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How Healthcare Will Change As We Know It

Reimbursement and Compliance: New Challenges, New Solutions

How will the Affordable Care Act affect healthcare as we know it? What are some solutions to the challenges payers and providers will face? To help those in the healthcare industry better understand what lies ahead, we invited industry experts to share how they have, and will be, managing solutions to the new challenges.

Dr. Sydney V. Ross-Davis, MD; Lynn Anderanin, CPC, CPC-I, COSC; Philip Quick and Chris Rohn joined us as panelists for our panel discussion “Reimbursement and Compliance: New Challenges, New Solutions,” as part of our Thought Leadership Series. 

Challenge: Planning infrastructure

One of the greatest challenges is developing the workforce needed to care for the influx of new patients. Thirty-five million people will become eligible to receive healthcare under the new law. Has the number of doctors also increased to take care of these patients?  The short answer – no. Over the last five years, residency enrollment grew by just 2,400, which is already short of covering for routine growth, let alone the incoming 35 million patients.  

Healthcare technology has become more important in hopes of facilitating processes. However, technology is a tool, not a solution to the challenge.

There are a lot of moving parts to the system. The biggest challenge is planning the infrastructure to care for these new patients.

Challenge: Uncertainty

With the healthcare exchange launch just around the corner, we still don’t know what the Affordable Care Act will look like in actuality. Will this system get build and no one will come? What will enrollment look like? Are physicians and patients ready?

At first, enrollment will be more of a soft launch. The really sick patients who are heavily subsidized will be the first to sign up for the exchange. It also might pick up the uninsured healthy 20-somethings (or whose mothers have told them to enroll). Another group might be the early retiree population.

We can predict that there will be need a lot of education for physicians and patients. For patients, create a financial navigator position to help navigate patients through the entire application process. Review benefits package with them. Are there other resources to tap into? Is this eligible for a grant? Exhaust all resources before going to government aid. This allows for more timely reimbursement and perhaps better reimbursement rates.

Placing resources on the pre-access side will hopefully streamline the billing process. Furthermore, making sure patients understand their bills and are satisfied with their care will affect providers’ patient evaluations.

Challenge: Getting physicians on board

As Dr. Ross-Davis said, physicians didn’t go into medicine to be corporate. They want to be self-employed, are self-motivated, and are in medicine to help people, not to manage billing and administration. They are frustrated that they were not given enough consideration in the change. Now offices will be making the decisions on patient care.

Physicians are now asked to do more coding, which they are not trained to do in any residency program. It’s not in their background; it doesn’t make sense to them.

     Solution? You need to change the hearts and souls of providers. Go in for the “What’s in it for me?”

Challenge: Being a part of a small physician group

The majority of patients are seen by groups of up to 5 doctors, but the money is coming from larger groups.

Smaller groups don’t have coders but are still trying to run as a sole proprietorship. Their main job is to see the patient.  They will now need to hire coders or become coding experts themselves, whereas large groups can hire consultants.  Smaller groups seem to be getting their ACA information from what they read in the break rooms or from colleagues, which can lead to misinformation.

Unfortunately, these smaller groups probably won’t consolidate. The older physicians may leave the groups, and lots of doctors will run, which is unfortunate because they’re the good ones, the ones you want to keep.

Challenge: ICD-10

The change to ICD-10 means codes will be more specific. The, or one of, the challenges here is educating physicians on the concepts of what needs to be recorded. They are not trained to code in any residency program; it’s not in their background and it doesn’t make sense to them.

Physicians can get in the habit of recording notes that they and their teams understand because they know the patient, but the coders need to know exactly, in detail, what the patient’s diagnosis and treatment is in order to code it properly. This is where coders are needed. They are the “new cool kids” because they are trained are in high demand.

      Furthermore, ICD-10 is more in-depth than ICD-9. Some new challenges:

·  The system is going from 14,000 codes with ICD-9 to 69,000 codes with ICD-10. 

·  Codes had 3-5 characters with ICD-9 and will have up to seven characters with ICD-10.

·  In ICD-10, the letter “U” is omitted, but “O” is not, which will cause confusing between a “0” and an “O.” 

·  Insurance companies have already come out to say they will not accept codes marked as “unspecified,” whereas with ICD-9, unspecified codes were submit
ted and accepted quite regularly.

·  The increase in detail of the codes will most likely increase code denials.

Challenge: ROI

The financial implications are huge. The incentives are huge. There’s going to be heavy competition. Institutional providers hope the more specified codes will increase revenue. 

The intent of ICD-10 is to have more data and better data. What will be done with this data? It’s already being used to market to people who have chronic conditions that are well-managed. Providers will start to build a network around these patients with chronic conditions.

Will the Affordable Care Act work to normalize costs?

Citing the recent studies that highlight the discrepancies in costs for the same procedure in the same city, will this new system work to normalize costs? The reality of these discrepancies in charges comes down to how each provider bills – there may be more hands in the process at one hospital than another. Providers will now have to answer why they charge more.

The system is creating more competition but also more transparency. The desired effect is to have more normalized costs, but time will tell.

Finally, what’s the future of healthcare?

·  From a coder’s perspective, they’re finally being recognized. They’re the “new cool kids”. They will be, and already are, highly in-demand, making it difficult to find certified coders in the future.

·   The Affordable Care Act is not perfect. The administrations need to work with it to figure out what works and what doesn’t and build upon this. They need to answer what is best for our country.

·  Technology is important, yes, but it’s only a tool, not a solution.

·  The system will become more patient-centered. Patients will have more options and choices.

·  There will be challenges in hiring and retaining high caliber individuals.

·  Instead of “who gets covered,” it’ll be “what gets covered.”

·  Unless we make the population healthier, costs will continue to go up and up.

·  Healthcare will become much more localized.


Predictably, there is some uncertainty as to how the Affordable Care Act will play out. As we learned from our panelists, solutions to these new challenges will take a lot of planning and educating.

We’d like to thank Ms. Anderanin, Dr. Ross-Davis, Mr. Quick, and Mr. Rohn for sharing how they are managing the challenges of the Affordable Care Act. And thank you to all how attended! We look forward to our next Thought Leadership Event!

Topics: Healthcare

Posted by Advanced Resources on September 24, 2013