Coding and Billing Changes Too Complex to Go it Alone

A Q&A with Timothy Mills, Chief Growth Officer, Alpha II
Twitter: @Alpha_II

Q: How are medical practices managing the transition to value-based care? Are initiatives like the CMS Quality Payment Program (QPP) effective enough to guide them through the process?

A: At the end of the day, physicians want to do what’s in the best interest of patients. Physician practices are eager to make the transition to value-based care, but fee-for-service continues to rule that visit and how the physician gets reimbursed. Value-based care should be focused on saving money and on better health outcomes, which is in the best interests of both patients and physicians. So there is a desire to continue that transition. QPP is in line with what physicians want. The “how” is the right question, because many physicians don’t have the resources to manage this on their own.

Q: In your opinion, are the majority of healthcare providers staying on track with the various QPP deadlines, requirements and quality measures?

A: We’re definitely moving in the right direction, from the Physician Quality Reporting System (PQRS) to QPP. The challenge is staying on track. Physician groups and larger practices tend to have more internal resources to deal with regulatory deadlines and requirements, but even they need assistance and guidance regarding what measures to track and how to track them. At the same time, they still need to bill fee-for-service to drive reimbursement. Many practices are struggling, with smaller practices needing higher degrees of assistance to make sense of this new reimbursement environment.

Q: Beyond the quality program, are there other ways in which healthcare reimbursement is evolving? For instance, what are some other challenges that hospitals and medical practices will be faced with?

A: Certainly, I would say one ongoing shift is patient financial responsibility. The “Patient Payer” now stands beside private insurance, Medicare and Medicaid as another source of significant revenue. With the increasing use of high-deductible health plans, it’s critical that providers know how much a patient will owe early in the process. When the patient walks out the door, paying that medical bill loses top-of-mind awareness. With shrinking reimbursements on the fee-for-service side, providers need to collect patient pay as soon as possible. Managing the complexities of today’s billing and reimbursement environment is key. Changing rules and coding complexities affect not only daily/weekly cash flow but overall revenue stability.

Q: Alpha II partners with a number of healthcare organizations in a reseller capacity. Why would these organizations choose to integrate your products like ClaimStaker and CodeWizard into their EHR and practice management systems, rather than just develop these claims and coding offerings themselves?

A: There are literally millions of variations in rules/edits across multiple data sets, private insurance plans, Medicare/Medicaid, NCD/LCD and place of service, etc. They realize there is a nearly infinite set of possibilities. And these rules and coding edits are constantly being updated, not just annually, but quarterly and sometimes monthly. It’s a daunting task to merely keep up, much less manipulate and analyze those data elements to help practice or hospital clients get a clear picture of their revenue health.

ClaimStaker and CodeWizard are very sophisticated in order to reduce the coding complexity for providers. Just as important, our Alpha II team includes certified coders, EDI specialists, nurses and others who are constantly gathering, analyzing and interpreting changing rules through the lens of medical necessity. This complexity requires not only an integrated partner with a strong solution, but someone who can help manage that overall change. Partners see us as integrated partners because we’re not selling a product and walking away. We live and breathe this stuff, just like coders and billing specialists do, and we deliver an integrated solution.