HSMN, a leading ICD-10-CM/PCS consulting firm, is advising their clients of new revenue cycle opportunities. They are predicting hospital and physician reimbursement will decline due to the PPACA but there are opportunities in reimbursement to regain the loss that may be missed if medical staff clinical documentation, coding and critical thinking coders don’t interact in a seamless and symbiotic process.
Moody investors have recently said that hospital executives expect that “Exchange Health Plans” will pay rates that are close to Medicare rates which will be significantly lower than commercial ones.
Exchange plan reimbursement rates will place downward pressure on overall rates. HSMN has no direct knowledge of whether the Affordable Care Act will be hobbled by congressional action. What they are telling their clients is that by making health care networks narrower and only including lower reimbursement providers, some money will be saved.
“HSMN’s recent work with several of our clients indicate that beyond the impact of the Affordable Care Act is the looming presence of the implementation of an entirely new clinical documentation and coding scenario which will further reduce revenue.”
In HSMN’s recent study of five hospitals, it found that largest category of rejection by their internal claims systems was the result of diagnoses and modifiers. The total was more than 85%.
ICD-10-CM/PCS will require exquisitely specific clinical documentation to support a correct diagnoses for claims purposes and coders who not only have had ICD-10 training but also lots of experience in working closely with the medical staff in order to create the appropriate procedure code.
HSMN suggests that physicians and management look beyond their coding systems and enterprise wide clinical records at the source of information and begin a process of demonstrating to the medical staff that they must translate their clinical decision making in a way that supports the incredibly difficult specificity of ICD-10-CM.
HSMN has been working with hospitals and clinical practices for almost 30 years helping them to transition to each iteration of reimbursement requirements. They have often heard that “as soon as our new system is installed and the XYZ company does their thing we should be in good shape. “
HSMN suggests that the astute administrator will look more deeply at current physician behaviors (through analysis) and show them how what they may do currently when translated into the ICD-10-CM world will lose money for both the hospital and their practice.
For more information please contact HSMN or call us at: 866-908-4226.