Navigating through Regulatory Changes that Dramatically Affect Medical Billing


The limited reach of US healthcare network leaves a large part of American population outside the net of healthcare. This problem has stalked US governments traditionally and to expand the reach of healthcare to make healthcare available to a larger part of US population, successive governments (in varying degrees and as suited their political beliefs) have introduced regulations to make healthcare cheaper for and easily accessible to the care receiver.

In continuity of this tradition, the last few years under Obama administration have been witness to a flurry of regulations. Whilst one can argue that they have addressed the traditional concerns and empowered US healthcare to stand up to the challenges of technology and needs of modern day healthcare, the regulations have also affected the day-to-day healthcare operations carried out by medical practitioners coiling up every treatment procedure with regulatory activities burdening care providers with activities they neither have time nor qualification to perform.

The Affordable Care Act will expand the number of insured people by more than 30 million people. To restrict the increasing cost of Medicare, the act will create a panel of experts to prevent reimbursing for treatments not found effective and create incentives for healthcare providers to offer bundled payment modules to care receivers.

These are indeed very effective measures to take healthcare to lower income groups in the US and reduce healthcare costs, but they throw considerable operational challenges to healthcare operators. The effect of increase in number of insured Americans from a care provider standpoint is quite simple to understand: it will mean more regulatory responsibilities for care providers in way of having to deal with technical details related to billing and coding, using codes appropriately, etc., leading to not just time spent by them on nonmedical activities but also exposing them to the prospect of inaccuracies in preparing insurance claims resulting in claim denials.

However, the bundled payment aspect warrants a deeper look to understand the impact of regulations on day-to-day healthcare operations. A treatment episode is a sprawling affair. It includes various phases of treatment an individual goes through from pre-hospitalization diagnosis through hospitalization to post hospitalization care. Each one is a distinct healthcare activity and traditionally has had separate healthcare fees. Bundled payments club together the different fees associated with each phase of a treatment episode and offer the care receiver one fee for the entire treatment life-cycle, saving him money.

Albeit, this everything-rolled-together approach requires sound coordination among various specialties involved in a treatment episode for data sharing and final pulling together of medical information to prepare claims using appropriate codes for each phase of treatment. Big healthcare bodies have addressed some of these concerns (like internal coordination and easy availability of medical data while preparing claims) by making all the services available under one roof but are struggling with others, like using appropriate codes and spending resources (time and money) on non-medical activities, all leading to low rates of claim reimbursement and revenue leakage. Finding it difficult to withstand the financial onslaught wrought by denied claims and losing patients to big care providers, small operators have aligned themselves with big care providers losing their entrepreneurial independence.

Coping with the changes caused to medical billing:

The irony of this whole US healthcare industry saga is that what has caused this is not a healthcare issue but an administrative one. To handle this issue, a care provider either needs an in-house setup with a strong revenue management system staffed by well-trained billers and coders to handle the entire claim preparation process using appropriate codes and medical details where necessary and knowledge of software platforms to submit the claims electronically to ensure HIPPA compliance or needs to outsource the entire claim administration process to a biller and coder.

Medical Billers and Coders, the largest billing and coding consortium in the US,  has helped care providers in all 50 states of rural and urban US to address these issues helping them to save time and cost, an advantage they can divert to their core business, healthcare, and also share with the customer. MBC’s experienced billers and coders are familiar with all regulatory details and prepare claims with high degree of accuracy ensuring low rejection rates.

MBC can also spruce up your revenue management cycle by pruning up your processes, replacing your old software platforms with new and appropriate ones and training your staff in administrative details as also cross-functional competencies thus reducing your downtime and ensuring the continuity of your billing process in the absence of a staff.

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