Regarding payments, there is a new special case today for EM. The ever-increasing incidence of the new self-pay patient, engendered by the increasing incidence of high-deductible insurance patients, requires new patient follow-up techniques and protocols. As a first step, the quality of patient ED registration data and information becomes critical. The self-pay patient has always been a nemesis for EM practices, and we now have a new category of these patients. This impacts cash flow and the overall financial strength of EM practices. Payments by these patients need constant monitoring and new and creative follow-up protocols.
Explore This IssueACEP Now: Vol 33 – No 09 – September 2014
The issue of claims denials and appeals is important even along with a move toward partnering with payers, which in some instances can be part of hospital plans regarding physician integration. It is one thing to consider closer relationships with payers, but it is also imperative to be fully knowledgeable of the insurance industry’s historical track record, both before and after the numerous class-action settlements. The Medicare program today, its payments and denials, necessitates strong management and monitoring as evidenced in the recent lawsuit filed by several hospitals against the Department of Health and Human Services, with millions of dollars remaining outstanding due to substantial appeal backlogs.7 Today’s denials processing for hospitals and physician groups requires aggressive revenue-cycle tracking and follow-up protocols coupled with technological tools that can wrap and send all appeals and required supporting documentation quickly and expeditiously to payers. The market is changing on a daily basis, and it is imperative for EM practices to rethink, retool, and aggressively monitor these practice indices along with all other standard indices to ensure the financial health and strength of the specialty. The most recent alarm is sounded by Medscape Medical News journalist Robert Lowes, who notes that the Affordable Care Act rollout involving exchanges is causing significant accounts-receivable issues, which is again a warning for EM practices.8
EM has its own “Triple Aim” and a new practice-management ABC protocol. Acuities, baseline/benchmark payments, and appeals/denials analysis require strong management, constant monitoring, and sophisticated tools to ensure the financial strength and longevity of EM practices. As the landscape continues to substantially change, EM practices must adjust to meet these challenges. It is an opportunity to emerge as strong financial leaders in this new world.
Mr. Holstein is director of business development for Zotec Partners in Bala Cynwyd, Pennsylvania.
- Berwick DM, Nolan TW, Whittington J. The triple aim: care, health and cost. Health Aff (Millwood). 2008;27:759-69.
- Centers for Medicare & Medicaid Services. Medicare Provider Utilization and Payment Data. Centers for Medicare & Medicaid Services Web site. Available at: http://www.cms.gov. Accessed April 9, 2014.
- Demko P. Health insurance giants to make payment data accessible to public. Modern Healthcare Web site. Available at: http://www.modernhealthcare.com/article/20140514/NEWS/305149981. Accessed August 1, 2014.
- Herman R. What if Medicare were the only payer? Becker’s Hospital Review Web site. Available at: http://www.beckershospitalreview.com/finance/what-if-medicare-were-the-only-payer.html. Accessed August 1, 2014.
- Augustine J. Survey: the ED is the nexus of care. Emergency Physicians Monthly Web site. Available at: http://www.epmonthly.com/features/current-features/survey-the-ed-is-the-nexus-of-care/. Accessed August 1, 2014.
- Herman B. Crozer-Keystone Health System facing steep losses, low admissions. Becker’s Hospital Review Web site. Available at: http://www.beckershospitalreview.com/finance/crozer-keystone-health-system-facing-steep-losses-low-admissions.html. Accessed August 1, 2014.
- Adamopoulos H. Hospitals sue HHS over Medicare appeals. Becker’s Hospital Review Web site. Available at: http://www.beckershospitalreview.com/finance/hospitals-sue-hhs-over-medicare-appeals.html. Accessed August 1, 2014.
- Lowes R. Most medical groups are in ACA exchanges and dislike it. Medscape Medical News Web site. Available at: http://www.medscape.com/viewarticle/825732. Accessed August 1, 2014.
- Evans M. Ascension considers major insurance play. Modern Healthcare Web site. Available at: http://www.modernhealthcare.com/article/20140522/NEWS/305229947. Accessed August 1, 2014.
- Snow B. Online blood work: no doctor’s visit required. Fox News Web site. Available at: http://www.foxnews.com/health/2014/04/05/online-blood-work-no-doctors-visit-required. Accessed August 1, 2014.
- Dunn L. Priceline.com for healthcare? Yes, please. Becker’s Hospital Review Web site. Available at: http://www.beckershospitalreview.com/healthcare-blog/priceline-com-for-healthcare-yes-please.html. Accessed August 1, 2014.
- Robeznieks A. CHE Trinity, Walgreen enter coordinated-care agreement. Modern Healthcare Web site. Available at: http://www.modernhealthcare.com/article/20140521/NEWS/305219963. Accessed August 1, 2014.
- Williams KB. Why insurers have no choice but to hire retail execs. Healthcare Dive Web site. Available at: http://www.healthcaredive.com/news/why-insurers-have-no-choice-but-to-hire-retail-execs/265614. Accessed August 1, 2014.