ACA losses for a number of insurance companies have been staggering because of the traditionally small margins with which they are confined by contract. The Revenue Cycle is in turmoil because companies like HIGHMARK (a Blue Cross/Blue Shield affiliate) will ding physicians with whom they are affiliated by 4.5%. Until this point the physicians were paid on a Commercial fee schedule while the hospital continues being paid their contracted amounts. Essentially this means that the losses incurred because of the ACA are being taken out “on the backs of physicians”. We are witnessing the ACA taking on patients who more sick than the average populations and driving up costs.

At the very same time the OIG is quite focused on having money returned to CMS as a result of overcharging Medicare recipients. The amounts could be very large and go back for six years. The physicians are also threatened with doing their own audits to assure that they have not overcharged or accepted reimbursement unreasonably. This self policing is something that our clients are very concerned about. Some have requested audits so that they know what the financial impact may be. Physicians are also wondering how they will cope with self policing without extremely knowledgeable staff who understand through analysis and experience where the problems lie. This is the time to be proactive because while the current White House will be winding down, any new administration will pick up the same theme. “Cough up or be fined”. If you as hospital or physician find overpayments your treatment by the feds will not be as severe. However if the OIG finds overpayments, watch out.

If you need help looking into your over reimbursements or overpayments, feel free to contact us.

Cathy Idema, President and CEO

Health Systems Management Network, INC

A Revenue Cycle Management Company since 1987

Source: http://www.modernhealthcare.com/article/20160307/NEWS/160309890