Taking Inventory of Current Changes in Healthcare Reimbursement

By Randy Wilson

As we begin 2017 in the ever changing healthcare environment, it is important that we take inventory of current changes already on the books and evolving events that may impact the world of reimbursement in healthcare. The list is not meant to be all-inclusive and is to serve as a guide to the reader to be diligent in doing additional research to become more informed. Each of these items in itself could represent a career opportunity for a consultant. A word of caution as you review this list is to be careful of the resources you use to gain an understanding of their impact on your business and healthcare in general. I would recommend using authoritative sources.  Your neighbor may not be an expert, and may know just enough to offer solutions that may NOT be solutions.

  • MIPS and APMs – In 2017 PQRS changes and now we must prepare for a new payment system which becomes effective in 2019, but the data used for the basis of the payment will be collected in 2017. MIPS, Merit-based Incentive Payment Systems and APMs, Alternative Payment Models, are the two new kids on the block. Quality measures are more important than ever in 2017 and the sooner in 2017 you are able to select and begin using them, the better your chances of preventing a loss of reimbursement in 2019.
  • Balance Billing – There is a lot of misunderstanding associated with these terms. It’s all about educating the patient to understand deductibles, and co-payments/co-insurance are not “balance billing”. Several states are passing legislation related to balance billing and it is a good idea to be aware of what is happening in your state. Your state representatives are a good source of information as well as organizations like ACEP and EDPMA.
  • “Surprise Bill” legislation – The new buzzword closely related to the balance billing issue is the “surprise bill”. This is a bill received by the patient because a provider does not participate with an insurance plan the hospital participates with. Many states are addressing this issue and some are proposing legislation that requires providers who are out of network to “act as if they are in network”. Again, be aware of legislative efforts in your state with regard to Surprise Bill efforts.
  • Affordable Care Act – With a new administration starting in January, there will be much activity around potential changes to the ACA.