Tennessee Holds Off on Medicaid Expansion: What does it mean for physicians?
In a Joint Convention of the House and Senate yesterday morning, Governor Haslam announced his decision not to use federal funds to expand Tennessee’s Medicaid program at this time, TennCare, to individuals with incomes up to 133 percent of the federal poverty level. Instead, Haslam hopes to use the federal funds to pay for private health insurance for around 175,000 low income individuals in the state, a plan which has not yet received approval from the Obama administration.
While this announcement will undoubtedly concern the many low income families currently without health insurance, how will Haslam’s decision affect the physicians who treat these patients? Unless Haslam gets approval to use the funds to buy private insurance, his announcement essentially means nothing has changed for the current and potential TennCare population and its providers. Right?
Well, not necessarily.
Essential Health Benefits in the Tennessee Insurance Exchange
By Katie Dageforde
While Tennessee insurers are still deciding whether to participate in the insurance exchange, set to be open for enrollment in October, CMS has given some direction on what insurers will be required to offer consumers if they do. On February 25th CMS released its final rule on essential health benefits (EHBs) and other standards with which health plan issuers will have to comply within the exchange.
Instead of creating an exhaustive list of EHBs, CMS has chosen benchmark plans within each state, including states like Tennessee that opted to have their exchange housed with the federal government instead of the state. These benchmark plans will be the minimum requirements for any health plan that chooses to participate within the exchange.
Read TMA’s Health Care Reform Blog for a more detailed explanation of the new final rule and links to additional information.
Transitioning to Electronic Reimbursements: The Pros and Cons of EFTs
By Katie Dageforde and Angie Madden
Under the Affordable Care Act (ACA), numerous technological changes have been thrust upon the healthcare community in an effort to bring it into the 21st century. For the more tech-savvy medical practices, you may be thinking “It’s about time”! But for others, especially practices in rural areas where some technologies are not as reliable, these new changes may seem daunting.
In last Friday’s TMA Weekly email to members, you may have seen our Primer on EFT Physician Reimbursement, in which we explained the various insurers’ current stance on electronic funds transfers (EFTs). For those of you who have not yet made the switch, EFT is essentially a direct deposit form of reimbursement, similar to getting an employee paycheck sent electronically to your bank account rather than a paper check. EFTs have the ability to save time and hassles, but like with any technology they have the potential to cause a few headaches along the way. In this Ask TMA blog post, we will outline some of the benefits and potential detriments to signing up for EFTs in your practice.
How the federal insurance exchange will affect physicians: Patient Churning
By Katie Dageforde
In the first two parts of this series on the pitfalls of the insurance exchange, we discussed how the physician shortage and unknown reimbursement rates will affect how physicians practice medicine. In this final post of this series, we will talk about patient churning, which has the potential to affect physicians both financially and operationally.
Patient churning occurs when patients involuntarily cycle between health plans or systems of coverage. For our purposes, churning would likely happen among those eligible for Medicaid or TennCare, those eligible for subsidies on plans offered through the exchange, and those ineligible for participation in the exchanges at all. If Tennessee opts into the Medicaid expansion under the ACA, individuals up to 133 percent of the federal poverty level (FPL) will be covered. Additionally, individuals with incomes up to 400 percent of the FPL with no employer-sponsored insurance will qualify for federal subsidies to purchase insurance within the exchange. Since individuals cannot participate in both Medicaid and the subsidies, some are likely to flip-flop between the two.
How the federal insurance exchange will affect physicians: Predicting Reimbursement Rates
By Katie Dageforde
As you already know, Tennessee has opted for the federally-facilitated insurance exchange. We’ve previously discussed how the exchanges will increase the number of insured individuals, likely exacerbating the physician shortage to some degree. The next issue to address is how increased insurance coverage will affect physicians financially.
In other words, what will reimbursement look like within the exchange?
How the federal insurance exchange will affect physicians: The Growing Physician Shortage
by Katie Dageforde
The main goal of the Affordable Care Act (ACA) is ultimately to provide insurance coverage for every American in one way or another, which is the purpose of the individual mandate, potential Medicaid expansions, as well as the insurance exchanges. This means that in about a year from now, there will be a massive influx of newly insured patients entering the health care market. The Congressional Budget Office (CBO) estimates that 12 million individuals will purchase insurance through the exchanges, and the total exchange enrollment is set to reach over 29 million by 2021. About 75 percent of the enrollees in 2014 will be newly insured people, unfamiliar with the insurance system, and likely not previously involved with a primary care physician (PCP).
How the federal insurance exchange will affect physicians: Potential Pitfalls
By Katie Dageforde
Governor Haslam announced on Monday, December 10th, that Tennessee will not create its own insurance exchange in line with the Affordable Care Act (ACA). Insurance exchanges under the ACA are online marketplaces that are open to individuals without employer-sponsored health care and employers with fewer than 100 employees to shop for and compare health insurance plans. The governor’s announcement does not mean that Tennesseans will not have the option to participate in an insurance exchange. Instead, the federal government, through the Department of Health and Human Services, will create its own exchange for states that opted out of the state-run exchange path. Health plans that wish to participate in the exchanges must be deemed “qualified health plans,” which means they must offer essential health benefits and be in good standing with the state. The exchanges will also provide subsidies for individuals with incomes between 100 and 400 percent of the poverty level.
Internal and External Billing Audits: Resources for Physician Practices
By Katie Dageforde
Billing procedures are burdensome, but they can save a lot of time and money in the long run if done properly and on a regular basis. Erroneous billing procedures can result not only in insurance hassles, but also federal and state prosecution if done continuously. Internal prospective audits can help detect errors in billing and correct them before they result in a full blown investigation from either the insurer or the government, while internal retrospective audits can identify overpayments and underpayments and address them accordingly. Steps to complete an internal audit include identifying who in the office will be in charge of the audit and creating a compliance plan. The OIG of the Department of Health and Human Services has issued guidance on how to structure a compliance plan for small physician practices.
Practice Management Alert Issued by the AMA: 2013 OIG Work Plan Released
The Office of Inspector General of the U.S. Department of Health and Human Services (OIG) has released its 2013 Work Plan. Review the plan to determine if your practice may have any associated compliance vulnerabilities and use the plan as a guide in prioritizing and updating your current compliance efforts. The voluntary compliance program document developed by the OIG may help in your efforts to assure your compliance. The AMA also developed resources that provide the basic structure that physicians and others may follow for establishing a compliance plan that can be incorporated into the physician practice.
New and continuing areas of focus for physicians as outlined in the 2013 OIG Work Plan include:
• Medicare and Medicaid Incentive Payments for Electronic Health Records
• Potentially Inappropriate E & M Payments in 2010 relating to EHR documentation
• Noncompliance With Assignment Rules and Excessive Billing of Beneficiaries
• Error Rate for Incident-To Services Performed by Non physicians
• Place-of-Service Coding Errors
• Use of Modifiers During the Global Surgery Period
• Non-Hospital-Owned Physician Practices Using Provider-Based Status
• Payments to Providers Subject to Debt Collection
ICD-10: Don’t overlook hospital documentation requirements and their impact on your office
It is highly unlikely that any practicing physician has not heard the buzz about the impending ICD-10 coding transition – or that at least some thought has not been given to how they might prepare for this HIPAA-mandated change. This will transform the way physicians code and document their services and procedures. One often overlooked area is the impact that documentation created at the hospital might have on the ambulatory provider. If you see patients at your local hospital, you will need to include education about documentation created there in your transition training program. Hospitals rely on attending physicians to provide the level of documentation necessary to bill for facility services. Likewise, physicians will use the same documentation, as in dictated reports and medical records, to bill for their own professional services. Each is dependent on the other to get paid. These shared documents create proof of what services were actually performed by the physician, what the hospital provided, the complexity of the patient’s condition, and the services rendered.