Medicare Compliance & Reimbursement

Look ahead to doctor-patient relationship and billing changes.

Ever since the Supreme Court upheld the constitutionality of the Patient Protection and Affordable Care Act (ACA) all kinds of healthcare providers -- practices, facilities, labs -- have been wondering how they are going to be affected. (For an overview of the ACA see Medicare Compliance & Reimbursement, Vol. 38, No 17.) Here are further updates from our experts on how this mammoth reg may affect medical specialties.

Look Ahead to Greater FP Demand

For family physicians, the current trajectory of the law, as upheld by the Court, means that many more folks will have insurance in a few years, which should increase the demand for primary care, says Kent J. Moore, manager of healthcare financing and delivery systems for the American Academy of Family Physicians (AAFP) in Leawood, Kan. That, given the apparent shortage of primary care physicians, should mean a higher value placed on the services of family physicians and other primary care providers.

The provision requiring parity with Medicare for Medicaid primary care services will also mean more money in the pockets of family physicians that treat Medicaid patients, Moore adds. In short, the Supreme Court ruling may be good news for family physicians as physicians, as long as demand does not swamp supply. What it will mean for them as small business employers in relation to the insurance mandate is unclear to me.

Expect Doctor-Patient Relationship Changes

I believe the Affordable Care Act will have an impact on the doctor-patient relationship, says Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management, Inc., in Spring Lake, N.J. Remember, the law's emphasis is on health insurance, and for those who can't afford to buy health insurance, their coverage will be Medicaid. Therefore, the Medicaid program will get larger with more people (patients) on Medicaid. The question is who will care for these Medicaid patients? Will there be mandatory provider participation? Will providers who don't accept third party insurance be mandated to accept some -- or all -- policies?

I believe internal medicine and family medicine providers will be hardest hit financially, Brink adds. Their 'volume of patients' will increase to cover costs, which could mean their staff will increase due to administrative needs, such as processing patients and insurance claims. That means more expense.

Plan for Billing Changes

It is not apparent that the Supreme Court ruling will have much impact on family medicine coders specifically, Moore says. That doesn't mean, however, that some things related to coding might not change.

Don't forget the effects of PQRS, Brink points out. Providers will be mandated to comply with entering patient medical data, which translates to more administrative time for providers, which means less time for patients. The procedures for claims submission and processing by insurance companies undoubtedly will be impacted by increased volume. Billing staff time may increase to track claims and monitor reimbursement. Again, more billing staff may be needed -- which will have a financial impact on practices.

Prepare to Wait and See

There are certainly some good components of the bill, but also some pretty complex components, says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, Co. It's a case of wait and see what happens -- time will tell if it will be good or not.

The next big hurdle for the law is the outcome of the Congressional and Presidential elections this fall, adds Moore. Significant changes in the House, Senate, or White House could lead to legislative or executive action that might otherwise alter the law and its impact.

Since the U.S. has never had a healthcare law that mandates everyone must have health insurance, I believe it is difficult to know or predict the effects it will have on providers and their practices, Brink agrees. It is anyone's best guess right now.

Your lab too needs to be ready for changes that could affect your bottom line. Our experts have identified the four areas that could impact you.

Look for Cancer Screening Uptick

Based on the Supreme Court ruling, there will continue to be a 'push' on preventive care, says Dennis Padget, MBA, CPA, FHFMA, president of DLPadget Enterprises Inc. and publisher of the Pathology Service Coding Handbook, in The Villages, Fla.

Because the ACA preventive care benefit has been in place since the law was passed, your lab may already be processing a higher volume of screening tests such as cancer screens, cholesterol evaluations, and HIV tests. The law requires both Medicare and private payers to cover the cost of preventive services, including screening tests, that the U.S. Preventive Services Task Force rates A or B.

Millions of Americans are getting cancer screenings, mammograms and other preventive services for free thanks to the health care law, said HHS Secretary Kathleen Sebelius in a statement.

In fact, according to CMS statistics, more than 16 million Medicare beneficiaries have gotten at least one free preventive service so far in 2012 because of the ACA regulations.

Don't Expect Fee Schedule Relief

Medicare payments are set to drop by 27 percent in 2013, unless Congress acts. Readers have asked if the Supreme Court decision changes that. The answer is no -- the ACA has no impact on the proposed Medicare Physician Fee Schedule, which sets payment for physician services, including pathology.

The Sustainable Growth Rate (SGR) formula is not addressed in the ACA and is not affected by the ruling, says Barbara J. Cobuzzi, MBA, CPC, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J. Congress is expected to act to keep rates frozen for the foreseeable future. This is a political hot potato that Congress just does not want to touch.

Clinical labs beware: Some observers expect pain on the Clinical Laboratory Fee Schedule as well: Clinical labs will see payment cutbacks, because that's a big dollar line item in the national budget, Padget says.

Anticipate Demise of 'Fee for Service'

How you get paid for services might see a major shift starting with ACA enactment.

Now that the Supreme Court has ruled that the reform law is constitutional, the extensive delivery system reforms embedded in the law move forward for implementation, said Stanley J. Robboy, MD, FCAP, president of the College of American Pathologists (CAP) in a prepared statement. The shift from volume-based fee-for-service payment to coordinated care and incentive-based reimbursement continues to gain momentum ..., he says.

You can expect to see many more restrictions as part of this shift, according to Padget, such as frequency limits (Medically Unlikely Edits), bundling restrictions (Correct Coding Initiative), coverage constraints (fewer covered ICD-9 codes), and higher penalties for failing to meet quality measures.

Heed Your Own Healthcare Costs

Just like any business, you need to anticipate ACA's impact on your bottom line.

Pathologists and labs need to be thinking about their own practices and companies too, Padget says. Employee healthcare costs will increase significantly for them too, even if they have fewer than 50 employees.