“No matter what changes will take on place to the ACA, it is the Cost of Care that matters

Why a new law? To reduce the premiums and deductibles for ordinary citizens? Is it the current rationale for obliterating the ACA? While it all appears to be payback and retribution and pure politics, we all need to think about where we stand because where you stand may not be where you end up sitting in your setting as a Physician group/small practice/large Hospital, Ambulatory care facility and everywhere else clinicians see patients.

There is an incredible dynamic that is surfacing in our culture. As a society, we want more perks and as a society we want all of them for less cost. Organized medicine doesn’t want to lose reimbursement whether Institution or an individual clinician. We have to remember that since the inception of Medicare or at least early on, practicing Medicine paid well. In Schools of Public Health, a standard line would be that Healthcare is the only product decided upon by a physician (Institutional provider) and paid for by a third party. In the last 25 years, all insurers have created mechanisms to change that paradigm through regulations or rules that don’t allow certain treatment without prior approval. CMS, which pays for more of the care than any other insurer, has thousands of regulations to reduce costs that have evolved over the last 15 years. So, the Good Old Days are done and we have to face a new paradigm that require an understanding of the cost of care, use of resources in care and reasonable amounts for reimbursement. It is the cost of care, resources used for care, the documentation of care, and the management of care which are all under scrutiny and subject to severe penalties for noncompliance or will be soon.

Recently, a very prestigious organization providing the very best care, innovation and a brilliant training ground for all clinical disciplines, was asked to return $41.9 million dollars to CMS. What Happened? The Office of the Inspector General did an audit of 261 claims finding 110 resulting in overpayments and those findings were extrapolated to all of the Mt. Sinai claims for the same period resulting in those severe penalties. “It is the peoples’ money Stupid”.

And the “people” are always happy when the Government is looking out for them by finding fraud and abuse.

As clinicians, we should not be so focused on the politics as many of our professional associations are, but rather what our culture is trying to tell us. “Reduce our premiums, let me have access to the best care, reduce my deductibles and make sure I keep my physician and favorite hospital provider.” As a group, the larger Society is saying, reduce taxes, reduce costs, reduce wait times and keep me healthy. As providers, we are asking to be paid for the value of our services regardless of setting. Thus we must face the paradigm understanding our costs, our documentation which supports what we have done, the resources we have used, the real costs, and a pretty good idea of what we must be paid.

If you follow the politics, and only the politics you are watching the hole, not the donut. You have it in your power to be successful, but the following must take place in the practice setting

  1. Create internal audits done by certified professionals. This is the equivalent of having your CPA or your lawyer whose past experience includes working for the IRS or the Inspector General. This is not the time to shy away from the truth.
  2. Audits can be done prospectively (before claims are dropped) so that there is concurrent knowledge of any problems before a sample of claims are submitted. Hire certified and highly skilled people to do it regardless of what the clinical manager and the Practice Manager tells you.
  3. Review your denials closely and parse them to see where the problems are. It may be that there are services not billed or some that should not be billed. The moment we discover overpayments, we should have a corrective plan prepared and a report to the third party payer especially Medicare/Medicaid.
  4. We must also look at our Charge Master to assure that everything that describes a procedure and the codes associated with it are accurate and in Sync; the clinical event must be accurately represented in the Clinical documentation
  5. The results of any of these exercises should be used not only for a teaching moment but also for achieving best practice. It means clinicians need to know how to apply the results. Again, using highly skilled and certified professionals is critical to the success of knowing where you are.

We have advised many of our clients that now is the time to begin these processes. Regardless of what happens in congress, the focus will be on the cost of care, accuracy in claims, and medical Necessity for all payers. Reimbursement has to be based on real numbers. In hospitals and other such providers, the Charge Master must be a living, breathing entity that reflects reality of cost. Everyone will be watching. Why? Lower costs are the only way to lower premiums; adjusting service requirements (services provided) may not help because everything depends on a clinicians’ diagnosis, the treatment plan, the problem list and all of the services needed. There are other considerations patients age, and condition, etc.

So enjoy the politics, the articles pro and con the American Health Care Act, and the ACA, but do due diligence so that both clinicians and institutional providers arrive at the starting gate for the “new Paradigm.


Cathy Idema



866-908-4226 ext. 101