Strategic Realignment to Affordable Care Organization Model – providers perspective

“While physicians embark on such transformational healthcare model, their quantum of Medicare reimbursement, and its amicable distribution among themselves is sure going to be complex issue. Given such complex calculation on Medicare reimbursements and qualifying incentives, an external medical billing services that is best acquainted with Medicare environment becomes more pronounced.”

As time closes in on the Accountable Care Organization model of healthcare under Medicare, physicians across the US are busy realigning their practice models and alliances in congruence with the mandate of Section 3022 of the Patient Protection and Affordable Care Act (ACA). Commencing with January 2012, physician networks intending to participate in the program will be required to enter into an agreement with the Secretary to participate in the program for not less than a 3-year period, and be accountable for quality healthcare to at least 5,000 Medicare beneficiaries.

Coupled with the mandatory agreement with the Program Secretary, physicians also have an ominous task of setting up of mutually complimentary alliances among themselves that can efficiently enable division of diagnosis, treatment, and supervision of their target group of patients. Yet, incentives for keeping Medicare expenditure as minimum as possible will not be guaranteed until and unless the participation physicians:

• Become accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it.

• Adhere to the formal legal structure that would allow the organization to receive and distribute payments for shared savings to participating providers of services and suppliers.

• Abide by the ACO’s policy of including primary care ACO professionals that are sufficient for the number of Medicare fee-for-service beneficiaries assigned to the ACO under subsection.

• Agree to be supervised by a leadership and management structure that includes clinical and administrative systems

• Work in sync with processes that  promote evidence-based medicine and patient engagement, report on quality and cost measures, and coordinate care, such as through the use of telehealth, remote patient monitoring, and other such enabling technologies

• Demonstrate to the Secretary that it meets patient-centeredness criteria specified by the Secretary, such as the use of patient and caregiver assessments or the use of individualized care plans

• Do not cross over to other Medicare shared savings programs

Commit themselves for evaluation vis-à-vis their ACO’s patients’ health needs
Therefore, amidst such governing principles, the intending physicians need to realign their practices in a way that best meets the Accountable Care concept. While physicians embark on such transformational healthcare model, their quantum of Medicare reimbursement, and its amicable distribution among themselves is sure going to be complex issue. Given such complex calculation on Medicare reimbursements and qualifying incentives, an external medical billing services that is best acquainted with Medicare environment becomes more pronounced.

About Medicalbillersandcoders.com

Medicalbillersandcoders.com – known for a healthy rapport with Medicare for more than a decade, and self-sufficient in the requisite qualification and competence, such as certification from  American Association of Professional Coders (AAPC); expertise in advanced technology interface for medical billing and coding;  proficiency in applying standard CPT, HCPCS procedure and supply codes, and ICD diagnosis coding as per CMS guidelines and HIPAA compliant medical reporting – should be a preferential recourse to physicians on the verge of forming Accountable Care Organization model.

Outsourced Medical Billing – the prescription for new practices’ impressive ROI

Given the rapidly expanding patient base, and an insatiable demand for quality medical care, it is not surprising that each passing-by moment is witness to the birth of a new practice. Despite being driven by a larger healthcare vision, new practices – operating in a market-driven environment – are inevitably forced to lend equal significance to Rate of Return on Investment (ROI), which is the operational yard-stick for sustenance and growth in a highly competitive medical service market.

If pooling in the requisite resources to launch your medical services is one huge task, operating it on profitable basis is altogether a different proposition. Having ventured into a socially-responsible service, most of your time and resources will be expended on employing the best of physicians, diagnostic and curative measures, support and administrative staff, and facilities – all of which have direct impact on quality medical care, patient satisfaction, patient retention, and credibility that would further expand your patient referrals.

Assuming that you go on, and eventually achieve the objective you set out for – medical service credibility – would there be any guarantee that you would have achieved an equally credible and sustainable Rate of Return on Investment (ROI)? Medical bill realization, which is a matter of insurance coverage, would weigh heavily on venture practices, who are generally novice to stringent billing regimen governed by CMS. Further, a full-fledged in-house medical billing team may not be advisable as it, being slow to yield results, is equally capital-intensive requiring heavy investment on: Installation of Billing and Coding Platforms, and Training the staff on best practices in medical billing.

Amidst the prevalence of such uncertainty on in-house medical billing results, it is prudent to source your medical billing needs from a competent outside agency;

• Application of Advanced Technology Interface comprising use of latest medical billing softwares such as Lytec, Medic, Misys, Medisoft, NextGen, IDX, etc.,
• Use of latest coding softwares such as EncoderPro, FLashcode and CodeLink
• Application of standard CPT, HCPCS procedure and supply codes, and ICD-9-CM diagnosis coding as per CMS guidelines and HIPAA compliant medical reporting
• Successful track-record of processing medical bills with the leading private insurance carriers such as United health, Wellpoint, Aetna, Humana, HCSC, Blue Cross Group, and Government sponsored Medicare and Medicaid as well

Beyond the above requirements, the Medical Billing agency must also provide comprehensive medical billing complete with:

• Patient Enrollment
• Insurance Enrollment
• Scheduling
• Insurance Verification
• Insurance Authorizations
• Charge Entry
• Coding
• Billing and Reconciling Of Accounts
• Denial Management & Appeals, and
• Physician Credentialing

Medicalbillersandcoders.com (www.medicalbillersandcoders.com), the largest consortium of medical billers in U.S. for over a decade, and whose medical billing service – complete with accurate charge-capture, intricate procedure coding, electronic filing of claims, patient billing, multi-tiered appeal process, denial elimination initiatives, account receivables, and compliance standards – can be an ideal solution for new practices that require phased implementation of medical billing process before considering in-house medical billing themselves.

Going by the recent statistics – 30 to 40% reduction in medical billing costs – our comprehensive billing solution is the prescription for new practices that seek an impressive ROI through simplification of revenue cycle, appreciable increase in collection rates, more patient inflow and referrals, and increased avenue for medical research and development.

• Tampa, FL Medical Billing
• St Petersburg, FL Medical Billing
• Orlando, FL Medical Billing
• Columbus, GA Medical Billing
• Fayetteville, AR Medical Billing
• Jersey City, NJ Medical Billing
• Pittsburg, PA Medical Billing
• Providence, RI Medical Billing
• Richmond, VA Medical Billing
• Honolulu, HI Medical Billing

Assess the capability of your workforce: Is your clinic administration in the right hands?

The capability of your workforce as a physician is directly impacted by the number of people you hire and the efficiency of the staff. Ideally every business entity needs to find the right balance between the number of people employed and the profits or revenue that they help generate. This factor along with the efficiency of your staff directly affects your revenue and accuracy. Physicians in the United States face numerous challenges when it comes to choosing the right administrative staff because of the ever changing face of the health industry. Therefore it becomes important to analyze whether the administrative aspect of your practice is in the right hands.

The clinical staff cannot completely focus on your patients and handle the negotiations with insurance company all at the same time. Even if this is possible, it may drive down the profits due to errors from work overload. The best solution for this problem is to hire extra staff or medical billers and coders who are experienced in this field. Even though this may increase your investment in staffing, it will also increase your revenue, justifying the addition of such experienced medical billers and coders.

The three most important professionals that affect your productivity are the assistants, the receptionist and the support staff for billing and coding who can also negotiate and interact with payers. The most crucial role played in the administrative and revenue cycle management is that of medical billers and coders. It is important to hire medical coders and billers who are excellent in technical skills, have updated knowledge of HIPAA guidelines, and have experience in handling negotiations with payers. The technical skills required in medical billing and coding is not just about having good computer literacy but is also about numerous other qualities such as good communication skills and knowledge of recent trends in reimbursement in your specialty.

There are numerous other ways of enhancing your staff’s productivity and these may be as practical as optimal utilization of office space to something as intangible as motivating your workers. Some simple ways of enhancing or gauging the efficiency of the staff is measuring individual productivity, revising methods to modify or channel employee behavior and talent in the right direction, setting clear goals that are achievable, rewarding the staff whenever required, and keeping a follow-up by evaluating whether the changes made are having a positive financial impact on your practice.

The reforms in the health care IT sector have also affected physicians dramatically, and utilizing latest technology such as EHR (Electronic Health Records), using practice management software efficiently and other IT tools has become necessary.

EMR system support and training are also important when deciding whom to hire to run the EMR system. Without an effective EMR installation, your practice may not be entirely proficient. EMR systems can profit medical facilities in numerous ways; the reports driven from an EMR can highlight the lacunae in a physician’s system and staff productivity. EMRs with facilities to audit logs, assigning tasks to specific staff member and regular follow up and reminders on pending tasks, provide tools to streamline systems. This means that EMR not only improve patient care but also assist in increasing the revenue in the long run. Efficient use of EMR or EHR is one of the most important aspects of the administrative side of a physician’s practice.

Assessing the productivity and capability of your administrative staff is a job that entails not just number crunching but also the level of patient satisfaction, the amount of time saved due to professionalism, the accuracy of medical billers and coders, HIPAA compliance, and meaningful use of the technology that is adopted for billing and coding. If all these aspects do not result in improved revenue over a period of time then it would be better to look for staff and medical billers and coders who can do the job efficiently and in a timely manner.

For more information about improving the productivity and appraisal of administrative tasks, please visit medicalbillersandcoders.com.

Boston Medical Billing, San Jose Medical Billing, Phoenix Medical Billing, LasVegas Medical Billing


About Medicalbillersandcoders.com


Medicalbillersandcoders.com is the largest ‘Consortium of Medical Billers and Coders,’ across the US. The portal brings together hundreds of billers, with experience in different specialties, on the same platform to service physicians in their local areas. This network of coders and billers is growing rapidly and is currently servicing over 50 specialty physicians, across the US (Iowa Medical Billing, New York Medical Billing, Ohio Medical Billing, Texas Medical Billing), with the most prominent being Cardiology Medical Billing, Mental Health Medical Billing, Dental Billing, Oncology Medical Billing, and General Practice.

Payment Posting – Key to Revenue Cycle Management

Payment posting is one of the most important steps that can assist in improving a physician’s revenue if done efficiently. Although payment posting is becoming electronic and automated there is still the need for checking for accuracy and errors in the posting. There are numerous ways in which physicians can benefit from accurate and efficient payment posting and its analysis.


Explanation of Benefits (EOB)


The ability to carefully read and comprehend the EOB is one of the crucial aspects of medical payment posting. Avoiding errors in EOB or correcting the errors made by an insurance payer can lead to avoidance of long term financial loss. Studying and minutely examining the EOB for correct information such as the claim number, provider, type of service, the not covered amount, and insured ID number can drastically reduce mistakes and ensure that you are properly remunerated.


Electronic Remittance Advice (ERA)


ERA is provided by most insurance providers and is an electronic form of EOB or explanation of benefits. This helps in increasing your productivity and streamlining your workflow and can be integrated to your PMS. However, facts about underpayments, denials, multiple adjustments, cross-overs, reversals, and secondary remittance have to be analyzed in order to ensure correct reimbursement in a timely manner.


Insurance Follow up


Correct payment posting also supports insurance follow up which ensures optimal revenues for physicians. Insurance companies can deny claims based on any type of error and it is important for billers and coders to keep in touch with such providers in order to ensure that the issue is being addressed. Therefore accurate payment posting can eliminate such delay in denied claims by avoiding errors. Payment posting sets the stage for effective Account Receivables follow up.


Reduce costs and tool to measure efficiency


The cost of billing can be reduced along with an increase in revenue due to better payment posting processes. The reduction in cost is also due to the time saved by electronically done payment posting which is verified by experienced billers and coders. Moreover Payment Posting is a key tool to measure the efficiency of Medical Billers and Coders as it stands testimony to clean claims and error free billing.


Quantitative advantages


The recent health reform is going to ensure more doctor-patient encounters and the sheer volume of EOB and the amount of posting would become staggering. This is where attention to detail while reading EOBs and familiarity and experience in advanced electronic remittance scenarios is important. Balancing receivables by accurate and timely Payment Posting, makes performance reports more clear and concise to draw financial decisions.


EOB or ERA, the human intervention in the analysis is inevitable; the best computing system can not drive efficiency in collection all by themselves. Expert medical billers are required to scrutinize those customized reports. Medical Billing specialists at medicalbillersandcoders.com are experienced in such scenarios and keep updated about payment posting processes and also all other adjustment clauses in the reimbursement policy.


Ohio Medical Billing | Michigan Medical Billing | Maryland Medical Billing | Arizona Medical Billing | Washington Medical Billing | Oklahoma Medical Billing 

Payment Posting – Key to revenue cycle management

Increased inaccuracy in claims payments by health insurers

Commercial health insurance has registered an increase of 2% over the existing average claims processing error rate of 19.3%. This 2% translates to an extra 3.6 million in erroneous claim payments, and costs an additional estimated $1.5 billion in highly avoidable administrative costs to the health system.


AMA (American Medical Association) has released its Fourth Annual National Health Insurer Report Card which underscores the 2% increase in inaccurate claim payments since last year among the leading commercial health insurers. Claims-processing errors by health insurance companies squander billions of hard-earned dollars, frustrating general public as well as physicians in the process. The AMA estimates that eliminating health insurer claim payment errors would save $ 17 Billion.


The key findings of this report are as follows:


Performance: United Healthcare emerged as the only commercial health insurers with an accuracy rating of 90.23% while Anthem Blue Cross Blue shield scored the worst with an accuracy rating of 61.05% according to the report.


Denials: A noticeable reduction in denial rates has occurred since last year at Aetna, Health Care Service Corporation and United Healthcare, which reduced its denial rate by half to 1.05%. CIGNA maintained its industry low denial rate of 0.68%. The common reason for denials continues to be the absence of patient eligibility for medical services.


Non-payment from Insurers: Nearly 23% of claims submitted by physicians in 2010 received no payment at all from the commercial health insurers. One of the most frequent reasons cited by insurers was deductible requirements that shift payment responsibility to patients until a dollar limit is exceeded.


Administrative requirements: The report has also mentioned how frequently claims included information on insurers requiring physicians to ask permission before performing a treatment or service. A recent AMA survey of physicians indicated that insurers’ requirements to preauthorize care delayed or interrupted medical services, consumed significant amounts of time and complicated medical decisions.


Analyzing the various facts highlighted in the report, it appears likely that physicians would continue to experience roadblocks in reimbursement for their payments. In order to streamline the process of reimbursement, they would have to rely on experts who are well versed and experienced enough to pre-empt the loopholes and grey areas in the payer system and avoid falling prey to those. Physicians and healthcare organizations facing obstinate rates of non-payment and/or denials do not have to take it lying down; they can take the help of qualified professionals from medicalbillersandcoders.com to experience error-free claims filing to ensure a healthy reimbursement rate.


Ohio Medical Billing | Michigan Medical Billing | Maryland Medical Billing | Arizona Medical Billing | Washington Medical Billing | Oklahoma Medical Billing 


Increased inaccuracy in claims payments by health insurers

Improving Quality And Revenue In Face Of Healthcare Reforms

The recent healthcare reforms proposed by the white house may affect the revenue as well as the quality of the service provided by physicians in the United States. According to a recent survey by Thomson Reuters, almost two-third of doctors in the US fear that health care reforms proposed by Mr. Obama might flood their offices which in turn would mean reduced individual attention to patients. Simply put, doctors would end up working more for lesser remuneration.

 Medical Billing
The survey also reveals that almost 68% of doctors think that the quality of service would drop because of the reforms. However, repealing the bill would also mean that more than 100 million people under the age of 65 would not be able to get health insurance because of a pre-existing condition. Nevertheless, the repeal of this bill is likely to fail in the senate. This effectively means that doctors would have to find a solution for plugging the gap between demand and supply of health care services.


2,958 doctors were surveyed by Thomson Reuters and physician services company HCPlexus in various states and of different specialties. When asked about how they were going to handle the newly insured, more than half of them said they would have to delegate the work to an assistant or a nurse. Although this may ease the pressure on doctors, it is just a make-shift solution for a change that looms large and can take place in as less as four years.


Electronic medical records might help according to 39% of doctors who were surveyed. Moreover, delegating administrative work can also be a solution. For instance, all billing and coding can be taken care of by highly trained professionals resulting in better time management and increased revenue.


The health care reform may be a radical change but still everyone would not be covered for everything and it would still be a good practice to send electronic files to a clearing house for determining eligibility. This can save time because it would reduce the amount of claims which are denied. Providing the patients with an electronic version of the bill and E-statements instead of mailing a paper bill would further cut costs by as much as 12 to 15%.


Some resident doctors would find themselves busier than before and since Federal law does not place any limit on the working hours of residents, it would be inevitable that they would spend more and more hours treating patients who are newly insured. Although the Accreditation Council for Graduate Medical Education (ACGME) has limited the work hours of residents to 80 hours, many residents work more and report less for fear of losing accreditation. This can be advantageous for doctors who would rely on nurses, residents and assistants to catch-up with the increasing demand for health care services.


There is no quick-fix solution to this since we cannot “import” doctors from other countries and the number of doctors and nurses cannot increase to a level in such a short period of time where they would be able to meet the demands. However, since Medicare is responsible for funding a majority of residency programs, there is a possibility that the recent bottleneck in such funding can be solved in the years to come which would result in recruitment and training of new residents. Moreover, there has been a growth of around 4% in residency slots from 1998-2004 which is the result of funding from a large number of teaching hospitals.


Some branches of medicine such as radiology and internal medicine do not require long working hours and can cope with increased volume of work. However, most of the branches would struggle to cope with the increased work pressure if a pragmatic solution is not developed before the reforms take place.


The biggest advantage a doctor or a health care provider can have are good medical billers and coders who can ensure quality even when meeting deadlines. This will make the process smoother for the physician as well as relieve him or her of work pressure. For instance you can get in touch with medical billers and coders in your area and your specialty at no cost at www.medicalbillersandcoders.com

Medical Billing Florida | Medical Billing California | Texas Medical Billing

Better Revenue Cycle Management For Physicians With Skilled Billers And Coders

Accurate revenue cycle management essentially means that you get paid in a timely manner and the account receivables balance is zero when the cycle is completed. However, this type of management could become cumbersome for physicians since it is not their primary occupation and the recent health care reforms would mean more patients and work pressure. Therefore it becomes imperative that you have a system in place whereby you can delegate this job to professionals and concentrate on your practice.

 Medical Billing

Gathering of data is one of the crucial steps in revenue cycle management and the process starts when the patient calls your office for an appointment. With a busy schedule which may get busier by the day, it would not be a surprise if you are unable to verify the eligibility of the patient by checking with the insurance company.


The best way to ensure that you enhance the efficiency of your revenue cycle is using the correct and updated CPT, HCPCS, and ICD codes. This can be easily accomplished by hiring top notch coders who can deliver in a timely manner. Sometimes many physicians end up holding their charge slips for a complete day which can cause a delay in the billing process. Moreover, if you hire staff that does not have in-depth knowledge of the Medical Terminology or do not follow CCI edits and LMRP standards or have the correct coding exposure, it could jeopardize your collections for that month.


There are some basic steps in achieving better revenue cycle management including proper data gathering, automation (E-statements, e-prescribing, e-labs and accommodating electronic Remittance Advice instead of opting for EOBs), and professional billing and coding staff. This is the best way to achieve a zero accounts receivable balance. Therefore hiring office assistance with limited knowledge or expertise in this field can lead to problems. Moreover if these billers had no support to verify if there billing processes are accurate, that could lead to high denial rates or RAC audits. The best way to ensure that your revenue cycle management is a smooth and efficient process is to hire medical billers and coders who are experienced and have trained and up-to-date knowledge peers who they can consult in times of doubt.


Evaluate the services of the largest consortium of Medical Billers and Coders across all 50 States, for more information please refer to www.medicalbillersandcoders.com.

Medical Billing Florida | Medical Billing California | Texas Medical Billing