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Many practices are running on razor-sharp margins. That puts them at a distinct disadvantage when it comes to dealing with payer-generated work.
The 2014 rollouts of federal- and state-mandated healthcare insurance exchanges were highly anticipated as a game changer. Yet, practices are just now feeling the effects of the new legislation. Primarily, they are dealing with the task of collecting much-higher patient deductibles and copays; and also explaining the intricacies of less generous health plans to frustrated and sometimes angry patients. Lucien Roberts, practice administrator at Gastrointestinal Specialists in Richmond, Va., says that patients are often confused about their health plans and don't understand why they have a larger cost share. Yet, it takes time to educate patients, a responsibility Roberts thinks should belong to payers. He says lack of patient education on higher deductibles, copays, etc., has become an unanticipated drain on practice resources and time.
"With some of the exchange plans, patients don't know the rules. It puts practices in a bad position - to be the bad guy when patients get an unexpected bill. I think it is a general rule with all the exchange [plans] that they've signed patients up without fully explaining the 'gotchas' to patients," says Roberts.
Another hurdle that practices must negotiate is the lack of operating consistency between payers.
Practices must cope with differing technical platforms, conflicting rules, and reliance on disparate paper forms; making it particularly difficult to work with multiple payers. In response to this problem, Roberts says that Virginia has passed legislation to require a common electronic format for insurance prior authorizations.
Which payer behaviors tend to cause the worst trouble? Delays in credentialing; inconsistent payer rules for processing claims; claims requiring extra documentation; and passing a greater percentage of cost on to patients; these processes place a greater burden on practices and require them to expend more effort to collect from both payers and patients.
"At the end of the day in the small practice environment, I don't have a health system subsidizing me, so I'm pretty much in an eat-what-you-treat environment. I collect so much money for everything that the practice does, I pay all the bills, and what's left is the physician's income," says Marshall Baker, president and CEO at Boise, Idaho-based Physician Advisory Services. So there are significant disadvantages for small practices when it comes to not having the money to spend on marketing campaigns, patient education programs, upgrading EHR systems, and the like. All things that could potentially help sway a payer to reimburse the practice at better rates.