PA discusses ways to create stronger, better payor/payee relationships and make the reimbursement process a smoother, faster one.
PA says that creating better provider/payor relationships is the direction that healthcare is headed. “The Affordable Care Act (ACA) puts pressure on the payors to focus more and more on both cost and outcomes for their subscribers. Communication between the medical practice and the insurer is critical. If there are ambiguities or irregularities, or worse, consistent debate about coding, etc., the workload on both sides will increase.”
PA notes that most private U.S. insurers had already decided to implement the majority of the provisions of the ACA before the United States Supreme Court ruled on ACA and have embraced the idea that focusing on long-term outcomes will result in long-term cost savings.
On how better relationships can be achieved, PA says that payors and providers must avoid a “defensive medicine” stance to reimbursement. PA explains that focusing on the best description of the treatment, rather than simply finding a code that will be reimbursed, will enable the process to be more straightforward and cooperative. PA says: “With no-deductible regulations for physicals, women’s health, etc., billing and reimbursement for routine office visits should eventually become easier. As primary care physicians and other practices move toward electronic health records, the transparency will become even greater.”
PA also points out that providers must stay away from activity that feels like “bill everything and see what they pay” conduct. PA cautions that in the new ACA environment, this behaviour will have both substantial commercial and legal risks.
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