy a number of benefits by using the services of a well established medical billing company:
o Electronic processing
o HIPAA compliance
o Complete medical billing management
o Improve your cash flow and collections
o Reduce billing costs
o Reduce payer denials
o Eliminate billing headaches
Before relying on a medical billing firm in Texas, it is better to perform considerable research in terms of rates, services, and other associated factors. As many of the medical billing companies offer free trial version for service quality evaluation, it is an excellent idea to take advantage of those free trial packages.
Article Directory: http://www.articledashboard.com
The process of medical billing involves preparing, submitting as well as following up on insurance claims. The procedures involved in medical billing applications and insurance claims are highly complex. Since most medical office personnel do not have much time to process claims with the insurance companies, they outsource their medical billing assignments to other locations.
Most of the medical billing companies in Texas provide medical billing services to all types of practices and organizations, including physicians’ groups, clinics, hospitals, large healthcare facilities and insurance companies. The companies appoint well trained and highly qualified billing specialists to carry out all the medical billing procedures in an efficient way. They also take care of your insurance details and medical coding processes as part of their services.
Mentioned below are some of the medical billing services provided by medical billing companies:
o Demographic and insurance information
o Insurance verification procedures
o Authorization
o Cash posting
o Charge entry
o Accounts receivable follow up and collections
o Insurance collection
You can enjoy a number of benefits by using the services of a well established medical billing company:
o Electronic processing
o HIPAA compliance
o Complete medical billing management
o Improve your cash flow and collections
o Reduce billing costs
o Reduce payer denials
o Eliminate billing headaches
Before relying on a medical billing firm in Texas, it is better to perform considerable research in terms of rates, services, and other associated factors. As many of the medical billing companies offer free trial version for service quality evaluation, it is an excellent idea to take advantage of those free trial packages.
Article Directory: http://www.articledashboard.com
Outsource Medical Billing - Deciding If It Is Right For You
Over the next several articles I plan to discuss a framework for thinking through whether outsourced medical billing is the right decision for you. The decision is a critical one, so it is imperative that it be based in facts and not in urban legends and myths. Although I am focusing on medical insurance billing services, the basic concepts apply to any outsourcing decision. Today I will outline the main benefits to consider when making the decision about medical insurance billing outsourcing and the most typical concerns and risks associated with the decision to outsource medical billing. Over the following days I will discuss each element in more detail.
The fundamental principal behind outsourcing is the focus on core competencies. The idea is that you and your practice are geared towards treating patients, not fighting insurance companies and pursuing personal balances. On the other hand, medical insurance billing services focus on billing and should have the scale, focus and employees to do a better job than most medical practices or medical facilities. The primary benefits that a medical practice should see from the right medical billing service are:
1. They have more scale to purchase and deploy the technologies required to properly submit claims, battle with insurance companies and collect personal balances.
2. They are able to attract a higher caliber of billing specialists and retain these individuals.
3. They have a deeper bench of employees and this provides a layer of protection for your practice by decoupling you from the risk associated with losing a key (if not the key) billing employee.
4. They are better positioned to properly utilize the technology they have.
5. They have a broader scope than any single medical practice or facility. This allows them to see patterns across practices, specialties, states and payers that can add money to your medical practice's bottom line.
The typical concerns that physicians and practice managers have when deciding whether they want to outsource medical billing are:
1. Will billing services fight as hard for me with insurance companies as my own employees?
2. Can outsourced billing companies handle the unique elements of my practice?
3. Will I lose control and visibility into how my accounts are being worked?
4. Will an outsourced billing company alienate my patients through heavy handed collection practices?
5. Will medical insurance billing services only go after the low hanging fruit, and leave the more difficult money uncollected?
Over the upcoming articles I will go into more depth on each of the benefits and concerns outlined above. I will go ahead and give you a peek at the final chapter. The trick is finding the right insurance billing company. Once you have a company with a proven track record you will be able to see substantial improvements in your practice's revenues have a more attractive bottom line and have more time and energy for your patients, growing your practice and - heaven forbid - a life outside the office.
Article Directory: http://www.articledashboard.com
The fundamental principal behind outsourcing is the focus on core competencies. The idea is that you and your practice are geared towards treating patients, not fighting insurance companies and pursuing personal balances. On the other hand, medical insurance billing services focus on billing and should have the scale, focus and employees to do a better job than most medical practices or medical facilities. The primary benefits that a medical practice should see from the right medical billing service are:
1. They have more scale to purchase and deploy the technologies required to properly submit claims, battle with insurance companies and collect personal balances.
2. They are able to attract a higher caliber of billing specialists and retain these individuals.
3. They have a deeper bench of employees and this provides a layer of protection for your practice by decoupling you from the risk associated with losing a key (if not the key) billing employee.
4. They are better positioned to properly utilize the technology they have.
5. They have a broader scope than any single medical practice or facility. This allows them to see patterns across practices, specialties, states and payers that can add money to your medical practice's bottom line.
The typical concerns that physicians and practice managers have when deciding whether they want to outsource medical billing are:
1. Will billing services fight as hard for me with insurance companies as my own employees?
2. Can outsourced billing companies handle the unique elements of my practice?
3. Will I lose control and visibility into how my accounts are being worked?
4. Will an outsourced billing company alienate my patients through heavy handed collection practices?
5. Will medical insurance billing services only go after the low hanging fruit, and leave the more difficult money uncollected?
Over the upcoming articles I will go into more depth on each of the benefits and concerns outlined above. I will go ahead and give you a peek at the final chapter. The trick is finding the right insurance billing company. Once you have a company with a proven track record you will be able to see substantial improvements in your practice's revenues have a more attractive bottom line and have more time and energy for your patients, growing your practice and - heaven forbid - a life outside the office.
Article Directory: http://www.articledashboard.com
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