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The Affordable Care Act comes as a boon for all Americans as it helps them in accessing quality healthcare at affordable costs. Although it is the duty of Primary Care Physicians (PCPs) and physicians in other specialties like ENT/Otolaryngology to ensure that everyone is able to access healthcare at low costs, the ACA-based payment models may not be quite favorable. Most of the physicians are bent on shifting their reimbursement models and managing the financial aspects of their practices poses a real challenge.

ENT revenue management will focus on the shift from fee-for-service (FFS) to value-based payment, which will certainly turn out to be quite dramatic. The need of the hour is for the physicians to understand payment reform and make necessary plans to adapt to the new conditions. ENT billing services like all others know that ENT physicians need high productivity along with better value. However, physicians cannot afford to be paid less as cost savings does not mean cost-cutting but better efficiency with a reduction in duplication of services will certainly benefit most of the physicians who are still adjusting themselves to the new learning curve.

It is all about sharing risks and not ignoring the need to share the savings as well, which is the focus of new models including ACOs (accountable care organizations). That is probably why more and more private players are opting to enter into contracts that are similar to ACO ones. However, for small practitioners and those who practice on their own (solo), pay-for-performance models may not be the answer to value-based reimbursement.

ENT revenue management experts feel that it is better for small practices to collect and evaluate their own outcomes. With the country being dotted prominently with small practices, it is not easy to find administrative mechanisms that are applicable to all these small practices because small practices are more proactive than reactive.

The ENT billing guide based on Pay for performance models are primarily meant to reimburse physicians on clinical and cost-saving effects rather than for services rendered and procedures carried out. PCPs are not on a mission to help patients deal with their chronic maladies and avoid hospitalization whenever possible and do not prescribe a string of tests that are quite unnecessary, nor do they prescribe branded drugs that are expensive.

This leads to overall savings in healthcare. Pay for performance models ensure that physicians get their due rewards if they monitor how they have been keeping patient care at cost-effective levels.

Although there is an emphasis to persuade physicians to adopt these payment models, most of the physicians and small practice owners are not very sure how well it will suit their size and level. Until very recently ENT and other primary care physicians have had only paltry earnings based on performance measures as per the physician compensation and production survey conducted by the Medical Group Management Association (MGMA).

Experts are of the view that physicians should not receive more than 10% of their salaries on a performance metrics basis. In order to develop working pay for performance models, it is important to track clinical data in order to track and reward quality patient management.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete revenue cycle services. To know more about our Otolaryngology billing and coding services, contact us at

Published By - Medical Billers and Coders
Published Date - Nov-17-2016 Back

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