While the transition from meaningful use to value-based care is at its starting point, this shift reforms healthcare and brings in a wide range of novelties across domains.
Billing is not an exception, as the need to balance costs and outcomes has always been one of the constant struggles in healthcare. Bound to complicated coding rules and lengthy payment processes, this part of healthcare strains after significant changes.
This is an overview of trends that influence medical billing now. These are expected to reshape the billing process, streamline workflows and improve revenue management.
EHRs: From minimum to maximum
While EHR adoption rates are extremely high, not all of such systems feature embedded billing. However, the trend is moving towards all-in-one systems with data analytics, billing, patient engagement and other crucial features included. More and more EHR vendors not only aim at outsourcing software development, but also offer clinical stakeholders to outsource EHR systems themselves, releasing them as cloud-based (for example, the new eClinicalWorks 10e).
This evolution allows overcoming the administrative burden tied to on-premises systems and bringing in more mobility, which is especially important for home care nurses and physicians. With the ability to put in all necessary billing information right away, providers will be able to significantly reduce the number of preventable medical errors related to CPT coding and billing.
ACOs: The forerunner of value-based payments
If you want more drama in medical billing, then look no further. Accountable care organizations (ACOs) are the home to drama here. The key role of ACOs is to ensure coordinated fee-for-service care, while keeping patient health outcomes high. If an ACO meets all performance and quality goals, then it takes its share of savings.
For ACOs, simple billing systems are insufficient as these organizations has to deal with a larger patient database and, most likely, each independent part of the ACO (hospitals, groups of PCPs, home care agencies, etc.) will most likely have their own EHR system.
The challenge here is in the need to synchronize workflows across multiple EHRs to eliminate double billing and wrong medical claims. Only integrated practice management software can ensure that the needed data will be in place in real time, tackling the synchronization challenge. Therefore, each provider within an ACO will be able to transparently submit claims to insurers and track their processing.
Telemedicine: Distant care expansion
As predicted by Transparency Market Research (TMR), the global video telemedicine market is expected to grow to $1,624.4 million by the end of 2020. As telehealth continues to evolve, caregivers look for tools to monitor their patients and provide distant care in the comfort of patients' homes.
Accordingly, the healthcare community also continues to put pressure on payers and policymakers to mandate and regulate the coverage of telemedicine. Certainly, billing processes are among the central concerns here.
Currently, providers are practically demotivated to offer telehealth services to their patients, since the set of covered patients is quite narrow (Medicare and Medicaid patients with 2 and more chronic conditions). Moreover, reimbursements vary across states, therefore caregivers have to be in control of the telemedicine coverage in their state and by their payers. A provider's billing specialists must be on the same page to ensure that their caregivers are being paid accurately for their services.
While the major point of telemedicine is to allow patients to receive care services from their office or home, Medicare reimbursement terms require patients to travel to a 'qualified originating site' for this purpose. If a patient wasn't at the qualified originating site, the private payer can withhold reimbursement. Hopefully, this requirement will soon become history, as 26 states have already adopted telehealth parity laws which enforce reimbursements for telehealth services that patients receive whenever they like to.
Same with the EHR trend, the telehealth expansion influences the demand for the ability to use a mobile device as a tool for billing, charting and interaction with patients in an HIPAA-secure way.
Patients: Paying more, demanding more
Healthcare faces multiple challenges all the time, but this one can be a game-changer. Hospitals and health systems face the need to re-evaluate their billing processes, shifting the focus from groups of private and public payers to consumers as their major revenue drivers.
The reason is that patients are becoming critical stakeholders in the healthcare industry thanks to their increasing enrollment into high-deductible health plans (HDHP) coming with such out-of-pocket expenses as deductibles, copayments and/or coinsurance. Particularly, the amount a patient should pay before the service is covered has increased by 255% since 2006, according to Health System Management eMagazine.
With increasing out-of-pocket costs, patients obviously starting to seek out pricing transparency, especially keeping in mind the wild price ranges across states. For example, as of 2013, the price for one MRI scan was ranging from $650 to $1650 depending on the state, according to Harvard Business Review.
Accordingly, patients start to approach appointments differently, asking questions about payments, requesting convenient billing and paying options. Not every caregiver offers payment information beforehand, leaving patients in the dark. Some providers choose to ignore the technology and send patients paper bills, which is costly and inefficient for the healthcare organization itself and fatal for patient experience.
Surely, if providers will ignore the demand and continue to focus their business strategies on payers instead of patients, this may hurt even in the short run. Patients have started to compare their options due to higher deductibles, therefore they will choose the caregiver that is able to ensure transparency, convenience and pleasant experience above quality care.
Medical billing world is under a major pressure
Yet the pressure is the only way to get a diamond from a piece of coal. Directly or implicitly, multiple domains influence how medical billing evolves. While EHRs are extending their capabilities, caregivers can streamline claim creation and processing with the ability to use mobile devices for instant billing.
The booming era of telehealth introduces bundled codes and opens up new reimbursement options, yet requires attention from policymakers to ensure that providers will be paid for their services. ACOs face the challenge of workflows distributed across multiple systems, which can be tackled with practice management software. In their turn, patients are becoming the main healthcare stakeholders, therefore they will decide on acceptable pricing and payment options themselves without leaving this decision to insurers.
By Abby Adams, Senior Business Analyst, Itransition
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.