Anthony
The most preferred method would be the "greater than highest payer’s reimbursement method." I like the idea of it being a "step back tool" to take a look at the overall costs of all the services provided and dividing up what insurers will pay and compare it to the costs. A good example of this would be when a patient comes in for a service like a MRI and their insurance wouldn't allow them to go to St.Luke's due to the costs of doing it there versus another company like Metro Imaging, which would be cheaper for the insurance to reimburse. So they are basically saying, "we will cover it if you choose to go to the cheaper location."
I like your reasoning on how insurers operate because their activities have significant impacts on costing of services. As you noted, it is essential that setting up fees ought to consider the cost of all services. As a result, the method you chose is reliable and can apply in many healthcare institutions. The emerging concern is whether the payment method benefits the patients or the insurers.
Emily post.
I would prefer relative value units (RVUs) because more and more practices are converting to a provider’s fee schedule that is based on RVUs. Since some medical bills are sent electronically, it is easy to attach RVUs to each procedure. This provides an explanation for patients who ask about the cost of procedures. Patients have a better understanding and acceptance of how fees based on relative value are arrived at. I would choose this method because RVUs are the language the payers speak when contracting with practices and for reimbursing physicians for the services they provide. I also would choose this method because RVUs are a useful way of comparing how well payers reimburse for the same service or procedures given to a number of patients.
Post question What techniques would you suggest for improving the accuracy of claims data in the practice? Why do you think these techniques will work? How would you implement them?
Thank you, Emily, for you post. I also appreciate that the relative value units (RVU) tend to be universal because providers are shifting to setting up fees based on them. I like that you noted the ease of attaching the RVUs to the procedures. Besides, it is the best approach that would involve the patients because they can understand it easily and compare the cost of treatment quickly.
Emily post
There are three techniques for improving the accuracy of claims data. First, it is important for the practice to know the patients and have a relationship with each of them. This allows patients to feel comfortable sharing their information so claims have correct patient demographics. Next, the practice needs to improve operational efficiency. No matter how complex the service provided is, the practice needs to document correctly and efficiently. Finally, it is important for the practice to identify, predict, and minimize the likelihood of fraud. In order to manage the risk, the practice needs to thoroughly look over each claim before sending it off.
I think these techniques will work because the practice is already gathering information from the patients, so it can easily make sure all patient demographics are correct by asking the patient the necessary questions each time the enter the office. The practice will also already be preforming efficiently but it is important to continue documenting the correct information on each patient’s chart as they visit the physician. Fraud is a major risk for medical practices so it is crucial staff is aware of how to file claims correctly with the right information. I would implement these techniques by conducting monthly meetings and practice examples with the entire medical staff so the team is on the same page and can work together to improve claims data.
I agree with you that having the right data is crucial because that would reduce chances of occurrence of errors. However, the methods of entering data, whether correct or not may lead to mistakes due to the multiplicity of point of entering the information. Moreover, data capture on patients tends to be complex because the procedures may change along the way leading to errors. Therefore, the need for cyclic regular monitoring, error analysis and intervention to improve on the mistakes is paramount. I believe that training employees on how to detect fraud would help reduce the risk.
Anthony post
The biggest thing is electronic charting. By using a EMR system it is easy to track and process claims. It makes it more efficient and more secure. Everything is done by codes and are translated in a computer system a lot faster. It is also easier to correct mistakes on codes as well. I think using electronic billing in all offices would be a great technique to implement. There are still a lot of offices out there that still use paper charting which would be difficult when mixing both electronic and paper charting. I would implement my EMR billing software to my team and make sure everyone is familiar with it and how it operates so that if there are ever any questions or changes that need to be made then anyone can handle it instead of having one person handle all the billing.
I noted with interest your proposition that one can change data after entry when using electronic billing. They may be easily applied and data sharing swiftly. However, the fact that one can modify the data may render them prone to fraud. A foolproof system is necessary to ensure that only a few people can amend the information to reduce the risk of fraud.
Post question
What is the difference, if there is one, between a practice’s fee schedule and a payer’s allowable reim bursement? What does this difference mean for the practice? For the payer?
Emily post
The difference between a fee schedule and a payer's allowable reimbursement can be shown through the definitions of both terms. A fee schedule is a complete listing of services used in order to pay or reimburse the physicians/providers for the work they perform. On the other hand, a payer's allowable reimbursement is the 'maximum allowed payment' for every CPT code which determines what they will pay.
For the practice, it is crucial to make revenue enhancement a priority where the goal should be to get paid for the services provided. This means the practice fees should be higher than the allowable reimbursement set by payers. Together, the practice and payers should avoid changing fees suddenly or dramatically, be sensitive to the patient market, establish fees based on the resource-based relative value scale (RBRVS), and have a uniform fee schedule for all physicians.
You captured the difference between fee schedule and payer’s allowable reimbursement very well. You also noted the need not to raise prices suddenly as that can hurt the patients and reputation of the service providers. However, changes are inevitable in response to market trends.
