Rheumatology Practice Management December 2013 Vol 1 No 2 — December 30, 2013

San Diego, CA—Most elements of the Affordable Care Act (ACA) will be implemented by 2014. With it, providers should expect changes in patient demographics and payer mix, said Audrey E. Coaxum, CHI, CMCO, CMC, CMIS, CMOM, faculty/consultant at the Practice Management Institute in San Antonio, TX.

Providers may want to think about a plan of action with respect to patient eligibility verification and payment contracts in anticipation of such changes, she said at a practice management course held prior to the 2013 meeting of the American College of Rheumatology.

Practices should be ready for any changes in patient profiles as the healthcare exchange programs under the ACA are rolled out. Some patients who were previously self-pay may now have insurance, others who were part of a preferred provider network may move to point-of-service plans or health maintenance organizations. Many patients may have higher deductibles under their plans, and those patients may need to be considered similar to self-paying patients, said Ms Coaxum.

“Offices will have to do their due diligence as it relates to eligibility verifications up front, before patients actually show up in the facility,” she said. “They may have to alert them about any changes in their benefits plans or even explain to them how to work through their benefits plans, because they may be dealing with patients that never had insurance before. The upfront education will potentially cause a change in their operations, especially with respect to the time doing education.”

Obtaining up-to-date patient demographic information is paramount to the collection process. “If practices have to do any collections on the back end, they have to make sure that the information they’re getting is current because the worst thing to have in collections is bad demographic information,” she said.

Some services offered by the practice may have different levels of medical necessity as the coding system is switched to International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM). The ICD-10 coding system is much more specific than International Classification of Diseases, Ninth Revision.

“There may again be the potential for a refocus as far as benefits interpretation,” said Ms Coaxum. “Again, it may be more patient financial responsibility versus a service that’s covered by the patient’s insurance.”

“The exchanges don’t go into effect until 2014, but clinics should be gearing up right now to get ready for next year. They need to start working toward creating a plan of action to get policies and procedures in place.”

Transitioning your practice to electronic health record (EHR) technology, if you have not already done so, is a must if you treat Medicare patients, said Ms Coaxum, as failure to demonstrate meaningful use of EHR will incur a penalty starting in 2015.

The 3 main components of meaningful use are:

  • he use of a certified EHR in a meaningful manner, such as electronic prescribing.
  • The use of certified EHR technology for electronic exchange of health information to improve quality of healthcare.
  • The use of certified EHR technology to submit clinical quality and other measures.


The American Recovery and Reinvestment Act of 2009 provided funding for practices to receive incentive payments totaling $44,000 per physician over 5 years to partially offset the cost of implementing EHR technology. The last year to begin participation in the Medicare EHR Incentive Program is 2014, but the incentive payment is reduced to a maximum of $29,000 if participation was delayed until after 2012. The penalty starts at 1% and increases each year that a Medicare-eligible professional does not demonstrate meaningful use, to a maximum of 5%.

Getting on Board with Quality Reporting
Insurers will start sharing basic information about providers with their customers, including whether or not the practice is participating in the Physician Quality Reporting System (PQRS). “The PQRS is designed to give the patient population all of the ammunition they need to select the best providers for them based on how providers deliver healthcare, what their outcomes are, and how cost-effective they are,” said Ms Coaxum.

Quality determinations that are inferred from claims data, as has been done traditionally, does not provide an accurate picture of outcomes, she said. Health professionals not currently participating in PQRS were supposed take action by October 15, 2013, to avoid a 1.5% penalty from Medicare in 2015.

According to the Centers for Medicare & Medicaid Services (CMS), providers can report their quality information to CMS on their Medicare Part B claims, to a qualified PQRS registry, to CMS via a qualified EHR product, or to a qualified PQRS EHR data submission vendor.

Physicians who meet PQRS reporting deadlines currently receive a 0.5% Medicare bonus payment. In 2015, the bonus payments will be replaced by a 1.5% penalty for those who do not meet the deadlines, which increases to 2% in 2016.

Analyze Your Contracts
Now is also the time to start analyzing your managed care contracts with the intent of renegotiation based on your patient demographic mix, said Ms Coaxum. “Providers need to start analyzing the types of patients they have and the types of insurance they carry, their volumes, and how much it costs them to deliver care to these groups,” she said. “Many times practice administrators don’t focus much on the financial viability of their practices, and we want to change that mindset.”

In some instances, joining an accountable care organization may make sense financially, and may help a practice meet their reporting requirements or with administrative processing. “It sometimes provides them the leverage that they potentially need to work with contract negotiations and get more reimbursement in some areas,” Ms Coaxum said.

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