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Mar 28

The Reimbursement Landscape in Healthcare

Understanding the Uncertainties in the Healthcare Industry

While it displays no real thoughtfulness or industry expertise to parrot the currently prevailing message as is so commonplace, the uncertainty in the United States healthcare market is certain, and it has become the starting point for most articles and conversations on the general topic.  Each individual physician, practice or service provider has the task of understanding the ramifications of the healthcare environment most pertinent to their own organization, making decisions accordingly, and then executing. Following are a few of the pertinent topics related to the reimbursement landscape in healthcare, aiming to identify your practice’s approach and preparedness.

  • As your practice moves to embrace the final rule for MACRA/MIPS, some key topics need to be addressed to ensure a successful transition. The final rule is here, and while pay-for-reporting was an important factor with PQRS in the past, the emphasis now is on pay-for-performance and demonstrating that clinicians are performing optimally, actively addressing quality improvement measures as necessary.

Your billing group, whether a third-party RCM company or an internal department, needs to be aware of all the quality measures and reporting on them at the individual physician level.  Only the clinicians themselves can alter professional behavior, but your billing group should be prepared to both measure this performance and provide insight in to how to apply improvements and then report on progress

  • Beginning more than a decade ago with PQRI/PQRS and now replaced by the current MACRA/MIPS requirements, electronic health records (EHRs) are the source of the data flow in to your billing department. IT infrastructure is now more critical than ever in handling the vast amounts of secure data being transferred through interfaces from the hospital, clinic, EHRs, labs, clearinghouses and payers since in most cases, there are no boxes of paper documents in a storage facility to piece through if backup is needed.

Security, redundancy, support and accessibility to the data are vital to your reimbursement performance.  Additionally, your practice’s billing technology must be provably ready and reliant to adapt to the constant changes common within the industry.  With all that mission-critical technology responsibility related to IT, alternatives exist to ensure that systems are always ready, backed-up and have the malleability needed to protect and sustain your practice.  Again, whether you have a third-party billing partner or an internal department, a well-documented plan needs to be in place to ensure the success of your practice.

  • The patient experience has continued to evolve, and whether foisted upon the patient or gladly welcomed, the fact is that we are now seeing “active consumers” of healthcare, not necessarily passive patients as in the past. With the rise of high deductible plans, health savings accounts (HSAs), and services that rank clinicians on a variety of factors including prices making major inroads, the awareness your practice displays in how the patient experience takes place is another vital factor towards long-term success.

Making sure patients have easy access and a well-defined process to submit their insurance or make a payment is key, and the process needs to consider the varying patient age ranges and behaviors around this interaction.  The aging patient on a Medicare plan is likely going to handle this interaction differently than the young professional who runs their life from their smart phone device. The takeaway here is that simple and clear patient communications will serve as a differentiator for your practice at best, or at least keep you up to speed with the market around you.

This short list of key considerations for the modern healthcare practice as it relates to reimbursement of patient encounters just scratches the surface of issues.  Each practice has multiple decisions to make, and it is difficult to have expertise and experience in each area required to “mind the shop.”  Relying on the cumulative and specific industry knowledge of those vendor relationships your practice has in place should provide advantages for your practice to leverage – in other words, selecting the best partners can provide you with much more than you are paying for on the surface.

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