Urology Coding Alert

Review the opinions of these top-in-the-field urology professionals on how ACA will affect the industry.

On June 28, 2012, the United States Supreme Court announced its decision to uphold the constitutionality of the Patient Protection and Affordable Care Act (ACA). In that decision, the Supreme Court also ruled that the requirement that all individuals have health care coverage or face a penalty was a tax, rather than a penalty, and therefore allowable under the Federal taxing authority.

So what does the upholding of the ACA mean for the future of your urology practice? Here's what a few urology and other healthcare experts have to say on how this will affect practices:

• "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. It is anyone's best guess right now.

"I believe the Affordable Healthcare Act law will have an impact on the doctor-patient relationship. 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. Having been involved in administrating medical practices for over 35 years, I have never known any doctor who participates with Medicaid. So the question is who is going to care for these Medicaid patients? Mandatory provider participation?

"Over the next 5-10 years more baby boomers will be on Medicare. There a lot of practices, right now that don't accept Medicare or Medicaid and some even third party insurance. Will they be mandated to accept a certain percentage of Medicare and even Medicaid patients? 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 since their "volume of patients" will increase to cover costs which could mean their staff will increase due to administrative needs -- processing patients and insurance claims -- which means more expense. Specialty surgical practices may feel the same effects since their insurance reimbursement for large dollar surgeries may decrease.

"In an article in the Wall Street Journal, the CEO of a chain of hospitals was interviewed about the new healthcare law. Since this law is expected to cut compensation by $150 million, hospitals (and you have to include providers), he stated "will make up for it in volume" (meaning patients).

"Don't forget the effects of PQRS. 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 with, again, volume. Billing staff time may increase to track claims and monitor reimbursement. Again more billing staff may be needed -- financial impact on practices.

"Also remember that, as of now, ICD-10 kicks in Oct 2014. So there will be a lot of 'learning and changes' for providers and staff.

"There is no doubt in my mind this law will have a definite impact on the doctor-patient relationship since the emphasis of the law is health insurance."

Catherine Brink, BS, CMM, CPC, CMSCS, president of Healthcare Resource Management, Inc., in Spring Lake, N.J., www.hrminc.com

• "The ruling merely upholds the legality of the ACA, not saying whether or not the policies are good for individuals or for our society. While most urologists and urology groups agree that the ability to provide healthcare to millions of uninsured Americans should be upheld, many worry that key aspects of the law may ultimately hurt the ability to actually provide individualized healthcare. One of the greatest concerns to urologists is the presence of the Independent Payment Advisory Board (IPAB), which may ultimately negatively affect physicians' ability to provide quality care to patients; the IPAB has the ability to make spending decisions on health care that can't be changed by Congress and are unreviewable in the courts.

"How do I see the future of healthcare? Republicans have used this decision as a rallying cry to make changes and to ultimately get the law repealed, so ultimately the outcomes of the 2012 elections will be watched very closely by all parties involved. We are really all in a status quo until then. While urologists are encouraged that they will be seeing fewer uninsured patients, there is still no Medicare payment solution and [urologists] are still are facing a potential 30 percent reimbursement cut in January 2013. Certain large urology groups may be in a better position to weather this storm, especially those who have already started positioning themselves in disease-state management rather than a purely fee-for-service model, while others maybe feel forced into joining accountable care organizations. Those who are employed by hospitals will likely feel the squeeze even more."

Jonathan Rubenstein, MD, practicing urologist and director of coding and physician compliance for Chesapeake Urology Associates in Baltimore.

• "The United States Supreme Court's recent landmark decision to uphold the Affordable Care Act, ACA, will have little to no effect on the coding and billing for urological services. In the ACA there are no real provisions for change in physician's reimbursements for the near future. We are scheduled to see a reduction of greater than 30 percent in the conversion factor for 2013 leading to a decrease payment for urological services especially surgical procedures and a possible increase in co-payments and deductibles. General medical offices may be swamped with more patients as the uninsured become insured or mandated to be insured. However, for the urologist, the effect of these changes overall is likely to be marginal because in the past most urologists did not serve a significant number of these uninsured patients. This lack of urological service will unfortunately continue because of lower reimbursements, and urologists will elect not to see the newly insured Medicaid patients.

"The ACA should have little to no effect on Medicare's incentive plans, e-prescribing and PQRS. These plans will continue to be mandated in the future and monetary penalties imposed if these plans are not incorporated into urological practices. In addition, the Supreme Court's decision will have no effect on the 'Meaningful Use' rules established to aid urologists financially in their purchase and implementation of EMR technology.

"The uncertainty of new and changing policies for coding and billing, falling reimbursements, and mandated medical and financial changes in urological practice will drive many urologists to join large urological groups or full time hospital staffs. This transformation of urological practice will lead invariably to less physician participation and involvement in coding and billing with more financial responsibilities placed on the urological coder and biller. I believe this type of scenario will become more frequent and lead to inaccurate coding and subsequent loss of revenue as the urologist spends less time in this important part of his everyday practice."

 Michael A. Ferragamo, MD, FACS, clinical assistant professor of urology, University Hospital, State University of New York, Stony Brook.