5 Claims Reimbursement Questions and Answers

December 15, 2015 - Money talks and the healthcare industry is listening. Claims reimbursement was one of many weighty revenue cycle management topics the healthcare industry kept an ear out for this year. From the art of claims scrubbing to figuring out how to keep denial rates low, numerous questions nonetheless emerged over the past twelve months.

The universal and timeless desire to get paid remains the heart of healthcare. Here are 5 claims reimbursement questions, as answered by leading experts earlier this year.

Is telemedicine the reimbursement solution?

“[The] regulatory focus is shifting away from reimbursement issues and focusing more on allowing telemedicine access without state barriers. Although Medicaid, Medicare, and private health insurance reimbursement will always be sought, telemedicine is thriving and profitable with or without governmental reimbursement,” stated Nadia de la Houssaye, Partner at Jones Walker LLP, to RevCycleIntelligence.com.

“Historically, one of the biggest challenges facing reimbursement for telemedicine services was the lack of hard evidence establishing the cost savings and patient outcome. Today, the clinical and devise data overwhelmingly demonstrates that the integration of telemedicine in the care of patients not only reduces hospitalizations and re-admissions rates, but also improves patient outcome.”

“Corporate America is investing billions of dollars into the telemedicine industry. Investors are closely monitoring medical devices and understand that telemedicine is essential to the future of healthcare, largely due to changing demographics and reimbursement models. The capacity of new technologies to remotely monitor chronic health problems in an effective, secure, and real time manner, allows for better management of chronic conditions in the home setting.”

Is telemedicine the reimbursement problem?

“Medicare is the slowest to adopt the use of this technology, so it is going to be a few years for them to really come in line to do everything they should,” asserted Jonathan Linkous, CEO of the American Telemedicine Association.

“There is some reimbursement now through Medicare and as we move through other kinds of payment mechanisms — the payment for quality rather than quantity — and when those take hold it is going to accelerate it, but we have to move faster than that pace.”

“We are still in the beginnings of it, but clearly the tidal wave is coming. … Teamed with that on the state level, the fact that we have some 40 states that are moving in the direction of putting legislation through the state governors’ offices that mandate private payer insurance or expanding Medicaid reimbursement or other types of incentives.”

Is ICD-10 implementation hindering reimbursement?

“If the physician doesn’t appropriately document, then it won’t get appropriately coded. If it doesn’t get appropriately coded, there is risk of reimbursement and cash flow to both the physician and the health system,” said Michael Clark, Evariant’s Chief Operating Officer, to RevCycleIntelligence.com.

“There is no near-term perceived benefit to the physician going to ICD-10, which is why the AMA, MGMA, and physician advocates have fought this so hard for so long,”

“CMS does not really care if it takes you 1 day or 100 days to file that claim. The anxiety is upstream with the physicians and health systems who depend on their Medicare/Medicaid mix and reimbursement. CMS wants to make sure when you file it, it comes in, in the right format, in an electronic format they can manage efficiently on their side.”

“At the end of the day, the heavy burden is on the physician with little to no meaningful immediate benefit to spend time documenting. He or she knows what the patient’s condition is and in a referral situation – when done effectively – the receiving physician is well aware of specificity through other verbal and non-verbal conveyance.”

“With ICD-10, physicians are the ones treating the patient and the expectation is they need to document a greater level of specificity for appropriate care, professional appropriate reimbursement, and medical/legal/regulatory compliance consistent with the expanding ICD-10 code set, and that takes time.”

Why are rural hospitals in reimbursement trouble?

“For rural PPS [prospective payment system] hospitals to continue to survive, we need Congress to continue to support these rural reimbursement programs, in fact, making them permanent,” said Tim Wolters, Director of Reimbursement at Citizens Memorial Hospital.

“Likewise, rural hospitals should be exempted from sequestration and any future cuts to Medicare programs.”

“Testing telehealth to demonstrate effectiveness of care and cost efficiencies is especially important as CMS currently restricts reimbursement for telehealth to patients who receive treatment in a Rural Health Professional Shortage Area or in a county that is not considered part of a Metropolitan Statistical Area,” stated Kristi Henderson, DNP, CFNP, CACNP, FAEN, Chief Telehealth & Innovation Officer for the University of Mississippi Medical Center.

“Within the Department of Health and Human Services alone, there are numerous definitions of what ‘rural’ means, leading to confusion.” 

Do physician compensation models need a new target?

“Non-productivity incentives play a key role in the current compensation arena and will continue to gain importance in future years,” said Justin Chamblee, Senior Manager at the Coker Group. “But you cannot incentivize physicians based on outcomes when all your reimbursement is on [fee-for-service].”

“As the reimbursement methodology changes, health systems, in order to be successful, will need to adjust their compensation methodologies.”

Widespread opposition to Affordable Care Act implementation stems from physicians’ low reimbursement concerns, according to research from Locum Tenens.

Physicians need to follow how reimbursement landscape is progressing from fee-for-service to become value-based, commented Chris Franklin, Executive Vice President of Locum Tenens, to RevCycleIntelligence.com.

Surveyed physicians “mentioned that hitting the Meaningful Use deadlines and milestones for EHR implementation had been particularly expensive, time-consuming and burdensome for them. … Many also mentioned more regulation and ‘red tape’ from the government and insurers who manage the plans.”

“Since so many practices and hospitals were already operating on razor-thin margins prior to the implementation of the ACA, ensuring that their operations are as efficient as possible will be very important going forward. ... Physicians will also need to follow how the reimbursement landscape is changing from that of a fee-for-service to outcome-based reimbursement.”

Read more about claims reimbursement strategies here.