Three of the top revenue cycle management challenges are Medicare and Medicaid payments, claims denial and value-based payments.
Medicare and Medicaid Payments: Complicated payment reforms, shrinking reimbursements and government mandates contribute to the delay and denial of payments for services covered by Medicare and Medicaid. Medicare and Medicaid represent an ever-increasing segment of the population and timely and adequate payment from these organizations rank as a top issue for healthcare practitioners. The Centers for Medicare & Medicaid Services (CMS) have significantly increased provider education tools including on demand webinars and other resources.
Claim Denials: Some healthcare organizations say 25% of their claims are denied. Some for a technicality such as a missing signature on a medical chart, an incorrect spelling or inconsistent data entry. Sixty percent of healthcare organizations did not see a revenue impact, from the recent implementation of ICD-10 but 34% reported they did in a recent post ICD-10 survey. Continue to monitor your denial trends so patterns can be triaged and treated early on from the cause vs. the symptom. Also note while you are able to submit a valid diagnosis code from the right family and receive potential payment, you may not see the same after October 1, 2016, because coding to the correct level of specificity will be required.
Value-Based Payments: ACA brought in the transition from fee-for-service to value-based payment model. The intent is to improve the quality of healthcare services being provided to patients so healthcare providers are paid based on the value of care they deliver instead of being paid for the number of patients’ visits or tests ordered. This means healthcare practices need to reconcile the new payment model with the traditional fee-for-service environment changing analytics and metrics to ensure payments cover costs.
In addition, the U.S. Department of Health and Human Services (HHS) announced that by the end of 2016, 30% of Medicare reimbursements will be linked to the “quality or value” of services and 50% by the end of 2018. Penalties for not improving data quality include a docking of 2% of Medicare reimbursements.
The 90-Day Grace Period
Another factor impacting revenue cycle management is the eighty-five percent of patients that received an advance premium tax credit via the ACA rules. They are eligible for a 90-day grace period to pay their outstanding premiums before insurers can drop their coverage. This rule applies to all consumers that purchased subsidized coverage through the Affordable Care Act’s (ACA) health insurance marketplace. It has the potential to be a problem not only to track patients in this situation but in the delay of payments. Identify if your patient is up to date on their premium payment as part of your registration process.