The healthcare reforms brought by the Obama administration have in many ways been an industry-churning affair. They have changed the number of patients the healthcare centers receive today, affected the administrative activities that revolve around a typical treatment episode, shifted the professional location of several medical practitioners (independent physicians aligning with hospitals) etc.
These changes have caused severe hurt to small healthcare centers and left the big ones financially ruffled, leaving organizations ill-equipped to meet their future goals leaving them far behind organizational aspirations.
If we look at the changes triggered by reforms as separate facts without any connecting link between them, the situation will look irretrievable. But if we look a little closer to find out that link which unites them, what will spring to our attention is the fact that all of them have a revenue impact on a healthcare organization.
For example, a healthcare organization receiving more patients stems from the fact that the reforms have widened the healthcare security net to include more people than before. It is commendable but more patients may lead to more rejection of reimbursement claims if their insurance eligibility and extent of insurance coverage are not properly checked and proper codes not assigned while preparing their claims, not to mention the fact that more volume causes oversight of minor details.
The second example pertains to administrative responsibilities. While administrative responsibilities were always part of a treatment episode, they have become a concern today as the new changes brought by reforms need a greater collaboration among medical and nonmedical (billing and coding) sections of a healthcare organization to ensure a steady flow of medical information between them based on which decisions will be made. A point in case is the Medicare frauds coming to light in case of E&M coding where the choice of appropriate codes is done by the coder based on medical inputs he/she receives.
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There is also a need to understand the medical information (about procedures and diagnoses) passed on to billers and coders accurately so that proper coding choices can be made preventing making under-claims and over-claims, especially the latter as it can lead to security by Medicare authorities, now overly sensitized by rising insurance frauds. Similarly, there are other operational challenges brought in by reforms.
Independent physicians aligning with hospital is not a very old phenomenon and one that had been sparked by healthcare reforms – because, to transfer cost benefit to the patient, reimbursement requires services to be bundled up, which has forced hospitals to align with independent physicians to offer varied medical services under one roof, begetting a new set of problems for in-house billing and coding and administrative teams to contend with.
And the impacts of these challenges accumulated over a period of time starts showing on the financial performance of a healthcare organization leading to a situation where yearly financial targets missed by small margins each year adds up to form a big lag after the lapse of a passage of time, sapping vigor and life out of the organization.
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