THE EFFICIENT OPHTHALMOLOGIST

Health care reform impacts billing

Recent changes complicate the collections process.

By Steven M. Silverstein, MD, FACS

Regardless of subspecialty, the ophthalmic practice’s mission is to deliver quality patient care, a hard task considering the Affordable Care Act; the chaos it’s created and the current case the Supreme Court is considering concerning the exchanges.

The complexity of all the new requirements means that ophthalmology practices need more sophisticated administrative staff, more training and upgrades to their computer systems to aid the complicated billing and collecting processes.

CROSS-TRAINING STAFF

Remaining fiscally strong and in control while maintaining high-quality care is challenging and can place cash flow at significant risk. Therefore, it is efficient and essential that billing department personnel cross-train for filing, scrubbing, submitting claims, as well as pre-certification and interfacing with Medicare/Medicaid and third-party payers.

In our practice, we work the denied claims on a daily basis, which alleviates aging claims that are not getting paid or, more importantly, lessens the risk on nonpayment for “failure to timely file.” Cross-training ensures that someone is available to work claims on a daily basis.

EMRS AID COLLECTIONS

Remaining up to date with the latest required EMR software vendor regulatory and security changes is critical.

We have found that sending electronic patient statements directly through our EMR sofware vendor, instead of paper statements, has largely increased our accounts receivables directly from patients.

COLLECTING HIGH DEDUCTIBLES

Currently, patients’ deductibles under the ACA are growing $1,000 to $10,000 or more. Therefore, we must aggressively collect high deductibles/coinsurance and copays before the patient leaves the office.

We precertify all surgeries so that our patients are aware of their out-of-pocket expenses in advance. We also encourage our patients to take advantage of CareCredit to help with the cost of these high deductibles and out-of-pocket expenses.

BOUNCED CLAIMS ISSUES

We suggest that you re-examine your fee schedules and credentialing with insurance companies. Ensure that all claims are posted correctly with the correct insurance fee schedule to maintain a smooth cash flow with minimal bounced-back claims.

PRESSURE BUILDS

Payers demand more detailed accounting of how we work, which forces practices to become more efficient. So, the experts say, fewer ophthalmologists can operate with creativity and autonomy, and only the pragmatic will thrive. Above all, mounting government regulations and increasing economic pressure forces many practices to consolidate and cut costs.

COLLECTION ROAD BLOCKS

Collecting copays and deductibles has always been a challenge, but new plans created under the ACA have added to the burden.

Numerous plans exist, but not all plans pay at the same level or in the same timely fashion. With some plans, patients have a longer window to receive treatment, even before they pay their premium. This leaves some patients a 90-day window to pay their premiums.

Some enrollees take advantage of this by having surgical procedures and medical services during this window but they don’t pay their premium. So, the insurer does not reimburse the ophthalmologist for the services.

DIFFICULTY INCREASES

This year, physicians’ payments were increasingly tied to providing higher-value care and outcomes under the ACA. In February, financial penalties kicked in for practices accepting Medicare that could not attest to meaningful use. And come October, we expect to transition to ICD-10. These complex, time-consuming programs will lead to payment delays and denials, requiring claims scrubbing and refiling.

Despite our efforts toward compliance with the new EMR regulations and other mandates, submitting a clean claim has become difficult.

One can only hope the Supreme Court’s deliberations on this latest challenge to the ACA will include all these concerns, as they are burdens on both physician and patient. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.